title: Post-pancreaticoduodenectomy hemorrhage: risk factors, managements and outcomes.
abstract: BACKGROUND
  Post-pancreaticoduodenectomy (PD) hemorrhage (PPH) is an uncommon but serious complication. This retrospective study analyzed the risk factors, managements and outcomes of the patients with PPH.
  
  
  METHODS
  A total of 840 patients with PD between 2000 and 2010 were retrospectively analyzed. Among them, 73 patients had PPH: 19 patients had early PPH and 54 had late PPH. The assessment included the preoperative history of disease, pancreatic status and surgical techniques. Other postoperative complications were also evaluated.
  
  
  RESULTS
  The incidence of PPH was 8.7% (73/840). There were no independent risk factors for early PPH. Male gender (OR=4.40, P=0.02), diameter of pancreatic duct (OR=0.64, P=0.01), end-to-side invagination pancreaticojejunostomy (OR=5.65, P=0.01), pancreatic fistula (OR=2.33, P=0.04) and intra-abdominal abscess (OR=12.19, P<0.01) were the independent risk factors for late PPH. Four patients with early PPH received conservative treatment and 12 were treated surgically. As for patients with late PPH, the success rate of medical therapy was 27.8% (15/54). Initial endoscopy was operated in 12 patients (22.2%), initial angiography in 19 (35.2%), and relaparotomy in 15 (27.8%). Eventually, PPH resulted in 19 deaths. The main causes of death were multiple organ failure, hemorrhagic shock, sepsis and uncontrolled rebleeding.
  
  
  CONCLUSIONS
  Careful and ongoing observation of hemorrhagic signs, especially within the first 24 hours after PD or within the course of pancreatic fistula or intra-abdominal abscess, is recommended for patients with PD and a prompt management is necessary. Although endoscopy and angiography are the standard procedures for the management of PPH, surgical approach is still irreplaceable. Aggressive prevention of hemorrhagic shock and re-hemorrhage is the key to treat PPH.
authors.affiliation: Institute of Hepatobiliary Surgery, Chinese PLA General Hospital, Beijing 100853, China. wys936602@163.com.
authors.forename: Jian
authors.initials: J
authors.lastname: Feng
authors.forename: Yong-Liang
authors.initials: YL
authors.lastname: Chen
authors.forename: Jia-Hong
authors.initials: JH
authors.lastname: Dong
authors.forename: Ming-Yi
authors.initials: MY
authors.lastname: Chen
authors.forename: Shou-Wang
authors.initials: SW
authors.lastname: Cai
authors.forename: Zhi-Qiang
authors.initials: ZQ
authors.lastname: Huang
mesh_terms: D018784:Abdominal Abscess / Q000150:complications / Q000453:epidemiology; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000792:Angiography; D002648:Child; D002675:Child, Preschool; D057510:Endovascular Procedures; D005260:Female; D016558:Hemostasis, Endoscopic; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D010183:Pancreatic Ducts / Q000033:anatomy & histology; D010185:Pancreatic Fistula / Q000150:complications / Q000453:epidemiology; D016577:Pancreaticoduodenectomy / Q000009:adverse effects*; D010193:Pancreaticojejunostomy / Q000009:adverse effects / Q000379:methods; D019106:Postoperative Hemorrhage / Q000453:epidemiology / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D012008:Recurrence; D012086:Reoperation; D012189:Retrospective Studies; D012307:Risk Factors; D012737:Sex Factors; D013997:Time Factors; D016896:Treatment Outcome; D055815:Young Adult