title: Hemorrhage after Major Pancreatic Resection: Incidence, Risk Factors, Management, and Outcome.
abstract: OBJECTIVE
  Hemorrhage is a rare but dreaded complication after pancreatic surgery. The aim of this study was to examine the incidence, risk factors, management, and outcome of postpancreatectomy hemorrhage in a tertiary care center.
  
  
  METHODS
  A retrospective observational study was conducted on 500 consecutive patients undergoing major pancreatic resections at our institution. Postpancreatectomy hemorrhage was defined according to the International Study Group of Pancreatic Surgery criteria.
  
  
  RESULTS
  A total of 68 patients (13.6%) developed postpancreatectomy hemorrhage. Thirty-four patients (6.8%) had a type A, 15 patients (3.0%) had a type B, and the remaining 19 patients (3.8%) had a type C bleed. Postoperative pancreatic fistula Grades B and C and bile leakage were significantly associated with severe postpancreatectomy hemorrhage on multivariable logistic regression. For patients with postpancreatectomy hemorrhage Grade C, the onset of bleeding was in median 13 days after the index operation, ranging from 1 to 85 days. Twelve patients (63.2%) had sentinel bleeds. Surgery lead to definitive hemostatic control in six of eight patients (75.0%). Angiography was able to localize the bleeding source in 8/10 (80.0%) cases. The success rate of angiographic hemostasis was 8/8. (100.0%). The mortality rate among patients with postpancreatectomy hemorrhage Grade C was 2/19 (10.5%), and both fatalities occurred late as a consequence of eroded vessels in association with pancreaticogastrostomy.
  
  
  CONCLUSIONS
  Delayed hemorrhage is a serious complication after major pancreatic surgery.Sentinel bleed is an early warning sign. Postoperative pancreatic fistula and bile leakage are important risk factors for severe postpancreatectomy hemorrhage.
authors.affiliation: 1 Department of Surgery, Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden.
authors.forename: D
authors.initials: D
authors.lastname: Ansari
authors.affiliation: 1 Department of Surgery, Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden.
authors.forename: B
authors.initials: B
authors.lastname: Tingstedt
authors.affiliation: 1 Department of Surgery, Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden.
authors.forename: G
authors.initials: G
authors.lastname: Lindell
authors.affiliation: 2 Department of Radiology, Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden.
authors.forename: I
authors.initials: I
authors.lastname: Keussen
authors.affiliation: 3 Department of Cardiothoracic Surgery, Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden.
authors.forename: D
authors.initials: D
authors.lastname: Ansari
authors.affiliation: 1 Department of Surgery, Clinical Sciences Lund, Lund University and Skåne University Hospital, Lund, Sweden.
authors.forename: R
authors.initials: R
authors.lastname: Andersson
mesh_terms: D000368:Aged; D005260:Female; D005500:Follow-Up Studies; D006489:Hemostatic Techniques; D006801:Humans; D015994:Incidence; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D010180:Pancreatectomy; D019106:Postoperative Hemorrhage / Q000175:diagnosis / Q000453:epidemiology / Q000209:etiology / Q000628:therapy; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome
keywords: Hemorrhage; incidence; management; outcome; pancreatic resection; risk factors