title: Recommendation of treatment strategy for postpancreatectomy hemorrhage: Lessons from a single-center experience in 35 patients.
abstract: BACKGROUND
  Postpancreatectomy hemorrhage (PPH) is a life-threatening complication of pancreatic surgery. The shift from surgical to radiological intervention was recently reported in retrospective cohort studies, but it has remained controversial as to which emergent intervention provides optimal management.
  
  
  METHODS
  All 553 patients who underwent standard pancreatic resection at Kobe University Hospital between January 2003 and December 2013 were included. Patient data and complication data were identified from a prospective database.
  
  
  RESULTS
  The overall incidence of PPH was 6% (35 of 553 patients). Ten patients underwent endoscopic intervention or observation monitoring, or suffered hemorrhagic sudden death. Among the remaining 25 PPH patients, primary surgical intervention was successful in the 6 hemodynamically unstable PPH patients. Primary radiological intervention could successfully stop the bleeding in 15 of the 17 patients with late-PPH. Nine patients who had bleeding from the hepatic artery after pancreaticoduodenectomy were rescued by endovascular embolization of the artery-trunk. The in-hospital mortality of PPH was 20% (7 of 35). Four of the 5 PPH patients who died following any intervention eventually died due to the other complications associated with prolonged pancreatic fistula.
  
  
  CONCLUSIONS
  The leading treatment has been radiological intervention. Endovascular embolization of the hepatic artery-trunk can be securely performed only if blood flow to the liver by an alternate route is confirmed. To reduce mortality of PPH patients, it is necessary to prevent other complications associated with pancreatic fistula following hemostasis. Proactive surgical intervention such as abscess drainage or remnant pancreatectomy is a key consideration.
authors.affiliation: Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Japan.
authors.forename: Sadaki
authors.initials: S
authors.lastname: Asari
authors.affiliation: Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Japan. Electronic address: ippeimm@gmail.com.
authors.forename: Ippei
authors.initials: I
authors.lastname: Matsumoto
authors.affiliation: Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Japan.
authors.forename: Hirochika
authors.initials: H
authors.lastname: Toyama
authors.affiliation: Department of Radiology and Center for Endovascular Therapy, Kobe University Graduate School of Medicine, Japan.
authors.forename: Masato
authors.initials: M
authors.lastname: Yamaguchi
authors.affiliation: Department of Radiology and Center for Endovascular Therapy, Kobe University Graduate School of Medicine, Japan.
authors.forename: Takuya
authors.initials: T
authors.lastname: Okada
authors.affiliation: Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Japan.
authors.forename: Makoto
authors.initials: M
authors.lastname: Shinzeki
authors.affiliation: Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Japan.
authors.forename: Tadahiro
authors.initials: T
authors.lastname: Goto
authors.affiliation: Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Japan.
authors.forename: Tetsuo
authors.initials: T
authors.lastname: Ajiki
authors.affiliation: Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Japan.
authors.forename: Takumi
authors.initials: T
authors.lastname: Fukumoto
authors.affiliation: Division of Hepato-Biliary-Pancreatic Surgery, Department of Surgery, Kobe University Graduate School of Medicine, Japan.
authors.forename: Yonson
authors.initials: Y
authors.lastname: Ku
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D000066491:Clinical Decision-Making; D005260:Female; D006489:Hemostatic Techniques; D017052:Hospital Mortality; D006801:Humans; D015994:Incidence; D008297:Male; D008875:Middle Aged; D010180:Pancreatectomy; D016577:Pancreaticoduodenectomy; D019106:Postoperative Hemorrhage / Q000453:epidemiology / Q000628:therapy*; D012189:Retrospective Studies; D016896:Treatment Outcome; D055815:Young Adult
keywords: Endovascular procedure; Interventional radiology; Pancreatic fistula; Pancreatic resection; Pancreaticoduodenectomy; Postpancreatectomy hemorrhage