title: Severe post-pancreatoduodenectomy haemorrhage: An analytical review based on 118 consecutive pancreatoduodenectomy patients in a South African Academic Hospital.
abstract: BACKGROUND
  Bleeding after a major pancreatic resection, although uncommon, has serious implications and substantial mortality rates.
  
  
  OBJECTIVE
  To analyse our experience with severe post-pancreatoduodenectomy haemorrhage (PPH) over the last 7 years to establish the incidence, causes, intervention required and outcome.
  
  
  METHODS
  All patients who underwent a pancreatoduodenectomy (PD) between January 2008 and December 2015 were identified from a prospectively maintained database. Data analysed included demographic information, operative details, anastomotic technique, histology, postoperative complications including pancreatic fistula and PPH, length of hospital stay, need for blood products and special investigations. Pancreatic fistula was classified according to the International Study Group of Pancreatic Surgery (ISGPS) classification. A modified ISGPS classification was used for PPH.
  
  
  RESULTS
  One hundred and eighteen patients underwent PD during the study period of whom 6 (5.0%) died perioperatively. Twenty patients (16.9%) developed a pancreatic fistula and 11 patients (9.3%) had a severe PPH of whom one (9.1%) died. No patients had a severe bleed during the first 24 hours postoperatively. Four patients bled within the first 5 days and the remaining 7 after five days. Six patients bled from the gastroduodenal artery and were all preceded by a pancreatic fistula. Three of the 7 patients who bled late presented with extraluminal bleeding, 3 presented with intraluminal bleeding and 1 with a combination of both. Patients presenting in the first 5 days were all successfully managed either endoscopically or surgically. Five patients who presented beyond 5 days postoperatively were managed primarily with interventional angiography, either with coiling or deployment of a covered stent. Three patients who had radiological intervention developed a liver abscess or necrosis.
  
  
  CONCLUSIONS
  Severe PPH is associated with substantial morbidity. Clinical factors including the onset of the bleeding, presentation with either extra and/or intraluminal haemorrhage, and the presence of a pancreatic fistula give an indication of the likely aetiology of the bleeding. A management algorithm based on these factors is presented.
authors.affiliation: HPB Surgical Unit; University of Cape Town Health Sciences Faculty, Groote Schuur Hospital and Netcare University of Cape Town Private Academic Hospital.
authors.forename: M M
authors.initials: MM
authors.lastname: Bernon
authors.affiliation: HPB Surgical Unit; University of Cape Town Health Sciences Faculty, Groote Schuur Hospital and Netcare University of Cape Town Private Academic Hospital.
authors.forename: J E J
authors.initials: JE
authors.lastname: Krige
authors.affiliation: HPB Surgical Unit; University of Cape Town Health Sciences Faculty, Groote Schuur Hospital and Netcare University of Cape Town Private Academic Hospital.
authors.forename: E
authors.initials: E
authors.lastname: Jonas
authors.affiliation: HPB Surgical Unit.
authors.forename: J C
authors.initials: JC
authors.lastname: Kloppers
authors.affiliation: HPB Surgical Unit; University of Cape Town Health Sciences Faculty, Groote Schuur Hospital and Netcare University of Cape Town Private Academic Hospital.
authors.forename: S
authors.initials: S
authors.lastname: Burmeister
authors.affiliation: HPB Vascular Unit.
authors.forename: N G
authors.initials: NG
authors.lastname: Naidoo
authors.affiliation: Department of Surgery and Department of Radiology; University of Cape Town Health Sciences Faculty, Groote Schuur Hospital and Netcare University of Cape Town Private Academic Hospital.
authors.forename: S J
authors.initials: SJ
authors.lastname: Beningfield