Critical appraisal of postpancreatectomy hemorrhage after pancreatoduodenectomy: an analysis of risk factors, treatment and outcomes in 860 consecutive cases

Chun Yuet Khoo; Hwee Leong Tan; Titus Q W Tan; Delphina B X Yeo; Ye Xin Koh; Jin Yao Teo; Pierce K H Chow; Peng Chung Cheow; Alexander Y F Chung; London L P J Ooi; Brian K P Goh

doi:10.1016/j.pan.2025.05.015

Critical appraisal of postpancreatectomy hemorrhage after pancreatoduodenectomy: an analysis of risk factors, treatment and outcomes in 860 consecutive cases

Pancreatology. 2025 Jun 2:S1424-3903(25)00113-9. doi: 10.1016/j.pan.2025.05.015. Online ahead of print.

Affiliations

¹ Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore.
² Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Surgery Academic Clinical Program, Duke National University of Singapore Medical School, Singapore.
³ Department of Hepatopancreatobiliary and Transplant Surgery, Singapore General Hospital and National Cancer Centre Singapore, Singapore; Surgery Academic Clinical Program, Duke National University of Singapore Medical School, Singapore. Electronic address: bsgkp@hotmail.com.

PMID: 40603134
DOI: 10.1016/j.pan.2025.05.015

Abstract

Background: Postpancreatectomy haemorrhage (PPH) is an important and potentially life-threatening complication after pancreatoduodenectomy (PD). The aim of this study is to characterize PPH in a single institutional cohort of patients who underwent PD and analyse the incidence, risk factors, treatment and outcomes of PPH.

Methods: We performed a retrospective analysis of 860 consecutive patients who underwent PD between January 1997 and July 2021 at a tertiary referral centre. Key perioperative data and outcome measures were analysed for all patients who developed PPH.

Results: A total of 108 patients (12.6 %) developed PPH, of which 95 patients (88.0 %) had late PPH with the median onset on postoperative day 8. Multivariate analysis revealed that pancreatogastrostomy (PG) anastomosis, intraoperative blood loss >1000 mL and postoperative pancreatic fistula (POPF) grades B and C were independent predictors of late PPH. The majority of patients with intraluminal PPH (42.6 %) underwent endoscopy as first-line intervention while most patients with extraluminal PPH underwent initial surgical haemostasis (40.7 %) and initial angiography (16.7 %). Pancreatojejunostomy anastomosis was associated with a higher rate of POPF compared to PG, although PG was associated with a higher incidence of PPH.

Conclusion: The optimal approach to treatment of PPH takes into account location, timing and severity of the bleeding as well as the type of pancreatoenteric anastomosis. Appropriate treatment strategies for both early and late PPH include angiography, endoscopy, reoperation and conservative management or a combination of them.

Keywords: Pancreatectomy; Pancreatoduodenectomy; Postoperative complication; Postoperative pancreatic fistula; Postpancreatectomy haemorrhage.