Management of early hemorrhage from pancreatic anastomoses after pancreaticoduodenectomy

Background: Pancreatic surgery remains a challenge with considerable morbidity rates. The leading cause of emergency reexploration is early postoperative hemorrhage due to technical failure of hemostasis. Failure of hemostasis is usually tackled without difficulty, except when the bleeding arises from pancreatic anastomosis, since it poses a unique surgical challenge of preserving its integrity and also controlling the hemorrhage. The practical aspects and outcomes of management of this complication are unclear, with limited data. Methods: Data from 458 patients undergoing pancreaticoduodenectomy were analyzed. Early hemorrhage emanating from pancreatic anastomoses resulting in a relaparotomy was identified. Results: Eight patients (1.7%) had pancreatic anastomotic bleeding. The initial 2 patients underwent completion pancreatectomy, and the latter 6 patients underwent enterotomy with control of bleeding without disturbing the pancreatic anastomosis. The median interval between primary surgery and relaparotomy was 30.5 h, with a median overall hospital stay of 26.5 days; the 90-day mortality was zero. Based on these results, a step-by-step illustrated approach is described. Conclusions: This uncommon complication of early hemorrhage from pancreaticojejunostomy after pancreaticoduodenectomy can be successfully managed by an enterotomy without endangering the pancreatic anastomosis. By this approach, a completion pancreatectomy may be prevented and the integrity of the anastomosis preserved.