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Introduction: Postoperative mortality in high volume centers for pancreaticoduodenectomy (Whipple) has decreased to less than 4%. Late postoperative bleeding occurs in 0.5-5% of cases, with reported mortality rates of up to 60%.
Patients/Methods: This is a retrospective analysis of 313 patients who underwent pancreaticoduodenectomy from 2003-2012 at our institution, a high-volume, multidisciplinary hepato-pancreato-biliary center. The main outcome measure was mortality.
Results: From 2003-2012, 10 out of 313 patients (3%) presented with delayed major hemorrhage following pancreaticoduodenectomy, occurring between postoperative days 6-18. Visceral arteries known to be affected were the gastroduodenal artery (GDA) (4), hepatic artery (3), and the pancreaticoduodenal artery (1). 5 patients presented with gastrointestinal hemorrhage and 5 patients presented with hemoperitoneum. 1 patient underwent immediate operative intervention, 2 patients underwent immediate operation followed by percutaneous intervention by interventional radiology (IR). Immediate IR intervention was performed in 7 patients. Mortality from GDA/visceral arterial hemorrhage occurred in 1 patient (10%).
Conclusion: Delayed mesenteric arterial hemorrhage following pancreaticoduodenectomy requires early recognition and management. The mortality rate in our early experience with immediate operative intervention was 33%. A modified operative technique led to preservation a long GDA stump and use of a large metallic clip as a radiographic marker/guide. This was found to aid in easier and quicker IR localization and coiling or stenting of the bleeding vessel. The mortality rate has decreased to 0% in patients undergoing immediate IR intervention.