Abstract
Pancreatic operations are complex surgical procedures with a significant risk of severe postoperative morbidity. Post-pancreatectomy hemorrhage (PPH) is one such complication with potentially devastating life-threatening consequences. While PPH represents a rare clinical entity, the identification and management provide significant challenges to surgical providers. There are a variety of classifications of PPH that can alter the diagnostic and therapeutic interventions necessary to manage these bleeding events. The PPH may be either intraluminal within a hollow-viscous organ such as the stomach or small intestine, or extraluminal within the peritoneal cavity. Intraluminal PPHs present with melena, hematemesis, or hematologic effluent from a nasogastric tube, while extraluminal PPHs present with bloody abdominal drain output or blood within the abdominal cavity seen on cross-sectional imaging. Endoscopic, interventional angiographic, or open surgical interventions may be required to intervene in the bleeding process. Additionally, PPH can be classified as early (less than 24 h after original operation) or late (greater than 24 h). Early PPH is often related to a technical misstep during the index operation such as inadequate hemostasis or patient coagulopathy (inherent or acquired). Late PPH is often related to postoperative abscess or pancreatic fistula that may cause vascular injuries such as arterial pseudoaneurysms and lead to clinically significant bleeding. The data regarding PPH suggest that pancreatic surgery should be performed in high-volume centers where close collaboration between interventional specialties is available and capable of rescuing patients from this relatively uncommon but potentially high contributor to morbidity and mortality.