Abstract: Abstract: Object Although postpancreaticoduodenectomy hemorrhage (PPH) is the most lifethreatening complication following pancreatic surgery, standardized rules for its management do not exist. To analyze and study clinical courses and outcome of PPH after major pancreatic surgery. Methods Between 2000 and 2009, 295 patients operated on for periampullary neoplasia were included in a prospective database. A risk stratification of PPH according to the following parameters was performed: severity of PPH classified as mild (drop of hemoglobin concentration <30 g/L) or severe (>30 g/L), time of PPH occurrence (early, first to fifth postoperative day; delayed, after sixth day), coincident pancreatic fistula, intraluminal or extraluminal bleeding manifestation, and presence of “complex” vascular pathologies (erosions, pseudoaneurysms). Success rates of management were analyzed as well as PPH-related overall outcome. Results Prevalence of PPH was 6.4% (n=19). Mild PPH was 47.4%(n=9), Severe PPH was 52.6% (n=10), “Sentinel” bleed was 26.3%(n=5). Extraluminal PPH was 21.1%(n=4), Intraluminal PPH was 73.6%(n=14), Extraluminal and intralumina PPH was 5.3% (n=1). Pancreatic fistula prior to PPH was 31.6%(n=6). Treatment-related overall success rates were 84.2%(n=16), included observational monitoring 5, interventional endoscopy 1, interventional radiology 5, and relaparotomy 5. PPH-related overall mortality of 15.8% (n =3) was closely associated with 1) delayed PPH occurrence; 2) the occurrence of pancreatic fistula; and 3) vascular pathologies, ie, erosions and pseudoaneurysms. Conclusion Early PPH was mainly due to surgical technical failures. Prognosis of delayed PPH depends mainly on the presence of preceding pancreatic fistula. Decision making as to the indication for nonsurgical interventions or relaparotomy should consider time of onset, presence of pancreatic fistula, vascular pathologies.

Key words: postpancreaticoduodenectomy, hemorrhage, pancreatic fistula, interventional radiology, relaparotomy