Muhammad Mohsin Ali, Muhammad Zeeshan Sarwar, Muhammad Asad Asif
Hemorrhage after pancreatic surgery is a common occurrence, accounting for 5-12% of post-pancreatectomy complications. Major risk factors for hemorrhage can be classified temporally as pre-operative, intra-operative, and post-operative, and include perioperative coagulopathy, technical failure of hemostasis at suture line, post-operative pancreatic fistulas grades B and C, biliary leakage, localized or intra-abdominal sepsis, higher age and Body Mass Index, and intraoperative transfusions, among others. Post-pancreatectomy hemorrhage can be mild or severe, with grading from A to C, and timing from early (within 24 hours) to late (after 24 hours): diagnostic and therapeutic modalities vary widely based on the grading and location of post-pancreatectomy hemorrhage, while non-operative management is sufficient for mild grade. A post-pancreatectomy hemorrhage, interventions such as angiography for extra-luminal and endoscopy for intraluminal hemorrhage are required for late grade B or C hemorrhage. Re-exploration to secure hemostasis is preferred in hemodynamically unstable patients, and is only used for late post-pancreatectomy hemorrhage after failure of less invasive modalities. Late post-pancreatectomy hemorrhage is associated with a poor prognosis, especially in low-flow centers. Careful monitoring for sentinel bleeding, as well as control over modifiable risk factors can help decrease the incident burden of post-pancreatectomy hemorrhage, thereby reducing long-term morbidity and mortality after pancreatic surgery.