Journal Article Ppublish
PubMed: 42594685 DOI: 10.1016/j.surg.2026.110460
Redefining postpancreatectomy hemorrhage: Bleeding sources, cryptogenic events, and predictors of severity-analysis of 1,722 consecutive pancreaticoduodenectomies.
Surgery 198:110460
Authors: Kunal Nandy, Aamir M Parray, Harsh Karun, Vinayaka S Bairannavar, Vikram Chaudhari, Shailesh V Shrikhande, Manish S Bhandare
Affiliations
- Division of HPB and GI Oncology, Department of Surgical Oncology, Cancer Institute (WIA), Chennai, India. Electronic address: https://twitter.com/iamThe_Surgeon.
- Division of HPB and GI Oncology, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India. Electronic address: https://twitter.com/iam@aamirparray18.
- Department of Surgical Oncology, Homi Bhabha Cancer Hospital and Mahamana Pandit Madan Mohan Malaviya Cancer Centre, Varanasi, India.
- Division of HPB and GI Oncology, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India.
- Division of HPB and GI Oncology, Department of Surgical Oncology, Tata Memorial Hospital, Homi Bhabha National Institute, Mumbai, India. Electronic address: https://twitter.com/iamDrVAChaudhari.
- GI and HPB Cancer Surgery, Gleneagles Hospital, Mumbai, India. Electronic address: https://twitter.com/iamShrikhande_SV.
- HPB & Upper GI Unit, Department of Surgical Oncology, Tata Memorial Centre - ACTREC, Homi Bhabha National Institute, Mumbai, India.
Abstract
BACKGROUND
Postpancreatectomy hemorrhage complicates 3%-10% of pancreaticoduodenectomies and is associated with mortality rates up to 20%. Clinically relevant postoperative pancreatic fistula is a major risk factor. This study aimed to characterize bleeding sources and identify predictors of severe hemorrhage in patients with clinically relevant postoperative pancreatic fistula.
METHODS
We retrospectively analyzed 1,722 consecutive pancreaticoduodenectomies performed between January 2013 and December 2024 at a high-volume tertiary center. Bleeding sources were systematically classified, and microbiological profiles of peripancreatic collections were reviewed. Multivariable logistic regression identified independent predictors of grade B/C postpancreatectomy hemorrhage in patients with clinically relevant postoperative pancreatic fistula. Cryptogenic postpancreatectomy hemorrhage was defined as grade B/C hemorrhage without an identifiable source despite comprehensive evaluation.
RESULTS
Postpancreatectomy hemorrhage occurred in 135 patients (7.8%), including 89 cases (5.2%) of grade B/C hemorrhage. The pancreaticojejunal anastomosis was the most frequent bleeding source (15.6%), followed by branches of the superior mesenteric (9.6%) and hepatic (8.1%) arteries; the gastroduodenal artery accounted for only 3.7%. Independent predictors of severe hemorrhage were bile leak (odds ratio, 4.50; 95% confidence interval, 2.01-10.07; P < .001) and gram-negative infection, predominantly Klebsiella pneumoniae (odds ratio, 2.55; 95% confidence interval, 1.18-5.51; P = .017). A nomogram incorporating these factors showed acceptable discrimination (area under the curve, 0.701) with good internal validation (area under the curve, 0.791). Cryptogenic postpancreatectomy hemorrhage occurred in 24.7% of grade B/C cases and was associated with lower mortality than source-identified hemorrhage.
CONCLUSION
In clinically relevant postoperative pancreatic fistula patients, bile leak and K pneumoniae infection independently predict severe postpancreatectomy hemorrhage. The pancreaticojejunal anastomosis was the most common bleeding site, whereas cryptogenic postpancreatectomy hemorrhage appears to represent a lower-mortality subgroup once arterial bleeding is excluded.
MeSH
Bile, Mortality, Confidence Intervals, Fistula, Hemorrhage, Pancreaticoduodenectomy, Arteries, Odds Ratio, Pancreatic Fistula, General Surgery, Infections