DELAYED MASSIVE HEMORRHAGE AFTER PANCREATIC AND BILIARY SURGERY

The purpose of this retrospective study was to determine the causes, symptoms and optimal management of massive delayed haemorrhage after pancreatic and biliary surgery. In a series of 686 patients who underwent major pancreatic and biliary surgery between 1983 and 1993, those with massive haemorrhage (necessitating more than 6 units packed cells within 24 h) more than 24 h after the initial surgery were selected. Two groups were formed, according to the aetiology of bleeding: bleeding caused by erosion of a major artery or that from the (gastro)intestinal suture line. The groups were compared with respect to bleeding parameters, symptoms, diagnostic and interventional procedures, and mortality. Massive postoperative haemorrhage occurred in 22 patients (3.2 per cent): 12 (1.7 per cent) with arterial bleeding and ten (1.5 per cent) with suture-line bleeding were identified. Patients with arterial bleeding had a longer interval between initial surgery and haemorrhage (P = 0.02), more frequent septic complications (P = 0.03) and had a higher mortality rate than those with suture-line bleeding (50 versus 0 per cent respectively, P = 0.02). If minimally invasive diagnostic and therapeutic techniques are not successful, early aggressive surgical intervention is mandatory, including thorough exploration of the area of the resection, ligated artery stumps and inspection of anastomoses by enterotomy.