1. 4/18 whipple for adenocarcinoma 4/25 PJ leak, wound infection 5/16 GI bleed, endoscopy 5/17 reexploration, drainage of abscess, death

2. 5/2 whipple for adenocarcinoma 5/4 sepsis, reintubation 5/8 PJ leak 5/21 reexploration 5/28 reexploration, death

4. Cameron – 1000 Whipple Procedures

5. Vascular Complications of Pancreatectomy JOP. J Pancreas (Online) 2007; 8(1 Suppl.):102-113 1997 – 2006 - 818 consecutive pancreatic resections were prospectively collected Early post-operative bleeding - 29 patients (3.5%), mean of 3 days (range 0-7 days). Usually related to technical failure and/or medical reasons (e.g., excessive anti-thrombotic prophylaxis). Delayed bleeding - 19 patients (2.3%) mean period of 17.7 days (range 10-33 days) heralded by sentinel bleeding in 21.1% (4/19). –3 bleeding episodes (15.8%) seen through the gastrointestinal tract, although the majority of them resulted from erosion of the large retroperitoneal vessels with fistulization into the bowel. –16 (84.2%) bleeding appeared to be primarily intra-abdominal origin and was often related to erosion of the retroperitoneal vasculature. –7 (36.8%) with delayed hemorrhage had retroperitoneal abscesses of pancreatic fistulas.

7. Patients with delayed bleeding are rushed into the operating room while being resuscitated. Endoscopy and/or angiography are then performed, as necessary, with the patient lying on the operating table and with the surgical team ready to intervene. (However, if the patient cannot be promptly resuscitated and/or the bleeding cannot be stopped, we prefer to proceed immediately with repeat surgery. Our policy favors early division of the interposing intestine (either stomach or small bowel) to gain prompt and direct access to the eroded vessel. After stopping the hemorrhage, our preference is a complete pancreatectomy since we feel that this procedure reduces the likelihood of bleeding recurrence which might be caused by the persistence of either an occult or a poorly drained pancreatic fistula. The gastrointestinal tract is hence reconstructed and large bore drains are left in the upper retroperitoneum.

8. Although the literature shows that repeat surgery can be avoided in some of these patients by means of angiography with coil embolization, there are also reports of patients who have died before reaching the radiology suite or during angiography. From our perspective, further incentives to repeat surgery are the risk of delaying surgery beyond the limits of shock reversibility as well as the inability of interventional remedies to eliminate the etiologic factors, such as retroperitoneal sepsis and pancreatic fistula, possibly leading to bleeding recurrence.

9. Hemorrhage after pancreaticoduodenectomy: when is surgery still indicated? Am J Surg. 2007 Jul;194 Am J Surg. 411 pts Hemorrhage in 27 (7%), 11 early, 18 late 2 pts had successful conservative treatment 2 stable pts with pseudoaneurysm, diagnosed by computed tomography scan, underwent successful embolization 4 pts with active bleeding underwent unsuccessful angiography Overall, 23 patients were reoperated on without any completion pancreatectomy, 3 rebled, and 3 (11%) died (including 2 with delayed hemorrhage) CONCLUSIONS: Both embolization and surgery have a role in the management of hemorrhage after PD. For early hemorrhage, reoperation is appropriate. In case of sentinel bleeding, pseudoaneurysms can be detected by CT and treated by embolization. For delayed active hemorrhage, reoperation is still indicated.

12. TAE – transcath arterial embolization

21. Sagittal, cross-sectional drawing showing the deep location of potentially eroded retroperitoneal vessels behind viscera used for reconstruction of the gastrointestinal tract.