J Curr Surg

Journal of Current Surgery, ISSN 1927-1298 print, 1927-1301 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Curr Surg and Elmer Press Inc

Journal website https://jcs.elmerpub.com

Original Article

Volume 16, Number 1, June 2026, pages 1-8

Management and Outcome of Late Post-Pancreatectomy Hemorrhage After Pancreaticoduodenectomy: Experience From a High-Volume UK Tertiary Center

↓ **Table 1.** Patients’ Demographics, Intervention, and Outcome of Delayed Bleeding Post-PD
Patient No.	Sex	Age	Operation	Interval of delayed bleeding (days) > 24 h post-op	Bleeding site	Systemic response (tachycardia/hypotension, etc.)	Location of bleeding after/endoscopy imaging including invasive angiogram	Type of intervention	Outcome
GDA: gastroduodenal artery; GI: gastrointestinal tract; GJ: gastrojejunostomy; IR: interventional radiology; PD: pancreaticoduodenectomy; PDA: pancreaticoduodenal artery; Post-op: postoperatively; PV: portal vein; SMA: superior mesenteric artery.
1	Male	75	PD	3	Surgical drain	Yes	GDA	IR	Deceased
2	Male	56	PD	9	Surgical drain	Yes	GDA	Surgery	Deceased
3	Male	48	PD	20	GI tract	Yes	Pancreatic branch from splenic artery	IR	Discharged
4	Male	81	PD	1	GI tract	No	Possibly left gastric	Surgery	Discharged
5	Male	67	PD	17	GI tract	Yes	GDA	IR	Discharged
6	Male	51	PD	28	Surgical drain	Yes	GDA	IR	Discharged
7	Female	48	PD + PV resection	4	GI tract	Yes	Right hepatic artery	IR	Discharged
8	Male	66	PD	1	Surgical drain	Yes	GDA	Surgery	Discharged
9	Female	60	PD	1	Surgical drain	Yes	Left hepatic	IR	Discharged
10	Female	78	PD	7	GI tract	Yes	GJ	Surgery	Discharged
11	Male	62	PD	5	GI tract	Yes	Pancreatic stump	Surgery	Discharged
12	Male	54	PD + PV resection	16	GI tract	Yes	SMA	IR (+ surgery for PV thrombosis)	Discharged
13	Male	83	PD	15	Surgical drain	Yes	Left hepatic artery	IR	Discharged
14	Male	72	PD	19	GI tract	No	GDA	IR	Discharged
15	Female	74	PD + PV resection	25	GI tract	Yes	Common hepatic artery	IR	Discharged
16	Male	44	PD + PV + SMA resection	27	GI tract	Yes	GDA	IR	Discharged
17	Male	58	PD	15	Surgical drain	Yes	Left hepatic	IR	Discharged
18	Male	74	PD	43	GI tract	Yes	GDA	IR	Discharged
19	Male	77	PD	5	Surgical drain	Yes	GDA	IR	Deceased but due causes not related to bleeding
20	Male	60	PD	29	GI tract	Yes	Common hepatic artery	IR	Deceased
21	Female	62	PD	40	GI tract	Yes	GDA	IR	Discharged
22	Male	70	PD	14	Surgical drain	No	Not identified	IR	Discharged
23	Male	51	PD	14	Surgical drain	No	Not identified	IR	Discharged

↓ Table 1. Patients’ Demographics, Intervention, and Outcome of Delayed Bleeding Post-PD

Patient No.

Sex

Age

Operation

Interval of delayed bleeding (days) > 24 h post-op

Bleeding site

Systemic response (tachycardia/hypotension, etc.)

Location of bleeding after/endoscopy imaging including invasive angiogram

Type of intervention

Outcome

GDA: gastroduodenal artery; GI: gastrointestinal tract; GJ: gastrojejunostomy; IR: interventional radiology; PD: pancreaticoduodenectomy; PDA: pancreaticoduodenal artery; Post-op: postoperatively; PV: portal vein; SMA: superior mesenteric artery.

Male

Surgical drain

Yes

GDA

Deceased

Male

Surgical drain

Yes

GDA

Surgery

Deceased

Male

GI tract

Yes

Pancreatic branch from splenic artery

Discharged

Male

GI tract

Possibly left gastric

Surgery

Discharged

Male

GI tract

Yes

GDA

Discharged

Male

Surgical drain

Yes

GDA

Discharged

Female

PD + PV resection

GI tract

Yes

Right hepatic artery

Discharged

Male

Surgical drain

Yes

GDA

Surgery

Discharged

Female

Surgical drain

Yes

Left hepatic

Discharged

Female

GI tract

Yes

Surgery

Discharged

Male

GI tract

Yes

Pancreatic stump

Surgery

Discharged

Male

PD + PV resection

GI tract

Yes

SMA

IR (+ surgery for PV thrombosis)

Discharged

Male

Surgical drain

Yes

Left hepatic artery

Discharged

Male

GI tract

GDA

Discharged

Female

PD + PV resection

GI tract

Yes

Common hepatic artery

Discharged

Male

PD + PV + SMA resection

GI tract

Yes

GDA

Discharged

Male

Surgical drain

Yes

Left hepatic

Discharged

Male

GI tract

Yes

GDA

Discharged

Male

Surgical drain

Yes

GDA

Deceased but due causes not related to bleeding

Male

GI tract

Yes

Common hepatic artery

Deceased

Female

GI tract

Yes

GDA

Discharged

Male

Surgical drain

Not identified

Discharged

Male

Surgical drain

Not identified

Discharged

↓ **Table 2.** Interval to Investigations for Patients With Delayed Bleeding After PD
PATIENT NO.	INTERVAL TIME TO CT ANGIOGRAM AFTER SIGNS OF BLEEDING	INTERVAL TIME TO IR ANGIOGRAM AFTER SIGNS OF BLEEDING	EVIDENCE OF PANCREATIC FISTULA	TYPE OF IR	LOCATION OF BLEEDING AFTER/ENDOSCOPY IMAGING INCLUDING INVASIVE ANGIOGRAM	TYPE OF SURGERY
CT: computed tomography; IR: interventional radiology; PD: pancreaticoduodenectomy.
1	1 day	2 days	Yes	Embolization of hepatic artery	GDA	N/a
2	12 h	N/a patient too unstable	Yes	N/a	GDA	Gastroduodenal stump bleeding oversewn
3	12 h	24 h	Yes	Embolization of pseudoaneurysm arising from a branch of the splenic artery	Pancreatic branch of the splenic artery	N/a
4	24 h	24 h	Yes	N/a	Left gastric	General hemostasis, no obvious bleeding point identified
5	72 h	72 h	Yes	Embolization of GDA stump and hepatic artery stent graft	GDA	N/a
6	24 h	6 days	Yes	Hepatic artery stent graft	GDA	N/a
7	4 days	4 days	Yes	Mesenteric angiography and embolization of hepatic artery pseudoaneurysm	Right hepatic artery	N/a
8	12 h	N/a patient too unstable	Yes	N/a	GDA	GDA stump oversewn
9	12 h	12 h	No	Embolization of the left hepatic artery	Left hepatic	N/a
10	12 h	Not performed	No	N/a	GJ	Gastrojejunostomy suture line oversewn
11	12 h	12 h	Yes	N/a	Pancreatic stump	Pancreatic stump bleeder oversewn
12	24 h	24 h	Yes	1. Splenic artery embolization for portal vein reduced flow within the PV graft 2. SMA stent	1. Thrombosed PV 2. SMA pseudoaneurysm	Laparotomy for thrombosed portal repaired with interposition vein graft, but no surgical intervention for bleeding.
13	12 h	12 h	No	Coil embolization left hepatic artery	Left hepatic artery	N/a
14	24 h	24 h	No	Common Hepatic Artery Stenting across leaking GDA stump	GDA	N/a
15	12 h	12 h	No	Common hepatic artery pseudoaneurysm embolization	Common hepatic artery	N/a
16	12 h	24 h	No	Failed Spontaneous Bleeding stopped after monitoring	GDA	N/a
17	12 h	48 h	Yes	Stenting of the left hepatic artery	Left hepatic	N/a
18	12 h	24 h	Yes	Embolization of GDA	GDA	N/a
19	6 days	6 days	No	Stent graft IN common hepatic artery across GDA	GDA	N/a
20	24 h	24 h	No	Stent-graft of common hepatic artery	Common hepatic artery	N/a
21	12 h	12 h	Yes	Embolization and stent-graft across the GDA	GDA	N/a
22	12 h	24 h	Yes	Embolization of GDA stump	Not identified	N/a
23	12 h	24 h	Yes	Stent graft common hepatic artery	Not identified	N/a

↓ Table 2. Interval to Investigations for Patients With Delayed Bleeding After PD

PATIENT NO.

INTERVAL TIME TO CT ANGIOGRAM AFTER SIGNS OF BLEEDING

INTERVAL TIME TO IR ANGIOGRAM AFTER SIGNS OF BLEEDING

EVIDENCE OF PANCREATIC FISTULA

TYPE OF IR

LOCATION OF BLEEDING AFTER/ENDOSCOPY IMAGING INCLUDING INVASIVE ANGIOGRAM

TYPE OF SURGERY

CT: computed tomography; IR: interventional radiology; PD: pancreaticoduodenectomy.

1 day

2 days

Yes

Embolization of hepatic artery

GDA

N/a

12 h

N/a patient too unstable

Yes

N/a

GDA

Gastroduodenal stump bleeding oversewn

12 h

24 h

Yes

Embolization of pseudoaneurysm arising from a branch of the splenic artery

Pancreatic branch of the splenic artery

N/a

24 h

Yes

N/a

Left gastric

General hemostasis, no obvious bleeding point identified

72 h

Yes

Embolization of GDA stump and hepatic artery stent graft

GDA

N/a

24 h

6 days

Yes

Hepatic artery stent graft

GDA

N/a

4 days

Yes

Mesenteric angiography and embolization of hepatic artery pseudoaneurysm

Right hepatic artery

N/a

12 h

N/a patient too unstable

Yes

N/a

GDA

GDA stump oversewn

12 h

Embolization of the left hepatic artery

Left hepatic

N/a

12 h

Not performed

N/a

Gastrojejunostomy suture line oversewn

12 h

Yes

N/a

Pancreatic stump

Pancreatic stump bleeder oversewn

24 h

Yes

1. Splenic artery embolization for portal vein reduced flow within the PV graft
2. SMA stent

1. Thrombosed PV
2. SMA pseudoaneurysm

Laparotomy for thrombosed portal repaired with interposition vein graft, but no surgical intervention for bleeding.

12 h

Coil embolization left hepatic artery

Left hepatic artery

N/a

24 h

Common Hepatic Artery Stenting across leaking GDA stump

GDA

N/a

12 h

Common hepatic artery pseudoaneurysm embolization

Common hepatic artery

N/a

12 h

24 h

Failed Spontaneous Bleeding stopped after monitoring

GDA

N/a

12 h

48 h

Yes

Stenting of the left hepatic artery

Left hepatic

N/a

12 h

24 h

Yes

Embolization of GDA

GDA

N/a

6 days

Stent graft IN common hepatic artery across GDA

GDA

N/a

24 h

Stent-graft of common hepatic artery

Common hepatic artery

N/a

12 h

Yes

Embolization and stent-graft across the GDA

GDA

N/a

12 h

24 h

Yes

Embolization of GDA stump

Not identified

N/a

12 h

24 h

Yes

Stent graft common hepatic artery

Not identified

N/a

↓ **Table 3.** Proposed Classification of PPH: Clinical Condition, Diagnostic and Therapeutic Consequences
GRADE	TIME OF ONSET, LOCATION, SEVERITY, AND CLINICAL IMPACT OF BLEEDING	CLINICAL CONDITION	DIAGNOSTIC CONSEQUENCE	THERAPEUTIC CONSEQUENCE
^aLate, intra- or extraluminal, mild bleeding may not be immediately life threatening to patient but may be a warning sign for later severe hemorrhage (“sentinel bleed’’) and is therefore grade B. ^bEndoscopy should be performed when signs of intraluminal bleeding are present (melena, hematemesis, or blood loss via nasogastric tube). Reprinted from Reference [8] with permission from Elsevier. ICU: intensive care unit; PPH: pancreaticoduodenectomy hemorrhage.
A	Early, intra- or extraluminal, mild		Well	Observation, blood count, ultrasonography and, if necessary, computed tomography	No
B	Early, intra- or extraluminal, severe	Late, intra- or extraluminal, mild^a	Often well/intermediate, very rarely life-threatening	Observation, blood count, ultrasonography, computed tomography, angiography, endoscopy^b	Transfusion of fluid/blood, intermediate care unit (or ICU), therapeutic endoscopy^b, embolization, relaparotomy for early PPH
C		Late, intra- or extraluminal, severe	Severely impaired, life-threatening	Angiography, computed tomography, endoscopy^b	Localization of bleeding, angiography, and embolization, endoscopy^b or relaparotomy, ICU

↓ Table 3. Proposed Classification of PPH: Clinical Condition, Diagnostic and Therapeutic Consequences

GRADE

TIME OF ONSET, LOCATION, SEVERITY, AND CLINICAL IMPACT OF BLEEDING

CLINICAL CONDITION

DIAGNOSTIC CONSEQUENCE

THERAPEUTIC CONSEQUENCE

^aLate, intra- or extraluminal, mild bleeding may not be immediately life threatening to patient but may be a warning sign for later severe hemorrhage (“sentinel bleed’’) and is therefore grade B. ^bEndoscopy should be performed when signs of intraluminal bleeding are present (melena, hematemesis, or blood loss via nasogastric tube). Reprinted from Reference [8] with permission from Elsevier. ICU: intensive care unit; PPH: pancreaticoduodenectomy hemorrhage.

Early, intra- or extraluminal, mild

Well

Observation, blood count, ultrasonography and, if necessary, computed tomography

Early, intra- or extraluminal, severe

Late, intra- or extraluminal, mild^a

Often well/intermediate, very rarely life-threatening

Observation, blood count, ultrasonography, computed tomography, angiography, endoscopy^b

Transfusion of fluid/blood, intermediate care unit (or ICU), therapeutic endoscopy^b, embolization, relaparotomy for early PPH

Late, intra- or extraluminal, severe

Severely impaired, life-threatening

Angiography, computed tomography, endoscopy^b

Localization of bleeding, angiography, and embolization, endoscopy^b or relaparotomy, ICU