The role of CT imaging in proposed algorithm for managing post-operative hemorrhage after pancreaticoduodenectomy: case series

Post-pancreatectomy hemorrhage (PPH) is among the most severe complications after pancreaticoduodenectomy. Gastroduodenal artery pseudoaneurysm rupture may prove fatal without expeditious invasive treatment, while other causes of PPH can often be treated medically. Pseudoaneurysms may be effectively managed with endovascular stenting or angioembolization techniques. CT imaging allows for non-invasive evaluation prior to intervention but may delay treatment and result in false-negatives. Patients who developed PPH after pancreaticoduodenectomy at a high-volume institution over a 24-month span were included. Perioperative factors and clinical management data were analyzed to examine management and imaging utility. Twelve patients (thirteen bleeds) were evaluated. Six were extraluminal and suspicious for pseudoaneurysm rupture. Three of these bleeds were preceded by sentinel events. Obtaining CT imaging prior to interventional radiological management delayed treatment by a mean of 6.7 hours. Four bleeds were treated with endovascular therapy. These were successful interventions without bleed recurrence. Based on the current findings and limited relevant literature, this manuscript presents recommendations for managing PPH as developed by interdepartmental consensus between surgery and interventional radiology.