Pancreatic Fistula Pathways as Determinants of Surveillance and Strategies for Late Post-Pancreatectomy Hemorrhage

Postoperative pancreatic fistula (POPF) remains one of the most critical complications following pancreatic resections, with significant implications for morbidity, particularly concerning post-pancreatectomy hemorrhage (PPH). Late PPH, in particular, poses diagnostic and therapeutic challenges. This study observed Grade B POPF, with an incidence of late PPH, along with the anatomical site of pancreatic leak, either anterior (presenting through the wound) or posterior (through the abdominal drain), and their implications. The study aimed to observe the relation between POPF and PPH, and strategies to predict in terms of the location of the pancreatic leak, either anterior or posterior. A retrospective, cross-sectional study was conducted among 41 patients who had either Grade B POPF or late PPH, or both, following Whipple's surgery at Kathmandu Medical College and Teaching Hospital (KMCTH) from March 1, 2018, to April 1, 2025. POPF and PPH were defined as per the International Study Group on Pancreatic Surgery criteria. Patients with Grade C POPF or those requiring re-exploration for organ failure were excluded to focus on the intermediate-risk population. Clinically relevant POPFs were identified in 45 patients, among whom 41 patients had Grade B fistulas. These fistulas were detected via surgical drains in 23 patients and through the wound in 16 patients. However, 14 patients among these 39 patients with Grade B POPF developed late PPH simultaneously. The site of the pancreatic leak was termed anterior or posterior, with the development of the hemorrhagic complications, specifically late PPH. Notably, 13 of these 14 patients had posterior leaks, while only 1 patient had an anterior leak. This might suggest a probable relationship between posterior pancreatic leaks and late hemorrhagic complications (35.8%). All cases of late hemorrhage in this group occurred in patients with persistent drainage, suggesting a trajectory toward vascular erosion or pseudoaneurysm formation. In contrast, anterior leaks were more often self-limiting and amenable to conservative management. Two additional patients who underwent divestment of the hepatic artery developed late PPH. There is a significant risk of late PPH in patients with Grade B POPF, especially when the fistula is posterior and identified through the abdominal drain. This finding underscores the necessity for rigorous postoperative surveillance, including serial imaging and hemodynamic monitoring in this subgroup. Anterior leaks, often evident through the wound, may indicate a less challenging course. The data support strategies based on the anatomical source of the leak, with posterior leaks necessitating vigilance to mitigate risks of pseudoaneurysm and eventually hemorrhage.