Surgical Rescue for Refractory Post-sphincterotomy Hemorrhage: Preserving a Critical, Vanishing Competency for the Next Generation of Surgeons

Post-endoscopic retrograde cholangiopancreatography bleeding is a classic, well-documented clinical hurdle. While contemporary management successfully resolves the vast majority of these episodes via repeat endoscopy or transcatheter arterial embolization, refractory hemorrhage requiring an emergency open operation remains a rare, highly dangerous threat. We report the case of a 64-year-old woman who developed a severe, delayed post-sphincterotomy hemorrhage. The bleeding achieved initial hemostasis with an aggressive mechanical dual-stent tamponade, but the patient subsequently re-bled, completely resisting further endoscopic modalities and empiric endovascular angioembolization using both coils and glue. Driven by rapid clinical decline and unrelenting hemorrhagic shock, the team bypassed further minimally invasive revisions and proceeded immediately to the operating room. Emergent exploratory laparotomy, broad duodenal mobilization (Kocher maneuver), forward duodenotomy, and direct transfixion suture ligation of an actively spurting vessel within the pancreaticoduodenal arcade achieved immediate, definitive hemostasis. The patient recovered smoothly and was discharged without secondary issues. This case strongly reminds the clinical community that while open surgery has largely been supplanted by modern technology, it remains an indispensable, life-saving fallback. Crucially, because the current generation of general and hepatobiliary surgeons seldom encounters this clinical crisis during training, preserving technical familiarity with open ampullary vascular control is an essential educational priority to prevent catastrophic patient outcomes when minimally invasive choices fail.