Delayed Post-Pancreaticoduodenectomy Hemorrhage: Is Endovascular Treatment A Strategic Necessity?

Background Late post-pancreaticoduodenectomy hemorrhage (PPH) is a rare but potentially fatal complication associated with high morbidity and mortality. Early recognition and prompt intervention are critical for improving patient outcomes. This study aimed to evaluate the clinical features, treatment modalities, and outcomes of late-onset PPH cases managed in our institution. Materials and Methods Between January 2016 and January 2025, a total of 220 patients underwent pancreaticoduodenectomy (PD) at the Department of General Surgery, XXX University Faculty of Medicine. Patients who developed late arterial hemorrhage, defined by the International Study Group of Pancreatic Surgery (ISGPS) as occurring more than 24 hours after the index operation, were included. Demographic data, histopathological diagnoses, timing and source of bleeding, radiological and angiographic findings, treatment modalities, rebleeding events, morbidity, and mortality rates were analyzed. In patients undergoing endovascular treatment (EVT), technical success and complications were recorded. Results Late PPH occurred in 5.9% (13/220) of patients, with a mean onset of 10.3 days postoperatively. The most frequent bleeding source was the gastroduodenal artery (61.5%), and 61.5% of patients had an anastomotic leak. Sentinel bleeding was present in 76.9% of cases. EVT was performed in eight patients, achieving technical success in 75% after the first attempt and 100% after repeat procedures; rebleeding occurred in 25%. Surgical intervention was performed in five patients, with remnant pancreatectomy required in 60% of cases. Mortality was 60% in the surgical group and 25% in the EVT group. No cases of hepatic ischemia or abscess were observed following hepatic artery embolization. Conclusion Endovascular therapy is associated with lower mortality and higher technical success compared to surgery in managing late PPH. Surgical intervention should be reserved for cases where EVT is unavailable or unsuccessful. Performing PD in centers with 24-hour interventional radiology capability is essential to improve safety and reduce preventable mortality.