Elsevier

Surgery

Volume 142, Issue 1, July 2007, Pages 20-25
Surgery

Original communication
Postpancreatectomy hemorrhage (PPH)–An International Study Group of Pancreatic Surgery (ISGPS) definition

https://doi.org/10.1016/j.surg.2007.02.001Get rights and content

Background

Postoperative hemorrhage is one of the most severe complications after pancreatic surgery. Due to the lack of an internationally accepted, universal definition of postpancreatectomy hemorrhage (PPH), the incidences reported in the literature vary considerably, even in reports from randomized controlled trials. Because of these variations in the definition of what constitutes a PPH, the incidences of its occurrence are not comparable.

Methods

The International Study Group of Pancreatic Surgery (ISGPS) developed an objective, generally applicable definition of PPH based on a literature review and consensus clinical experience.

Results

Postpancreatectomy hemorrhage is defined by 3 parameters: onset, location, and severity. The onset is either early (≤24 hours after the end of the index operation) or late (>24 hours). The location is either intraluminal or extraluminal. The severity of bleeding may be either mild or severe. Three different grades of PPH (grades A, B, and C) are defined according to the time of onset, site of bleeding, severity, and clinical impact.

Conclusions

An objective, universally accepted definition and clinical grading of PPH is important for the appropriate management and use of interventions in PPH. Such a definition also would allow comparisons of results from future clinical trials. Such standardized definitions are necessary to compare, in a nonpartisan manner, the outcomes of studies and the evaluation of novel operative treatment modalities in pancreatic surgery.

Section snippets

Methods

The consensus definition in this manuscript was developed by the International Study Group of Pancreatic Surgery (ISGPS), which was founded in the spring of 2006. All participating surgeons are specialists from high-volume centers with long-term experience in pancreatic surgery and scientific research. An extensive Medline search was performed to identify the existing literature on definitions of postoperative hemorrhage after pancreatic resection. All available major publications from the past

Terminology

For the purposes of the definition and this paper, “pancreatic surgery” includes the following procedures: pylorus-preserving or classical pancreaticoduodenectomy, pancreatic left resection, duodenum-preserving pancreatic head resection, pancreatic segment resection, or total pancreatectomy. The terms used most commonly to identify this complication (postoperative hemorrhage after pancreatic resection) were as follows: intraabdominal or gastrointestinal hemorrhage; early or delayed

Discussion

Unlike for other complications after pancreatic surgery, such as postoperative pancreatic fistula,11 an internationally accepted, objective definition is lacking for PPH. Previously reported “definitions” of postoperative hemorrhage vary widely and are heterogeneous regarding time of onset, grade, severity, and clinical impact.

A clear, objective differentiation into early and late hemorrhage will allow further analysis and comparison of causes of PPH, such as a direct failure of intraoperative

References (37)

  • M.I. van Berge Henegouwen et al.

    Delayed massive haemorrhage after pancreatic and biliary surgery

    Br J Surg

    (1995)
  • C. Fernandez-del Castillo et al.

    Standards for pancreatic resection in the 1990s

    Arch Surg

    (1995)
  • J.H. Balcom et al.

    Ten-year experience with 733 pancreatic resections: changing indications, older patients, and decreasing length of hospitalization

    Arch Surg

    (2001)
  • S.M. de Castro et al.

    Delayed massive hemorrhage after pancreatic and biliary surgery: embolization or surgery?

    Ann Surg

    (2005)
  • B.W. Miedema et al.

    Complications following pancreaticoduodenectomyCurrent management

    Arch Surg

    (1992)
  • M. Trede et al.

    The complications of pancreatectomy

    Ann Surg

    (1988)
  • C.J. Yeo et al.

    Six hundred fifty consecutive pancreaticoduodenectomies in the 1990s: pathology, complications, and outcomes

    Ann Surg

    (1997)
  • C.A. Pellegrini et al.

    An analysis of the reduced morbidity and mortality rates after pancreaticoduodenectomy

    Arch Surg

    (1989)
  • Cited by (0)

    The first two authors contributed equally to this publication.

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