Postpancreatectomy hemorrhage (PPH) - An International Study Group of Pancreatic Surgery (ISGPS) definition

University of Verona, Verona, Veneto, Italy
Surgery (Impact Factor: 3.38). 08/2007; 142(1):20-5. DOI: 10.1016/j.surg.2007.02.001
Source: PubMed


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.
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.
Postpancreatectomy hemorrhage is defined by 3 parameters: onset, location, and severity. The onset is either early (< or =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.
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.

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Available from: Dirk J Gouma, Dec 08, 2014
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    • "PFs were identified by the presence of amylase-rich fluid of more than three times than the serum concentration collected from postoperative day 3 from the drain placed intraoperatively in the abdomen, in accordance with criteria defined by the International Study Group on Pancreatic Fistula (ISGPF) [14]. Haemorrhage was defined according to ISGPF criteria by three parameters, including onset, location and severity [15] and classified as Grade A, B or C. Sepsis was defined by the presence of both infection and systemic inflammatory response. "
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    ABSTRACT: Background: Pancreatic anastomotic leakаgе is one of the most serious complications following pancreaticoduodenectomy (PD). The most significant risk factors for pancreatic leakage are pan-creatic texture, main pancreatic duct (MPD) size and anastomotic technique. Herewith we des-cribe our technical modifications for single-layer pancreaticojejunostomy (PJ) with a soft pancreas and nondilated MPD for reconstruction after PD. Methods: We report our early experience using this technique in 52 patients who underwent PD between May 2009 and December 2012. Results: Overall postoperative mortality rate was 1.92%. Postoperative morbidity rate was 32.69%, with major complications occurring in three patients (5.77%). Pancreatic leak was diagnosed in six patients (11.54%). Three patients with pancreatic fistulae (PF) of Grades A and B were managed conservatively, whereas three other patients with PF of Grade C required relaparotomy. Con-clusions: According to our early experience with this modified technique for PJ, usage of hori-zontal mattress sutures, "everting" of MPD and incorporation of its wall into a single layer pan-creatic-enteric anastomosis result in a low pancreatic anastomotic leakage rate after PD. This technique for PJ with a soft pancreas and nondilated duct ensures ideal preconditions for anasto-mosis healing. They consist of an excellent blood supply, an anatomical position with tension-free approximation and unobstructed pancreatic juice flow from the pancreas into the jejunal loop.
    Surgical Science 10/2014; 5(5):444-453. DOI:10.4236/ss.2014.510069
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    • "Although it is not among the most frequent complications after pancreatectomy, it is considered life-threatening for its high mortality. Postpancreatectomy hemorrhage is defined as early, developing within 24 h from the operation, and late, developing 24 or more hours following the operation [1, 2]. "
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    ABSTRACT: Postpancreatectomy hemorrhage (PPH) and pancreatic fistula are main and serious complications following pancreaticoduodenectomy. Postpancreatectomy hemorrhage is considered life-threatening for its high rate of mortality. Postpancreatectomy hemorrhage is defined as early, occurring within 24 h after surgery, and late. The authors present a case of late PPH which developed in the third week following pylorus-preserving pancreaticoduodenectomy. A 58-year-old man was operated on for cancer of the pancreatic head. Hemorrhage occurred when the patient was in full health, convalescing at home. The cause was bleeding from a pseudoaneurysm of the stump of the gastroduodenal artery directly into the gastrointestinal tract. Diagnosis was established based on computed tomography angiography. Treatment was performed using minimally invasive technique during angiography. The implantation of a stent graft into the common hepatic artery for bridging the stump of the gastroduodenal artery was performed. This method thus enabled at once both diagnosis and successful minimally invasive treatment.
    Videosurgery and Other Miniinvasive Techniques / Wideochirurgia i Inne Techniki Malo Inwazyjne 06/2014; 9(2):297-301. DOI:10.5114/wiitm.2011.38178 · 1.09 Impact Factor
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    • "Postpancreatectomy hemorrhage (PPH) and delayed gastric emptying (DGE) were also defined based on the International Study Group of Pancreatic Surgery (ISGPS) definitions. [21, 22]. However, the definitions of ISGPS for POPF, PPH, and DGE were not published until 2004 and 2007, respectively. "
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    ABSTRACT: Introduction. Although ampullary carcinoma has the best prognosis among all periampullary carcinomas, its long-term survival remains low. Prognostic factors are only available for a period of 10 years after pancreaticoduodenectomy. The aim of this retrospective study was to identify factors that influence the long-term patient survival over a 15-year observation period. Methods. From 1992 to 2007, 143 patients with ampullary carcinoma underwent pancreatic resection. 86 patients underwent pylorus-preserving pancreaticoduodenectomy (60%) and 57 patients underwent standard Kausch-Whipple pancreaticoduodenectomy (40%). Results. The overall 1-, 5-, 10-, and 15-year survival rates were 79%, 40%, 24%, and 10%, respectively. Within a mean observation period of 30 (0-205) months, 100 (69%) patients died. Survival analysis showed that positive lymph node involvement (P = 0.001), lymphatic vessel invasion (P = 0.0001), intraoperative administration of packed red blood cells (P = 0.03), an elevated CA 19-9 (P = 0.03), jaundice (P = 0.04), and an impaired patient condition (P = 0.01) are strong negative predictors for a reduced patient survival. Conclusions. Patients with ampullary carcinoma have distinctly better long-term survival than patients with pancreatic adenocarcinoma. Long-term survival depends strongly on lymphatic nodal and vessel involvement. Moreover, a preoperative elevated CA 19-9 proved to be a significant prognostic factor. Adjuvant therapy may be essential in patients with this risk constellation.
    HPB Surgery 03/2014; 2014(3):970234. DOI:10.1155/2014/970234
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