Management of severe postpancreatectomy hemorrhage requiring emergency intervention: treatment pathways and surgical salvage in a single-center case series

Postpancreatectomy hemorrhage (PPH) is a life-threatening complication after pancreatic resection. Although interventional radiology has become the preferred first-line treatment for delayed arterial hemorrhage, some patients still require surgical salvage. We aimed to describe the clinical characteristics, treatment pathways, and outcomes of severe PPH requiring emergency intervention. We retrospectively reviewed consecutive patients who underwent pancreatectomy at our institution between April 2009 and October 2025. Severe PPH was defined according to the criteria of the International Study Group of Pancreatic Surgery. Clinical characteristics, timing of onset, associated postoperative complications, treatment pathways, and outcomes were evaluated. Among 750 pancreatectomies, 16 patients developed severe PPH requiring emergency intervention, yielding an overall incidence of 2.1%. The incidence was 2.7% after pancreaticoduodenectomy and 0.9% after distal pancreatectomy. Four patients had early severe grade B hemorrhage and 12 had late severe grade C hemorrhage. Initial treatment consisted of surgery first in 3 patients, interventional radiology only in 10 patients, and interventional radiology followed by surgery in 3 patients. Pseudoaneurysm was identified in 7 patients. Early severe PPH was categorized as technical failure, whereas late severe PPH was associated with postoperative pancreatic fistula, bile leakage, pseudoaneurysm, and other local postoperative complications. Severe PPH is a heterogeneous clinical entity requiring individualized management. Interventional radiology is the principal first-line treatment for delayed arterial hemorrhage, but endovascular hemostasis alone may not always achieve definitive clinical rescue, and selected patients still require prompt surgical salvage.