Computed tomographic angiography for diagnosis of post-pancreatoduodenectomy hemorrhage

To the Editor:Even in high volume specialist hepato-pancreato-biliary surgery centres,hemorrhage after pancreatoduodenectomy remains a feared and potentially lethal complication[1]and an important cause of postoperative morbidity and mortality[2].Whilst early hemorrhage after pancreatoduodenectomy is typically managed by re-operation,detection and treatment of bleeding later in the postoperative course can be problematic.Patients who are hemodynamically unstable with evidence of brisk bleeding are usually treated by urgent re-operation.However,not all bleeding episodes present in such a dramatic fashion.The“sentinel bleed”–a harbinger of major hemorrhage–represents a clinical opportunity for detection and treatment[3].Traditionally,patients who presented with luminal bleeding episodes with hematemesis or melena underwent fibre optic endoscopy as first-line investigation whereas patients presenting with a bleed into surgical drains would have undergone selective mesenteric angiography[4].