site. It implies the presence of a structural vas­cular defect and requires immediate evaluation [23]. Sentinel hemorrhage, as mentioned previ­ously, is often associated with local sepsis and an anastomotic leak; it is uncommon to see late PPH in a patient who has had a completely uneventful postoperative course [24]. Patients who develop a sentinel bleed, as defined as a low volume of hemorrhage in a patient who is hemodynamically stable at the time of the event, are at high risk of developing massive hemorrhage and should undergo diagnostic and therapeutic intervention as soon as possible [7, 8, 16]. The second epi­sode of bleeding may follow in minutes or hours and is often severe, being accompanied by hemo­dynamic instability and a high risk of mortality. Vigilance is critically important, as up to 90 % of patients who experience PPH have been through a turbulent postoperative period characterized by some form of intra-abdominal infection. Those patients who have had conservative management or radiological interventions for intra-abdominal fluid collections are at particularly high risk, and therefore, a sentinel hemorrhage in this setting warrants immediate attention [7, 16].

Management of the exsanguinating patient with late PPH is unlikely to be successful and there­in lies the rationale for immediate action in the setting of a sentinel bleed. A patient presenting with a sentinel bleed should undergo immediate angiography. If the diagnosis of a sentinel bleed is less clear, for example, the blood in the drain may have been associated with accidental trac­tion on the drain, or the issue of a possible mela­notic stool is in question, then CT imaging prior to angiography is quite reasonable. Ultrasound imaging may depict a false aneurysm but has no role in the investigation of acute bleeding. CT an­giography may reveal the cause, site, and nature of bleeding if contrast extravasation is seen or a pseudo-aneurysm is visualized. A triple-phase examination (unenhanced, arterial, and venous phases) is performed with iodinated contrast material. Images are reviewed with multiplanar

Complication rates for pancreatectomy still per­sist due to the large magnitude of the operation which is usually performed in patients of ad­vanced age with associated comorbidities. PPH is one of the major causes of morbidity and mor­tality after PD. PPH can be divided into early and late postoperative bleeding. Early PPH is that which occurs within 24 caused by technical failure of appropriate hemo­stasis during the index operation (failure to per­form the SMA dissection correctly and to iden­tify and ligate the IPDAs) or by an underlying perioperative coagulopathy. Late PPH occurs more than 24 one or more weeks from the date of surgery. Late PPH is associated with more common complica­tions of the operation, most notably a leak from the pancreaticojejunostomy. Local sepsis from a pancreatic fluid collection or intra-abdominal abscess may erode the vascular wall adjacent to a loop of bowel leading to PPH. Prevention of PPH depends both on careful dissection of the portahepatis and the hepatic artery/GDA and on creation of a pedicled falciform ligament flap to protect the vessels from possible pancreatic fis­tula and fluid collections. For patients who re­ceive a distal pancreatectomy, reinforcement of the pancreas transection site with Gore-Tex or pledgeted sutures can also be followed with fal­ciform ligament flap coverage. The occurrence of a sentinel bleed is a key sign which often occurs before the onset of late PPH. Patients who de­velop a sentinel bleed, especially those who have had a complicated/septic postoperative period have a high risk of developing imminent massive hemorrhage and should undergo immediate diag­nostic and therapeutic angiography.

drain is placed in the region of the anastomosis to help detect leakage and manage smaller leaks in the postoperative period. Although not classi­cally described in the literature, in the opinion of the authors, attention should also be paid to the placement of the biliary anastomosis with respect to the pancreatic anastomosis. Whenever pos­sible, at least 10–15 cm should be left between the two anastomoses to prevent reflux of biliary fluid into the pancreatic anastomosis. Although little clinical evidence exists to support this prac­tice, it is an important anecdotal observation that may decrease the incidence of massive pancre­atic anastomotic disruption.