Pancreatic surgery is complex and the corresponding complication rate is higher than that of ordinary surgery, especially because the pancreas is soft and some of them are like tofu, which can be easily cut during suturing; and the pancreatic fluid secreted by the pancreas is highly corrosive, so the pancreatic-intestinal anastomosis often leaks, or “pancreatic fistula”. The pancreatic fistula itself is not terrible, but the pancreatic fistula will bring about corrosion of the surrounding tissues and blood vessels by the pancreatic fluid, causing infection and even bleeding, so pancreatic fistula, infection and bleeding constitute a vicious circle, which is called the “death triangle” of pancreatic surgery. This is my article published in the September 2014 issue of the Chinese Journal of Surgery, which discusses “Treatment strategies for post-pancreaticoduodenectomy bleeding”. Complications have caused patients to suffer and even taken precious lives. It tortures the surgeon’s self-esteem and guilt. Patients and surgeons alike are tormented and tested. As a surgeon, facing the serious complication of postoperative bleeding, calm judgment and decisive decision making is the key, thus saving the patient and the surgeon himself from the danger. Pancreaticoduodenectomy (PD) is characterized by complex surgery, many organs involved and high complication rate. The incidence of post pancreatomy hemorrhage (PPH) is 3-10%, which is clinically more dangerous than common complications such as pancreatic fistula, abdominal infection and gastric emptying disorder, with a mortality rate of 20%-50%. Compared with common complications such as pancreatic fistula, abdominal infection and gastric emptying disorder, PPH is clinically more dangerous and has a mortality rate of 20%-50%, and the diagnosis and treatment process are not conclusive. The purpose of this article is to discuss the common causes of PPH and its diagnosis and treatment strategies. Classification of PPH In 2007, the International Study Group of Pancreatic Surgery classified PPH into early and delayed bleeding (<24< span="">hours, >24 hours); gastrointestinal and abdominal bleeding; and mild and severe bleeding based on the time, location and severity of the bleeding; and the combined classification of bleeding into 3 grades: A, B and C. This definition provides some guidance for the treatment of PPH and offers the possibility of comparison between different studies. When combined with gastrointestinal fistula, gastrointestinal bleeding and abdominal bleeding can be mutually epiphenomenal and are called pseudo-gastrointestinal bleeding or abdominal bleeding. Risk factors and causes of PPH Early PPH is often associated with defective surgical procedures. Incorrect ligation of vessels, detachment of ligature wires or cutting of vessels, postoperative reopening of spastic vessels, and extensive exudation from the abdominal trauma are the main causes of early PPH and are called surgical technique-related bleeding. The common risk factors for delayed PPH, also known as complication-related bleeding, include pancreatic fistula, abdominal infection, bile leak, lymph node dissection, and vascular skeletonization, with pancreatic fistula and abdominal infection predominating with an incidence of 62%. Delayed PPH is often associated with vascular injury due to surgical complications or surgical operation defects. The main causes include: 1. Excessive emphasis on skeletonization of the abdominal artery or superior mesenteric artery branches during resection or lymph node dissection, thermal injury or inappropriate clamping leading to vascular wall damage and subsequent formation of pseudoaneurysm rupture and bleeding. 2. Postoperative pancreatic fistula, bile leak or abdominal infection eroding the vascular wall, leading to vascular rupture and bleeding. Bleeding. 3, inaccurate hemostasis of the pancreatic section: inappropriate hemostasis by electrocoagulation or ultrasonic knife, postoperative scorch off; arterial suture ligation is too tight to produce cutting effect, etc. 4, improper placement of drainage tube, compressing exposed vessels. 5, inappropriate use of anastomosis: too tight compression leads to collapse of anastomotic tissue; too loose compression leads to inaccurate hemostasis of the anastomosis. Common sites of PPH PPH occurs after PD, the abdominal cavity accounts for 62%, the digestive tract accounts for 28%, and both account for 10%. The common sites of bleeding are: arterial bleeding (66%), pancreatic section (12%), gastrointestinal anastomosis (6%), and other or unknown sites (16%); among them, arterial bleeding includes: gastroduodenal artery (49.5%), common hepatic artery (20.8%), intrinsic hepatic artery (10.9%), splenic artery (7.9%), superior mesenteric artery (7.9%), and other arteries (3.0%). Diagnosis of PPH After PPH has occurred, it is particularly important to identify the site of bleeding in order to select the appropriate intervention. Currently, commonly used methods include: endoscopy, digital subtraction angiography (DSA), CT angiography and dissection. For hemodynamically unstable PPH, early dissection is still emphasized to identify the cause of bleeding and to provide rapid intervention. For intra-digestive bleeding with stable vital signs, endoscopy should be performed as early as possible to clarify the presence of active bleeding from the anastomosis or pancreatic section, but the accumulation of blood in the digestive tract and the anatomical changes after reconstruction may affect the endoscopic observation or reaching the location of bleeding.DSA and CT angiography have high diagnostic value for active arterial bleeding, but DSA has low diagnostic value for intermittent bleeding, while CT angiography delayed scan has a higher diagnostic value for intermittent bleeding in the gastrointestinal tract. “Sentinel hemorrhage” is a small amount of abdominal drainage or GI bleeding that precedes delayed hemorrhage, which can occur in nearly 45% of delayed PPH. In clinical practice, sentinel bleeding can stop on its own or with conservative hemostatic treatment and is easily overlooked. For the pancreatic surgeon, any abdominal drainage or GI bleeding should not be ignored and endoscopy or DSA should be aggressively performed to rule out the possibility of pseudoaneurysm. Treatment of PPH PPH attacks are vicious and have high mortality rate. Early decisive intervention is the key to improve the cure rate and reduce the mortality rate. The difficulty of treatment lies in grasping the reasonable timing of intervention and choosing the appropriate intervention method. At present, the main treatment methods of PPH include: conservative treatment, endoscopic hemostasis, interventional embolization and surgical intervention, and the selection of which is mainly based on the time of occurrence, location of bleeding and severity of PPH. Early bleeding: For early abdominal bleeding, conservative treatment is considered if it is grade A, and open surgery is preferred if it is grade B/C. For early gastrointestinal bleeding, endoscopic hemostasis is preferred. Delayed hemorrhage: management complexity and mortality are higher than early hemorrhage. Endoscopic hemostasis: endoscopy is preferred for GI bleeding and is mainly indicated for gastrointestinal anastomotic bleeding, while for pancreatic dissection or pancreatic-intestinal anastomotic bleeding, open surgery is preferable. The advantage of electronic gastroscopy is that it can treat while diagnosing, and the disadvantage is that massive bleeding may interfere with observation. Delayed gastrointestinal bleeding may come from the gastrointestinal tract itself or from abdominal bleeding entering the gastrointestinal tract through an anastomotic fistula, so delayed gastrointestinal bleeding requires a combination of interventional and endoscopic applications. If endoscopic intervention fails, surgical exploration is required. Intraoperative incision of the gastric and intestinal walls is required accordingly to explore the bleeding point, and intraoperative endoscopy can help to confirm the bleeding point. Interventional hemostasis is mainly indicated for hemodynamically stable arterial bleeding, especially in cases with pseudoangioma formation. In cases of bleeding without pancreatic fistula and abdominal infection, interventional embolization can avoid secondary surgical trauma and has a success rate of up to 80%. In cases of bleeding from the stump of the gastroduodenal artery, if the angiogram indicates a long stump, direct embolization can be performed to stop the bleeding; if the stump is short, the hepatic artery needs to be embolized, and if the conditions are available, a stent with a membrane vessel can be applied to ensure the patency of the intrinsic hepatic artery. For bleeding from the abdominal trunk or branches of the superior mesenteric artery with hemangioma formation, the use of vascular stents is also recommended, which can achieve effective hemostasis while ensuring vascular integrity and avoiding complications associated with vascular embolization, such as: biliary ischemia caused by bile duct ischemia, liver abscess, liver failure, biliary ischemia or intestinal ischemia. In cases of bleeding with pancreatic fistula and abdominal infection, although temporary hemostasis may be obtained by interventional embolization, there is still a possibility of recurrent pseudoaneurysm formation or bleeding after intervention because the risk factors leading to bleeding still exist. Meanwhile, active management of pancreatic fistula and abdominal abscess is really necessary, and CT-guided puncture and drainage can be performed to avoid vascular erosion caused by pancreatic fluid or pus accumulation or active surgical intervention. PPH that is hemodynamically unstable or has failed other treatments is an absolute indication for surgical intervention. The aim of surgery is to rapidly stop bleeding and to manage other abdominal complications causing bleeding. Although a meta-analysis showed that surgical intervention nearly doubles the mortality rate compared to intervention (43% vs. 20%), such patients are more often complicated and have more complications. Delayed PPH occurs mostly at one week postoperatively and mostly originates from vascular erosion from pancreatic fistula or abdominal infection, with significant tissue adhesions and edema in the surgical area, fragile texture of the vessel wall, difficult exposure of bleeding points and difficult surgery. The main point of surgery is to control bleeding while intervening in pancreatic fistulas or abdominal abscesses at the same time. The management of abdominal infection lies in adequate drainage, while the management of pancreatic fistula is quite complex and will be further described below. Bleeding from the pancreatic section or pancreatic-enteric anastomosis often presents as gastrointestinal bleeding or pseudo-abdominal bleeding. Due to the longer jejunal input loop, it is often difficult to reach the bleeding site by gastroscopy, and surgical hemostasis is advisable. Early total pancreatectomy for pancreatic section bleeding has been abandoned due to the complexity of surgery, trauma and many postoperative complications. For cases with intact pancreatic-enteric anastomosis, we recommend opening the jejunal wall vertically in the pancreatic section. Although the exposure is slightly worse, it can avoid the jejunal ischemia between the incision and pancreatic-enteric anastomosis caused by parallel opening, and it can also avoid the uncontrollable secondary pancreatic fistula caused by direct opening of the pancreatic-enteric anastomosis. Pancreatic fistula is the source of all evils and also the main cause of abdominal bleeding and infection, and the three often form a vicious circle, therefore, the management of pancreatic fistula is the key to success or failure. In mild pancreatic-enteric anastomotic fistula, the pancreatic-enteric anastomosis can usually be repaired in situ, while internal or external drainage of the pancreatic duct can be added to drain the pancreatic fluid out of the body or away from the pancreatic-enteric anastomosis, and external abdominal drainage can be placed at the same time. A large omental peri-pancreatic-enteric anastomosis wrap can be chosen to isolate and protect the vascular stump around the pancreatic-enteric anastomosis and block the corrosive effect of pancreatic fluid on the vessels. For severe pancreatic-enteric anastomosis fistula, rupture or even detachment, repair is almost impossible, and removal of the broken jejunum will result in the jejunum between the pancreatic-enteric and biliary-enteric anastomoses being too short to complete the pancreatic-enteric anastomosis. We recommend the use of Roux-en-Y pancreaticenteric reanastomosis (biliopancreatic bypass) to reconstruct the digestive tract. The main point of the procedure is to remove the original pancreatic-enteric anastomosis, close the jejunal stump between the bile-pancreatic anastomosis, take another jejunum and perform Roux-en-Y pancreatic-enteric anastomosis, and choose whether to place external drainage according to the anastomosis effect and peripancreatic infection. By reconstructing the pancreatic-intestinal anastomosis, the bile and pancreatic juice can be separated to avoid activation of pancreatic enzymes, which can transform the pancreatic fistula into a simple pancreatic fistula and significantly reduce its ability to erode blood vessels, while ensuring the internal and external secretion function of the pancreas. Three cases of severe pancreatic fistula with abdominal hemorrhage and infection have been successfully treated by this procedure in our center, and the pancreatic fistula and hemorrhage were cured at the same time after surgery. The following options have also been reported in the literature. External pancreatic drainage: Silicone stent tube is placed inside the pancreatic duct and drained directly out of the body, which has the advantages of simple operation, little damage and reliable drainage effect. The outcome of external drainage is either the formation of external pancreatic fistula, which can be followed by jejunostomy of the fistula; or the gradual loss of exocrine function of the pancreas and gradual reduction of drainage, which can be directly removed, and embolization of the pancreatic duct has also been reported. Internal and external drainage of the bridged pancreatic duct: it is suitable for cases of anastomotic dissection after pancreatic duct to jejunal mucosa pancreatic-enteric anastomosis, if the peripancreatic infection is mild, internal drainage can be chosen after bridging, if the peripancreatic infection is heavy, external drainage can be chosen after bridging. This procedure is relatively simple, but experience is limited (only 4 cases were reported), and the effectiveness still needs further verification. The advantages of pancreatogastric anastomosis are: 1) the gastric wall is thick and rich in blood supply, which is conducive to the healing of the anastomosis; 2) the pancreas is located in the posterior part of the stomach, which can complete a tension-free anastomosis; 3) unlike the alkaline environment of the jejunum, the acidic environment in the stomach can avoid the activation of pancreatic enzymes, and the gastric wall does not secrete enterokinase, which activates pancreatic enzymes, while the disadvantage is that too rapid proliferation of the gastric mucosa may lead to obstruction of the pancreatic duct, which may cause atrophy of the residual pancreas and The disadvantage is that too rapid proliferation of gastric mucosa may lead to obstruction of the pancreatic duct, which in turn causes atrophy of the residual pancreas and leads to exocrine dysfunction of the pancreas. Conclusion: Post-pancreaticoduodenectomy bleeding is a dangerous complication that often endangers patients’ lives. It needs to be selected according to the bleeding time, bleeding site, bleeding degree, and the operator’s own experience, and multidisciplinary cooperation is needed to develop a reasonable timing of intervention and appropriate intervention strategies. A famous watchword in abdominal surgery: “When the abdominal cavity is opened, it is subject to you; when the abdominal cavity is sutured, you are subject to it!” When postoperative hemorrhage occurs, the surgeon has few options other than prayer and diaphoresis. Therefore, it is very important to prevent bleeding. A good surgeon must be adept at stopping bleeding, meticulous in every step of the operation, delicate and appropriate in every vessel, careful in stopping bleeding at the wound, and fully aware and alert to possible dangers. It is not uncommon today for people to receive anticoagulants and patients with coagulation disorders. A deep understanding of such medical bleeding is essential to reduce surgical bleeding complications. Experience has shown that surgeons who take bleeding seriously can greatly reduce the incidence of this complication. Surgeons are often indecisive when dealing with complications in their own patients, especially when they need to “go back in”. The ensuing pressure from the patient’s family, the community, the hospital, and our own reputation can often cloud our judgment and decision-making. This may result in lost opportunities to save lives and put us in a more disadvantageous position. A decisive drive in may sometimes be the wisest choice. Remember, the patient’s safety and life must be paramount at all times.