Reappraisal of post-pancreatectomy hemorrhage (PPH) classifications: do we need to redefine grades A and B?

Background: Post-pancreatectomy hemorrhage (PPH) remains a major complication. The aim of this study was to reappraise the International Study Group of Pancreatic Surgery (ISGPS) classification. Methods: The clinical utility of the ISGPS classification was tested on consecutive pancreatic resections performed at the Pancreas Institute of the University of Verona Hospital. Results: PPH occurred in 65 of the 2429 patients (6.8%) undergoing pancreatic resection. Outcome of patients without PPH and with grade A PPH were comparable in terms of mortality, length of stay, ICU stay and readmission. Patients with grade B late and mild and grade B early and severe PPH had similar hospital stay and mortality rates, but differed in relaparotomy rate (10.1 vs. 81.2%, p < 0.01). Replacing “time of PPH onset” criterion with post-operative pancreatic fistula (POPF), severe PPH alone, mild PPH/POPF and severe PPH/POPF differed significantly for hospital stay (14 vs. 23 vs. 35 days, p < 0.01) and mortality rate (0 vs. 4 vs. 25%, p = 0.05). Conclusion: Grade A PPH shared the same outcome of patients without PPH. Grade B PPH included two categories of patients with different treatment modalities. The use of “concomitant POPF” instead of “time of onset” segregated three discrete categories that differed significantly in terms of clinical outcomes and management.