Blood Loss in Pancreatic Resections: Definitions, Risk Factors and Strategies for Intra- and Postoperative Bleeding Prevention - A Narrative Review.

AIM: Pancreatic resections are among the most complex procedures in general surgery and are associated with high morbidity. Intraoperative blood loss and post-pancreatectomy hemorrhage (PPH) are clinically relevant yet inconsistently defined and reported, limiting comparability across studies. This narrative review integrates current evidence on definitions, risk factors, and preventive approaches for bleeding in pancreatic surgery. METHODS: A selective PubMed literature review was conducted without restrictions on publication date or study design, limited to full-length English-language articles. Multiple targeted searches addressed definitions of blood loss, PPH, patient- and procedure-related risk factors, patient blood management, tranexamic acid, surgical techniques, and perioperative outcomes. RESULTS: Blood loss estimation is highly heterogeneous across studies. Key risk factors for increased blood loss and/or PPH include obesity, antithrombotic therapy, preoperative anemia, vascular resection, and prolonged operative time. Higher intraoperative blood loss correlates with higher reoperation rates, prolonged intensive care unit (ICU) stay, and increased 90-day mortality. While perioperative transfusions are associated with shorter long-term survival in observational studies, causal interpretation remains limited by confounding, suggesting that blood loss and preoperative anemia rather than transfusion itself drive adverse outcomes. Effective preventative approaches include Patient Blood Management (PBM) programs, preoperative intravenous iron supplementation, the artery-first approach, and minimally invasive surgical techniques, which may reduce blood loss and/or transfusion requirements; prophylactic falciform ligament wrapping may reduce the risk of PPH. CONCLUSIONS: Systematic preoperative risk assessment, structured PBM protocols, and tailored surgical strategies are necessary to minimize hemorrhagic complications in pancreatic surgery.