# Impact of precise preoperative vascular assessment and different dorsal pancreatic artery variant subtypes on pancreatic surgery-related bleeding

## TL;DR

This study explores how preoperative vascular assessments and variations in the dorsal pancreatic artery affect bleeding during and after pancreatic surgery.

## Contribution

A precise preoperative vascular assessment protocol and classification of dorsal pancreatic artery variants are proposed for pancreatic surgery.

## Key findings

- Precise preoperative vascular assessment did not significantly reduce overall intraoperative blood loss or postoperative bleeding.
- Type IIB dorsal pancreatic artery variants may increase early postoperative hemoglobin decline, while type IC variants may reduce it.
- Dorsal pancreatic artery head-side branches and certain pancreatic vein drainage types are associated with greater postoperative hemoglobin decline.

## Abstract

The variability of pancreatic vasculature, especially the dorsal pancreatic artery (DPA), increase surgical difficulty and may elevate the risk of intra- and postoperative bleeding. This study aimed to establish a precise preoperative vascular assessment protocol for pancreatic surgery, summarize DPA variant patterns, and evaluate their impact on pancreatic surgery-related bleeding.

In this prospective study, 206 patients undergoing pancreatic surgery were included and evaluated preoperatively using computed tomography (CT) imaging and Preoperative Accurate Assessment Form for Pancreatic Vascular Variations (PAAF-PVV). 50 historical controls who underwent pancreatic surgery without PAAF-PVV were retrospectively included. DPA variants were systematically classified. The impact of PAAF-PVV-based vascular assessment and DPA variants on bleeding outcomes was analyzed.

Among patients who underwent precise preoperative vascular assessment for the pancreas (n = 148) versus those who did not (n = 32), no significant differences were observed in intraoperative blood loss, PPH incidence and postoperative hemoglobin decline (ΔHb). However, in the distal pancreatectomy group, the hemoglobin decline on POD2 differed significantly (ΔHb_POD2-POD1, -5.11 vs. -10.69 g/L, 95% CI 1.45–9.71, P = 0.010).

Then, DPA origins were classified into five types and no significant association was found with intraoperative blood loss or PPH incidence. However, type IIB DPA may increase the risk of early postoperative hemoglobin decline, whereas type IC DPA appeared to be associated with a lower risk, as reflected by ΔHb_POD2-POD1 values (-12.45 ± 11.605 vs. -1.15 ± 6.902 g/L, P = 0.046). DPA branching patterns were also documented. Patients with DPA head-side branch (HB) showed more postoperative hemoglobin decline than those without HB in distal pancreatic surgery, as reflected by ΔHb_POD3-POD1 values (-11.65 ± 6.434 vs. -7.45 ± 8.667 g/L, P = 0.049).

Interestingly, we also found that centro-inferior pancreatic vein (CIPV) drainage type was associated with ΔHb_POD3-POD1, with inferior mesenteric vein (IMV) drainage type linked to greater hemoglobin decline (-12.52±11.422 vs. -7.27±9.508 g/L, P=0.009). Besides, the minimally invasive surgical approach, distal pancreatic resection, and benign pancreatic disease appeared to be associated with fewer intra-operative blood loss.

Variations in the pancreatic vasculature, including both arterial and venous systems, may influence surgery-related bleeding. Robust statistical evidence for bleeding reduction is not established in the overall study. Although the clinical outcome related measures presented in this study are merely associative and exploratory findings, a precise preoperative vascular assessment could help enhance anatomical understanding and optimize preoperative procedural planning, which is particularly valuable for surgeons during their learning phase.

The online version contains supplementary material available at 10.1186/s12876-026-04687-8.