Journal of the Korea Academia-Industrial cooperation Society (한국산학기술학회논문지)

The Korea Academia-Industrial cooperation Society (한국산학기술학회)
권호 표지
DOI QR코드

DOI QR Code

Pancreatic trauma with acute hemorrhage successfully treated surgically after Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA) and angioembolization

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)와 혈관색전술 후 수술적 치료로 호전된 급성 출혈을 동반한 외상성 췌장 손상

  • Kang, Wu Seong (Department of Trauma Surgery, Wonkwnag University Hospital) ;
  • Park, Chan Yong (Department of Trauma Surgery, Wonkwnag University Hospital)
  • 강우성 (원광대학교병원 외상외과) ;
  • 박찬용 (원광대학교병원 외상외과)
  • Received : 2018.11.28
  • Accepted : 2019.01.04
  • Published : 2019.01.31
Download PDF
⟨ Previous Next ⟩

Abstract

The role of resuscitative endovascular balloon occlusion of the aorta (REBOA) in hemodynamically unstable pancreatic trauma is unclear. We report here a case of traumatic pancreatic bleeding controlled with REBOA and angioembolization of the splenic artery before surgery. A 65-year old man experienced blunt trauma upon falling from a height of 20 m. Computed tomography (CT) revealed distal pancreatic trauma (grade III) and contrast extravasation around the splenic artery. Shortly after CT, his systolic blood pressure was 60 mmHg and REBOA was performed for hemodynamic stability. His systolic pressure increased to 130 mmHg after balloon inflation and angioembolization of the splenic artery was performed. On angiography, no further arterial bleeding was identified and the balloon was removed. Subsequently, the patient underwent emergent laparotomy with distal pancreatectomy. There was no active bleeding during surgery and distal main pancreatic duct injury was identified. After surgery, the patient recovered without complication. In this case, hemodynamically unstable hemorrhagic pancreatic trauma was treated effectively and safely with distal pancreatectomy after REBOA with angioembolization.

혈역학적으로 불안정한 췌장손상의 치료에서 Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA)의 역할은 아직 불명확하다. 저자들은 출혈을 동반한 췌장손상에서 REBOA와 경도관 동맥색전술을 시행하여 출혈을 먼저 제어한 후 수술을 시행한 증례를 보고하고자 한다. 65세 남자가 20 m 높이에서 추락하면서 발생한 복통과 흉통을 호소하며 본원 응급실을 통하여 내원하였다. 전산화단층촬영에서 췌장 미부에 grade III 손상이 의심되고 비장동맥으로부터 조영제 누출이 관찰되었다. 전산화단층촬영 시행 후 수축기혈압이 60 mmHg까지 하강하여 혈역학적 안정을 위해 REBOA를 시행하였다. REBOA 시행 후 수축기혈압이 130 mmHg로 상승하였으며, 비장동맥에 대해 색전술을 시행하였다. 혈관조영술에서 더 이상 출혈이 없는 것을 확인하고, REBOA 제거 후 응급 개복 및 췌장미부절제술을 시행하였다. 수술 소견에서 췌장미부의 주췌관 손상을 동반한 열상이 관찰되었으며, 수술 중 큰 출혈은 관찰되지 않았고 주 췌관의 손상이 확인되었다. 술 후 환자는 합병증 없이 회복하였다. 본 증례에서 저자들은 혈역학적으로 불안정한 출혈을 동반한 췌장손상 환자에서 REBOA와 동맥색전술 시행 후 췌장미부절제술을 안전하고 효과적으로 진행할 수 있었다.

Keywords

SHGSCZ_2019_v20n1_371_f0001.png 이미지

Fig. 1. Abdominal CT scan on arrival. (A) Blue arrow indicates laceration of the distal pancreas and red arrow indicates extravasation around the splenic artery. (B) The red arrow indicates balloon inflation at Zone I.

SHGSCZ_2019_v20n1_371_f0002.png 이미지

Fig. 2. Angiography. (A) Extravasation from the splenic artery (red arrow). (B) Coil embolization (red arrow)

SHGSCZ_2019_v20n1_371_f0003.png 이미지

Fig. 3. Operative findings. (A) Distal margin after distal pancreatectomy using the stapler (black arrow). (B) Distal pancreas with the spleen.

References

  1. Kang WS, Park YC, Jo YG, Kim JC, "Pancreatic fistula and mortality after surgical management of pancreatic trauma: analysis of 81 consecutive patients during 11 years at a Korean trauma center", Ann Surg Treat Res, Vol. 95, No. 1, pp. 29-36, 2018. DOI: https://dx.doi.org/10.4174/astr.2018.95.1.29
  2. Scollay JM, Yip VS, Garden OJ, Parks RW, "A population-based study of pancreatic trauma in Scotland", World J Surg, Vol. 30, No. 12, pp. 2136-2141, 2006. DOI: https://dx.doi.org/10.1007/s00268-006-0039-z
  3. Akhrass R, Yaffe MB, Brandt CP, Reigle M, Fallon WF, Jr., Malangoni MA, "Pancreatic trauma: a ten-year multi-institutional experience", Am Surg, Vol. 63, No. 7, pp. 598-604, 1997.
  4. Ho VP, Patel NJ, Bokhari F, Madbak FG, Hambley JE, Yon JR, Robinson BR, Nagy K, Armen SB, Kingsley S, Gupta S, Starr FL, Moore HR, 3rd, Oliphant UJ, Haut ER, Como JJ, "Management of adult pancreatic injuries: A practice management guideline from the Eastern Association for the Surgery of Trauma", J Trauma Acute Care Surg, Vol. 82, No. 1, pp. 185-199, 2017. DOI: https://dx.doi.org/10.1097/ta.0000000000001300
  5. Lee KJ, Kwon J, Kim J, Jung K, "Management of blunt pancreatic injury by applying the principles of damage control surgery: experience at a single institution", Hepatogastroenterology, Vol. 59, No. 118, pp. 1970-1975, 2012. DOI: https://dx.doi.org/10.5754/hge11808
  6. DuBose JJ, Scalea TM, Brenner M, Skiada D, Inaba K, Cannon J, Moore L, Holcomb J, Turay D, Arbabi CN, Kirkpatrick A, Xiao J, Skarupa D, Poulin N, "The AAST prospective Aortic Occlusion for Resuscitation in Trauma and Acute Care Surgery (AORTA) registry: Data on contemporary utilization and outcomes of aortic occlusion and resuscitative balloon occlusion of the aorta (REBOA)", J Trauma Acute Care Surg, Vol. 81, No. 3, pp. 409-419, 2016. DOI: https://dx.doi.org/10.1097/ta.0000000000001079
  7. Stannard A, Eliason JL, Rasmussen TE, "Resuscitative endovascular balloon occlusion of the aorta (REBOA) as an adjunct for hemorrhagic shock", J Trauma, Vol. 71, No. 6, pp. 1869-1872, 2011. DOI: https://dx.doi.org/10.1097/TA.0b013e31823fe90c
  8. Hughes CW, "Use of an intra-aortic balloon catheter tamponade for controlling intra-abdominal hemorrhage in man", Surgery, Vol. 36, No. 1, pp. 65-68, 1954.
  9. Gupta BK, Khaneja SC, Flores L, Eastlick L, Longmore W, Shaftan GW, "The role of intra-aortic balloon occlusion in penetrating abdominal trauma", J Trauma, Vol. 29, No. 6, pp. 861-865, 1989. https://doi.org/10.1097/00005373-198906000-00026
  10. Rasmussen TE, Clouse WD, Peck MA, Bowser AN, Eliason JL, Cox MW, Woodward EB, Jones WT, Jenkins DH, "Development and implementation of endovascular capabilities in wartime", J Trauma, Vol. 64, No. 5, pp. 1169-1176; discussion 1176, 2008. DOI: https://dx.doi.org/10.1097/TA.0b013e31816b6564
  11. Inoue J, Shiraishi A, Yoshiyuki A, Haruta K, Matsui H, Otomo Y, "Resuscitative endovascular balloon occlusion of the aorta might be dangerous in patients with severe torso trauma: A propensity score analysis", J Trauma Acute Care Surg, Vol. 80, No. 4, pp. 559-566; discussion 566-557, 2016. DOI: https://dx.doi.org/10.1097/ta.0000000000000968
  12. Pieper A, Thony F, Brun J, Rodiere M, Boussat B, Arvieux C, Tonetti J, Payen JF, Bouzat P, "Resuscitative endovascular balloon occlusion of the aorta for pelvic blunt trauma and life-threatening hemorrhage: A 20-year experience in a Level I trauma center", J Trauma Acute Care Surg, Vol. 84, No. 3, pp. 449-453, 2018. DOI: https://dx.doi.org/10.1097/ta.0000000000001794
  13. Shin HK, Han H-S, Lee T, Park D-J, Jung K, Kim K, "Resuscitative Endovascular Balloon Occlusion of the Aorta in a Trauma Patient with Hypovolemic Shock", The Korean Journal of Critical Care Medicine, Vol. 30, No. 2, pp. 115-118, 2015. DOI: http://dx.doi.org/10.4266/kjccm.2015.30.2.115
  14. Krige JEJ, Kotze UK, Hameed M, Nicol AJ, Navsaria PH, "Pancreatic injuries after blunt abdominal trauma: an analysis of 110 patients treated at a level 1 trauma centre", South African journal of surgery, Vol. 49, No. 2, pp. 584 passim, 2011.
  15. Krige JE, Navsaria PH, Nicol AJ, "Damage control laparotomy and delayed pancreatoduodenectomy for complex combined pancreatoduodenal and venous injuries", Eur J Trauma Emerg Surg, Vol. 42, No. 2, pp. 225-230, 2016. DOI: https://dx.doi.org/10.1007/s00068-015-0525-9
  16. Krige JEJ, Kotze UK, Setshedi M, Nicol AJ, Navsaria PH, "Management of pancreatic injuries during damage control surgery: an observational outcomes analysis of 79 patients treated at an academic Level 1 trauma centre", Eur J Trauma Emerg Surg, Vol. 43, No. 3, pp. 411-420, 2017. DOI: https://dx.doi.org/10.1007/s00068-016-0657-6
  17. Diener MK, Seiler CM, Rossion I, Kleeff J, Glanemann M, Butturini G, Tomazic A, Bruns CJ, Busch OR, Farkas S, Belyaev O, Neoptolemos JP, Halloran C, Keck T, Niedergethmann M, Gellert K, Witzigmann H, Kollmar O, Langer P, Steger U, Neudecker J, Berrevoet F, Ganzera S, Heiss MM, Luntz SP, Bruckner T, Kieser M, Buchler MW, "Efficacy of stapler versus hand-sewn closure after distal pancreatectomy (DISPACT): a randomised, controlled multicentre trial", Lancet, Vol. 377, No. 9776, pp. 1514-1522, 2011. DOI: https://dx.doi.org/10.1016/s0140-6736(11)60237-7