Management of post-pancreatectomy haemorrhage using resuscitative endovascular balloon occlusion of the aorta

Is REBOA the Last Card to Control a Massive Gastrointestinal Bleeding?

INTRODUCTION

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a potential tool for the management of massive gastrointestinal bleeding (MGB). This study aims to describe the experience of the use of REBOA as adjunctive therapy in patients with MGB and to evaluate its effectiveness.

METHODS

Serial cases of patients with hemorrhagic shock secondary to MGB in whom REBOA was placed were collected. Patient demographics, bleeding severity, etiology, management, and clinical outcomes were recorded.

RESULTS

Between 2017 and 2020, five cases were analyzed. All patients had a severe gastrointestinal bleeding (Glasgow Blatchford Bleeding Score range 12-17; Clinical Rockal Score range 5-9). The etiologies of MGB were perforated gastric or duodenal ulcers, esophageal varices, and vascular lesions. Systolic blood pressure increased after REBOA placement and total occlusion time was 25-60 min. REBOA provided temporary hemorrhage control in all cases and allowed additional hemostatic maneuvers to be performed. Three patients survived more than 24 h. All patients died in index hospitalization. The main cause of death was related to hemorrhagic shock.

CONCLUSIONS

Endovascular aortic occlusion can work as a bridge to further resuscitation and attempts at hemostasis in patients with MGB. REBOA provides hemodynamic support and may be used simultaneously with other hemostatic maneuvers, facilitating definitive hemorrhage control.

Triple Thoracic Injury Caused by Foreign Body Ingestion: A New Approach for Managing an Unusual Case

Patient: Male, 31-year-old

Final Diagnosis: Esophageal perforation

Symptoms: Chest pain

Medication: —

Clinical Procedure: —

Specialty: Surgery

Endovascular Hepatic Artery Stents in the Modern Management of Postpancreatectomy Hemorrhage

Background

Postoperative hemorrhage is a potentially lethal complication of pancreatoduodenectomy. This study reports on the use of endovascular hepatic artery stents in the management of postpancreatectomy hemorrhage.

Methods

This is a retrospective analysis of a prospectively maintained, consecutive dataset of 440 patients undergoing pancreatoduodenectomy over 68 months. Data are presented on bleeding events and outcomes, and contextualized by the clinical course of the denominator population. International Study Group of Pancreatic Surgery terminology was used to define postpancreatectomy hemorrhage.

Results

Sixty-seven (15%) had postoperative hemorrhage. Fifty (75%) were male and this gender difference was significant (P = 0.001; 2 proportions test). Postoperative pancreatic fistulas were more frequent in the postoperative hemorrhage group (P = 0.029; 2 proportions test). The median (interquartile range [IQR]) delay between surgery and postoperative hemorrhage was 5 days (2-14 days). Twenty-six (39%) required intervention comprising reoperation alone in 12, embolization alone in 5, and endovascular hepatic artery stent deployment in 5. Four further patients underwent more than 1 intervention with 2 of these having stents. Endovascular stent placement achieved initial hemostasis in 5 of 7 (72%). Follow-up was for a median (IQR) of 199 days (145-400 days) poststent placement. In 2 patients, the stent remained patent at last follow-up. The remaining 5 stents occluded with a median (IQR) period of proven patency of 10 days (8-22 days).

Conclusions

This study shows that in the specific setting of postpancreatoduodenectomy hemorrhage with either a short remnant gastroduodenal artery bleed or a direct bleed from the hepatic artery, where embolization risks occlusion with compromise of liver arterial inflow, endovascular hepatic artery stent is an important hemostatic option but is associated with a high risk of subsequent graft occlusion.

[Postpancreatectomy hemorrhage]

Surgical treatment of pancreatic diseases is always associated with a large number of complications. Postoperative hemorrhage is a specific complication of pancreatic surgery requiring a clear classification and surgical strategy. According to literature data, postoperative hemorrhage occurs in 3-30% of cases. Incidence of hemorrhages depends on intraoperative, anamnestic, histological and postoperative factors. Early postoperative hemorrhage (within 24 hours after surgery) is usually a consequence of technical errors in intraoperative hemostasis, perioperative coagulation disorders. The mechanism of delayed bleeding is more complex and often associated with various arrosive factors: pancreatic fistula, biliary fistula, abscess. Currently, there is no a single treatment algorithm for patients with postpancreatectomy hemorrhage. According to various researchers, contrast-enhanced CT is preferred for diagnosis. In recent years, the role of endovascular hemostasis has significantly increased. This problem requires further study and development of a single treatment and diagnostic algorithm that will reduce mortality in these patients.

Resuscitative Endovascular Balloon Occlusion of the Aorta (REBOA): update and insights into current practices and future directions for research and implementation

Background

In this review, we assess the state of Resuscitative Endovascular Occlusion of the Aorta (REBOA) today with respect to out-of-hospital (OOH) vs. inhospital (H) use in blunt and penetrating trauma, as well as discuss areas of promising research that may be key in further advancement of REBOA applications.

Methods

To analyze the trends in REBOA use, we conducted a review of the literature and identified articles with human or animal data that fit the respective inclusion and exclusion criteria. In separate tables, we compiled data extracted from selected articles in categories including injury type, zone and duration of REBOA, setting in which REBOA was performed, sample size, age, sex and outcome. Based on these tables as well as more detailed review of some key cases of REBOA usage, we assessed the current state of REBOA as well as coagulation and histological disturbances associated with its usage. All statistical tests were 2-sided using an alpha=0.05 for significance. Analysis was done using SAS 9.5 (Cary, NC). Tests for significance was done with a t-test for continuous data and a Chi Square Test for categorical data.

Results

In a total of 44 cases performed outside of a hospital in both military and civilian settings, the overall survival was found to be 88.6%, significantly higher than the 50.4% survival calculated from 1,807 cases of REBOA performed within a hospital (p<.0001). We observe from human data a propensity to use Zone I in penetrating trauma and Zone III in blunt injuries. We observe lower final metabolic markers in animal studies with shorter REBOA time and longer follow-up times.

Conclusions

Further research related to human use of REBOA must be focused on earlier initiation of REBOA after injury which may depend on development of rapid vascular access devices and techniques more so than on any new improvements in REBOA. Future animal studies should provide detailed multisystem organ assessment to accurately define organ injury and metabolic burden associated with REBOA application. Overall, animal studies must involve realistic models of injury with severe clinical scenarios approximating human trauma and exsanguination, especially with long-term follow-up after injury.

[Resuscitative endovascular balloon occlusion of the aorta (REBOA) : Current aspects of material, indications and limits: an overview]

Hintergrund

„Resuscitative endovascular balloon occlusion of the aorta“ (REBOA) stellt ein endovaskuläres Verfahren dar, bei dem ein Blockballon in die Aorta eingeführt wird, um eine distal des Ballons gelegene Blutung zu verringern und gleichzeitig die kardiale und zerebrale Oxygenierung zu verbessern.

Ziel der Arbeit

Vorstellung der REBOA-Technik, der möglichen Indikationen, der benötigen Materialien und der möglichen Komplikationen des Verfahrens.

Material und Methoden

Nichtsystematischer Übersichtsartikel über die aktuelle Literatur.

Ergebnisse

REBOA stellt gerade bei traumatisch bedingten Blutungen und rupturierten Aortenaneurysmen ein mögliches additives Verfahren zur hämodynamischen Stabilisierung dar. Die Komplikationsrate des Verfahrens liegt bei ungefähr 5 %, wobei Zugangskomplikationen im Vordergrund stehen, jedoch auch letale Komplikationen möglich sind.

Diskussion

Eine aortale Ballonblockade wird bei der Versorgung rupturierter Aortenaneurysmen standardmäßig eingesetzt. Es gibt wachsende Evidenz, dass REBOA bei der Versorgung polytraumatisierter Patienten mit einem hämorrhagischen Schock aufgrund einer abdominellen oder viszeralen Blutung eine vergleichsweise minimal-invasive Alternative zur offen chirurgischen Aortenklemmung mittels Thorakotomie darstellt. Mit der Entwicklung neuer Ballonkatheter, die ohne Führungsdraht und mit geringeren Schleusendurchmessern auskommen, wird auch ein Einsatz bei anderen Krankheitsbildern wie postoperativen abdominellen Nachblutungen, gynäkologischen Blutungen oder als additives Verfahren bei der kardiopulmonalen Reanimation diskutiert.

Endovascular balloon occlusion during reconstruction of portal vein injury

PURPOSE

Repair of portal vein injury in a hostile abdomen can be very challenging, complicated by massive hemorrhage or stenosis. It can seldom be successfully carried out, even by experienced hepatobiliary surgeons. The ideal venous clamping technique is often not feasible and increases the risk of lethal portal vein laceration. The common mistake being the forceful use of clamps around the vein in the attempt to obtain vascular control, resulting in additional injuries.

METHODS

We provide a descriptive report of two cases detailing a careful step-by-step technique for the management of portal vein injury by inserting an endovascular balloon inflated with serum to control bleeding and repair the vein.

RESULTS

In patients who required this technique, no bleeding recurrence, nor portal vein thrombosis or stenosis was detected by CT-scan during follow-up.

CONCLUSION

The endovascular balloon occlusion technique for the reconstruction of portal vein injuries in hostile abdomen is a safe and life-saving procedure that should be part of the armamentarium of visceral surgeons.