Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (65 page)

BOOK: Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice
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Interventional radiology

In a significant number of patients, interventional radiology, with arterial embolisation (AE), stent or stentgraft placement, has become either the first line of treatment or an important adjunct to non-operative management of abdominal and other injuries.
80
Clinical evaluation, however, determines the course of treatment. Patients who are haemodynamically stable should be evaluated with CECT.

Angio-embolisation in liver injuries

Non-operative management (NOM) of blunt liver injuries in haemodynamically stable or stabilised patients has become standard practice. The introduction of AE has been reported to increase the success rate of NOM to well above 80%.
81

Operative treatment of liver injuries, even in experienced hands, still carries a high mortality and morbidity risk. AE seems to be a valuable adjunct to operative management since most patients are haemodynamically abnormal at the end of a damage control laparotomy, and ongoing arterial bleeding is difficult to rule out clinically.

The indications for AE should include CT evidence of ongoing bleeding with contrast extravasation outside or within the liver, a drop in haemoglobin, tachycardia and haemoperitoneum, as well as formation of pseudoaneurysm. The risk of bleeding with NOM in OIS grade 4 and 5 liver injuries is significant, and operative intervention, with packing, followed by AE is preferable.
82

Angio-embolisation in blunt splenic injuries

Indications for AE include CT evidence of ongoing bleeding with contrast extravasation outside or within the spleen, a drop in haemoglobin, tachycardia and haemoperitoneum, as well as formation of pseudoaneurysm. Selective catheterisation of the splenic artery is performed, followed by superselective catheterisation of the bleeding arteries or feeders to the pseudoaneurysm.
83
,
84

Angio-embolisation in severe pelvic fractures

Severe pelvic fractures, particularly with disruption of the sacroiliac joints, are associated with a high risk of severe arterial and venous bleeding. The application of a sheet or external fixation may control the venous bleeding, which constitutes about 85% of all pelvic bleeding. However, arterial bleeding often requires AE, which has become the first line of treatment in patients stable enough to reach angiography.
85
Established indications are CT evidence of ongoing bleeding such as contrast extravasation and pelvic haematoma with bladder compression and ongoing transfusion requirements without evidence of other extrapelvic bleeding sources.

There is also a possibility in this subgroup of patients of severe venous bleeding. The patient in shock refractory to resuscitation should be considered for damage control with (extraperitoneal) pelvic packing before AE.

AE is carried out after performing an abdominal aortography followed by selective catheterisation of the internal iliac arteries. When contrast extravasation is demonstrated, the bleeding vessels are catheterised superselectively and embolised with coils, or a combination of coils and gelfoam particles.

 

Key points

• 
In order to avoid missed injuries and preventable deaths, trauma patients who have any of the risk factors for abdominal injury should undergo objective evaluation of the abdomen.
• 
Delay in surgery is the most common cause of unnecessary ongoing bleeding.
• 
In patients who are unstable, the preferred objective study is a bedside ultrasound. If an ultrasound examination is unavailable or equivocal, a DPL should be performed.
• 
In stable patients, abdominal CT with intravenous contrast is the preferred method of objective examination of the abdomen.
• 
When laparotomy is required, it should be approached in a systematic fashion and the treatment of injuries prioritised.
• 
In patients who are cold, coagulopathic and acidotic, a damage control operation should be accomplished promptly.
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