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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3645_Библиотеки_им_академика_М_И_Перельмана
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History
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▶ A14-Year-Old Girl with Le Upper Quadrant Pain Following a Motor Vehicle Accident
Case 37
Figure 37.1
Figure 37.2
Figure 37.3
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Case 37 Splenic Trauma
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Figure 37.4 Figure 37.5
Figure 37.6 Figure 37.7
Findings
▶ Axial and coronal enhanced computed tomography (CT) images (Figs. 37.4 and 37.5) demonstrate a splenic
laceration with involvement of the hilar vessels.
▶ Splenic angiogram (Fig. 37.6) shows early draining splenic vein (hollow arrow), consistent with traumatic
arteriovenous stula. Note the heterogenous perfusion of the spleen with areas of poorly perfused parenchyma
(arrows).
▶ Coil embolization of the splenic artery distal to the origin of the dorsal pancreatic was performed to stasis
(Fig. 37.7).
Teaching Points
▶ e spleen is the most frequently injured intraperitoneal organ following blunt abdominal trauma.
▶ Categories of splenic injury from the American Academy of Surgery and Trauma Organ Injury scale:
I—subcapsular hematoma <25% surface area, capsular tear <1cm of parenchymal depth
II—subcapsular hematoma 25%–50% of surface area, intraparenchymal hematoma < 5cm in diameter;
1–3cm laceration without involvement of trabecular vessels
III—subcapsular hematoma >50% of surface area, intraparenchymal hematoma >10cm; laceration >3cm
parenchymal depth with involvement of trabecular vessels
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IV—laceration involving segmental/hilar vessels with >25% devascularization
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V—completely shattered spleen, total splenic devascularization
▶ When no active extravasation is identied, proximal embolization to decrease perfusion pressure of the spleen
is performed to stop hemorrhage. Collateral blood ow to the splenic parenchyma from short gastric and
capsular arteries usually prevents total splenic infarction. In the setting of discrete extravasation, subselective
embolization may be performed.
▶ When possible, embolization of the splenic artery embolization should be distal to the dorsal pancreatic
artery, which typically arises from the proximal third of the splenic artery.
Treatment
▶ Patients who remain hemodynamically unstable aer resuscitation should be managed surgically.
▶ e indications for splenic artery embolization vary but include ongoing hemorrhage in a hemodynamically
stable patient, and imaging ndings of contrast extravasation or direct vascular injury, with a high grade of
injury.
Further Reading
Imbrogno BF, Ray CE. Splenic artery embolization in blunt trauma. Semin Intervent Radiol. 2012; 29(2):147–149.
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Case 38
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History
▶ Fevers and Leukocytosis 1 Week aer Gastrectomy Complicated by Abscess
Aer removal of the drainage catheter, the patient became hypotensive and tachycardic, and a computed
tomography (CT) (Fig.38.3) was obtained.
Figure 38.1
Figure 38.3
Figure 38.2
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Case 38 Drainage of Abdominal Abscess Complicated by
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Inferior Epigastric Artery Injury Pseudoaneurysm
Figure 38.4 Figure 38.5
Figure 38.4
Figure 38.6 Figure 38.7
Figure 38.5
Figure 38.8
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Findings
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▶ Abilobed collection with an enhancing rim is seen in the le lower quadrant Fig. 38.4. Percutaneous drainage
was performed (Fig. 38.5), inadvertantly crossing the inferior epigastric vessels (arrow, Fig. 38.4).
▶ CT performed immediately aer catheter removal (Fig. 38.6) when the patient became hypotensive shows
hyperdense intraabdominal hematoma at the site of the previous collection (arrows).
▶ Le inferior epigastric angiogram (Fig. 38.7) shows a focal pseudoaneurysm where the catheter had crossed
the vessel (arrow). is was successfully embolized with 3–5mm stainless steel coils (Fig.37.8).
Teaching Points
▶ Preprocedure planning must include a careful review of available imaging and consideration of
interpositioned normal anatomic structures to minimize the risk of injury or complication.
▶ e inferior epigastric artery is a distal branch of the external iliac artery. Because of the proximity to the
common femoral artery which is typically accessed for lower-extremity intervention, catheterization of the
inferior epigastric artery is best performed from a contralateral approach.
▶ Apseudoaneurysm is an injury to at least one layer of the arterial wall. Whereas a true aneurysm may be
treated by occluding the sac, there is no “sac” in a pseudoaneurysm because it represents a contained rupture.
▶ Most reported cases of inferior epigastric pseudoaneuryms are iatrogenic, related to abdominal wall
procedures including hernia repair, surgical drains, and trocar injury during laparoscopy.
Management
▶ Embolization of a pseudoaneurysm should include the vessel immediately distal and proximal to the injury to
prevent revascularization from collateral vessels.
▶ Alternative treatment options include ultrasound-guided thrombin injection in larger lesions, or surgical
ligation.
Further Reading
Georgiadis GS, Souas VD, Papas TT, etal. Inferior epigastric artery false aneurysms:review of the literature and case report.
Eur J Vasc Endovasc Surg. 2007; 33(2):182–186.
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History
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▶ A45-Year-Old Female with History of Roux-en-Y Gastric Bypass Presents with Melena
Figure 39.1
Case 39
Figure 39.2
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Case 39 Upper Gastrointestinal Bleed
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Figure 39.3
Figure 39.4
Figure 39.5
Findings
▶ Figure 39.3 represents a tagged red blood cell scan showing radiotracer activity in the right upper quadrant
(black arrow). Cine images (not shown) demonstrate increased pooling and movement of the activity across to
the le abdomen.
▶ Selective angiogram of the inferior pancreaticoduodenal artery arising from the superior mesenteric artery
(Fig. 39.4) shows active contrast extravasation (black arrow).
▶ Superselective arteriogram of a branch of the pancreaticoduodenal artery shows contrast extravasation into
the duodenum (black arrow in Fig. 39.5).
▶ Figure 39.6 shows successful coil embolization and exclusion of the bleeding branch.
Teaching Points
▶ Common causes of acute upper gastrointestinal bleeding include peptic ulcer disease, variceal bleeding,
gastritis, Mallory Weiss tears, postoperative marginal ulcers, and iatrogenic causes such as aer an endoscopic
sphincterotomy.
Figure 39.6
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▶ Radionuclide scintigraphy is most commonly performed with
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to detect bleeding as slow as 0.4 mL/min. 99Tc-labeled red blood cell scans are more sensitive than catheter
angiography, which detects bleeding at a rate of 0.1 to 1.0 mL/min. Additionally, the chance of identifying
hemorrhage on a 99Tc-labeled red blood cell scan is higher because it can be imaged over several hours
compared to angiography, which images over a few seconds.
99
Tc-labeled red blood cells with the ability
Management
▶ Endoscopic diagnosis and management with clipping or cauterization is eective in the majority of cases of
upper gastrointestinal bleeding. Cases refractory to endoscopic techniques or unreachable by endoscopic
techniques can be treated with angiography and embolization. In this case, secondary to the Roux-en-Y
anatomy, the endoscopist could not reach the bleeding segment.
▶ In cases with a negative angiogram, empiric embolization of the gastroduodenal artery or le gastric artery
(depending on cause and ndings on endoscopy) is oen successful in treatment of the acute episode and
prevents recurrent bleeding.
▶ Embolization can be performed with microcoils, gelfoam, polyvinyl alcohol particles, or glue.
Further Reading
Loror R, Rao P, Ota S, etal. Embolization of acute nonvariceal upper gastrointestinal hemorrhage resistant to endoscopic
treatment:results and predictors of recurrent bleeding. Cardiovasc Intervent Radiol. 2010; 33:1088–1100.
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Case 40
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History
▶ A60-Year-Old Male with Acute Lower Gastrointestinal Bleeding (Radionuclide Scanning Was Unavailable)
Figure 40.1
Figure 40.2
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