MODERN CONDITION OF PROBLEM OF TREATMENT OF PATIENTS WITH ONGOING INTRAPELVIC BLEEDING AFTER UNSTABLE PELVIC RING INJURIES Egiazaryan K.A, Starchik D.A., Gordienko D.I., Lysko A.M.
Pirogov Russian National Research Medical University, Moscow, Russia,
North-Western State Medical University named after I.I. Mechnikov, Saint Petersburg, Russia
The problem of treatment of intrapelvic bleedings after unstable pelvic ring injuries is still actual and is mainly characterized by quite high incidence of lethal outcomes and significant medical and social consequences. According to various authors, retroperitoneal hematomas complicate up to 44 % of all closed abdominal and pelvic injuries [1, 2]. Ishikawa [3] in his study of causes of retroperitoneal hematomas concluded that the main cause of retroperitoneal haemorrhage was traumatic damage of the pelvic ring in more than half of cases. It is necessary to note that injuries to pelvic bones present 2-8 % of all injuries to axial skeleton, but they are a part of associated or multiple injuries in more than 22 % [4-7]. 30-60 % of such injuries are lethal, with almost each third case as a consequence of uncontrolled bleeding [8-12].
In 8 of 10 cases, the main causes of massive bleeding into small pelvis cavity are spongy pattern of pelvic bones, unconnected vessels in bone matter in fracture site, common injury to sacral venous plexus, and coagulopathy in patients with acute associated injury. Moreover, blood loss can achieve 3.5-6 l [13, 14].
Considering the importance of the reviewed problem, the search for the universal and efficient technique for arresting intrapelvic bleeding has been continuing for years. However at the present time, each developed and clinically tested methods has its own limitations for use and the range of complications influencing on the final result.
External fixation of pelvic ring
According to the modern recommendations, the presence of mechanical instability of the pelvic ring, regardless of hemodynamics condition, is the indication for urgent fixation, which has to be realized as early as possible after hospital admission [15-17].
The simplest technique of primary stabilization of the pelvic ring is pelvic bandage or manual constriction of pelvic bones with the sheet. According to actual recommendations from ATLS [18], it is obligatory to use the pelvic bandage if the patient has some clinical signs of any injury to the pelvic ring. Biomechanical studies of postmortem materials showed the efficiency of use of the pelvic bandage in decreasing intrapelvic volume and control of hemorrhage [19-21]. However the use of the pelvic bandage is associated with the risk of development of necrosis and skin erosion. The main cause was its long term use – more than 24-48 hours from the moment of application. It is recommended to prevent such problems with use of external fixation tools.
The specific methods of stabilization have been developed on the basis of distribution of the pelvic ring into anterior and posterior semi-rings [22]. Two main method of external fixation apparatus have been developed and are used for the anterior semi-ring: the first – with introduction of Shants’s screws into iliac wings, the second – in supraacetabular manner. The first way is considered as more simple and quick, but small bony corridor is the cause of enough weak fixation of pins, and this cause is associated with high amount of secondary displacements and disorders of fixation, and with high probability of penetration of corticals and soft tissue injuries. A compared to this, the second method allow fixation of Shants’s screws in wider bone tunnel with high amount of strong bone tissue. The main disadvantage of this method is its complexity, which is determined by need for X-ray devices. This requirement is determined by higher risk in conduction of pins. So, the main complications of the second method are penetration of the ipsilateral hip joint or penetration into greater ischiadic with risk of an injury to the sciatic nerve and vascular nervous bundles [9, 23].
However fixation with the above mentioned techniques for injuries to posterior parts of the pelvic ring is unstable. For such cases, C-frame, which was created by Ganz in 1991, is recommended [24]. C-frame allows fast stabilization of hemodynamic values [25, 26]. During fixation of posterior parts of the pelvic ring with C-frame, it is recommended to control the reposition and correct position of the frame by means of X-ray techniques. Otherwise, the complications are possible such as migration of the fixator into the greater ischiadic, with possibility of an injury to the sciatic nerve, gluteal vascular nervous bundles, intestine puncture, perforation of pelvic walls, insufficient compression of posterior parts, infectious contamination in region of upcoming complete fixation of posterior parts of the pelvic ring [27, 28]. Kim [29] described a clinical case of pseudoaneurysm of superior gluteal artery after fixation of posterior parts of the pelvic ring with C-frame in blind manner.
At the present time, a new technique for low-invasive external fixation of the pelvic ring has been becoming popular. It was described by Knutter in 2009 [30] and was named later as internal fixation (INFIX) [31]. The best clinical results of its use were noted in patients with excessive development of subcutaneous fat and in older patients [32-34]. The essence of the method consists in introduction of pedicular screws into the supraacetabular region with subsequent subcutaneous connection with the premodelled spinal bar. As compared to the common external fixation of the anterior semi-ring, this technique decreases the risk of infectious complications, results in early activation of patients, a possibility for supine position during surgical interventions for the spine, and a great comfort as a technique for final stabilization of the pelvic ring. However the first results of use of the new technique of fixation indicate some complications such as a possibility for compression of external iliac vessels, femoral skin nerve paresis, femoral nerve paresis, deep infection, loosening of fixators, and residual chronic pain [35, 36].
Therefore, external fixation is the obligatory component of anti-hock therapy in patients with ongoing intrapelvic bleeding as result of unstable injuries to the pelvic ring [37-40].
Actual methods of intrapelvic bleeding arrest
For cases of unstable hemodynamics after external fixation and closure of the pelvic ring, it is necessary to conduct the pelvic tamponade or vascular angioembolization [41, 42]. The analysis of international literature showed that American and European surgical schools have different opinions on an efficient method for intrapelvic bleeding arrest: angioembolization is more popular in USA, pelvic tamponade – in European countries [10, 43, 44].
Transcatheter angioembolization, which was firstly performed by Margolies in 1972 [45], was accepted by the world society as the efficient neurosurgical method for intrapelvic bleeding arrest. Angioembolization can be selective and non-selective. Selective angioembolization is more preferable due to lower amount of complications. However it is associated with higher risk of failure of bleeding arrest as compared to non-selective angioembolization [46]. The complications of this technique include the necrosis of gluteal muscle, urine bladder, urinary tract walls and the skin, development of deep infection, nerve injuries and contrast-induced nephropathy [47, 48]. However predominant development of bleeding from veins and pelvic ring fracture sites determine the efficiency of angiography as the primary method for bleeding arrest only in 10-20 % of cases [2, 37]. This fact was the cause of creation of the new technique for intrapelvic bleeding arrest.
A technique for retroperitoneal bleeding arrest, developed by T. Pohlemann et al. in Hannover [49], showed a reliable decrease in mortality in patients with unstable injuries to the pelvic ring and intrapelvic bleeding. Experienced persons can perform this procedure within 20 minutes with minimal blood loss [50]. Realization of a separate approach was more protected in relation to cross contamination from intraabdominal injuries to retroperitoneal space, resulting in reliable decrease in risk of infectious complications [51]. Drapes stay in the wound within 24-48 hours. Then they are changed or removed [52]. Pelvic tamponade is more invasive method in relation to angiography. It increases the risk of infectious complications (up to 15 %) and causes need for surgery, additional blood loss and problems relating to middle laparotomy. The need for recurrent tamponade increased the risk of infectious complications [26].
Some studies [11, 53] of comparison of both methods for intrapelvic bleeding arrest showed that time of carrying out and availability in groups of patients with pelvic tamponade was lower in comparison with angioembolization. Another important factor is the fact that realization of angioembolization requires for availability of special surgery room, equipment and trained team which are not available in each hospital. However it does not mean that realization of pelvic tamponade precludes the realization of angioembolization. Conversely, it is recommended to perform it for control of arterial source of bleeding in case of ongoing bleeding after pelvic tamponade [54, 55]. According to some authors [28, 56], the amount of patients who needed for angioembolization after pelvic tamponade was 13-20 %.
New trends in international practice of intrapelvic bleeding arrest
Recently, one can observe the increasing trend of return to the method of temporary occlusion of the aorta. According to some authors, this method gives the critical time for search of bleeding source and for its arrest.
This method was firstly mentioned in 1954 when Hudhes C.W. [57] used it as a way of first aid for soldiers in Korean war. However the high traumatic potential of this method caused some evident limitations of its use. After decades, it resulted in development of less invasive but similar technique for bleeding arrest – resuscitative endovascular balloon occlusion of the aorta (REBOA) [58-60].
Subsequent experimental animal studies [61] and 10-20 year experimental studies [62] showed the efficiency of this technique. However it has its own disadvantages. Some authors [59, 60, 63] described some cases of elevation or development of intracranial and intrapleural bleeding above the level of aortal occlusion, ruptures and dissection of the aorta, and possible risk of multiple organ failure after balloon purging after reperfusion injuries.
The world-wide trend to search for less invasive solutions for realization of medical interventions also resulted in development of this direction in intrapelvic bleeding arrest. In 2015, S. Huang [64] offered to perform the tamponade of mall pelvis by means of urinary bladder catheterization with its filling with 500-600 ml of saline. The main criterion, which is necessary for realization in clinical practice, was confirmation of integrity of urinary tract. The given clinical case showed the achievement of hemodynamics in early period after admission to the intensive care unit and tamponade with filled urinary bladder. However some time after removal of fluid, the patient’s hemodynamics destabilized. Therefore, the surgeons needed to perform laparotomy for correction of ongoing bleeding.
In December 2016, the group of researchers headed by K.K. Sokol [65] published the experimental animal study. The essence of the study consisted in testing and comparison of the new technique of low invasive balloon tamponade in comparison with the group of animals without tamponade and with the group receiving the pelvic tamponade according to the standard technique. The scientists proved the efficiency of low invasive balloon tamponade, with balloons placed into the Retzius's cavity in pigs, resulting in successful effect of pelvic tamponade. The method was quite simple and fast, with controlled purging and injection of fluid for simplification of angiography.
Therefore, the new low invasive techniques present the quite perspective direction of surgical treatment of patients with unstable injury to the pelvic ring complicated by intrapelvic bleeding from the point of extension of indications and decrease in amount of complications. However the precise techniques of such operations have not been studied yet and they require for development of individual indications for its realization, technique and clinical administration in practice.
DISCUSSION
Generally, the conducted analysis of the modern literature of the problem of intrapelvic bleeding arrest after unstable injuries to the pelvic ring showed the absence of the current uniform opinion on selection of the optimal technique for treatment of the studied injury despite of high amount of modern methods which decrease the risk of complications.
It is known that external fixation of the pelvic ring, despite of all advantages of mechanical stabilization at the urgent stage of first aid, is not always an efficient method for restoration of hemodynamic values that requires additional actions of the surgical team. Currently, such techniques are endovascular balloon occlusion of the aorta, angioembolization and pelvic tamponade. REBOA is currently considered as the intermediate stage in arrangement of care for fast and efficient arrest of bleeding, but ischemic and reperfusion complications causes the serious limitations of the temporary interval of use of this technique. Owing to predominance of venous bleeding over arterial one, angioembolization has more limited indications for use in relation to pelvic tamponade, despite of low invasiveness, and difficulties in realization of selective technique cause the development of ischemic injuries to internal organs and surrounding soft tissues which can be the source of septic inflammation in future. Pelvic tamponade is quite invasive technique for bleeding arrest that influences on the incidence of infectious complications and on need for recurrent surgical interventions.
Considering the world-wide trend to low invasiveness and low traumatic potential of surgical interventions and need for fast rehabilitation, we can state that closed low-invasive pelvic tamponade is one of the most perspective techniques for intrapelvic bleeding arrest. However despite of the first encouraging experimental results, there are a lot of unsolved issues relating to technique of such surgical interventions.
CONCLUSION
Summing the results, we should note that the problem of selection of a technique for intrapelvic bleeding arrest in patients with unstable pelvic ring injuries is still actual. The first research works of low invasive methods of urgent pelvic surgery (REBOA, cystic and low invasive balloon cystic pelvic tamponade) demonstrate the perspective possibilities in view of efficiency and safety at the background of quite small approaches. However the final opinion on positive aspects of the above mentioned techniques requires for special topographic and anatomical examination of details of surgical techniques and targeted estimation of distances from implanted devices to magistral vessels, nerves and internal organs of small pelvis. Moreover, successful clinical implementation of the discussed techniques requires for realization of an experimental animal study. Without evidences, the wide clinical use of low invasive techniques for profile patients is impossible.
Information on financing and conflict of interests
The study was conducted without sponsorship.
The authors declare the absence of any clear and potential conflicts of interests relating to publication of this article.