Manoj Gupta, Sangeeta Nimbalkar, Punit Singla, Vinay Kumaran, Ravi Mohanka, Naimish Mehta, Satish Saluja, A S Soin, S Nundy
Department of Surgical
Gastroenterology and Liver Transplantation
Sir Ganga Ram Hospital,
New Delhi 110060, India
Corresponding Author:
Dr. Samiran Nundy
Email: snundy@hotmail.com
Abstract
Background: Using abdominal packs is often a life-saving technique for uncontrollable bleeding during operations. It prevents worsening of the hypothermia, coagulopathy and acidosis which usually accompanies massive bleeding till they may be corrected and the packs removed later. However, packing may be associated with a mortality of 56 to 82 % due to continued bleeding, intra-abdominal abscesses and the compartment syndrome. We follow a policy of early abdominal packing (considering it after a 6 unit intraoperative blood loss) before the situation becomes irreversible.
Patients and methods: Between January 1997 and September 2008, abdominal packing for uncontrollable bleed was done in 49 patients (M:F 34:15, mean age 43 years) . The risk factors for mortality were nalyzed. The reasons for uncontrollable bleed were : liver trauma (8), liver tumours (3), following liver transplantation 4), pancreatic necrosectomy (17) and miscellaneous causes (17).
Results: There were 16 postoperative deaths (32.7%). On univariate analysis, hypovolaemic shock, a low urine output, raised INR, blood requirement of more than 6 units, hypothermia <340C, metabolic acidosis nd sepsis were associated with an increased mortality. However, on multivariate logistic regression only hypothermia was significantly associated with mortality.
Conclusion: A fair survival rate can be achieved by early and judicious use of abdominal packing especially before hypothermia supervenes.
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The use of packing with abdominal swabs is often a lifesaving technique to control bleeding which cannot be controlled by conventional techniques like suturing. This usually follows emergency procedures like liver trauma or pancreatic necrosectomy. This may also occur after elective operations where there may be massive bleeding from raw hypervascular surfaces, for instance, after the excision of large cancers, pelvic operations, liver tumours and liver transplantation.
Success depends upon early recognition of the limitation to control the haemorrhage and early intervention in the form of adequate pack insertion followed by the appropriate timing of pack removal[1]. The main aim of packing is to forestall the worsening of acidosis, hypothermia, and coagulopathy and restoration of haemodynamic stability[2]. The subsequent relook laparotomy to remove the packs must be timed before infection occurs[3,4, 5].
The decision to insert abdominal packs is a difficult one. It implies a technical failure on the surgeon’s part to control bleeding and also means that the patient usually has to be transferred on a ventilator to an intensive care unit and undergo a second operation for pack removal. Packing is also associated with complications like intra-abdominal abscesses or compartment syndrome[3]. However, the timely and judicious use of packing may save a patient’s life and we consider using packs early as soon as the patient with bleeding has received 6 units of blood during operation, develops hypothermia, acidosis or inability of blood to clot.
We present a case series of patients with surgically uncontrollable haemorrhage who underwent abdominal packing.
Patients and Methods
We performed retrospective analysis of prospectively collected data. Between January 1997 to September 2008, we used abdominal packing in 49 consecutive patients who were undergoing operations in the Department of Surgical Gastroenterology and Liver Transplantation of Sir Ganga Ram Hospital, New Delhi.
The surgical procedures that required abdominal packing included uncontrollable bleeding following liver injuries (8), pancreatic necrosectomy (17), following other operations like diffuse oozing following a pancreaticoduodenectomy in jaundiced patients, large rectal tumours, large retroperitoneal tumours and following re-explorations with associated oozing from extensive raw surfaces (17), bleeding liver tumours (3) and after liver transplantation (4).
Packing was done in patients with liver trauma in whom bleeding could not be controlled in spite of ligation of visible bleeders, by the application of Pringle’s manoeuvre for 20 minutes and with grades 3-5 liver injuries. Adequate dry packs were used to stem the haemorrhage and overpacking was avoided so that the patient did not develop the bdominal compartment syndrome. Re-look laparotomy was performed approx 24-72 hrs after initial surgery following orrection of shock, hypothermia and coagulopathy.
In patients with acute pancreatitis, necrosectomy was usually done 3-4 weeks after the onset of symptoms or earlier in patients who had signs of septicaemia and failure of more than two organ systems. After open necrosectomy if there was continuous bleeding from many sites in the friable pancreatic bed packs were inserted and the abdomen was closed in a single layer without drains to apply additional tamponade. After 48 hours the packs were removed and reinserted if the bleed recurred.
Abdominal packs were used to control bleeding in liver transplantation after the donor organ had been implanted into a liver recipient with an uncorrected coagulation profile. The most common sites of bleeding were the retroperitoneal and subdiaphragmatic areas. Large abdominal packs were used to achieve tamponade between the body wall and bleeding surfaces. The abdomen was closed without drains. Pack removal was done 48 to 72 hours postoperatively when the transplanted liver had started producing sufficient clotting factors.
Postoperative bleeding which required packing was done after bleeding from liver tumours, after resection of pelvic malignancies and diffuse oozing following a pancreaticoduodenectomy in jaundiced patients.
Statistical analysis
Statistical analysis was performed using the Fisher’s exact test, the chi square test and multivariate logistic regression analysis of significant variables. SPSS 16 software was used for analysis. A p-value < 0.05 was considered to be statistically significant.
Results
There were 34 males and 15 females who had a mean age of 43.4 years.
The characteristics of the patients requiring abdominal packing were shown in Table 1.
Liver trauma: Preoperatively > 6 blood transfusions were required for 7 patients with liver injuries of whom one had preoperative coagulopathy as well as acidosis. Eight patients required packing for grade 3-5 liver injuries (two patients had grade 4 to 5 liver injuries and six patients had grade 3 injuries). Patients were shifted to the postoperative ICU for correction of shock, acidosis and coagulopathy. Re-look laparotomy was performed in 7 patients after 48 hours in 3 and before 48 hours in 4 patients. One patient died in the ICU after initial laparotomy in spite of packing due to grade 5 injuries with refractory haemorrhagic shock and multiorgan failure.
Pancreatic necrosectomy: Seventeen patients underwent packing after pancreatic necrosectomy, 7 patients before four weeks and 10 patients after four weeks of the onset of an attack of acute pancreatitis. 11 patients had septicaemia, 8 patients had renal failure with oliguria and 12 patients required postoperative ventilation. Re-look laparotomy for pack removal was done after 48 hours in 12 patients. 2 patients required repacking for continued bleeding. 5 out of 17 patients in this group died from septicaemia, multiorgan failure, acidosis and coagulopathy. Three out of seven patients who were operated before four weeks were died compared with only 2 of the 10 patients operated on after 4 weeks
Bleeding liver tumours: Three patients required packing following liver tumour bleed. One patient died with coagulopathy, acidosis and hypothermia. He required postoperative ventilatory support, > 10 units of blood and developed postoperative renal failure.
Liver transplantation: Four patients required perihepatic packing for surgically uncontrollable bleeding following liver transplantation. There were three females and one male with a mean age of 46.3 years. Blood transfusion requirement was more than 20 units in each of these patients. Pack removal was done between 48 and 72 hours. Two patients died within 30 days due to sepsis, and multiple organ failure. All the patients had coagulopathy, platelet count < 50 thousand, hypothermia and metabolic acidosis.
Other operations: 17 patients required packing for postoperative bleeding after other operations such as diffuse oozing following a pancreaticoduodenectomy in jaundiced patients, large rectal tumours, large retroperitoneal tumours and following re- explorations with associated oozing from extensive raw surfaces. In 12 patients more than 6 units of blood were transfused to compensate for hypovolaemic shock and 5 patients had intraoperative coagulopathy with deranged PT or INR. 13 of these patients required postoperative ventilatory support. Re-look laparotomy and pack removal was done after 48 hours in 9 patients and 2 patients died before pack removal. 6 patients died postoperatively due to shock, septicaemia and multiorgan failure in ICU.
Risk factors and mortality (Table 1): A significantly increased mortality was associated with the presence of hypovolaemic shock (p=0.012), renal failure (p=0.025), deranged INR (p=0.007), postoperative ventilator requirement (p=0.006), hypothermia (p=0.000), acidosis (p=0.00) and sepsis (p=0.002). No patient experienced the compartment syndrome. Intra-abdominal abscesses occurred in three patients who responded to conservative management with antibiotics and CT guided percutaneous aspiration. Multivariate logistic regression analysis of significant variables (Table 2) like shock, renal failure, deranged INR, blood transfusion requirement and hypothermia showed hypothermia to be the only significant factor (p=0.013).
Discussion
Our results suggest that the early use of abdominal packs to stem uncontrollable haemorrhage may be associated with a lowering of mortality. Previous studies have described mortality rates of up to 56-83 % when packing was used in bleeding which was more profuse[6,7,8].
The four main situations in which we used packs were after hepatic bleeding due to trauma or tumours, pancreatic necrosectomy, major extirpative procedures especially in the pelvis and liver transplantation.
In liver injury, patients guidelines recommend packing be considered when blood loss reaches 10 units[3,4,5,6,7,8,9]. However, in countries like ours where there is a shortage of blood and blood products we should consider packing at 6 units of blood loss[10] especially if there is accompanying acidosis and hypothermia[11].
For liver trauma, we had a low threshold for packing as is shown by the fact that we used the technique in 8 out of 49 patients. We packed patients who required more than 6 units of blood, who were hypothermic (< 34°C), coagulopathic (PT>16 seconds) or acidotic (pH < 7.2). As soon these abnormalities were corrected, we removed the packs usually after 48 hours although others have reported pack removal after varying periods[12],[13 ]which may be as long as 7 days[14]. Packing was done for grade 3-5 liver injuries only after ligation of arterial bleeding or application of Pringle’s manoeuvre for 20 minutes failed. Reported infection rates have varied from 18% to 33%[9,10,11,12,13,14,15].
In acute necrotising pancreatitis, we tried according to the current recommendations[16],[17] to delay operation as long as possible till the dead tissue was well demarcated. However, this was not always possible in some patients with septicemia and multiorgan failure. We followed a policy of open debridement with drain insertion and irrigation or, if there was bleeding, packing followed later by drainage. 12 out of 17 patients survived pancreatic necrosectomy and packing with vigorous ICU monitoring and correction of coagulation parameters, reversal of acidosis and treatment of septicemia and renal failure. We found packing to be effective in controlling the generalised ooze from the infected pancreatic bed following necrosectomy, till other parameters were corrected. However, selective ligation of arterial bleed was required in one patient with a ruptured pseudoaneurysm.
We also used abdominal packs in 17 patients who developed exsanguinating haemorrhage following major procedures in the pelvis, when there was diffuse bleeding after pancreaticoduodenectomy done in jaundiced patients and following any operations when there was diffuse ooze from raw surfaces which could not be controlled by suture ligation. Six of these 17 patients died, and 4 of these were more than 55 years old. Besides age, we found that other factors associated with an increase in mortality, expectedly, were the requirement of postoperative ventilator support, hypothermia and acidosis and sepsis in the postoperative period. In fact if a patient had acidosis, hypothermia and hypotension, the mortality rates were 71.4%.
Conclusion
Our experience has been that in certain select situations when the blood transfusion requirement during surgery has reached 6 units, abdominal packing can be lifesaving. The bleeding is controlled and after the coagulopathy, acidosis and hypothermia are corrected, the packs should be removed after 48 hours. This policy is especially useful in countries where there is a shortage of blood for transfusion and where facilities for doing complex procedures are not always available especially when massive bleeding occurs.
1. Braslow B. Damage control in abdominal trauma. Contemp Surg. 2006;62:65–74.
2. Stracieri LD, Scarpelini S. Hepatic injury. Acta Cir Bras. 2006;21:85–8.
3. Feliciano DV, Mattox KL, Burch JM, Bitondo CG, Jordan GL Jr. Packing for control of hepatic haemorrhage. J Trauma. 1986;26:738–43.
4. Parks RW, Chrysos E, Diamond T. Management of liver trauma. Br J Surg. 1999;86:1121–35
5. Pachter HL, Spencer FC, Hofstetter SR, Liang HG, Coppa GF: Significant trends in the treatment of hepatic trauma. Experience with 411 injuries. Ann Surg. 1992,215:492–500;discussion 500- 2.
6. Kouraklis G, Spirakos S, Glinavou A: Damage control surgery: an alternative approach for the management of critically injured patients. Surg Today. 2002;32:195–202.
7. Stylianos S: Abdominal packing for severe hemorrhage. J Pediatr Surg. 1998;33:339–42.
8. Sharp KW, Locicero RJ.Abdominal packing for surgically uncontrollable haemorrhage. Ann Surg 1992,215:467–74; discussion 474-5..
9. Cue JI, Cryer HG, Miller FB, Richardson JD, Polk HC Jr. Packing and planned reexploration for hepatic and retroperitoneal haemorrhage: critical refinements of a useful technique. J Trauma. 1990;30:1007–13.
10. Beal SL. Fatal hepatic hemorrhage: an unresolved problem in the management of complex liver injuries. J Trauma. 1990;30:163–9.
11. Feliciano DV, Mattox KL, Jordan GL Jr. Intra-abdominal packing for control of hepatic hemorrhage: a reappraisal. J Trauma. 1981;21:285–90.
12. Caruso DM, Battistella FD, Owings JT, Lee SL, Samaco RC. Perihepatic packing of major liver injuries: complications and mortality. Arch Surg. 1999;134:958–63.
13. NicolAJ, Hommes M, Primrose R, Navsaria PH, Krige JE. Packing for control of hemorrhage in major liver trauma. World J Surg. 2007;31:569–74.
14. Xu M, Bastos J, Dmitrewski J, Okajima H, Gunson B, Pirenne J, et al. Perihepatic Packing in Liver Transplantation. Transplant Proc. 1998;30:1850–1.
15. Carmona RH, Peck DZ, Lim RC Jr. The role of packing and planned reoperation in severe hepatic trauma. J Trauma. 1984;24:779–84.
16. Steinberg WM, Geenen JE, Bradley EL 3rd, Barkin JS. Controversies in clinical pancreatology. Recurrent “idiopathic” acute pancreatitis: should a laparoscopic cholecystectomy be the first procedure of choice? Pancreas. 1996;13:329–34.
17. Bradley E.L.3rd. Operative vs non-operative management in sterile necrotizing pancreatitis. HPB Surg. 1997;1
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