Date Published: November 27, 2019
Publisher: Wolters Kluwer
Author(s): Erika Samlowski, Chris Okwuosa, Nara Tashjian, Michel Wagner.
Resuscitative endovascular balloon occlusion of the aorta (REBOA) is designed to control traumatic intra-abdominal or pelvic hemorrhage. There are few case reports of REBOA use in nontraumatic gastrointestinal (GI) hemorrhage. A 53-year-old man with pancreatic cancer status post Whipple procedure presented with GI hemorrhage from the gastroduodenal artery. Endoscopy and angioembolization were unsuccessful at stopping the hemorrhage. REBOA was used to stabilize the patient until definitive surgical control. REBOA is a potentially lifesaving measure in cases of massive abdominal or pelvic hemorrhage. REBOA can be used as an adjunct in unstable patients with GI bleeding until definitive GI, interventional radiology, or surgical control.
Historically, pancreaticoduodenectomy or Whipple procedure was a highly morbid operation. Advancements in surgical techniques, postoperative intensive care, and interventional radiology (IR) techniques have improved morbidity and mortality rates. Late hemorrhage, more than 24 hours after surgery, is a rare but often lethal complication after Whipple.1,2 Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a device designed for temporary control of traumatic intra-abdominal or pelvic hemorrhage. Aortic occlusion during hemorrhage diverts blood flow to the coronary and cerebral circulation and minimizes blood loss until definitive intervention. We report a patient with massive gastrointestinal (GI) hemorrhage from the gastroduodenal artery (GDA) 2 years after Whipple, who was stabilized with REBOA.
A 53-year-old man with a medical history of pancreatic adenocarcinoma treated with pylorus-preserving Whipple procedure 2 years before presented with hematemesis. He had symptomatic GI bleeding in the month before admission. Workup included esophagogastroduodenoscopy, colonoscopy, pill endoscopy, angiogram, and tagged red blood cell scan, but we were unable to localize the source of bleeding. He was initially hemodynamically stable, and his hemoglobin level was 7.2 g/dL. After multiple episodes of hematochezia and hematemesis, he became hypotensive and was transferred to an intensive care unit for resuscitation.
Advancements in surgical technique, intensive care, and IR have significantly improved morbidity and mortality after pancreaticoduodenectomy. Morbidity rates still range from 30% to 40%, with a 5% mortality rate.1 Hemorrhagic complications occur in less than 10% but account for up to 44% of postoperative deaths.1,3,4 Early bleeding, within 24 hours of surgery, is secondary to technical failure and generally requires surgical re-exploration. Late bleeding, more than 24 hours after surgery, is secondary to pancreaticojejunostomy leak, fistula, pseudoaneurysm, or anastomotic dehiscence. Late bleeding may present with sentinel bleeding, minor GI bleeding before major hemorrhage. Concurrent sentinel bleeding with a pancreatic leak is associated with mortality rates upwards of 50%.5 A 2008 meta-analysis by Limongelli et al reviewed the management of delayed bleeding after Whipple.3 One hundred sixty-three cases were identified and the incidence of delayed bleeding was 3.9%. Presentation ranged from 5 to 206 (median 26) days after surgery. Sentinel bleeding was present in 33.1%. The underlying cause was a pancreatic leak (65.6%) and pseudoaneurysm (32.5%.) Of these patients, 47% underwent laparotomy, 45% underwent IR intervention, and 8% were managed conservatively with no statistical difference in morbidity and mortality noted.
Author contributions: E. Samlowski wrote the manuscript. C. Okwuosa, N. Tashjian, and M. Wagner edited the manuscript. M. Wagner is the article guarantor.