복부 및 골반 외상 환자에 있어 중재적 시술의 임상적 유용성

Abstract

[한글]

간, 비장 및 골반골 손상 환자에서 중재적 동맥 색전술의 유용성을 확인하고 적응증을 설정하기 위해 본 연구를 시행하였다.1992년 4월부터 2004년 4월까지 연세대학교 원주의과대학 원주기독병원 외과에서 외상성 손상으로 간동맥 색전술, 비장동맥 색전술, 골반 강내 동맥 색전술을 시행받은 91명의 환자를 대상으로 후향적으로 분석하였다. 환자의 손상 기전, 초기 혈압, 손상 정도, 초기 혈색소치, 혈역동학적으로 안정성을 유지하기 위해 필요한 초기 수혈양과 중재적 시술 후의 수혈양, shock index(heart rate/systolic blood pressure) 및 재원기간을 조사 하였다. 모든 대상환자는 동맥조영술 및 출혈부위에 대한 선택적 동맥 색전술을 시행 하였다.91명의 대상환자 중 간동맥 색전술을 시행 받은 환자 30명중 25명, 비장동맥 색전술을 시행 받은 환자 42명중 36명, 골반골 골절 환자 19명중 14명이 중재적 동맥 색전술 시행 후 생존하여 통계학적 의미 있는 shock index의 개선, 수액요법양 감소 및 수혈양 감소의 결과를 보여주었다.중재적 동맥 색전술은 외상성 간, 비장 및 골반골 손상 환자에서 유용한 비수술적 치료법임을 확인 할 수 있었고, 통계학적 정량적 분석을 통해 중재적 동맥 색전술의 적응범위로는 shock index 1 미만이고, 혈역동학적 안정성을 확보하기 위한 초기 수액 요법양은 2시간당 2000mL 이하이며, 혈색소 10g/dL를 유지하기 위한 초기 수혈양이 3 unit 이하인 경우로 설정할 수 있다.

[영문]Purpose: It is essential to define the indications of interventional artery embolization for patients with hepatic, splenic and pelvic injury, and to establish a guideline for its use as an adjunct to nonsurgical management. This article presents the experience with the nonsurgical approach to splenic, hepatic and pelvic injury, focusing on a new management algorithm that uses interventional artery emboization as an adjunct to treatment.Method: 91 patients with traumatic hepatic, splenic and pelvic injury who were treated with interventional arterial embolization from April 1992 to April 2004 were included in this retrospective study. Mechanism of trauma, initial vital sign, initial hemoglobin, hospital length, transfusion amount, shock index and fluid resuscitation amount were surveyed. After initial evaluation and resuscitation, patients suspected of having abdominal and pelvic injury who were hemodynamically stable without or with fluid resuscitation underwent computed tomographic (CT) scanning of the abdomen and pelvis. CT scanning also was performed in patients who initially were hemodynamically unstable but who were stabilized by fluid resuscitation. Patients with CT scan evidence of hepatic, splenic and pelvic injury were classified into five grades according to CT scan findings on the basis of the injury scale of the American Association for the Surgery of Trauma. All patients with CT scan grade 3 to 5 injury underwent angiography. When angiography showed extravasation of contrast medium extending from hepatic, splenic and pelvic arterial branches, transarterial embolization was performed.Result: Among 91 patients with traumatic liver, spleen and pelvis injury, 25 of 30 patients treated by hepatic arterial embolization, 36 of 42 patients by splenic artery embolization and 14 of 19 patients by pelvic artery embolization showed successful outcomes which were supported by shock index improvement (p <0.05), less requied fluid resuscitation amount (p < 0.05) and less required packed RBC amount (p<0.05).Conclusion: Intervenational artery embolization is a preferable non-surgical management in patient with traumatic hepatic, splenic and pelvic injury. Data of this study suggests that indications of intervnentional arterial embolization are shock index less than 1, transfusion amount less than 3 unit per day to maintain Hg 10g/dL and fluid resuscitation amount per 2 hours less than 2000mL to maintain hemodynamic stability.