S A O
PAULO
"j'tr
1,1",' , j,\U '0 $C A S E
REPORT
L u iz F e r n a n d o C o r r e a Z a n t u t , M a r c e l A u t r a n C e s a r M a c h a d o ,
P a u la V o lp e , R e n a t a S e r g io P o g g e t t i, D a r ia B ir o lin i
E xtrahepatic bile ducts injury: a report on 14 cases
Disciplina de Cirllrgia do Trallma da Facllldade de Medicina da Universidade de Siio Palllo - Siio Palllo, Brazil
T raum atic injuries of the extrahepatic biliary tract are infrequent, occurring in approxim ately 0.5 % of all patients w ith blunt and penetrating abdom inal traum a. T he incidence of this injury due to blunt abdom inal traum a is rare. T his study review ed patients w ith injuries of the extrahepatic biliary tract due to abdom inal traum a over a 6-year period to determ ine the incidence, traum a scores, associated injuries, surgical treatm ent perform ed, com plications and m ortality rate. W e report our experience w ith 14 patients w ith extrahepatic biliary tract traum a. A review of the literature and the discussion about the m anagem ent are presented.
U N IT E R M S : E xtrahepatic biliary tract, Injury, A bdom inal traum a.
IN T R O D U C T IO N
T
ra u m a ticre m a in re la tiv e lyin ju rie s ra re e v e n in th e b u sie stto th e e x tra h e p a tic b ile d u c tstra u m a c e n te rs. F o rm e rly , b lu n t tra u m a to th e rig h t u p p e r q u a d ra n t a c c o u n te d fo r m o st o f th e re p o rte d in ju rie s to th e b ile d u c ts, b u t in re c e n t y e a rs, p e n e tra tin g tra u m a h a s b e e n th e m o st c o m m o n c a u se . B e c a u se o f th e v a ria b le c o m p le x ity o f in ju rie s, a w id e v a rie ty o f su rg ic a l o p tio n s fo r re p a ir o f th e b ile d u c ts is p o ssib le . W e re p o rt, h e re in , o n o u r e x p e rie n c e w ith p a tie n ts w h o su sta in e d tra u m a tic in ju rie s to th e e x tra h e p a tic b ile d u c ts o v e r a six -y e a r p e rio d .M A T E R IA LS A N D M E T H O D S
D u rin g th e 6 -y e a r p e rio d fro m 1 9 8 6 to 1 9 9 1 , 5 ,0 6 9 p a tie n ts u n d e rw e n t la p a ro to m y fo r a b d o m in a l tra u m a a t th e D e p a rtm e n t o f S u rg e ry , U n iv e rsity o f S a o P a u lo S c h o o l o f M e d ic in e , B ra z il. E ig h te e n p a tie n ts (0 .3 5 % ) h a d in ju rie s in v o lv in g th e e x tra h e p a tic b ile d u c ts. R e c o rd s, in c lu d in g
A d d r e s s f o r c o r r e s p o n d e n c e :
L u iz F e r n a n d o C o r r e a Z a n t u t
A v . B r ig . L u is A n t o n io , 4521 -J d . P a u lis t a S a o P a u lo / S P - B r a s il- C E P 0 1 4 0 1 - 0 0 2
o p e ra tiv e a n d p a th o lo g y re p o rts, w e re re v ie w e d to stu d y th e site o f in ju ry , a sso c ia te d in tra -a b d o m in a l in ju rie s, in c id e n c e , tra u m a sc o re s, ty p e o f re p a ir, m o rb id ity a n d m o t1 a lity ra te s.
R E S U LT S
E ig h te e n p a tie n ts w ith e x tra h e p a tic b ile d u c ts in ju rie s w e re id e n tifie d in a g ro u p o f 5 ,0 6 9 p a tie n ts (0 .3 5 % ) w h o su sta in e d in tra -a b d o m in a l tra u m a o v e r a six -y e a r p e rio d . T h e p a tie n ts a g e ra n g e d fro m 1 5 to 3 0 y e a rs w ith a m e a n a g e o f 2 2 .5 y e a rs; 1 7 o f th e 1 8 p a tie n ts w e re m a le .
O f th e 1 8 e x tra h e p a tic b ile d u c ts in ju rie s, 1 5 (8 3 .3 % ) w e re c a u se d b y p e n e tra tin g w o u n d s, a n d th re e b y b lu n t tra u m a . A ll p a tie n ts u n d e rw e n te x p lo ra tO lY la p a ro to m y . In th e 1 8 p a tie n ts, 6 3 in tra -a b d o m in a l in ju rie s w e re fo u n d , o r 3 .5 p e r p a tie n t. T h irte e n o f th e 1 8 p a tie n ts (7 2 .2 % ) h a d la c e ra tio n s o f th e liv e r. P a n c re a s la c e ra tio n s(IIp a tie n ts), g a stric la c e ra tio n s (6 p a tie n ts) a n d d u o d e n a l la c e ra tio n s (6 p a tie n ts) w e re th e n e x t m o st c o m m o n ly se e n in ju tie s (T a b le .I).T h e d isttib u tio n o f in ju rie s to th e e x tra h e p a tic b ile d u c ts w a s a s fo llo w s: th e le ft h e p a tic d u c t in o n e p a tie n t, th e c o m m o n h e p a tic d u c t ju n c tio n in o n e p a tie n t, th e c o m m o n h e p a tic d u c t in th re e p a tie n ts, th e c y stic d u c t in o n e p a tie n t a n d d ista l c o m m o n b ile d u c t o r a m p u lla o f V a te r in 1 2 p a tie n ts (F ig .I) .F iv e o f th e 1 8 p a tie n ts d ie d (2 7 .7 % ), n o n e a s a re su lt o f th e ir b ile d u c t in ju ry . T w o o f th e se p a tie n ts h a d sim p le la te ra l re p a irs, o n e o f w h o m u n d e rw e n t d e c o m p re ssio n w ith a T tu b e . F iv e p a tie n ts w ith sim p le re p a irs su rv iv e d , a n d n o n e h a c l
Z A N T U T , L .F .C ; M A C H A D O , M A C ; V O L P E ,P .; P O G G E T T I, R .S . & B IR O L lN I, D . - E xtra h e p a tic b ile d u cts in ju ry: a re p o rt o n 1 4 ca se s
1 3 1 0
p ro b le m s re la te d to th e re p a ir o f th e b ile tra c t a t th e tim e o f
d isc h a rg e . T w o o f te n p a tie n ts w ith c o m p le x re p a irs d ie d in th e
h o sp ita l. S ix p a tie n ts w ith a n in tra p a n c re a tic c o m m o n b ile d u c t
il~ u ry u n d e rw e n t a d u o d e n o p a n c re a te c to m y . T w o p a tie n ts w ith
a c o m p le te tra n se c tio n o f th e c o m m o n h e p a tic d u c t a n d c o m m o n
h e p a tic d u c t ju n c tio n u n d e rw e n t R o u x e n Y h e p a tic o
-je ju n o sto m y . O n e p a tie n t w ith d ista l c o m m o n b ile d u c t le sio n
u n d e rw e n t R o u x -e n - Y c h o le d o c h o je ju n o sto m y . O n e p a tie n t
w ith d ista l c o m m o n b ile d u c t in ju ry u n d e rw e n t
c h o le d o c h o d u o d e n o sto m y (T a b le 2 ).
a c h o lic sto o ls o c c u r. T h e ja u n d ic e is d u e to th e a b so rp tio n o f b ile p ig m e n t b y th e p e rito n e u m .
E x tra h e p a tic b ile d u c t in ju rie s a re u su a lly d e te c te d a t
th e tim e o f la p a ro to m y a n d a re se ld o m d ia g n o se d
p re o p e ra tiv e ly . E v e n d u rin g c e lio to m y , th e se le sio n s m a y
T a b le 2 S u rg ic a l P ro c e d u re s
T re a tm e n t
T a b le 1
A s s o c ia te d In tra -A b d o m in a l le s io n in p a tie n ts w ith e x tra h e p a tic b ilia ry d u c ts in ju rie s
A s s o c ia te d L e s io n s = 3 .4 L e s io n s / P a tie n t O th e rs
In fe rio r v e n a C a v a K id n e y
D ia p h ra g m
D u o d e n u m
D IS C U S S IO N
L iv e r (7 2 .2 % )
P a n c re a s
S u tu re
P a n c re a tic o d u o d e n e c to m y S u tu re + C h o le d o c h o s to m y C h o le d o c h o s to m y
H e p a tic o je ju n o s to m y R o u x -e n - Y C h o le d o c h o je ju n o s to m y R o u x -e n - Y C h o le c y s te c to m y
~ ~ ' 1
1
::J
31
C
7
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1
3 3
2
2
2 1
1
T ra u m a to th e e x tra h e p a tic b ile d u c ts is a ra re b u t
in sid io u s d ia g n o stic p ro b le m w h ic h is p o te n tia lly fa ta L
In c re a sin g c iv ilia n v io le n c e a n d a g re a te r fre q u e n c y o f
m o to r v e h ic le a c c id e n ts a re re su ltin g in a h ig h e r in c id e n c e
o f tra u m a to th e e x tra h e p a tic b ilia ry sy ste m . In ju ry to th e
d u c ts th e m se lv e s is ra re ly fa ta l, h o w e v e r a sso c ia te d in ju rie s
re su lt in sig n ific a n t m o rta lity . F u rth e rm o re , b ile tra c t
in ju rie s th e m se lv e s c a n b e a sso c ia te d w ith c o n sid e ra b le
m o rb id ity su c h a s b ile ste n o sis a n d le a k a g e . E x tra h e p a tic
b ile tre e in ju ry d u e to b lu n t a b d o m in a l tra u m a is ra re r th a n
p e n e tra tin g in ju ry . In th e p re se n t se rie s, th e in c id e n c e w a s 0 .1 2 % a n d 0 .5 7 % , re sp e c tiv e ly .
T h e c lin ic a l p ic tu re is v a ria b le . In itia lly , th e re c o u ld
b e sh o c k w ith se v e re o r m o d e ra te lo w b lo o d p re ssu re , a c c o m p a n ie d b y c o n sid e ra b le u p p e r a b d o m in a l p a in a n d
rig id n e ss, u su a lly m o st se v e re in th e rig h t u p p e r q u a d ra n t.
U su a lly th e p e rio d o f sh o c k a n d p a in is a m a tte r o f fe w
h o u rs o r le ss, a n d is fo llo w e d b y re la tiv e ly sy m p to m -fre e in te rv a l, u n le ss th e re a re a sso c ia te d in ju rie s. W ith le a k a g e
o f b ile in to th e p e rito n e a l c a v ity , ja u n d ic e , b ile a sc ite s a n d
F ig u re 1 -D is trib u tio n o f le s io n s in e x tra h e p a tic b ilia ry d u c ts
b e m isse d u n le ss th e b ile tra c t is c a re fu lly in sp e c te d , a
p ro c e ss w h ic h is m o re lik e ly to b e o m itte d in th e p re se n c e
o f life -th re a te n in g w o u n d s. In tra -o p e ra tiv e c h o la n g io g ra p h y
is e x tre m e ly h e lp fu l in m a k in g th e d ia g n o sis o f b ile d u c t
in ju ry a n d in a c c u ra te ly lo c a liz in g th e in ju ry .
M a n a g e m e n t o f p a tie n ts w ith tra u m a tic e x tra h e p a tic
le sio n s o f th e b ile tra c t d e p e n d s u p o n th e site , ty p e o f in ju ry
a n d g e n e ra l c o n d itio n s o f th e p a tie n t. In th e p ro fo u n d ly
h y p o te n siv e p a tie n t w ith a p a rtia l te a r, e x te rn a l d ra in a g e w ill p re v e n t b ile a sc ite s a n d m a y o c c a sio n a lly b e c u ra tiv e ,
a lth o u g h th e fo rm a tio n o f a stric tu re o fte n o c c u rs. O n
o c c a sio n , a sm a ll p e rfo ra tio n o r te a r m a y b e p re se n t in th e
re tro -p a n re a tic p o rtio n o f th e c o m m o n b ile d u c t. In th e u n sta b le p a tie n t o r th e sta b le p a tie n t in w h o m v isu a liz a tio n
is d iffic u lt, a n o th e r a lte rn a tiv e is th e in se rtio n o f a p ro x im a l
tu b e to d e c re a se th e o u tp u t fro m th e e x p e c te d fistu la . If
th e p a tie n t is sta b le a n d h a s a p a rtia l te a r, c y stic d u c t
a v u ls io n , o r s m a ll th r o u g h in ju r y , a p r im a r y r e p a ir w ith a n
a b s o r b a b le s u tu r e c a n b e p e r f o r m e d .
I f th e tr a n s e c tio n is c le a n a n d s im p le w ith o u t s ig n if ic a n t
c o n tu s io n o f b o th e n d s o f th e d u c t, a n e n d - to - e n d a n a s to m o s is
m a y b e u tiliz e d . D is s e c tio n a r o u n d th e d u c t w ill c a u s e
a d d itio n a l d e v a s c u la r iz a tio n o f th e e n d s , a n d s h o u ld b e
a v o id e d . W h e n te n s io n is p r e s e n t a t th e a n a s to m o s is , a s tr ic tu r e
w ill r e s u lt. W h e n a c o m p le x tr a n s e c tio n h a s o c c u r r e d , o r a
p o r tio n o f th e c o m m o n b ile d u c t h a s b e e n d e s tr o y e d o r
d e v a s c u la r iz e d in a s ta b le p a tie n t, a b ilio e n te r ic a n a s to m o s is
u s in g a R o u x - e n - Y lim b s h o u ld b e p e r f o r m e d .
1311
O n o c c a s io n , th e c o m b in a tio n o f a h e p a tic d u c ta l
in ju r y a n d a p a r e n c h y m a l in ju r y w ill le a d to a h e p a tic
lo b e c to m y . D u o d e n o p a n c r e a te c to m y is b e s t r e s e r v e d f o r
r a r e d is ta l b ile d u c t in ju r ie s c o m b in e d w ith in ju r ie s to th e
p a n c r e a to d u o d e n a l c o m p le x o r a m p u lla o f V a te r , a s
o c c u r r e d in th r e e o f o u r p a tie n ts .
W e c o n c lu d e d th a t th e ty p e o f r e p a ir e m p lo y e d in
o u r s e r ie s w a s r e la te d to th e h e m o d y n a m ic s ta b ility a n d
c lin ic a l c o n d itio n s ( b a s e d o n tr a u m a s c o r e s ) o f th e p a tie n t
m o r e th a n to th e s ite a n d c o m p le x ity o f th e in ju r y .
RESUMO
Asles6es das vias biliares extra-hepaticas sao condiy6es raras, graves e que possuem variadas form as de apresentayao. Foram estudados 5.069 pacientes com traum atism o abdom inal, atendidos no Pronto Socorro do Hospital das Clfnicas da Faculdade de M edicina da Universidade de Sao Paulo, no perfodo de 1986 a 1991, e identificados 14 deles com lesao em via biliar extra-hepatica. Foram analisados os fndices de traum a (RTS, ISS eTRISSCAN), sexo, idade, incidencia, presenc;a de les6es associ ad as, tratam ento cirurgico realizado, evoluc;ao p6s-operat6ria, m orbidade e m ortalidade. Dos 14 pacientes, som ente tres (21.4% ) tiveram esse tipo de lesao decorrente de traum a abdom inal fechado, sendo os dem ais devido a traum a penetrante. A idade m edia dos pacientes com lesao da arvore biliar foi de 23.2 anos. A incidencia foi de 0.28 % do total de pacientes e a m ortalidade de 21.4% .0 ffgado eo pancreas foram os 6rgaos m ais acom etidos, seguidos do estom ago e duodeno. 0 tipo de lesao associada foi fator que contribuiu na m ortalidade desses pacientes. 0 sHio m ais frequente de lesao foi 0 coledoco na sua porc;ao
intrapancreatica (50% dos casos). Os autores conclufram que0 tipo de cirurgia em pregado (conservador ou radical) esteve m ais
relacionado as condiy6es gerais do paciente (daf a im portancia dos fndices de traum a) do que a com plexidade das les6es.
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