Abordagem das lesões de vias biliares no trauma no Hospital João XXIII / Approach to trauma biliary lesions at the João XXIII Hospital

A lesão da via biliar no trauma não é comum. É observada, independente do seu mecanismo, em 0,1% das admissões nos serviços de trauma. A vesícula é o segmento da via biliar extra-hepática mais frequentemente acometida. As lesões dos canais biliares constituem desafio à perícia médica, com morbidade significativa; e tratamento dependente de vários fatores, como grau da lesão, momento do diagnóstico e experiência da equipe médica em sua abordagem. Devido à raridade dessas lesões, a correção cirúrgica, além de controversa, é difícil. Esta revisão apresenta a ótica do Serviço de Cirurgia Geral e do Trauma do Hospital João XXIII e da Fundação Hospitalar do Estado de Minas Gerais sobre esse tema, ressaltando sua incidência, o mecanismo de lesão e seu tratamento.

Trauma biliary lesion is not common. It is observed, regardless of its mechanism, in 0.1% of admissions to trauma services. The gallbladder is the segment of the biliary extra-hepatic pathway most often affected. Lesions of bile ducts constitute a challenge to medical expertise, with significant morbidity; treatment is dependent on several factors such as degree of lesion, time of diagnosis, and medical staff experience in their approach. Due to the rarity of these lesions, surgical correction is difficult and controversial. This review presents the perspective on this topic fromthe Service of General Surgery and Trauma at the João XXIII Hospital and the Hospital Foundation of the State of Minas Gerais highlighting its incidence, mechanism of lesion, and treatment.

Treatments of Proximal Bile Duct Necrosis and Stricture from Iatrogenic Bile Duct Injury of Laparoscopic Cholecystectomy

PURPOSE: Most bile duct injuries can be recognized intraoperatively, or within a few days after a laparoscopic cholecystectomy, with a favorable prognosis following proper management. However, a significant delay in the diagnosis, improper management, or other risk factors can lead to serious intractable biliary complications. Herein, the clinical courses of these serious biliary complications were analyzed to find their optimal treatment methods. METHODS: Between 1998 an 2003, 9 cases of serious biliary complications were encountered following a laparoscopic cholecystectomy. Patients detected early and with uneventful biliary reconstruction were excluded. Their mid- and long-term clinical courses were retrospectively analyzed. RESULTS: Their treatment methods undertaken to them were divided as follows: Primary hepaticojejunostiomy (HJ) to the necrotic proximal bile duct (n=3) : delayed stricture occurred in 1 patient among them; HJ to the delayed-onset proximal bile duct stricture (n=2) : There was no recurrence; Right lobectomy and HJ to the proximal bile duct stricture after right portal vein embolization (n=3) : There was no recurrence; And, induction of parenchymal atrophy applied to the isolated right posterior duct injury through portal vein embolization and sequential bile duct occlusion (n=1). CONCLUSION: Necrosis and stricture of the injured proximal bile duct should be managed by a case-by-case basis because every patient revealed different clinical features. Long- term surveillance over 5 years is recommended to detect late- onset biliary stricture.

Percutaneous Transhepatic Biliary Drainage Through the Normal Duct in Patients with Post-Operative Bile Leakage

PURPOSE: To evaluate the technical feasibility and clinical efficacy of percutaneous transhepatic biliary drainage (PTBD) through the normal duct in patients with post-operative bile leakage. MATERIALS AND METHODS: From January 1998 to December 2003, fourteen patients (male: 12, female: 2, mean age: 56) with biliary leak after laparoscopic cholecystectomy (n=5), T-tube removal (n=5), choledochojejunostomy due to small bowel perforation (n=1), right lobectomy (n=1), laparoscopic adrenalectomy (n=1), and subtotal gastrectomy (n=1) were treated by means of PTBD; this was performed with the two-step approach. The central bile duct was cannulated using a 21-G Chiba needle to map the intrahepatic biliary tree. An 8.5-F drainage catheter tip was positioned at the CBD after puncturing peripheral bile duct with an additional Chiba needle. We evaluated the technical feasibility, the procedure-related complications, clinical efficacy and the duration of catheter placement. RESULTS: PTBD of the normal duct with the two-step approach was successful in all but two cases. In these two cases, the two-step approach was failed due to the rapid disappearance of the targeted peripheral duct, and this was the result caused by biloportal fistula. PTBD was performed through the central bile duct in one patient, and through the remnant cystic duct in one patient. There were no procedure-related complications except for mild abdominal pain in seven patients. Bile leakage was demonstrated on cholangiogram in 10 of 14 patients; this occurred at the T-tube exit site (n=4), cystic duct stump (n=2), choledochojejunostomy site (n=1), resection margin of liver (n=1), caudate lobe (n=1), and GB bed (n=1). In 13 patients, the biliary leak stopped after drainage (mean duration: 32.1 days). In one patient, surgical management was performed one day after PTBD due to the excessive amount of bile leakage. CONCLUSION: PTBD is a technically feasible and clinically efficacious treatment for post-operative bile leakage, and it can replace the more invasive surgical or endoscopic management procedures.