Transplante hepático no tratamento da lesão iatrogênica da via biliar

Abstract

RESUMO Objetivo: avaliar os resultados dos nossos pacientes que foram submetidos a transplante hepático por lesão iatrogênica do ducto biliar. Métodos: todos os pacientes que foram submetidos a transplante hepático para tratamento de complicações da lesão do ducto biliar foram incluídos no estudo. Os prontuários e protocolos de estudo desses pacientes foram analisados retrospectivamente para determinar características demográficas e clínicas, tratamento e desfecho dos pacientes. Resultados: de um total de 846 transplantes hepáticos realizados, 12 (1,4%) foram por lesão iatrogênica de via biliar: 10 (83,3%) ocorreram durante colecistectomia, 1 (8,3%) após quimioembolização e 1 (8,3%) durante laparotomia para controle de sangramento abdominal. A colecistectomia foi realizada por via aberta em 8 pacientes e por via laparoscópica em dois. Haviam 8 mulheres (66,7%) e 4 homens (33,3%), com média de idade de 50,6 ± 13,1 anos (variação de 23 a 70 anos). Todos os transplantes foram realizados com fígados de doadores cadavéricos. O tempo operatório médio foi de 565,2 ± 106,2 minutos (variação de 400-782 minutos). A reconstrução biliar foi realizada com hepaticojejunostomia em Y de Roux em 11 pacientes e coledococoledocostomia em um. Sete pacientes morreram (58,3%) e cinco (41,7%) estavam vivos durante um seguimento médio de 100 meses (variação de 18 a 118 meses). Conclusão: o transplante hepático em pacientes com lesão iatrogênica das vias biliares é um procedimento complexo com elevada morbimortalidade.

Liver transplantation for the treatment of iatrogenic bile duct injury

“…The open technique predominates in this group of patients, since the surgery that caused the injury was usually performed in less complex centers and with less availability of minimally invasive surgery. All transplanted patients in the work by Zeni et al 1 and in ours 2 were referred from other centers.…”

“…In fact, as cited by Silva Filho et al 3 , biliary obstruction without adequate treatment can result in periportal fibrosis, hepatic fibrosis, and, subsequently, cirrhosis in respectively four, 22, and 62 months 10 . The time reported in Brazil for performing LT after the initial injury was on average 165, 140, and 62.2 months, respectively, in the studies by Fonseca Neto et al 2 , de Silva Filho et al 3 , and Zeni et al 1 . These data coincide with the experience of international centers.…”

“…We read with interest the article entitled “Liver transplantation in the treatment of iatrogenic bile duct injury”, published in 2022 by Zeni et al 1 , and we congratulate the team of authors and the Liver Transplant Service of the Federal University of Paraná for their work. The topic is of great relevance for the Brazilian surgical community.…”

“…As a contribution to the theme, it is worth highlighting, in contrast to the survey by Zeni et al 1 , that currently the Brazilian literature comprises three publications on the subject, with 30 patients submitted to LT secondary to IBDI 1 - 3 . Our experience was published in 2017 in the journal GED - Gastroenterologia Endoscopia Digestiva -, under the title: “Liver transplantation in the treatment of iatrogenic bile duct injury after cholecystectomy: a study in a reference center in Northeast Brazil” 2 .…”

“…In our study, we pointed out that, prior to LT, two patients had not undergone any surgical procedures, five underwent biliodigestive bypasses, and one was approached with choledochal suture and papillotomy. In the series by Zeni et al 1 , all patients had undergone at least one surgical procedure. However, there is no robust association between the prognosis of these patients and the number of previous biliary repairs, the level of injury, the time of injury, or the initial repair method 11 .…”