A influência do tempo de referencia no tratamento das lesões iatrogênicas da via biliar

Abstract

Objective: To evaluate the prognosis of patients with iatrogenic bile duct injury (IBDI) regarding time of referral (RT) to the unit of liver transplantation (LT). Methods: We reviewed 51 charts of patients who had suffered some kind of IBDI during cholecystectomy and who were referred to the Bonsucesso General Hospital (HGB) LT unit. Lesions were grouped according to the Bismuth classification. Besides cholecystectomy (time of injury), we also evaluated the RT and outcome. Results: Among the 51 patients studied, there were 17 men and 34 women, with a mean age of 42.7 years. Twenty-two patients (43.1%) had a type II lesion, 13 (25.5%) type III, 10 (19.6%) type I, 5 (9.8%) type IV and only 1 (2%) type V. Forty patients were operated, and three did not return for medical review, therefore, 37 were evaluated in relation to outcome. Among these, 25 patients (67.6%) had excellent or good results with average RT of 11.5 months (range: 2-48 months) and 47.2 months (range: 3-180 months) respectively. The 12 patients (32.4%) with poor results had a mean RT of 65.9 months (range: 3 264 months), which was significantly higher than the group with excellent or good results (p=0.004). Seven patients were listed for LT, but only two were transplanted. The RT of these seven patients was significantly higher (p=0.04) than those patients not listed. Seven patients died, six of which were due to liver complications. Conclusion: RT significantly influenced the prognosis of patients in our sample.

Liver Transplantation for Bile Duct Injury After Cholecystectomy

“…The incidence in laparoscopic cholecystectomy range between 0.3% and 0.6%, which is similar to open approach, where it ranges between 0.2% and 0.3% (1) . The bile duct injury is one of the most serious complications of cholecystectomy and patients may develop recurrent pyogenic cholangitis, secondary biliary cirrhosis, end-stage liver disease and even death (2,3) . Correct initial management is essential and requires careful planning, ideally with a multidisciplinary team with experience in complex hepatobiliary surgery.…”

“…The two most common factors related with these injuries are cholecystitis and misperception or inexperience of the surgeon (1) . Patients may experience repeated episodes of cholangitis, secondary biliary cirrhosis, end-stage liver disease and death (3) .…”

Lesões iatrogênicas da via biliar

“…18,44,48 A literatura enfatiza a necessidade do encaminhamento dos pacientes com lesões da via biliar para centros de referência de atendimento terciário o mais breve possível após o reconhecimento da injúria, porém na prática, isso não é observado. 39,42,54,58 Para explicar a conduta desses médicos, alguns fatores devem ser considerados: o anseio e a carga emocional do responsável em tentar reparar o dano, 56,59 o significativo impacto provocado na qualidade de vida desses pacientes, [60][61][62] o receio no envolvimento em processos legais por erro médico porque os pacientes e familiares são surpresos pela fatalidade e não reconhecem que apesar da incidência de lesão da árvore biliar ser baixa, as complicações podem ocorrer em todos os tipos de cirurgias.…”

“…Menos da metade das injúrias são detectadas e tratadas adequadamente durante a colecistectomia 32,[37][38][39][40]52,53,60. Todos os 91 pacientes selecionados com LIVB foram submetidos a colecistectomia em outros serviços ou por outras equipes, não sendo operados pelo grupo de Vias Biliares, Pâncreas e Obesidade.…”

Fatores associados à vontade de litigar e ao litígio judicial após lesão iatrogênica da via biliar

“…Atualmente, a colecistectomia é uma das cirurgias gastrointestinais mais realizadas no mundo; nos Estados Unidos da América, são realizados mais de 750.000 procedimentos por ano (BARROS et al, 2010) e, no Brasil, novas estratégias tem ampliado o acesso à colecistectomia videolaparoscópica, por meio da sua realização em regime ambulatorial (SANTOS et al, 2001).…”