Ulus Travma Acil Cerrahi Derg. Ahead of Print: UTD-25855

Tangential gunshot injury of the right portal vein branch resulting in subacute main portal vein thrombosis: Successful treatment without hepatectomy

Khalýg Rajabli¹, Serhat Kaya², Ýlgin Özden^1
1Baþakþehir Çam And Sakura City Hospital, Department Of General Surgery, Liver Transplantation And Hepatopancreatobiliary Surgery Unit, Istanbul, Turkey
²Baþakþehir Çam And Sakura City Hospital, Department Of Radiology, Istanbul, Turkey

This is a report on the successful treatment without hepatectomy of a patient who underwent laparotomy and bullet removal for gunshot injury to the liver only at another institution, was referred for hemobilia, had an unrecognized tangential injury of the right portal vein branch resulting in portal vein thrombosis diagnosed on the twelfth day and developed severe cholangitis. Hepatic arteriography did not reveal the source of hemobilia. After thrombectomy from the main portal vein and its left branch and portal vein repair, bilateral transcholedochal biliary drainage was applied. Hemobilia stopped after portal revascularization. The low-volume biliary fistula that developed in the early postoperative period healed in seventeen days with the gradual removal of abdominal drains. The patient had no further problems during the six-month follow-up and the results of standard biochemistry blood tests were within normal limits except for slightly increased alkaline phosphatase (167 U/L: 40-129) and gamma-glutamyl transpeptidase (100 U/L: 8-61) levels. Follow-up intravenous contrast-enhanced computed tomography scans performed on the tenth day and sixth month after surgery confirmed that the main portal vein and its left branch were patent. In addition, atrophy of the right lobe and hypertrophy of the left lobe were observed. In conclusion, inspiration from the principles of elective hepatopancreatobiliary surgery to trauma treatment and avoiding major hepatectomy in a patient with severe cholangitis played crucial roles in the successful outcome.

Keywords: hemobilia, isolated portal vein injury, penetrating portal vein injury, portal vein injury, portal vein ligation, portal vein thrombosis

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Portal ven sað dalýnýn kurþun ile teðetsel yaralanmasýna baðlý subakut ana portal ven trombozu: Hepatektomisiz baþarýlý tedavi.

Khalýg Rajabli¹, Serhat Kaya², Ýlgin Özden^1
1Baþakþehir Çam Ve Sakura Þehir Hastanesi, Genel Cerrahi Departmaný, Karaciðer Nakli Ve Karaciðer-pankreas-safra Yollarý Cerrahisi Birimi, Ýstanbul
²Baþakþehir Çam Ve Sakura Þehir Hastanesi, Radyoloji Departmaný, Ýstanbul,

Bu yazýda, ateþli silahla vurulma nedeniyle götürüldüðü ilk hastanede laparotomi yapýlan, izole karaciðer yaralanmasý saptanýp mermi çýkarýlan, sonrasýnda geliþen hemobili nedeniyle sevk edilen ve on ikinci günde portal ven sað dalýnda, daha önce bulgu vermemiþ teðetsel yaralanma sonucu, ana portal ven trombozu geliþen, aðýr kolanjiti baþlayan hastanýn, hepatektomi yapýlmadan baþarýlý bir þekilde tedavisi bildirilmiþtir. Hepatik arteriografide hemobili kaynaðý saptanmamýþtýr. Ana portal ven ve sol dalýndan trombektomi ve portal ven onarýmý yapýlmasý sonrasýnda bilateral transkoledokal biliyer drenaj uygulanmýþtýr. Hemobili, portal revaskülarizayondan sonra durmuþtur. Ameliyat sonrasý erken dönemde geliþen düþük hacimli safra fistülü, batýn drenlerinin aþamalý çekilmesi ile onyedi günde iyileþmiþtir. Hastanýn altý aylýk takibinde herhangi baþka bir sorunu olmamýþ, standart biyokimya kan testlerinin sonuçlarý, hafif artmýþ alkalen fosfataz (167 U/L: 40-129) ve gama-glutamil transpeptidaz (100 U/L: 8-61) seviyeleri dýþýnda normal sýnýrlar içinde seyretmiþtir. Ameliyat sonrasý onuncu gün ve altýncý ayda yapýlan takip amaçlý intravenöz kontrastlý bilgisayarlý tomografilerde ana portal venin ve sol dalýnýn açýk olduðu doðrulanmýþtýr. Ayrýca, sað lobda atrofi, sol lobda hipertrofi geliþmiþtir. Sonuç olarak bir travma hastasýnýn tedavisinde yaklaþýmýn, elektif hepatopankreatobiliyer cerrahinin ilkelerinden ilham alýnarak planlanmasý ve aðýr kolanjiti olan hastada majör hepatektomiden kaçýnýlmasý, baþarýlý bir sonuç alýnmasýný saðlamýþtýr.

Anahtar Kelimeler: hemobili, izole portal ven yaralanmasý, penetran portal ven yaralanmasý, portal ven yaralanmasý, portal venin baðlanmasý, portal ven trombozu

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