Liver transplantation for the treatment of iatrogenic bile duct injury / Transplante hepático no tratamento da lesão iatrogênica da via biliar

ABSTRACT Objective: to assess the outcomes of our patients who were subjected to LT for iatrogenic bile duct injury. Methods: all patients who underwent LT for treatment of complications of biliary duct injury were included in the study. Medical records and study protocols of these patients were retrospectively analyzed to determine demographic and clinical characteristics, treatment, and outcome of the patients. Results: of a total of 846 liver transplants performed, 12 (1.4%) were due to iatrogenic bile duct injury: 10 (83.3%) occurred during cholecystectomy, 1 (8.3%) following chemoembolization, and 1 (8.3%) during laparotomy to control abdominal bleeding. Cholecystectomy was performed by open access in 8 patients and by laparoscopic access in two . There were 8 female (66.7%) and 4 male (33.3%) with a mean age of 50.6 ± 13.1 years (range 23 to 70 years). All transplants were performed with livers from cadaveric donors. The mean operative time was 558.2 ± 105.2 minutes (range, 400-782 minutes). Biliary reconstruction was performed with Roux-en-Y hepaticojejunostomy in 11 patients and choledochocholedochostomy in one. Seven patients died (58.3%) and five (41.7%) were alive during a mean followed up of 100 months (range 18 to 118 months). Conclusion: liver transplantation in patients with iatrogenic bile duct injury is a complex procedure with elevated morbimortality.

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.

IS THERE NEURAL AND FUNCTIONAL RECOVERY AFTER CLIP REMOVAL IN CERVICAL EXPERIMENTAL SYMPATHECTOMY?

BACKGROUND: The surgical treatment of hyperhidrosis by thoracic sympathectomy has brought, in addition to symptomatic relief for many, its main adverse effect: compensatory or reflex sweating. The clipping technique in place of the sympathetic nerve section gave rise to the hope of reversibility, but the positive results showed to be quite divergent, evidencing the academic deficiency regarding the study of this phenomenon. AIM: To observe micro and macroscopic damage caused by the polymer clip on sympathetic nerve of rabbits seven days after their clipping and the findings after three weeks of clip removal. METHOD: In this experimental study, 20 rabbits were divided into two groups of 10, group 1 (clipping) and group 2 (de-clipping). The right cervical sympathetic nerve of all animals was clamped with polymeric clip, and in group 2 the nerve was unclipped seven days later. Group 1 rabbits were induced to death on the 7th postoperative day, and group 2 on the 21st after removal of the polymer clip. Macroscopic variables were: clip appearance, presence of discontinuity lesion, infection and adhesions around the nerve. H&E was used in the evaluation of the phases and degree of the inflammatory process and presence of necrosis, and picrosirius red F3BA for quantification of collagen. RESULTS: The cervical sympathetic nerve was intact, without necrosis or infection in all animals of the experiment; there were adhesions in both groups, being minimal in eight animals of each group and moderate or intense in two; the clip was completely closed in all animals at the 7th postoperative day; the inflammatory process shown was chronic, with monomorphonuclear predominance. There was no significant difference between groups regarding the intensity the inflammatory process, but the amount of collagen type I and type III was significantly higher in group 2. CONCLUSIONS: The injury caused by the polymer clip on the sympathetic nerve may be reversible, allowing functional return in the areas involved in the simulated cervical sympathectomy. Clipping of the cervical sympathetic nerve using a polymer clip does not cause discontinuity injury.

Is there neural and functional recovery after clip removal in cervical experimental sympathectomy? / Existe recuperação neural e funcional após a retirada de clipe quando da indução de simpatectomia cervical experimental?

ABSTRACT Background: The surgical treatment of hyperhidrosis by thoracic sympathectomy has brought, in addition to symptomatic relief for many, its main adverse effect: compensatory or reflex sweating. The clipping technique in place of the sympathetic nerve section gave rise to the hope of reversibility, but the positive results showed to be quite divergent, evidencing the academic deficiency regarding the study of this phenomenon. Aim: To observe micro and macroscopic damage caused by the polymer clip on sympathetic nerve of rabbits seven days after their clipping and the findings after three weeks of clip removal. Method: In this experimental study, 20 rabbits were divided into two groups of 10, group 1 (clipping) and group 2 (de-clipping). The right cervical sympathetic nerve of all animals was clamped with polymeric clip, and in group 2 the nerve was unclipped seven days later. Group 1 rabbits were induced to death on the 7th postoperative day, and group 2 on the 21st after removal of the polymer clip. Macroscopic variables were: clip appearance, presence of discontinuity lesion, infection and adhesions around the nerve. H&E was used in the evaluation of the phases and degree of the inflammatory process and presence of necrosis, and picrosirius red F3BA for quantification of collagen. Results: The cervical sympathetic nerve was intact, without necrosis or infection in all animals of the experiment; there were adhesions in both groups, being minimal in eight animals of each group and moderate or intense in two; the clip was completely closed in all animals at the 7th postoperative day; the inflammatory process shown was chronic, with monomorphonuclear predominance. There was no significant difference between groups regarding the intensity the inflammatory process, but the amount of collagen type I and type III was significantly higher in group 2. Conclusions: The injury caused by the polymer clip on the sympathetic nerve may be reversible, allowing functional return in the areas involved in the simulated cervical sympathectomy. Clipping of the cervical sympathetic nerve using a polymer clip does not cause discontinuity injury.

RESUMO Racional: O tratamento cirúrgico da hiperidrose pela simpatectomia torácica trouxe além do alívio sintomático para muitos, também seu principal efeito adverso: o suor compensatório ou reflexo. A técnica de clipagem do nervo simpático no lugar de sua secção deu margem à esperança de reversão do procedimento; porém, os resultados mostram-se bastante divergentes e pouco conclusivos Objetivo: Observar a lesão provocada pelo clipe de polímero em nervo simpático de coelhos sete dias após sua clipagem, comparando-a com os achados após três semanas da retirada do clipe. Método: Estudo experimental, com amostra formada por 20 coelhos, divididos em dois grupos de 10, sendo o grupo 1 chamado clipagem e o 2, desclipagem. Todos foram submetidos à clipagem do nervo simpático cervical direito com clipe polimérico, e no grupo 2 realizou-se a desclipagem sete dias após. Os coelhos do grupo 1 foram submetidos à eutanásia no 7º dia de pós-operatório, e os do grupo 2 no 21º dia após a remoção do clipe. Observou-se na macroscopia o aspecto do clipe, a presença de lesão de descontinuidade, infecção e aderências ao redor do nervo. Para estudo microscópico utilizou-se a coloração H&E na avaliação das fases, grau do processo inflamatório e presença de necrose, e a de picrosirius red F3BA para quantificação de colágeno. Resultados: O nervo simpático cervical foi identificado íntegro, sem necrose ou infecção em todos os animais do experimento; havia aderências em ambos os grupos, sendo mínimas em oito de cada grupo e moderadas ou intensas em dois; em toda a amostra o clipe encontrava-se completamente fechado no 7º dia de pós-operatório; o processo inflamatório presente foi do tipo crônico, com predomínio monomorfonuclear, não se observando diferença significativa em relação ao grau do processo inflamatório entre os grupos; porém, a quantidade de colágeno tanto do tipo I quanto do tipo III foi significativamente maior no grupo 2. Conclusões: A lesão provocada pelo clipe de polímero em nervo simpático pode ser reversível possibilitando o retorno funcional nas áreas envolvidas na simpatectomia cervical simulada. A clipagem do nervo simpático cervical com uso de clipe de polímero não causa lesão de descontinuidade.