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Ev bset2011
- 1. LESÃO IATROGÊNICA DAVIA BILIAR Paolo R. Salvalaggio São Paulo, 28 de setembro de 2011
- 2. AGENDA Definindo o problema Patogênese e fatores de risco Diagnóstico, manejo e planejamento cirúrgico Tratamento cirúrgico e modalidades complementares
- 3. DEFININDO O PROBLEMA Incidência: Na era coleciste aberta: 0.1%-0.3%: 0.2% Na era videolaparoscopia: - 0.2%-1.8%: 0.5% (1/200) - Não vem se alterando - Brasil=0.2% Aberta é mais segura que laparoscópica? McLean et al, Arch Surg 2006; 141: 643 Savassi-Rocha, Surg End 2003; 17:1356
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- 5. DEFININDO O PROBLEMARazões para maior erro com Vídeo: Operação banal Desorientação espacial (2D) Treinamento e curva de aprendizado Evitar conversão Não uso de colangiograma
- 6. DEFININDO O PROBLEMA Fatores de risco: Homem, idoso, asiático, obeso Inflamação e sangramento Campo cirúrgico hostil Variação anatômica (25%) Erros técnicos e personalidade do cirurgião Sem colangiografia e uso de ótica de zero grau
- 7. DEFININDO O PROBLEMALitígio nos EUA: 5 trabalhos 85% favorece paciente Erro técnico + reconhecimento tardio Pagamento médio de US$250mil McLean et al, Arch Surg 2006; 141: 643
- 8. DEFININDO O PROBLEMALitígio na Holanda: Fechamento de casos em 2a Média EU$100mil ~30% favorece paciente Risco de litígio 0.06% das coleciste por vídeo De Reuver, JACS 2008; 206:328
- 9. DEFININDO O PROBLEMAFatores de risco para processo: Cirurgiões que não fizeram residência, mas aprenderam em cursos Diagnóstico tardio Necessidade de re-op Múltiplas lesões: vasculares/intestino Morte Alkhaffaf et al, Ann Surg, 2010; 251:682
- 10. DEFININDO O PROBLEMAMorbidade Múltiplas cirurgias, intervenções e procedimentos, internamentos: até ressecção e transplante Colangite Estudos de qualidade de vida controversos
- 11. DEFININDO O PROBLEMA Mortalidade: Aumento de risco em cerca de 3x em estudo controlado Aumento risco até 50x, Brasil com MT de 4.2% Flum et al, JAMA; 290: 2168 Savassi-Rocha, Surg End 2003; 17:1356
- 12. PATOGÊNESE Variaçõesanatômicas Isquemia=falha de tratamento =estenose Fatores de risco Fatores técnicos Colangiograma
- 13. VASCULARIZAÇÃO Strasberg&Helton, HPB2011; 13: 1
- 14. VASCULARIZAÇÃO Strasberg&Helton, HPB2011; 13: 1
- 15. VASCULARIZAÇÃO Strasberg&Helton, HPB2011; 13: 1
- 16. LESÃO AHD Strasberg&Helton,HPB 2011; 13: 1
- 17. LESÃO VIA BILIAR+AHDStrasberg&Helton, HPB 2011; 13: 1
- 18. PATOGÊNESE IsquemiaAté 32% das lesões de VB há lesão vascular Mais comum AHD Lesão grave com péssimo prognóstico inicial Falha da reconstrução inicial se lesão da AHD: reconstruir artéria ou aguardar ao invés de reparo imediato Estudos em cadáveres sem repercussão
- 19. PATOGÊNESE IsquemiaLesões complexas Strasberg E3-5, Bismuth>3 CT angio MRA Angiografia
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- 21. MECANISMOS DE LESÃOMAIS COMUNS Confundir d. cístico com d. colédoco Confundir d. cístico com d. Post Dir Confundir a. cística com AHD Clipagem errada e as cegas para conter sangramento Dissecção muito baixa Dissecar longe da vesícula Uso excessivo do cautério Strasberg, JACS 1995; 180:101
- 22. LESÃO MAIS COMUMDavidoff, Ann Surg, 1992; 215: 192
- 23. RECOMENDAÇÕES Sempre ter1 ponto fixo Utilizar zoom “in and out” Prosseguir com precisão próximos passos Hugh et al, Surgery, 2002; 132: 826
- 24. RECOMENDAÇÕES Critical viewof safety Recomendação de multiplas sociedade cirurgicas americanas e europeias NÃO seccionar ou ligar até que… Wu&Linehan, SCNA 2010; 90: 787 Strasbert, JACS 1995; 180: 101
- 25. RECOMENDAÇÕES Stopping rules!!!Controlar sangramento precisamente Falha em progredir com passos, visualização prejudicada, incerteza da anatomia, falhas de tração ou preensão Converter, abortar ou usar coleciste parcial ou colecistostomia Strasberg, JACS 2005; 201: 604
- 26. RECOMENDAÇÕES Outros Usarótica de 30 graus de rotina Consulta intraoperatória Conversão NÃO é complicação Relacionamento e termo de consentimento Encaminhamento precoce
- 27. RECOMENDAÇÕES Evitar traçãoexcessiva e direção errada NÃO dissecar junção cístico/colédoco McMahon, BJS, 1995; 82: 307
- 28. RECOMENDAÇÕES Colangiograma intraoperatórioTécnica Não evita, mas diagnostica SABER INTERPRETAR US intraop como alternativa Strasberg, JACS, 1995; 180: 101 Massarweh, Surgery, 2008; 207:821 Flum, JAMA 2003; 289: 1639 Flum, JACS 2003: 196:385
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- 30. RECOMENDAÇÕES Alternativas técnicasColeciste anterógrada ou “fundus down” Colecistostomia Colecistectomia subtotal Colecistoduodenostomia
- 31. CASO 57a, IRC,listado pra tx renal DMII, cego, amputado, IAM previo, HAS, obeso Colecistite aguda Fim da cirurgia: fístula biliar CONVERSÃO pós colangiograma sem lesão Fístula PO com resolução espontânea
- 32. APRESENTAÇÃO CLÍNICA 50% dx no intraop 10% diagnosticada na primeira semana fraqueza, dor, distensão, febre, icterícia, peritonite, bacteremia, colangite BIL>3, FA 300-500 70% diagnosticada nos primeiros 6 meses
- 33. DIAGNÓSTICO CT/US- coleções fora da fossa VB HIDA Aspirar e drenar Colangiografia ERCP: terapêutica, não ultrapassa obstr. total MRCP: mapeia vasos, VB, coleções PTC: até 7% de complicações
- 34. DIFERENCIAL CEP PCTrauma Mirizzi Radiação Outras cirurgias abdominais Manipulação da VB: endoscópica e radiológica
- 35. MANEJO Tem abcessoou coleção que necessite drenagem? Há fístula? Qual nível de lesão? Há lesão vascular concomitante? Há sofrimento hepático ou atrofia lobar concomitante?
- 36. MANEJO AB etto de sépsis Corrigir coagulopatia e usar vit K Profilaxia pra DVT Correção dist. HE e função renal Suporte nutricional Cuidados com ferida Função hepática e HTN Portal
- 37. CLASSIFICAÇÕES BismuthStrasberg Hannover Way Neuhaus
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- 40. PLANEJAMENTO CIRÚRGICO Tempoe número de reparos Tipo de lesão, com ou sem lesão vascular Expertise da equipe Estabilidade do paciente
- 41. PLANEJAMENTO CIRURGICO Tratamento INTRAOP: Evitar fístula!!!! Preservar comprimento do ducto, mas lembrar da vascularização (reparo geralmente é alto) Certeza que todos os segmentos hepáticos estão drenados Usar anastomose sem tensão com tecidos saudáveis Hepaticojejunostomia é preferida Mercado, Surg Endosc 2003; 17: 1351
- 42. PLANEJAMENTO CIRURGICO Tratamento imediato (1a. SEMANA) Estável Com coleções drenadas sem infecção sem lesão vascular
- 43. CASO 32 anosCL de rotina e colega liga com lesão Strasberg E1 Transferida imediatamente com drenos Admitida ressuscitada, MRI sem lesão vascular Operada dia seguinte sem coleção Reparo HJ em 45 mim Alta no 5PO sem complic
- 44. PLANEJAMENTO CIRURGICO Tratamento tardio (APOS 2-3MESES) Sépsis e coleções resolvidas Estado geral otimizado Lesões complexas=centro com expertise - HEPATICOJEJUNOSTOMIA EM Y ROUX - ACESSO DHE: HEPP-COUINAUD - ACESSO A PLACA HILAR: SETORECTOMIA IV-V - HEPATECTOMIA DIREITA - TRANSPLANTE DE FÍGADO
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- 47. RESULTADOS MB: 4-40%MT: 1.8-5% Reparo bem sucedido em 75-95% … interpretação…
- 48. PAPEL DO RADIOLOGISTADX TTO
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- 59. PAPEL DO ENDOSCOPISTADX TTO
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- 63. CONCLUSÕES LIVB sãograves: $, MB, MT Reconhecer fatores de risco e entender mecanismo para evitar Saber como proceder para DIAGNOSTICAR e MANEJAR a lesão Como proceder para manejar o paciente e qdo encaminhar o paciente!
Notas do Editor
- #3 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #4 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #5 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #6 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #7 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #8 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #9 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #10 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #11 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #12 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #13 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #14 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #15 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #16 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #17 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #18 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #19 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #20 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #22 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #23 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #24 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #25 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #26 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #27 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #28 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #29 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #30 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #31 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #33 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #34 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #35 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #36 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #37 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #38 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #39 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #40 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #41 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #42 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #43 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #45 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #48 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #49 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #60 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up
- #64 Overall center follow-up reporting often inadequate -> reliance on select reports Single center studies - limited by power, bias from subject loss-to-follow-up