SCIENTIFIC PAPERS
Injuries to the Portal Triad David L. Dawson,
MD,
Kaj H. Johansen,
MD, PhD, Gregory
We reviewed the management and clinical course of 21 patients with extrahepatic injuries to the portal triad seen over the past 11 years at a Level I trauma center. These represented only 0.21% of patients with multiple trauma admitted during this time. Portal triad injury was never specifically diagnosed preoperatively. Extrahepatic bile duct injury occurred in 4 patients, portal vein injury in 14, and hepatic artery injury in 7; 3 patients had combined injuries. Eleven patients (52%) died, all due to uncontrolled hemorrhage from either an injured portal vein or associated intra-abdominal injuries. Management of the bile duct injuries included drainage alone, bile duct ligation, and Roux-Y hepaticojejunostomy. Survivors of portal vein injury were managed with lateral venorrhaphy. Ligation of the hepatic artery appeared to he optimal for injuries incurred by this vessel. Complications necessitating reoperation or percutaneous drainage procedures were encountered in 8 of 10 surviving patients ( 80% ) . Injuries to the portal triad are uncommon, difficult to diagnose, and technically challenging. Mortality is most directly related to uncontrolled intraahdominal hemorrhage, and salvage requires rapid control of bleeding as the first treatment priority.
From the Department of Surgery, Harborview Medical Center, University of Washington School of Medicine, Seattle, Washington. Requests for reprints should be addressed to David L. Dawson, MD, Department of Surgery, RF-25, University of Washington School of Medicine, Seattle, Washington 98195. Presented at the 77th Annual Meeting of the North Pacific Surgical Association, Seattle, Washington, November 9-10, 1990.
J. Jurkovich, MD, Seattle, Washington
T
he hepatoduodenal ligament contains several vital structures-the portal vein, hepatic artery, and the extrahepatic hepatic and common bile ducts-known collectively as the portal triad. Located deep in the right upper quadrant, they lie in close proximity to the liver, gallbladder, the stomach and duodenum, the aorta and the inferior vena cava, the pancreas, and the right kidney. Blunt or penetrating trauma to this region might be expected to threaten the portal triad structures, especially in the presence of known injury to an adjacent organ. Although portal triad injury is rare, its potential presence and significance must be appreciated at the time of operation for abdominal trauma. Appropriate surgical treatment requires familiarity with a number of therapeutic options. Previous publications have usually reported only anecdotal experience with these injuries, and most have looked at injuries to just one structure of this anatomic unit. The purpose of this report is to review our institution’s experience with portal triad injuries, and to examine the efficacy of various diagnostic and therapeutic options. PATIENTS AND METHODS We reviewed all injuries to the extrahepatic portal triad structures (biliary tree, portal vein, or hepatic artery) at Harborview Medical Center (HMC) in Seattle, the Level I trauma center for the Pacific Northwest, for the 1l-year period 1979 to 1990. Patient records were selected from our institution’s Trauma Registry and from discharge records that included these injuries in the list of diagnoses. Iatrogenic injuries or trauma limited to the liver, gallbladder or cystic duct, mesenteric or splenic veins, or celiac axis were excluded from this analysis. The records were reviewed for demographic characteristics, mechanisms of injury, and indicators of the severity of injury. These included the presence of shock (systolic blood pressure less than or equal to 90 mm Hg) prior to admission or in the emergency room, requirement for endotracheal intubation in the field or during the emergency room course, and hypothermia (emergency rmrn or operating morn temperature less than or equal to 34SOC). Associated injuries were recorded and Injury Severity Scores (ISS) [I] calculated. Blood alcohol level determinations, when performed, were recorded. Each patient’s evaluation was reviewed to determine how the diagnosis of portal triad injury was made (including whether this diagnosis was considered preoperatively). The use and accuracy of diagnostic peritoneal lavage (DPL), computed tomography (CT), angiography, ultrasound, cholangiography, hepatobiliary scintigraphy, or other tests was noted. The sequelae of patients’ portal triad injuries and their management were reviewed, and causes of death were noted. Morbidity was assessed by: (1) the need for reoper-
THE AMERICAN JOURNAL OF SURGERY
VOLUME 161 MAY 1991
545
DAWSONETAL
ation or adjunctive procedures to manage portal triad structure injury; (2) length of stay; and (3) need for readmission to the hospital. Student’s unpaired t test and Fisher’s exact test were used to test the statistical significance of differences between groups, with significance assumed for p
Injuries to the Portal Triad David L. Dawson,
MD,
Kaj H. Johansen,
MD, PhD, Gregory
We reviewed the management and clinical course of 21 patients with extrahepatic injuries to the portal triad seen over the past 11 years at a Level I trauma center. These represented only 0.21% of patients with multiple trauma admitted during this time. Portal triad injury was never specifically diagnosed preoperatively. Extrahepatic bile duct injury occurred in 4 patients, portal vein injury in 14, and hepatic artery injury in 7; 3 patients had combined injuries. Eleven patients (52%) died, all due to uncontrolled hemorrhage from either an injured portal vein or associated intra-abdominal injuries. Management of the bile duct injuries included drainage alone, bile duct ligation, and Roux-Y hepaticojejunostomy. Survivors of portal vein injury were managed with lateral venorrhaphy. Ligation of the hepatic artery appeared to he optimal for injuries incurred by this vessel. Complications necessitating reoperation or percutaneous drainage procedures were encountered in 8 of 10 surviving patients ( 80% ) . Injuries to the portal triad are uncommon, difficult to diagnose, and technically challenging. Mortality is most directly related to uncontrolled intraahdominal hemorrhage, and salvage requires rapid control of bleeding as the first treatment priority.
From the Department of Surgery, Harborview Medical Center, University of Washington School of Medicine, Seattle, Washington. Requests for reprints should be addressed to David L. Dawson, MD, Department of Surgery, RF-25, University of Washington School of Medicine, Seattle, Washington 98195. Presented at the 77th Annual Meeting of the North Pacific Surgical Association, Seattle, Washington, November 9-10, 1990.
J. Jurkovich, MD, Seattle, Washington
T
he hepatoduodenal ligament contains several vital structures-the portal vein, hepatic artery, and the extrahepatic hepatic and common bile ducts-known collectively as the portal triad. Located deep in the right upper quadrant, they lie in close proximity to the liver, gallbladder, the stomach and duodenum, the aorta and the inferior vena cava, the pancreas, and the right kidney. Blunt or penetrating trauma to this region might be expected to threaten the portal triad structures, especially in the presence of known injury to an adjacent organ. Although portal triad injury is rare, its potential presence and significance must be appreciated at the time of operation for abdominal trauma. Appropriate surgical treatment requires familiarity with a number of therapeutic options. Previous publications have usually reported only anecdotal experience with these injuries, and most have looked at injuries to just one structure of this anatomic unit. The purpose of this report is to review our institution’s experience with portal triad injuries, and to examine the efficacy of various diagnostic and therapeutic options. PATIENTS AND METHODS We reviewed all injuries to the extrahepatic portal triad structures (biliary tree, portal vein, or hepatic artery) at Harborview Medical Center (HMC) in Seattle, the Level I trauma center for the Pacific Northwest, for the 1l-year period 1979 to 1990. Patient records were selected from our institution’s Trauma Registry and from discharge records that included these injuries in the list of diagnoses. Iatrogenic injuries or trauma limited to the liver, gallbladder or cystic duct, mesenteric or splenic veins, or celiac axis were excluded from this analysis. The records were reviewed for demographic characteristics, mechanisms of injury, and indicators of the severity of injury. These included the presence of shock (systolic blood pressure less than or equal to 90 mm Hg) prior to admission or in the emergency room, requirement for endotracheal intubation in the field or during the emergency room course, and hypothermia (emergency rmrn or operating morn temperature less than or equal to 34SOC). Associated injuries were recorded and Injury Severity Scores (ISS) [I] calculated. Blood alcohol level determinations, when performed, were recorded. Each patient’s evaluation was reviewed to determine how the diagnosis of portal triad injury was made (including whether this diagnosis was considered preoperatively). The use and accuracy of diagnostic peritoneal lavage (DPL), computed tomography (CT), angiography, ultrasound, cholangiography, hepatobiliary scintigraphy, or other tests was noted. The sequelae of patients’ portal triad injuries and their management were reviewed, and causes of death were noted. Morbidity was assessed by: (1) the need for reoper-
THE AMERICAN JOURNAL OF SURGERY
VOLUME 161 MAY 1991
545
DAWSONETAL
ation or adjunctive procedures to manage portal triad structure injury; (2) length of stay; and (3) need for readmission to the hospital. Student’s unpaired t test and Fisher’s exact test were used to test the statistical significance of differences between groups, with significance assumed for p
