Safra yolu yaralanmaları tedavi yönetiminde morbidite ve mortalite üzerine etkin prediktif faktörlerin analizi
Management of iatrogenic bile duct injuries: Multiple logistic analyses of predictive factors effective on morbidity and mortality
Yazar: ELA EKMEKÇİGİL
Danışman: DOÇ. DR. LEVENT YENİAY
Ege Üniversitesi / Tıp Fakültesi / Genel Cerrahi Ana Bilim Dalı
Derece: Tıpta Uzmanlık, 2015
Konu: Genel Cerrahi = General Surgery

Özet:
Amaç: İyatrojenik safra yolu yaralanmaları, laparoskopik kolesistektomi sonrası
gelişebilen ciddi komplikasyonlardır. Postoperatif dönemde, tedavi başarısı üzerinde
etkin prediktif faktörleri incelemeyi amaçladık.
Yöntem: Laparoskopik kolesistektomi sonrası Ege Üniversitesi Tıp Fakültesi
Hastanesi'ne iyatrojenik safra yolu yaralanması nedeniyle başvuran 105 hastanın
klinik parametreleri retrospektif olarak lojistik regreyon analiz yöntemi kullanarak
incelendi. Yaralanma düzeyi Strasberg- Bismuth sınıflama yöntemine göre
sınıflandırıldı ve hastalar başvuru öncesinde uygulanan girişim yöntemlerine göre
gruplandırıldı.
Bulgular: 2004-2014 yılları arasında tedavi edilen 105 hasta içinde; ilk grup
laparoskopik kolesistektomi sonrasında yaralanma şüphesi ile yeniden girişim
uygulanmaksızın kliniğimize sevk edilen 47 hasta (%45), ikinci grup yaralanma
sonrasında tekrarlanan cerrahi girişimlerden sonra sevk edilen 32 hasta (%31) ve
üçüncü grup minor yaralanmalar nedeniyle girişimsel yöntemler (ERKP, PTK) ile
opere edilmeksizin tedavi edilen 26 hasta (%24) olmak üzere oluşturuldu. Klinik
parametreler SPSS version 8.0 ile analiz edildi. Forward LR yöntemi ile lojistik
regresyon analizinde kullanılacak parametreler, tek değişkenli analizde p değeri <
0.10 olan risk faktörleri arasından seçildi. Sepsis gelişimi yönünden olası prediktif
faktörler; yaralanma sonrası merkezimize başvuru öncesi uygulanan cerrahi
yöntemlerin tipine ve sayısına göre (RR: 10.1, RR: 3) belirleyici olduğu gözlendi.
Çoklu değişkenli lojistik regresyon analizinde ise Clavien –Dindo sınıflamasının ve
sepsis gelişiminin belirleyici faktörler olarak ön planda yer aldığı gözlemlendi
(DR:4.6 GA: 1.56-13.8). Final modelinde; abse gelişimi (RR: 5.4), eşlik eden
vaskuler yaralanma varlığı (RR: 11.8) ve kan biluribin değerinin (RR:14.7) morbidite
ve mortalite gelişimi üzerinde belirgin etkin olduğu gözlemlendi.
Sonuç: Sepsis durumu ve Clavien-Dindo sınıflaması prognoz seyri ile doğrudan
ilişkilidir. Abse formasyonu gelişimi, vaskuler yaralanma gelişimi ve kan biluribin
düzeyi etkin prediktif faktörlerdir. Hastaların yönetiminde uygulanması gereken
klinik yaklaşım, morbidite ve mortalite üzerinde etkin prediktif faktörlerin ışığında
belirlenmelidir.

Abstract:
Aim: Iatrogenic bile duct injury (IBDI) is a devastating complication of laparoscopic
cholecystectomy (LC) and associated with a nearly threefold increase in risk of
mortality . The appropriate management procedure can alter the disease course and
effect on the high morbidity and mortality rates. Prompt recognition is the
emphasized point but the best approach varies with regard to the type of injury and
featuring clinical symptoms. We aimed to determine the predictors of prognosis for
the success of the treatment in postoperative period.
Methods: We retrospectively analyzed the clinical parameters using logistic
regression analysis of 105 patients who referred to Ege University School of
Medicine Hospital after LC. The data was derived from the computer–based
verified system in Ege University and identified through the medical charts.
Univariate analysis was performed using Pearson x2 test and Fischer's exact test. A
two-tailed p value of < 0.005 was considered significant. The level of injury was
classified using Strasberg-Bismuth classification system.The patients were grouped
according to the prior attempts and the level of the injury. Clavien-Dindo
classification system is used for determining the severity grade of complications.
Results: A total of 105 patients was treated for IBDI between 2004-2014. Fortyseven
(45%) patients were operated following the first attempt of laparoscopic
cholecystectomy, thirty-two (31%) patients were operated after multiple prior
attempts following the injury in community hospitals and twenty-six (24%) patients
with minor injuries were treated only with interventional techniques etc. ERCP, PTC
. The clinical parameters of the patients were analysed using SPSS-PASW statistics
18.0 for Windows. The risk factors (p value < 0.10) in univariate analyse were
selected for logistic regression analyse with forward LR method. The predictive risk
for mortality was significant with the complicated level of injury (table 1). The
predictive effect of level of injury was determined using the 'type A-D'(minor
injuries) as reference group. The comparative groups were significantly increased the
risk for sepsis (type E1-2 OR: 6.0 CI:1.45-24.9, type E3-4-5 OR: 6.78 CI:1.74-
26.43). The predictive value of level of injury was also significantly showed the risk
for mortality when checked against the 'type E3-4-5' group (OR:8.86 CI:1.03-76.06).
The predicted probability of sepsis was revealed with the number and type of the
x
prior attempts (OR:3 CI:1.17-8.05, OR: 10.1 CI: 1.66-62.6 ) before referral to Ege
University School of Medicine. Before referral of the patients, ıt was clearly
identified that the increasing number and varying procedures for repair are the
aggravated factors for sepsis, even for the exclusive procedure of repair;
hepaticojejeunostomy (OR:1.69). Therefore, we can strongly recommend to refer the
patients with the prompt recognization immediately without intending further surgical
procedures. The accompanying vascular injury is one of the strongest predictive
factors for mortality and sepsis. As shown on the table 2; increasing level of repair
procedure before referral can result with worsen outcomes via vascular injury. After
referral of the patients to Ege University as tertiary center; the preferred approach for
repair can also vary the risk for mortality and sepsis. As shown on table 3; an
accompanying injury (vascular, intestinal,hepatic etc.) was increased the risk for
mortality and sepsis (OR:14.5 CI: 1.42-148.5, OR: 12.6 CI:2.40-65.9). The group
of nonsurgical procedures (ERCP, PTC etc.) was determined as the reference group.
The comparative results showed that performing hepaticojejunostomy had no effect
on risk of mortality and sepsis. Therefore, it was obvious to perform
hepaticojejeunostomy for repair in tertiary centers. The factors effective on length of
hospital stay was analysed using spearman's correlation coefficient test. The median
time for referral (r:0.221 p:0.028), number of attempts for percutan drainage (r:0.430
p:0.006) and number of prior attempts (r:0.319 p:0.001) were effective on length of
hospital stay. The analyse of the nonparametric correlation factors was inefficient for
the length of hospital stay. In multiple logistic regression analyse; Clavien- Dindo
classification system was the most significant variable for sepsis (Corrected odds:
4.62 CI: 1.56- 13.8). In the final model; the presence of abscess formation (CO:6.74
CI: 1.21- 37.60) , concomitant vascular injury (CO: 29.41 CI: 4.15 – 208.07) and the
level of biluribin in blood (CO: 4.25 CI:1.034- 17.47) were significantly effective for
mortality.
Conclusion: The sepsis status and Clavien- Dindo grading system correctly relates
the prognosis. The presence of abscess formation, vascular injury and biluribin
levels in the referral are the potential risk factors. The initial clinical approach has to
be determined in the light of predictive factors that are effective on morbidity and mortality.