Ate�li Silah Yaralanmas�na Ba�l� Nadir Bir Olgu: Akci�er ve Karaci�er Yaralanmas�yla Birlikte Portal Triad ��erisinde �zole Koledok Kanal� Yaralanmas�

G�m��, Tufan; Korucuk, Ebubekir; Er�zkan, Kamil; Demir, Halit Batuhan; U�uz, Alper

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Ate�li Silah Yaralanmas�na Ba�l� Nadir Bir Olgu: Akci�er ve Karaci�er Yaralanmas�yla Birlikte Portal Triad ��erisinde �zole Koledok Kanal� Yaralanmas� [Ulus Travma Acil Cerrahi Derg]

Ulus Travma Acil Cerrahi Derg. Bask�daki Makaleler: UTD-52199

Ate�li Silah Yaralanmas�na Ba�l� Nadir Bir Olgu: Akci�er ve Karaci�er Yaralanmas�yla Birlikte Portal Triad ��erisinde �zole Koledok Kanal� Yaralanmas�

Tufan G�m��, Ebubekir Korucuk, Kamil Er�zkan, Halit Batuhan Demir, Alper U�uz
Ege �niversitesi T�p Fak�ltesi Hastanesi, Genel Cerrahi Anabilim Dal�, �zmir

Giri�
Koledok kanal� yaralanmalar�, penetran bat�n travmas� vakalar�n�n %0,4�0,5�inde g�r�lmektedir. Ate�li silah yaralanmalar�, merminin neden oldu�u termal hasar�n yan� s�ra, koledok kanal�, portal ven ve hepatik arterin hepatoduodenal ligaman i�erisindeki yak�n anatomik kom�ulu�u nedeniyle t�m yap�larda hasar meydana getirebilir. Bu yak�nl�k, genellikle bu hayati yap�lar�n bir arada yaralanmas�na yol a�arak y�ksek perioperatif morbidite veya mortalite ile ili�kilidir. Hepatoduodenal ligaman i�erisindeki izole koledok kanal� yaralanmalar� son derece nadirdir. �zole koledok kanal� yaralanmalar�n�n y�netimi halen tart��mal� bir konudur. Olgu raporumuzda, karaci�er ve akci�er yaralanmas�na e�lik eden hepatoduodenal ligaman�n di�er bile�enlerine zarar vermeden portal triad i�erisinde yaln�zca koledok kanal�n�n yaraland�� nadir bir ate�li silah yaralanmas� vakas�n� sunmaktay�z.
Olgu
41 ya��nda, ate�li silah yaralanmas�na ba�l� koledok kanal� yaralanmas� nedeniyle acil servise ba�vuran erkek hastay� sunuyoruz. Acil serviste �ekilen bilgisayarl� tomografi (BT) g�r�nt�lemesinde, karaci�erin 6. segmentinden 4B segmentine kadar uzanan 14 cm�lik bir mermi yolunu ve buna ba�l� laserasyon ve kont�zyonu oldu�u saptand�. Eksplorasyonda safra kesesi duvar�nda termal hasar tespit edildi ve hepatoduodenal ligaman�n b�t�nl��n�n bozulmu� oldu�u g�r�ld�. Hastaya kolesistektomi uyguland� ve hepatoduodenal ligaman�n diseksiyonu uygulanmas� ard�ndan koledok duvar�n�n yakla��k %70 oran�nda a��lm�� oldu�u tespit edildi. Portal ven ve hepatik arter salim izlendi. Proksimal koledok kanal� klemplendi ve tam transeksiyon uyguland�. Roux-en-Y hepatikojejunostomi ile rekonstr�ksiyon uyguland�. Hasta postoperatif 7. g�nde taburcu edildi. Alt� ayl�k takipte hastada komplikasyon saptanmad�.
Tart��ma ve Sonu�
Hepatoduodenal ligaman yak�n�nda penetran yaralanmas� olan hastalarda, hemostaz sa�land�ktan sonra hepatoduodenal ligaman�n diseksiyonunun gerekli oldu�una inan�yoruz. Tam kat koledok yaralanmas� olan hastalar i�in hepatikojejunostomi etkili bir cerrahi tedavi y�ntemi olup, postoperatif komplikasyon riskini azaltmaktad�r.

Anahtar Kelimeler: Koledok Kanal�, Ate�li Silah Yaralanmas�, Penetran Bat�n Travmas�, Hepatikojejunostomi

A Rare Case of Abdominal Gunshot Trauma: Isolated Common Bile Duct Injury within the Portal Triad Accompanied by Liver and Lung Injury

Tufan G�m��, Ebubekir Korucuk, Kamil Er�zkan, Halit Batuhan Demir, Alper U�uz
Department of General Surgery, Ege University Hospital, Izmir

Introduction
Injuries to the common bile duct (CBD) have been reported in 0.4�0.5% of penetrating trauma cases across several series. Gunshot wounds pose unique challenges due to the thermal injury caused by the projectile, combined with the close anatomical proximity of the CBD, portal vein, and hepatic artery within the hepatoduodenal ligament. This proximity often results in combined injuries to these vital structures, which are associated with high perioperative morbidity or mortality. Isolated injuries to the CBD within the hepatoduodenal ligament are exceptionally rare, given the structure's protective location and the interconnected nature of its components. The management of isolated CBD injuries remains a topic of ongoing debate. Here, we present a rare case of a gunshot wound causing isolated CBD injury within the portal triad, accompanied by concomitant injuries to other intra-abdominal and thoracic organs.
Case
We present a 41-year-old male patient with an isolated CBD injury within the portal triad accompanied by liver and lung injury sustained from a gunshot. Emergency computed tomography (CT) imaging revealed a bullet trajectory of 14 cm extending from liver segment 6 to segment 4B, associated with laceration and contusion. Exploration revealed thermal damage to the gallbladder wall, and the integrity of the hepatoduodenal ligament was disrupted. A cholecystectomy was performed, and dissection of the hepatoduodenal ligament revealed that approximately 70% of the CBD wall was transected. Importantly, the portal vein and hepatic artery remained intact. The proximal CBD was clamped, and complete transection of the duct was performed. Reconstruction involved a Roux-en-Y hepaticojejunostomy after preparing the jejunal segment. The patient experienced an uneventful recovery and was discharged on postoperative day 7 following drain removal. At the 6-month follow-up, the patient remained asymptomatic, with no evidence of late complications.
Conclusion
We believe that dissection of the hepatoduodenal ligament is necessary in patients with penetrating injuries near the hepatoduodenal ligament after hemostasis. Hepaticojejunostomy is an effective surgical treatment for patients with full-thickness transection of the CBD and reduces the risk of postoperative complications.

Keywords: Common Bile Duct, Gunshot Trauma, Abdominal Trauma, Hepaticojejunostomy

Sorumlu Yazar: Kamil Er�zkan, T�rkiye
Makale Dili: �ngilizce

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