PORTAL TRIAD INJURIES

Objective: Injuries to the portal tried are a rare and complex challen ge in trauma surgery. The purpose of this review is to better characte rize the incidence, lethality, and successful management schemes used to treat these injuries.Design: A retrospective review of the experien ce of eight academic level I trauma centers over a combined 62 years. Results: Ninety-nine patients sustained 118 injuries to the anatomical structures of the porta hepatis: 55 extrahepatic portal vein injuries , 28 extrahepatic arterial injuries, and 35 injuries to the extrahepat ic biliary tree. Sixty-nine percent of the injuries were by penetratin g mechanism and 31% were by blunt mechanism. All patients had associat ed injuries with a mean Injury Severity Score of 34 in blunt trauma pa tients. Overall mortality was 51%, rising to 80% in patients with comb ination injuries. Sixty-six percent of deaths occurred in the operatin g room, primarily from exsanguination; 18% of deaths occurred within 4 8 hours of injury from refractory shock, coagulopathy, or cardiac arre st; 16% occurred late. Ten percent of patients undergoing portal vein ligation survived, compared to 58% managed by primary repair. Survival after hepatic artery ligation was 42%, compared to 14% after primary repair. Survival after biliary-enteric anastomosis as treatment of ext rahepatic bile duct injury was 89%, compared to 50% after primary repa ir and 100% after ligation of lobar bile duct injuries. Missed bile du ct injuries had a high (75%) severe complication rate. Conclusions: In juries to the anatomical structures of the portal triad are rare and o ften lethal. Intraoperative exsanguination is the primary cause of dea th, and hemorrhage control should be the first priority. Bile duct inj uries should be identified by intraoperative cholangiography and repai red primarily or by enteric anastomosis; lobar bile ducts can be manag ed by ligation.