Der Chirurg

, Volume 78, Issue 8, pp 698–712 | Cite as

Inzidentalome der Leber und der Gallenblase

Bewertung und therapeutisches Vorgehen
Leitthema

Zusammenfassung

Der zunehmende Einsatz von Ultraschalluntersuchungen in der alltäglichen Praxis führt zu einer kontinuierlich steigenden Zahl der Diagnosen von inzidentellen Lebertumoren. Die korrekte Diagnose des Leber-Inzidentaloms lässt sich in über 90% mit nichtinvasiven Methoden stellen. Eine kritische Indikationsstellung muss insbesondere bei fraglich symptomatischen Inzidentalomen erfolgen. Die „absolute“ Forderung nach operativer Resektion beim Verdacht auf ein Leberzelladenom muss nach neuester Literatur kritisch hinterfragt werden. Der nicht auszuräumende Verdacht auf Malignität stellt vor dem Hintergrund einer geringen Morbidität und weitgehend fehlender Mortalität beim chirurgischen Eingriff eine eindeutige Indikation zur Resektion dar, perkutane Biopsien sind aus onkologischen Überlegungen, oftmals fehlendem diagnostischen Nutzen und Komplikationsgefahr in vielen Fällen nicht sinnvoll.

Die stadiengerechte radikale Reoperation beim Inzidentalom der Gallenblase vermag, mit Erreichen einer R0-Situation, das Langzeitüberleben in den weniger fortgeschrittenen Tumorstadien T1b und dem am häufigsten vorkommenden Stadium T2 signifikant zu verlängern. Patienten mit erhöhtem Risiko für das Vorliegen eines inzidentellen Gallenblasenkarzinoms sollten umfassend über die potentiellen Risiken der laparoskopischen Cholezystektomie aufgeklärt werden. Multimodale Therapiekonzepte zur Behandlung der fortgeschrittenen Tumorstadien sollten im Rahmen von prospektiven Multizentrumstudien evaluiert werden.

Schlüsselwörter

Leber-Inzidentalom Gallenblasen-Inzidentalom Diagnostik Therapie Algorithmus 

Incidentalomas of the liver and gallbladder

Evaluation and therapeutic procedure

Abstract

The expanding use of ultrasound in general practice is leading to an ever increasing rate of detection of true hepatic incidentaloma. The correct diagnosis of hepatic incidentaloma may be made in over 90% with non-invasive means. The questionable diagnosis of “symptomatic” incidentaloma should undergo close scrutiny prior to a decision in favour of surgery. With regard to more recent literature, the former “absolute” requirement for surgical resection in all cases of liver cell adenoma may have to be reappraised. Final inability to rule out malignancy represents an unquestionable indication for surgery in the light of low rates of morbidity and lack of mortality in this otherwise healthy patient group. Percutaneous biopsies should not be performed due to oncological hazards, indeterminate results and potential for acute complications.

The stage-oriented radical re-resection following diagnosis of an incidentally detected gallbladder cancer may lead to significantly improved long-term survival, especially in the early tumour stages T1b and T2, which represents the most common stage of gallbladder cancer in incidentaloma. Patients at elevated risk for incidental gallbladder cancer should undergo thorough instruction with regard to the potential hazards of laparoscopic cholecystectomy. Multimodal therapeutic strategies directed at advanced stages of incidentally detected gallbladder cancer should be evaluated in prospective multicentre studies.

Keywords

Hepatic incidentaloma Gallbladder incidentaloma Diagnosis Treatment Algorithm 

Literatur

  1. 1.
    Adam R, Chiche L, Aloia T et al. (2006) Hepatic resection for noncolorectal nonendocrine liver metastases. Ann Surg 244: 524–535PubMedCrossRefGoogle Scholar
  2. 2.
    Anderson C, Pinson C, Berlin J et al. (2004) Diagnosis and treatment of cholangiocarcinoma. The Oncologist 9: 43–57PubMedCrossRefGoogle Scholar
  3. 3.
    Aretxabala X, Roa I, Berrios M et al. (2006) Chemoradiotherapy in Gallbladder Cancer. J Surg Oncol 93: 699-704PubMedCrossRefGoogle Scholar
  4. 4.
    Charny CK, Jarnagin WR, Schwartz LH et al. (2001) Management of 155 patients with benign liver tumours. Br J Surg 88: 808–813PubMedCrossRefGoogle Scholar
  5. 5.
    Colli A, Fraquelli M, Massironi S et al. (2007) Elective surgery for benign liver tumours (review). Google Scholar
  6. 6.
    Descottes B, Glineur D, Lachachi F et al. (2003) Laparoscopic liver resection of benign liver tumors. Surg Endosc 17: 23–30PubMedCrossRefGoogle Scholar
  7. 7.
    Donohue J, Nagorney D, Grant C et al. (1990) Carcinoma of the gallbladder. Arch Surg 125: 237–241PubMedGoogle Scholar
  8. 8.
    Drouard F, Delamarre J, Capron J (1991) Cutaneous seeding of gallbladder cancer after laparoscopic cholecystectomy. N Eng J Med 325: 1316Google Scholar
  9. 9.
    Farges O, Jago P, Kirstetter et al. (2002) Prospective assessment of the safety and benefit of laparoscopic liver resections. J Hepatobiliary Pancreat Surg 9: 242-248PubMedCrossRefGoogle Scholar
  10. 10.
    Fong Y, Fortner J, Sun RL et al. (1999) Clinical score for predicting recurrence after hepatic resection for metastatic colorectal cancer: analysis of 1001 consecutive cases. Ann Surg 230: 309–321PubMedCrossRefGoogle Scholar
  11. 11.
    Fong Y, Jarnagin W, Blumgart LH (2000) Gallbladder Cancer: comparison of patients presenting initially for definitive operation with those presenting after prior noncurative intervention. Ann Surg 232: 557–569PubMedCrossRefGoogle Scholar
  12. 12.
    Foster JM, Hoshi H, Gibbs JF et al. (2007) Gallbladder Cancer: Defining the indications for primary radical resection and radical re-resection. Ann Surg Oncol 14: 833–840PubMedCrossRefGoogle Scholar
  13. 13.
    Ibrahim S, Chen CL, Wang SH et al. (2007) Liver resection for benign tumors: indications and outcome. Am J Surg 193: 5–9PubMedCrossRefGoogle Scholar
  14. 14.
    Ito H, Matros E, Brooks DC, et al. (2004) Treatment outcomes associated with surgery for gall bladder cancer: a 20-year experience. J Gastrointest Surg 8: 183–190PubMedCrossRefGoogle Scholar
  15. 15.
    Kim J, Ahmad S, Lowy A et al. (2004) An algorithm for the accurate identification of benign liver lesions. Am J Surg 187: 274–279PubMedCrossRefGoogle Scholar
  16. 16.
    Kondo S, Nimura Y, Kamiya J et al. (2003) Factors influencing postoperative hospital mortality and long-term survival after radical resection for Stage IV gallbladder carcinoma. World J Surg 27: 272-277PubMedCrossRefGoogle Scholar
  17. 17.
    Kresl J, Schild S, Henning G et al. (2002) Adjuvant external beam radiation therapy with concurrent chemotherapy in the management of gallbladder carcinoma. Int J Radiat Oncol Biol Phys 52: 167–175PubMedCrossRefGoogle Scholar
  18. 18.
    Muratore A, Polastri, Bouzari H et al. (2000) Radical surgery for gallbladder cancer: a worthwhile operation? Eur J Surg Oncol 26: 160–163PubMedCrossRefGoogle Scholar
  19. 19.
    Neuhaus P, Jonas S, Settmacher et al. (2003) Surgical management of proximal bile duct cancer: extended right lobe resection increases resectability and radicality Langenbecks. Arch Surg 388: 194–200CrossRefGoogle Scholar
  20. 20.
    Ouchi K, Mikuni J, Kakugawa Y (2002) Laparoscopic cholecystectomy for gallbladder carcinoma: results of a Japanese survey of 498 patients. J Hepatobiliary Pancreat Surg 9: 256–260PubMedCrossRefGoogle Scholar
  21. 21.
    Paolucci V, Neckell M, Götze T (2003) Unsuspected gallbladder carcinoma The CAE-S/CAMIC registry. Zentrbl Chir 128: 309–312CrossRefGoogle Scholar
  22. 22.
    Paolucci V, Schaeff B, Schneider M, Gutt C (1999) Tumor seeding following laparoscopy: International Survey. World J Surg 23: 989–959PubMedCrossRefGoogle Scholar
  23. 23.
    Pietrabissa A, Giulanotti P, Campatelli A et al. (1996) Management and follow-up of 78 giant haemangiomas of the liver. Br J Surg 83: 915–918PubMedCrossRefGoogle Scholar
  24. 24.
    Shimizu S, Takayama T, Kosuge T et al. (1992) Benign tumors of the liver resected because of a diagnosis of malignancy. Surg Gynecol Obstet 174: 403–407PubMedGoogle Scholar
  25. 25.
    Shirai Y, Yoshida K, Tsukada K, Muto T (1992) Inapparent carcinoma of the gallbladder. Ann Surg 215: 326–331PubMedCrossRefGoogle Scholar
  26. 26.
    Sun CD, Zhang BY, Wu LQ et al. (2005) Laparoscopic cholecystectomy for treatment of unexpected earlystage gallbladder cancer. J Surg Oncol 2005 (91): 253–257CrossRefGoogle Scholar
  27. 27.
    Van der Windt DJ, Kok N, Hussain SM, et al. (2006) Case-orientated approach to the management of hepatocellular adenoma. Br J Surg 93: 1495–1502CrossRefGoogle Scholar
  28. 28.
    Vergara V, Garripoli A, Marucci M et al. (1993) Colon cancer seeding after percutaneous fine needle aspiration of liver metastasis. J Hepatol 18: 276–278PubMedCrossRefGoogle Scholar
  29. 29.
    Wakai T, Shirai Y, Hatakeyama K (2002) Radical second resection provides survival benefit for patients with T2 gallbladder carcinoma first discovered after laparoscopic cholecystectomy. World J Surg 26: 867–871PubMedCrossRefGoogle Scholar
  30. 30.
    Weimann A, Ringe B, Klempnauer J et al. (1997) Benign liver tumors: Differential diagnosis and indications for surgery. World J surg 21: 983–991PubMedCrossRefGoogle Scholar
  31. 31.
    Wilson S, Burns P (2006) An algorithm for the diagnosis of focal liver masses using microbubble contrast-enhanced pulse-inversion sonography. AJR 186: 1401–1412PubMedCrossRefGoogle Scholar
  32. 32.
    Woodfield JC, Rodgers M, Windsor JA (2004) Peritoneal gallstones following laparoscopic cholecystectomy. Surg Endosc 18: 1200–1207PubMedCrossRefGoogle Scholar
  33. 33.
    Yildirim E, Celen O,Gulben K,et al.(2005) The surgical management of incidental gallbladder carcinoma. Eur J Surg Oncol 31: 45–52PubMedCrossRefGoogle Scholar

Copyright information

© Springer Medizin Verlag 2007

Authors and Affiliations

  1. 1.Chirurgische Klinik und PoliklinikUniversitätsklinikum RegensburgRegensburgDeutschland

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