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Primäre Lebertumoren

Präoperative Konditionierung der Leber und perioperatives Management bei erweiterten Leberresektionen

Primary liver tumors

Preoperative conditioning of the liver and perioperative management in extended liver resection

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Zusammenfassung

Hintergrund

Chronische Leberparenchymschädigungen sind ebenso wie eine Cholestase Risikofaktoren für eine Funktionsstörung nach Leberresektion. Die Resektion hepatozellulärer (HCC) und intrahepatischer cholangiozellulärer Karzinome (CCC) stellt aufgrund der häufig beachtlichen Tumorgröße und möglichen Vorschädigung der Leber eine besondere Herausforderung dar. Da für primäre Lebertumoren keine potenten Systemtherapien zur Verfügung stehen, sondern die Chirurgie die einzig potenziell kurative Therapiechance eröffnet, kommt der Reduktion entsprechender Risikofaktoren für ein postoperatives Leberversagen entscheidende Bedeutung zu.

Fragestellung

In dieser Arbeit sollen Maßnahmen zur Risikominimierung bei erweiterten Leberresektionen analysiert werden.

Material und Methode

Diese Arbeit basiert auf einer selektiven Literaturrecherche in der Datenbank PubMed.

Ergebnisse

Der Steatosegrad und der Ischämie-/Reperfusionsschaden können medikamentös reduziert werden. Vor ausgedehnten Resektionen ikterischer Lebern ist eine Dekompression der Gallenwege unbedingt ratsam, da eine Cholestase die Regenerationsfähigkeit des Leberparenchyms vermindert. Durch die Embolisation (PVE) oder Ligatur (PVL) kontralateraler Pfortaderäste kann zudem das postoperativ verbleibende Lebervolumen gesteigert und somit das perioperative Risiko gesenkt werden. Ähnliche Effekte werden von der selektiven internen Radiotherapie (SIRT) berichtet. Auch mehrzeitige Resektionskonzepte steigern die Resekabilität bei gleichzeitiger Reduktion des perioperativen Risikos, wobei aufgrund eines zwischenzeitlichen Tumorprogresses die geplante zweite Leberresektion bei etwa 20–30 % der Patienten nicht durchgeführt wird. Demgegenüber ist im Rahmen des ALPPS-Verfahrens bei nahezu allen Patienten eine komplette Resektion des Tumors möglich. Langzeitergebnisse hinsichtlich des Rezidivrisikos und des Überlebens stehen jedoch aus.

Schlussfolgerungen

Das perioperative Risiko erweiterter Leberresektionen kann sowohl durch technische als auch medikamentöse Maßnahmen reduziert werden.

Abstract

Background

Chronic liver parenchymal diseases as well as cholestasis are established risk factors for liver failure after partial hepatectomy. As hepatocellular (HCC) and cholangiocellular (CCC) carcinoma often require extended resection due to the often considerable size of tumors – in an often priorly damaged liver – surgery for these entities is usually demanding. Due to the lack of potent systemic treatment for primary liver tumors, surgery remains the only potentially curative treatment option for CCC and most HCC; therefore, perioperative risk factors for liver failure should be reduced as far as possible.

Objectives

In this study measures for reducing the risk of liver failure after extended liver resections were analyzed.

Methods

This analysis was based on a selective literature search in the Pubmed databank.

Results

Medical measures can be used to lower the degree of steatosis or the inflammatory reaction of ischemia/reperfusion injury. In particular, biliary decompression should be achieved in obstructive jaundice prior to liver surgery, e.g. for hilar cholangiocarcinoma, as cholestasis impairs liver regeneration. Moreover, the future liver remnant volume after extended liver resection can be increased by embolization (PVE) or ligation of major branches of the portal vein. Similar results as for PVE regarding liver hypertrophy have been reported from unilateral selective internal radiotherapy (SIRT) although this effect appears prolonged and less impressive than after PVE. In addition, two-stage concepts for liver surgery, which are also based on the regenerative potential of the liver, may lower the complication rate and increase patient safety by increasing liver volume. However, conventional two-stage procedures harbor the risk of disease progression during the time lapse to the second step which contraindicates complete resection in 20–30 % of patients. In contrast to this, a complete tumor resection is possible in nearly all patients treated by the associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) procedure but long-term results regarding tumor recurrence rate are scarce due to the limited experience with this novel technique.

Conclusion

The perioperative risks of extended liver resection can be lowered by technical and medical measures.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. S. Heinrich und H. Lang geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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Authors and Affiliations

  1. Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsmedizin Mainz, Langenbeckstr. 1, 55131, Mainz, Deutschland

    S. Heinrich &  H. Lang MA, FACS

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  1. S. Heinrich
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  2. H. Lang MA, FACS
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Correspondence to H. Lang MA, FACS.

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Heinrich, S., Lang, H. Primäre Lebertumoren. Chirurg 86, 125–131 (2015). https://doi.org/10.1007/s00104-014-2881-0

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