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Arterielle und portalvenöse Gefäßkomplikationen nach HBP-Eingriffen

Interdisziplinäres Management

Arterial and portal venous complications after HPB surgical procedures

Interdisciplinary management

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Zusammenfassung

Die chirurgische Therapie hepatobiliopankreatischer (HBP-)Erkrankungen erfordert komplexe operative Prozeduren. Morbidität (36–50 %) und Mortalität (<5 %) dieser Eingriffe konnten in den letzten Dekaden gesenkt werden. Insgesamt treten postoperative Komplikationen nach wie vor in 41,2 % der Fälle auf, wobei die Pankreaschirurgie gegenüber hepatobilären Eingriffen mit einer höheren Komplikationsrate vergesellschaftet ist. Zu den schwerwiegendsten Komplikationen zählen postoperative Blutungen, die mit einer Inzidenz von 6,7 % nach Pankreaseingriffen und 3,2 % nach hepatobiliären Operationen auftreten. Frühe postoperative Blutungen sind auf operative Probleme zurückzuführen, späte Blutungen sind Ausdruck von Anastomoseninsuffizienzen, Fisteln oder Abszessen. Diese führen zur Gefäßarrosion oder zur Bildung von Pseudoaneurysmata. Ihnen geht häufig eine selbstlimitierende Sentinel-Blutung voraus. Die jeweilige Therapie orientiert sich an dem Blutungszeitpunkt, der Lokalisation und dem Schweregrad der Blutung. Frühe postoperative Blutungen erfordern eine chirurgische Therapie, während bei späten Blutungen interventionelle Methoden die führenden Behandlungsverfahren sind. Ausnahmen sind kreislaufinstabile oder septische Patienten, diese werden relaparotomiert. Essenziell ist zusätzlich die operative oder interventionelle Sanierung der zur Blutung führenden Ursache. Neben Blutungen sind arterielle und portalvenöse Stenosen und Thrombosen ein Faktor für die postoperative Morbidität und Mortalität. Thrombosen der Portalvene treten in 8,5–9,1 % nach Leberresektionen und 11,6 % nach Pankreasresektionen mit Gefäßbeteiligung auf. Je nach Zeitpunkt der Diagnose und Symptomatik kommen operative, interventionelle oder konservative Verfahren zur Anwendung. Nur durch eine enge interdisziplinäre Zusammenarbeit kann das Morbiditäts- und Mortalitätsrisiko nach HBP-Eingriffen gesenkt werden. Dieses trifft im Besonderen auf die vaskulären Komplikationen zu.

Abstract

The surgical treatment of hepatopancreatobiliary (HPB) diseases requires complex operative procedures. Within the last decades the morbidity (36–50 %) and mortality (<5 %) of these procedures could be reduced; nonetheless, postoperative complications still occur in 41.2 % of cases. Compared with hepatobiliary procedures, pancreatic surgery shows an increased rate of complications. Postoperative bleeding has a major effect on the outcome and the incidence is 6.7 % after pancreatic surgery and 3.2 % after hepatobiliary surgery. The major causes of early postoperative hemorrhage are related to technical difficulties in surgery whereas late onset postoperative hemorrhage is linked to anastomosis insufficiency, formation of fistulae or abscesses due to vascular arrosion or formation of pseudoaneurysms. In many cases, delayed hemorrhage is preceded by a self-limiting sentinel bleeding. The treatment is dependent on the point in time, location and severity of the hemorrhage. The majority of early postoperative hemorrhages require surgical treatment. Late onset hemorrhage in hemodynamically stable patients is preferably treated by radiological interventions. After interventional hemostatic therapy 8.2 % of patients require secondary procedures. In the case of hemodynamic instability or development of sepsis, a relaparotomy is necessary. The treatment concept includes surgical or interventional remediation of the underlying cause of the hemorrhage. Other causes of postoperative morbidity and mortality are arterial and portal venous stenosis and thrombosis. Following liver resection, thrombosis of the portal vein occurs in 8.5–9.1 % and in 11.6 % following pancreatic resection with vascular involvement. Interventional surgical procedures or conservative treatment are suitable therapeutic options depending on the time of diagnosis and clinical symptoms. The risk of morbidity and mortality after HPB surgery can be reduced only in close interdisciplinary cooperation, which is particularly true for vascular complications.

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Authors and Affiliations

  1. Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum Magdeburg A. ö. R., Leipziger Straße 44, 39120, Magdeburg, Deutschland

    J. Arend, S. Peglow, T. Däberitz, F. Popp, F. Benedix, S. Wolff & C. Bruns

  2. Klinik für Gastroenterologie, Hepatologie und Infektiologie, Universitätsklinikum Magdeburg, Magdeburg, Deutschland

    K. Schütte

  3. Klinik für Radiologie und Nuklearmedizin, Universitätsklinikum Magdeburg, Magdeburg, Deutschland

    M. Pech

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J. Arend, K. Schütte, S. Peglow, T. Däberitz, F. Popp, F. Benedix, M. Pech, S. Wolff und C. Bruns geben an, dass kein Interessenkonflikt besteht.

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Arend, J., Schütte, K., Peglow, S. et al. Arterielle und portalvenöse Gefäßkomplikationen nach HBP-Eingriffen. Chirurg 86, 525–532 (2015). https://doi.org/10.1007/s00104-015-0027-7

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