Zusammenfassung
GRUNDLAGEN: Bei Patienten mit destruktiver Cholangitis als Folge einer Gallengangskomplikation nach Cholezystektomie ist die Leberteilresektion oftmals die einzige Therapieoption. METHODIK: Analyse von 14 Patienten, bei denen aufgrund einer schwerwiegenden Gallengangskomplikation nach laparoskopischer (n = 12) oder offener (n = 2) Cholezystektomie eine Leberteilresektion durchgeführt wurde. ERGEBNISSE: Bei allen Patienten lag eine zentrale, auf Höhe bzw. oberhalb der Gallengangsgabel lokalisierte Verletzung vor. Die postoperative Mortalität betrug 14 %. Minor Komplikationen wurden bei 50 % der Patienten beobachtet. Die Histologie der resezierten Leber ergab in 50 % der Fälle eine schwere Cholangitis. Eine portale Fibrose lag bei 43 % der Patienten, eine sekundär biliäre Zirrhose bei 36 % der Patienten vor. Nach einer medianen Nachbeobachtungszeit von 6 Jahren, waren 50 % der überlebenden Patienten beschwerdefrei. Sechs Patienten berichteten über gelegentlich auftretende cholangitische Beschwerden ohne das eine Gallengangsstriktur nachgewiesen werden konnte. SCHLUSSFOLGERUNGEN: Um folgenschwere Komplikationen, wie die Manifestation einer sekundär biliären Zirrhose, zu vermeiden, stellt die Leberteilresektion bei diesem Patientengut eine geeignete Therapieoption dar. Entscheidend für den Erfolg ist die engmaschige Nachbeobachtung und rechtzeitige Entscheidung für die definitive chirurgische Therapie.
Summary
BACKGROUND: To remove infectious and destructed parenchyma, liver resection is often the only treatment option in patients with hepatic abscess or destructive cholangitis after cholecystectomy related complex bile duct injury. METHODS: We have analysed 14 patients requiring major liver surgery after bile duct injury following laparoscopic (n = 12) or open (n = 2) cholecystectomy. RESULTS: In all patients, the level of injury was at or above the hilar confluence. Postoperative mortality was as high as 14%. Minor complications occurred in 50% of patients. Histological examination showed severe cholangitis in 50%, portal fibrosis in 43% and liver cirrhosis in 36% of patients. After a median follow-up time of 6 years, 50% of the surviving patients have excellent results without biliary symptoms. Six patients have episodes of cholangitis up to three times per year without signs of biliary strictures. CONCLUSIONS: To avoid further complications such as secondary biliary liver cirrhosis, a decision for a definitive surgical intervention should be taken timely.
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References
Roslyn JJ, Binns GS, Hughes EF, Saunders-Kirkwood K, Zinner MJ, Cates JA. Open cholecystectomy. A contemporary analysis of 42,474 patients. Ann Surg 1993;218:129–37
Strasberg SM, Hertl M, Soper NJ. An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180:101–25
Sicklick JK, Camp MS, Lillemoe KD, et al. Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Ann Surg 2005;24:786–92
Walsh RM, Vogt DP, Ponsky JL, Brown N, Mascha E, Henderson JM. Management of failed biliary repairs for major bile duct injuries after laparoscopic cholecystectomy. J Am Coll Surg 2004;199:192–7
Frilling A, Li J, Weber F, et al. Major bile duct injuries after laparoscopic cholecystectomy: a tertiary center experience. J Gastrointest Surg 2004;8:679–85
Schmidt SC, Settmacher U, Langrehr JM, Neuhaus P. Management and outcome of patients with combined bile duct and hepatic arterial injuries after laparoscopic cholecystectomy. Surgery 2004;135:613–8
Koffron A, Ferrario M, Parsons W, Nemcek A, Saker M, Abecassis M. Failed primary management of iatrogenic biliary injury: incidence and significance of concomitant hepatic arterial disruption. Surgery 2001;130:722–31
Stewart L, Way LW. Bile duct injuries during laparoscopic cholecystectomy. Factors that influence the results of treatment. Arch Surg 1995;130:1123–8
Lopez RR Jr, Cosenza CA, Lois J, et al. Long-term results of metallic stents for benign biliary strictures. Arch Surg 2001;136:664–9
Thomson BN, Parks RW, Madhavan KK, Garden OJ. Liver resection and transplantation in the management of iatrogenic biliary injury. World J Surg 2007;31:2363–9
Neuhaus P, Schmidt SC, Hintze RE, Adler A, Veltzke W, Raakow R, Langrehr JM, Bechstein WO. Classification and treatment of bile duct injuries after laparoscopic cholecystectomy. Chirurg 2000;71:166–73
Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004;240:205–13
Fernández JA, Robles R, Marín C, Sánchez-Bueno F, Ramírez P, Parrilla P. Laparoscopic iatrogeny of the hepatic hilum as an indication for liver transplantation. Liver Transpl 2004;10:147–52
Blumgart LH, Kelley CJ, Benjamin IS. Benign bile duct stricture following cholecystectomy: critical factors in management. Br J Surg 1984;71:836–43
Bergman JJ, van den Brink GR, Rauws EA, et al. Treatment of bile duct lesions after laparoscopic cholecystectomy. Gut 1996;38:141–7
Murr MM, Gigot JF, Nagorney DM, Harmsen WS, Ilstrup DM, Farnell MB. Long-term results of biliary reconstruction after laparoscopic bile duct injuries. Arch Surg 1999;134:604–10
Johnson SR, Koehler A, Pennington LK, Hanto DW. Long-term results of surgical repair of bile duct injuries following laparoscopic cholecystectomy. Surgery 2000;128:668–77
Moore DE, Feurer ID, Holzman MD, et al. Long-term detrimental effect of bile duct injury on health-related quality of life. Arch Surg 2004;139:476–81
Seeliger H, Fürst A, Zülke C, Jauch KW. Surgical management of bile duct injuries following laparoscopic cholecystectomy: analysis and follow-up of 28 cases. Langenbecks Arch Surg 2002;387:286–93
Pottakkat B, Sikora SS, Kumar A, Saxena R, Kapoor VK. Recurrent bile duct stricture: causes and long-term results of surgical management. J Hepatobiliary Pancreat Surg 2007;14:171–6
Chaudhary A, Chandra A, Negi SS, Sachdev A. Reoperative surgery for postcholecystectomy bile duct injuries. Dig Surg 2002;19:22–7
Chijiiwa K, Yamashita H, Yoshida J, Kuroki S, Tanaka M. Current management and long-term prognosis of hepatolithiasis. Arch Surg 1995;130:194–7
Schmidt SC, Langrehr JM, Raakow R, Klupp J, Steinmüller T, Neuhaus P. Right hepatic lobectomy for recurrent cholangitis and right hepatic artery injury during laparoscopic cholecystectomy: a report of two cases. Langenbeck's Arch Surg 2002;387:183–7
Loinaz C, González EM, Jiménez C, et al. Long-term biliary complications after liver surgery leading to livertransplantation. World J Surg 2001;25:1260–3
Yan JQ, Peng CH, Ding JZ, et al. Surgical management in biliary restricture after Roux-en-Y hepaticojejunostomy for bile duct injury. World J Gastroenterol 2007;13:6598–602
Alves A, Farges O, Nicolet J, Watrin T, Sauvanet A, Belghiti J. Incidence and consequence of an hepatic artery injury in patients with postcholecystectomy bile duct strictures. Ann Surg 2003;238:93–6
Laurent A, Sauvanet A, Farges O, Watrin T, Rivkine E, Belghiti J. Major hepatectomy for the treatment of complex bile duct injury. Ann Surg 2008;248:77–83
Hammel P, Couvelard A, O'Toole D, et al. Regression of liver fibrosis after biliary drainage in patients with chronic pancreatitis and stenosis of the common bile duct. N Engl J Med 2001;344:418–23
Mercado MA, Chan C, Orozco H, et al. Long-term evaluation of biliary reconstruction after partial resection of segments IV and V in iatrogenic injuries. J Gastrointest Surg 2006;10:77–82
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Schmidt, S., Fikatas, P., Denecke, T. et al. Hepatic resection for patients with cholecystectomy related complex bile duct injury. Eur Surg 42, 77–82 (2010). https://doi.org/10.1007/s10353-010-0524-3
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DOI: https://doi.org/10.1007/s10353-010-0524-3