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Chirurgische Resektion kolorektaler Lebermetastasen

Was ist Standard?

Standard surgical resection of colorectal liver metastases

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Zusammenfassung

Derzeit ist die Leberresektion kolorektaler Metastasen unter potenziell kurativer Zielsetzung bei 15–20% der Patienten durchführbar. Chirurgisch ist die Erzielung eines R0-Stadiums entscheidend. Die perioperative Letalität hängt wesentlich vom dem Ausmaß der Resektion (Standardresektion [Klasse I], erweiterte Resektion [Klasse II]) ab. Versuche der intra- und postoperativen Risikominimierung durch medikamentöse oder ischämische Präkonditionierung sind nicht ausreichend validiert und ihr klinischer Wert anzuzweifeln. Unter Berücksichtigung dieser Faktoren beträgt die 5-Jahres-Überlebensrate bei primärer, aber auch bei wiederholter Metastasenresektion weiterhin um 30–40%. Eine weitere Prognoseverbesserung erscheint in erster Linie durch eine Erweiterung der Indikations- und Therapiespektren möglich. Entscheidende Bedeutung wird dabei der Konversion irresektabler und potenziell resektabler Metastasen in eine chirurgische Resektabilität zukommen. Dies kann präoperativ durch eine Embolisation mit Verkleinerung des tumortragenden Anteils/Vergrößerung des Leberrestgewebes oder neoadjuvante Chemotherapiekonzepte, intraoperativ mittels zweitzeitiger Resektion oder eine Kombination resezierender mit lokal ablativen Verfahren erreicht werden. Alle vorgeschlagenen Verfahren bei primär inoperablen Befunden sollten in klinischen Studien systematisch überprüft werden.

Abstract

Liver resection for colorectal metastases can be performed with curative intent in about 15−20% of patients. From a surgical point of view, achieving a radical (R0) resection is of paramount importance. Perioperative mortality is mainly linked to the extent of the resection (class I/II). Results of ischemic or drug-induced preconditioning have been ambiguous, and their clinical use is at most questionable. Five-year survival following primary and repeated liver resection is consistently reported at 30–40%. The options for improving prognosis by purely technical means appear limited. Instead, future strategies must aim at the conversion of primarily irresectable and potentially resectable liver metastases into resectable tumors. This could be achieved preoperatively via portal vein embolisation and neoadjuvant chemotherapy and surgically via sequential resection or a combination of surgery with local ablative therapy. All suggested modalities for primarily inoperable tumors should be systematically evaluated in clinical trials.

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  1. Klinik für Allgemein- und Gefäßchirurgie der Chirurgischen Universitätsklinik Frankfurt/Main

    W. O. Bechstein & M. Golling

  2. Klinik für Allgemein- und Gefäßchirurgie, Johann-Wolfgang-Goethe-Universität, Theodor-Stern-Kai 7, 60590 , Frankfurt

    W. O. Bechstein

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  2. M. Golling
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Correspondence to W. O. Bechstein.

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Bechstein, W.O., Golling, M. Chirurgische Resektion kolorektaler Lebermetastasen. Chirurg 76, 543–551 (2005). https://doi.org/10.1007/s00104-005-1045-7

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