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Präkonditionierung der Leber

Preconditioning of the liver

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Zusammenfassung

Das postoperative Leberversagen als schwerwiegende Komplikation nach Majorresektionen der Leber geht mit einer hohen Letalität einher. Neben einem zu geringen Restlebervolumen spielen in der Pathophysiologie mehrere weitere Faktoren eine wichtige Rolle. Die entscheidenden Größen sind neben dem Lebervolumen die Leberfunktion, die parenchymatöse Qualität, die Perfusion – gemeint sind der „inflow“ und „outflow“ – und zuletzt der Zustand des Patienten sowie etwaige Komorbiditäten. Während das Lebervolumen relativ einfach mittels moderner Bildgebung zu bestimmen ist, verlangt die Beurteilung der Leberfunktion und der Leberqualität eine differenziertere Betrachtung. Beide Faktoren werden unter anderem konstitutionell, durch Vorerkrankungen sowie Medikationen bestimmt und müssen entsprechende Berücksichtigung bei der Risikoevaluation erfahren. Die Erhaltung einer ausreichenden Perfusion, gemeint ist dabei die portale und arterielle Durchblutung und ein sicherer Abfluss über zumindest eine Lebervene, genauso wie eine sichere bzw. suffiziente biliäre Drainage sind entscheidend für die Regeneration. Nur die Betrachtung und das Verständnis all dieser Kriterien erlauben eine sichere Abschätzung der Resektabilität. Ebenso müssen die peri- und postoperativen Interventionsoptionen bekannt sein und am Standort zur Verfügung stehen. Im folgenden Beitrag werden die wesentlichen Fragen der Risikoevaluierung eines postoperativen Leberversagens aufgezeigt und die therapeutischen Optionen beschrieben. Ziel muss es sein, bei gegebener onkologischer Resektabilität die funktionelle Operabilität herzustellen. Gemeint ist: Stimmt die Indikation, so sollte reseziert werden, was resektabel ist, und resektabel gemacht werden, was primär nicht resektabel erscheint.

Abstract

Posthepatectomy liver failure (PHLF) still represents a severe complication after major liver resection associated with a high mortality. In addition to an insufficient residual liver volume various factors play an important role in the pathophysiology of PHLF. These include the quality of the parenchyma, liver function, perfusion, i.e. maintenance of adequate inflow and outflow, as well as the condition of the patient and comorbidities. While the liver volume is relatively easy to evaluate using modern imaging techniques, the evaluation of liver function and liver quality require a differentiated approach. Both factors can be influenced by the constitutional status of the patient, medical history and previous treatment and must be given sufficient consideration in the risk evaluation. An adequate perfusion, e.g. portal and arterial circulation and adequate outflow by at least one hepatic vein as well an adequate biliary drainage should be always guaranteed in order to allow regeneration of the residual liver tissue. Only the understanding of all these aspects will support the surgeon in a correct and safe evaluation of the resectability. Additionally, the liver surgeon should be aware of all available perioperative and postoperative options to treat and to prevent PHLF. In this review article the most important questions regarding the risk factors related to PHLF are presented and the potential therapeutic and prophylactic management is described. The main goal is to ensure functional operability of the patient if oncological resectability is possible. In other words: in the case of correct oncological indication, the liver surgeon should be able to resect what is resectable or, alternatively, make resectable what primarily was not resectable.

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Authors and Affiliations

  1. Universitätsklinik für Allgemeine, Viszeral- und Transplantationschirurgie Tübingen, Hoppe-Seylerstraße 3, 72076, Tübingen, Deutschland

    I. Capobianco, J. Strohäker, A. Della Penna, S. Nadalin &  A. Königsrainer

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  1. I. Capobianco
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  2. J. Strohäker
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  3. A. Della Penna
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Correspondence to A. Königsrainer.

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Interessenkonflikt

I. Capobianco, J. Strohäker, A. Della Penna, S. Nadalin und A. Königsrainer geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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Capobianco, I., Strohäker, J., Della Penna, A. et al. Präkonditionierung der Leber. Chirurg 90, 542–547 (2019). https://doi.org/10.1007/s00104-019-0926-0

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