Strategien zur Optimierung der R0-Resektionsrate von zentralen Gallengangskarzinomen

Zusammenfassung

Hintergrund: In großen Serien liegt die Häufigkeit einer R1-Resektion bei 20–40 % und stellt somit ein ernstzunehmendes Problem bei der Resektion von Klatskin-Tumoren dar. Methoden: Literaturübersicht zur Bedeutung der R1-Resektion bei Klatskin-Tumoren und zu möglichen chirurgischen Optionen zur Steigerung der Rate an kompletten Tumorresektionen. Ergebnisse: Bei der Planung des Resektionsverfahrens von Klatskin-Tumoren müssen anatomische Prädilektionsstellen für eine R1-Resektion berücksichtigt werden. Bei der Operationsplanung spielen vor erweiterten rechtsseitigen Hemihepatektomien insbesondere Aspekte der Leberfunktion eine wichtige Rolle. Aufgrund des hohen Verlusts an funktionellem Leberparenchym ist meist eine Pfortaderembolisation der Gegenseite anzuraten. Bei linksseitigen Hemihepatektomien ist insbesondere das prä- und intraoperative Management der rechten Leberarterie von zentraler Bedeutung. Diese weist bei typischem Verlauf oft einen langstreckigen Tumorkontakt über 180° der arteriellen Zirkumferenz auf, obwohl sich histologisch selten eine Gefäßinvasion findet. Trotzdem besteht das hohe Risiko einer manifesten oder okkulten R1-Resektion. In ausgewählten Fällen kann daher eine arterielle Resektion erwogen werden. Dies erhöht allerdings das Komplikationsrisiko und muss daher individuell abgewogen werden. Nach Arterienresektion ist entweder die direkte Rekonstruktion möglich, alternativ kann auch eine arterielle Transposition oder ein Gefäßinterponat zur Anwendung kommen. Als Reserveverfahren stehen zusätzlich die präoperative arterielle Embolisation ohne Rekonstruktion sowie die Arterialisierung der Pfortader zur Verfügung. Bei den beiden letzteren Verfahren ist die Gefahr von biliären Komplikationen hoch. In ausgewählten Fällen kann bei irresektablen und lymphknotennegativen Klatskin-Tumoren eine Lebertransplantation erwogen werden. Schlussfolgerung: Trotz vieler Weiterentwicklungen in den chirurgischen Techniken stellt die R1-Resektion von zentralen Gallengangskarzinomen weiterhin ein Problem dar, das durch das Fehlen evidenzbasierter adjuvanter Therapiemaßnahmen noch aggraviert wird.

Abstract

Background: Retrospective analyses have shown a 20–40 % incidence of R1 resection in hilar cholangiocarcinoma, which therefore represents a significant issue to be addressed. Methods: We have reviewed the literature on the impact of R1 resection in hilar cholangiocarcinomas and on possible surgical options to increase the rate of complete tumour resections. Results: To minimise the rate of R1 resections a preoperative risk assessment concerning the predisposed anatomic locations is required. During planning of the surgical strategy, liver function plays a central role prior to right-sided hemihepatectomies. Due to the loss of a high amount of functional liver parenchyma, contralateral portal vein embolisation is often used prior to right trisectionectomies. For left-sided hepatectomies the management of the right hepatic artery is fundamental. The right hepatic artery has a very close contact to the tumour region, although arterial invasion is rarely seen. However, the risk of manifest or occult R1 resection is relatively high along the right artery. In selected cases an arterial resection might be considered, but this increases the risk of postoperative complications. Arterial resection might be performed either via direct anastomosis or by using an interposition graft. As reserve procedures preoperative embolisation of the hepatic artery without reconstruction or an arterialisation of the portal vein are available. However, the latter two procedures come along with an increased rate of biliary complications. In selected lymph-node negative patients with irresectable hilar cholangiocarcinoma liver transplantation might be considered. Conclusion: Despite significant advances in surgical technique, R1 resection remains a problem, which is aggravated by the lack of evidence-based adjuvant measures.

Schlüsselwörter

zentrale Gallengangskarzinome - Klatskin-Tumor - Leberresektion - Lebertransplantation - Arterienrekonstruktion

Key words

hilar cholangiocarcinoma - Klatskin tumour - liver resection - liver transplantation - arterial reconstruction

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