Laparoskopische Leberchirurgie – Berliner Zentrumserfahrungen aus 250 konsekutiven Fällen

Zusammenfassung

Hintergrund Trotz überzeugender Ergebnisse international führender Leberzentren ist die laparoskopische Leberchirurgie in Deutschland weiterhin vergleichsweise wenig verbreitet. An der Chirurgischen Klinik der Charité – Universitätsmedizin Berlin wurde 2015 ein strukturiertes Programm zur Entwicklung der laparoskopischen Leberchirurgie etabliert, woraus sich mögliche Implikationen für die breite Etablierung an deutschen Kliniken ergeben.

Methode Wir berichten hier über unsere Zentrumserfahrungen aus 250 konsekutiven, laparoskopischen Leberresektionen zwischen 12/2013 und 1/2018. Es erfolgte eine retrospektive Auswertung in Hinblick auf Indikationen, Patientencharakteristika, Komplexität der Operationen und postoperative Ergebnisse. Die Entwicklung des Programmes wurde analysiert durch Vergleich des Zeitraumes 1 (1/2014 – 12/2015) und Zeitraumes 2 (1/2016 – 12/2017).

Ergebnisse Im Vergleich zum Zeitraum 1 (n = 16, 25% der Patienten) zeigte sich im Zeitraum 2 (n = 75, 50% der Patienten) ein signifikant höherer Prozentsatz von Patienten mit einem hohen ASA-Score (3/4; p = 0,001). Das hepatozelluläre Karzinom war die häufigste Indikation (n = 76, 30,4%), gefolgt von kolorektalen Lebermetastasen (n = 63, 25,2%), wobei sich über die Jahre eine Zunahme bösartiger Tumoren von 53,8% im Zeitraum 1 zu 75,7% im Zeitraum 2 (p = 0,001) zeigte. Es erfolgten 72 Major- (≥ 3 Segmente) und 178 Minorresektionen (< 3 Segmente) mit einer Zunahme an Majorresektionen vom Zeitraum 1 (n = 12, 17,9%) zum Zeitraum 2 (n = 56, 33,1%, p = 0,02). Trotz eines signifikant höheren Prozentsatzes an komplexen Eingriffen im Zeitraum 2 war die Rate an Majorkomplikationen (Dindo-Clavien ≥ III a) mit 16% (27 Patienten) nicht signifikant höher als im Zeitraum 1 mit 11,9% (8 Patienten, p = 0,432). 67 (26,8%) Patienten litten unter einer Leberzirrhose, wobei sich die postoperative Komplikationsrate (Dindo-Clavien ≥ III a) zwischen Patienten mit (12%) und ohne Zirrhose (15,8%) nicht signifikant unterschied (p = 0,424).

Schlussfolgerung Neben entsprechender Expertise in der konventionell offenen Leberchirurgie, in der minimalinvasiven Chirurgie und in der intraoperativen Sonografie ist ein strukturierter Aufbau eines Programmes notwendig, um die laparoskopische Leberchirurgie sicher an deutschen Kliniken zu implementieren. Aufgrund überzeugender Ergebnisse wird die konventionell offene Leberchirurgie in den nächsten Jahren auch in Deutschland durch laparoskopische Techniken weitestgehend abgelöst werden.

Abstract

Background In spite of convincing results from internationally prominent liver centres, laparoscopic liver surgery is not widely used in Germany. A structured program to develop laparoscopic liver surgery was established in 2015 at the Department of Surgery, Charité Hospital, Berlin, in order to provide support for establishing this approach in German hospitals.

Methods We now report the results of our centre for 250 consecutive laparoscopic liver resections between 12/2013 and 1/2018. A retrospective analysis was performed with respect to indications, patient characteristics, complexity of the operations and postoperative results. The development of the program was analysed by comparing period 1 (1/2014 – 12/2015) and period 2 (1/2016 – 12/2017).

Results In comparison with period 1 (n = 16, 25% of patients), patients in period 2 (n = 75, 50% of patients) included a significantly greater percentage of patients with a high ASA score (3/4; p = 0.001). Hepatocellular carcinoma was the most frequent indication (n = 76, 30.4%), followed by colorectal liver metastases (n = 63, 25.2%). Malignant tumours increased over the years from 53.8% in period 1 to 75.7% in period 2 (p = 0.001). 72 major (≥ 3 segments) and 178 minor resections (< 3 segments) were performed, with an increase in major resections (n = 12, 17.9%) in period 1 to period 2 (n = 56, 33.1%, p = 0.02). In spite of the significantly higher percentage of complex operations in period 2, the rate of major complications (Dindo-Clavien ≥ III a) in period 2 was 16% (27 patients) was not significantly higher than in period 1, with 11.9% (8 patients, p = 0.432). 67 patients (26.8%) suffered from liver cirrhosis; the postoperative complication rate (Dindo-Clavien ≥ III a) was not significantly different between patients with (12%) and without cirrhosis (15.8%, p = 0.424).

Conclusion Aside from appropriate expertise in conventional open liver surgery, minimally invasive surgery and intraoperative sonography, it is necessary to develop a structured program for the reliable implementation of laparoscopic liver surgery in German hospitals. Because of the convincing results, conventional open liver surgery will be largely replaced in Germany by laparoscopic techniques in the coming years.

Schlüsselwörter

laparoskopische Leberchirurgie - Lebermetastase - hepatozelluläres Karzinom

Key words

laparoscopic liver surgery - liver metastasis - hepatocellular carcinoma

^* Geteilte Erstautorenschaft.

• Literatur

• 1 Xiong JJ, Nunes QM, Huang W. et al. Laparoscopic vs. open total gastrectomy for gastric cancer: a meta-analysis. World J Gastroenterol 2013; 19: 8114-8132
• 2 Suda K, Nakauchi M, Inaba K. et al. Minimally invasive surgery for upper gastrointestinal cancer: Our experience and review of the literature. World J Gastroenterol 2016; 22: 4626-4637
• 3 Di Fabio F, Barkhatov L, Bonadio I. et al. The impact of laparoscopic versus open colorectal cancer surgery on subsequent laparoscopic resection of liver metastases: a multicenter study. Surgery 2015; 157: 1046-1054
• 4 Nguyen KT, Gamblin TC, Geller DA. World review of laparoscopic liver resection-2,804 patients. Ann Surg 2009; 250: 831-841
• 5 Antoniou SA, Antoniou GA, Koch OO. et al. Meta-analysis of laparoscopic vs. open cholecystectomy in elderly patients. World J Gastroenterol 2014; 20: 17626-17634
• 6 Parks KR, Kuo Y-H, Davis JM. et al. Laparoscopic versus open liver resection: a meta-analysis of long-term outcome. HPB (Oxford) 2014; 16: 109-118
• 7 Schiffman SC, Kim KH, Tsung A. et al. Laparoscopic versus open liver resection for metastatic colorectal cancer: a metaanalysis of 610 patients. Surgery 2015; 157: 211-222
• 8 Martínez-Cecilia D, Cipriani F, Vishal S. et al. Laparoscopic versus open liver resection for colorectal metastases in elderly and octogenarian patients: a multicenter propensity score based analysis of short- and long-term outcomes. Ann Surg 2017; 265: 1192-1200
• 9 Takahara T, Wakabayashi G, Nitta H. et al. Laparoscopic liver resection for hepatocellular carcinoma with cirrhosis in a single institution. Hepatobiliary Surg Nutr 2015; 4: 398-405
• 10 Yoon Y-I, Kim K-H, Kang S-H. et al. Pure laparoscopic versus open right hepatectomy for hepatocellular carcinoma in patients with cirrhosis: a propensity score matched analysis. Ann Surg 2017; 265: 856-863
• 11 Struecker B, Haber P, Öllinger R. et al. Comparison of single-port versus standard multiport left lateral liver sectionectomy. Surg Innov 2018; 365: 476-485
• 12 Jara M, Bednarsch J, Valle E. et al. Reliable assessment of liver function using LiMAx. J Surg Res 2015; 193: 184-189
• 13 Strasberg SM. Nomenclature of hepatic anatomy and resections: a review of the Brisbane 2000 system. J Hepatobiliary Pancreat Surg 2005; 12: 351-355
• 14 Wakabayashi G, Cherqui D, Geller DA. et al. Recommendations for laparoscopic liver resection: a report from the second international consensus conference held in Morioka. Ann Surg 2015; 261: 619-629
• 15 Desmet VJ, Gerber M, Hoofnagle JH. et al. Classification of chronic hepatitis: diagnosis, grading and staging. Hepatology 1994; 19: 1513-1520
• 16 Dindo D, Demartines N, Clavien P-A. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg 2004; 240: 205-213
• 17 Krenzien F, Wabitsch S, Haber P. et al. Validity of the Iwate criteria for patients with hepatocellular carcinoma undergoing minimally invasive liver resection. J Hepatobiliary Pancreat Sci 2018; DOI: 10.1002/jhbp.576.
• 18 Cipriani F, Shelat VG, Rawashdeh M. et al. Laparoscopic parenchymal-sparing resections for nonperipheral liver lesions, the Diamond Technique: technical aspects, clinical outcomes, and oncologic efficiency. J Am Coll Surg 2015; 221: 265-272
• 19 Sotiropoulos GC, Prodromidou A, Machairas N. Meta-analysis of laparoscopic vs. open liver resection for hepatocellular carcinoma: The European experience. J BUON 2017; 22: 1160-1171
• 20 Takahara T, Wakabayashi G, Beppu T. et al. Long-term and perioperative outcomes of laparoscopic versus open liver resection for hepatocellular carcinoma with propensity score matching: a multi-institutional Japanese study. J Hepatobiliary Pancreat Sci 2015; 22: 721-727
• 21 Schön MR, Kouladouros K, Hoffmann K. et al. Identical oncological results with lower perioperative morbidity after laparoscopic liver resection: Results of a matched pair analysis. Chirurg 2018; DOI: 10.1007/s00104-018-0646-x.
• 22 Heinrich S, Tripke V, Huber T. et al. A match-pair analysis of open versus laparoscopic liver surgery. JSLS 2017; 21: e2017.00061 doi:10.4293/JSLS.2017.00061
• 23 Wabitsch S, Denecke T, Geisel D. et al. Single-incision laparoscopic liver resection in ruptured liver adenoma. SLS 2017; 25: 439-449
• 24 Jemal A, Bray F, Center MM. et al. Global cancer statistics. CA Cancer J Clin 2011; 61: 69-90
• 25 Montalti R, Berardi G, Laurent S. et al. Laparoscopic liver resection compared to open approach in patients with colorectal liver metastases improves further resectability: oncological outcome of a case-control matched-pairs analysis. Eur J Surg Oncol 2014; 40: 536-544
• 26 Alkhalili E, Berber E. Laparoscopic liver resection for malignancy: a review of the literature. World J Gastroenterol 2014; 20: 13599-13606
• 27 Fretland ÅA, Dagenborg VJ, Bjørnelv GMW. et al. Laparoscopic versus open resection for colorectal liver metastases: The OSLO-COMET randomized controlled trial. Ann Surg 2017; 68: 569-582
• 28 Beppu T, Wakabayashi G, Hasegawa K. et al. Long-term and perioperative outcomes of laparoscopic versus open liver resection for colorectal liver metastases with propensity score matching: a multi-institutional Japanese study. J Hepatobiliary Pancreat Sci 2015; 22: 711-720
• 29 Ratti F, Catena M, Di Palo S. et al. Laparoscopic approach for primary colorectal cancer improves outcome of patients undergoing combined open hepatic resection for liver metastases. World J Surg 2015; 39: 2573-2582
• 30 Nachmany I, Pencovich N, Zohar N. et al. Laparoscopic versus open liver resection for metastatic colorectal cancer. Eur J Surg Oncol 2015; 41: 1615-1620
• 31 Memeo R, deʼAngelis N, Compagnon P. et al. Laparoscopic vs. open liver resection for hepatocellular carcinoma of cirrhotic liver: a case-control study. World J Surg 2014; 38: 2919-2926
• 32 Ahn KS, Kang KJ, Kim YH. et al. A propensity score-matched case-control comparative study of laparoscopic and open liver resection for hepatocellular carcinoma. J Laparoendosc Adv Surg Tech A 2014; 24: 872-877
• 33 Xiao L, Xiang L, Li J. et al. Laparoscopic versus open liver resection for hepatocellular carcinoma in posterosuperior segments. Surg Endosc 2015; 29: 2994-3001
• 34 Lee JJ, Conneely JB, Smoot RL. et al. Laparoscopic versus open liver resection for hepatocellular carcinoma at a North-American Centre: a 2-to-1 matched pair analysis. HPB (Oxford) 2015; 17: 304-310
• 35 Kim H, Suh K-S, Lee K-W. et al. Long-term outcome of laparoscopic versus open liver resection for hepatocellular carcinoma: a case-controlled study with propensity score matching. Surg Endosc 2014; 28: 950-960
• 36 Settmacher U, Scheuerlein H, Dittmar Y. et al. Liver transplantation – current aspects of allocation, indication and donor pool expansion. Zentralbl Chir 2013; 138: 604-610
• 37 Soubrane O, Goumard C, Laurent A. et al. Laparoscopic resection of hepatocellular carcinoma: a French survey in 351 patients. HPB (Oxford) 2014; 16: 357-365
• 38 Han H-S, Shehta A, Ahn S. et al. Laparoscopic versus open liver resection for hepatocellular carcinoma: case-matched study with propensity score matching. J Hepatol 2015; 63: 643-650