Zusammenfassung
Einleitung: Wir berichten über unsere Ergebnisse bei der Behandlung von Gallengangverletzungen nach laparoskopischer Cholezystektomie und stellen einen Algorithmus für die Behandlung dieser Komplikationen vor.
Patienten und Methoden: Im Zeitraum von Januar 1990 bis März 2002 wurden insgesamt 175 Patienten wegen Gallengangverletzungen nach laparoskopischer Cholezystektomie behandelt. Die Gallengangverletzungen wurden entsprechend dem Ausmaß, der anatomischen Lokalisation und der Pathogenese in 5 Typen klassifiziert. Zur Identifizierung von Risikofaktoren, die den postoperativen Verlauf hinsichtlich biliärer Komplikationen beeinflussen, wurde eine Uni- und Multivariatanalyse durchgeführt.
Ergebnisse: Bei 4 Patienten lag eine periphere Galleleckage (Typ A) vor. Bei 92 % der Patienten war die endoskopische Therapie erfolgreich. Bei 8 Patienten lag eine Okklusion des Hauptgallenganges durch einen Clip vor (Typ B). In 5 von 6 Fällen mit einem inkompletten Verschluss des Hauptgallenganges war die alleinige endoskopische Behandlung ausreichend. 52 Patienten wurden wegen einer tangentialen Läsion behandelt (Typ C). Hier war in 35 Fällen (67 %) die endoskopische Behandlung erfolgreich, während bei 17 Patienten (33 %) eine chirurgische Rekonstruktion notwendig war. Bei 27 Patienten lag eine komplette Durchtrennung des Ductus hepatocholedochus (DHC) vor (Typ D). In allen Fällen wurde eine chirurgische Rekonstruktion durchgeführt. Von 42 Patienten mit einer späten Gallengangstenose konnten 35 Patienten erfolgreich endoskopisch behandelt werden. Insgesamt wurde bei 55 Patienten eine chirurgische Rekonstruktion der Gallenwege durchgeführt, bei 114 Patienten war die endoskopische Therapie erfolgreich und bei 6 Patienten reichte die alleinige sonographiegestützte Drainage aus. Bei 11 von 55 operierten Patienten (20 %) traten im Verlauf biliäre Komplikationen auf. Risikofaktoren für Komplikationen waren inadäquate Voroperationen, Rekonstruktionen bei Peritonitis und kombinierte Verletzungen von rechter Leberarterie und Hauptgallengang. Nach einem medianen Follow-up von 44,6 Monaten (2-109 Monate) sind - einschließlich der Patienten, die sich wegen einer Komplikation einem Folgeeingriff unterziehen mussten - 51 von 55 (93 %) operierten Patienten beschwerdefrei.
Schlussfolgerung: Während vor allem die peripheren Verletzungen sowie kleinere tangentiale Läsionen und kurzstreckige Stenosen endoskopisch behandelt werden können, erfordern die komplexen und ausgedehnten Verletzungsmuster sowie langstreckige Stenosen in der Regel eine chirurgische Rekonstruktion. Voraussetzung für eine erfolgreiche Therapie ist eine interdisziplinäres endoskopisch chirurgisches Behandlungskonzept.
Abstract
Introduction: The aim of the present study is to analyse our experience in the treatment of bile duct injury following laparoscopic cholecystectomy and to propose an algorithm for the management.
Patients and methods: From January 1990 to March 2002 175 patients with biliary tract injury sustained during laparoscopic cholecystectomy were treated at our institution. We divided the injuries into five basic types according to the mechanism, localisation and time of manifestation of the lesion. Risk factors affecting the outcome after operative repair were analysed by uni- and multivariate analysis.
Results: There were 46 patients with peripheral bile leak (Type A). Endoscopic treatment was successful in 92 %. 8 patients presented with an occlusion of the common bile duct (CBD) (Type B). Five of 6 patients with an incomplete occlusion of the CBD could be treated by endoscopic options. Of 52 patients that presented a lateral lesion of the CBD (Type C), endoscopic treatment was successful in 35 patients (67 %), but surgical treatment was necessary in 17 (33 %). 27 patients with a complete transsection of the CBD required surgical reconstruction. Endoscopic treatment was successful in 34 of 42 patients with a late stenosis of the CBD. 11 of 55 patients (20 %) developed postoperative biliary complications. Univariate analysis identified three factors to be significant predictors of outcome: 1. attempts of repair before referral, 2. combined bile duct and hepatic artery injury, 3. Reconstruction in a situation of peritonitis. After a median follow-up of 44.6 months (2-109) a successful outcome was obtained in 51 of 55 (93 %) patients, including those requiring a secondary procedure for recurrent stricture.
Conclusions: Peripheral leakages, small lateral lesions and short stenosis usually can be treated endoscopically. Extended lateral injuries, complete CBD transsections and long stenoses require surgical therapy. For a successful therapy a specialized multidisciplinary team is crucial.
Schlüsselwörter
Laparoskopische Cholezystektomie - Gallengangverletzung - Management von Gallengangverletzungen
Key words
Laparoscopic cholecystectomy - bile duct injury - management of bile duct injuries
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S. C. Schmidt
Charité Campus Virchow Klinikum
Klinik für Allgemein-, Viszeral- und Transplantationschirurgie
Augustenburger Platz 1
13353 Berlin
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