Präoperative Risikoabschätzung und
perioperatives Management der Leberresektion

Zusammenfassung

Die radikale Resektion ist für die meisten primären und sekundären Lebertumoren die Therapie der Wahl. Die Abnahme der Morbidität und Mortalität nach Leberresektion infolge verbesserter chirurgischer Techniken sowie besserem perioperativen Management der Patienten erlaubte in den letzten Jahren eine immer breitere Indikationsstellung und Ausdehnung des Resektionsausmaßes auch bei älteren Patienten und Patienten mit einer präexistenten Erkrankung des Leberparenchyms. Trotzdem stellt das postoperative Leberversagen weiterhin die bedrohlichste Komplikation dar.
Der intraoperative Blutverlust, Zahl der transfundierten Erythrozytenkonzentrate sowie die warme Ischämiezeit durch Einstromokklusion bei Patienten mit eingeschränkter Leberfunktion stellen prognostische Faktoren für das operative Risiko bei Leberresektionen dar. Diese Faktoren sind aber nicht geeignet um bereits präoperativ das individuelle perioperative Risiko differenzieren zu können.
Bei der Planung ausgedehnter Parenchymresektionen in gesunden Lebern sollte das verbleibende Lebergewebe präoperativ quantitativ bestimmt werden um somit in Abhängigkeit der hepatozellulären Funktion die postoperative Parenchymreserve kalkulieren zu können. Erscheint diese nicht ausreichend, kann möglicherweise durch eine präoperative Intervention wie die transarterielle Chemoembolisation, neoadjuvante Chemotherapie oder portale Embolisation die quantitative Parenchymreserve verbessert werden. Für das postoperative Risiko bei Resektionen in zirrhotisch veränderten Lebergewebe ist weniger das Ausmaß der Resektion als die präexistente Leberfunktion entscheidend.

Abstract

A resection with tumour free margins is the treatment of choice for the most primary and secondary liver diseases. The significant decrease in mortality and morbidity due to improved surgical techniques and better knowledge of perioperative management has permitted a progressive broadening of the indications for hepatic resections even in elderly patients and patients with chronic liver diseases. Nevertheless, the postoperative liver failure still represents the most threatening complication after liver resection.
Intraoperative blood loss, number of transfusion units and time of warm ischemia during hepatic inflow occlusion in patients with a reduced liver function are predictors for the perioperative outcome, but the mentioned risk factors are not eligible to assess preoperatively the individual risk for patients undergoing a liver resection.
Furthermore, when planning extended resections in healthy livers the future liver remnant should be calculated for estimating the postresectional reserve of liver function. If it is expected that the future liver remnant is not sufficient to avoid a postoperative liver failure, a hypertrophy of the future liver remnant possibly could be induced by preoperative interventions such as transarterial chemoembolization, neoadjuvant chemotherapy or portal embolization for improving the postoperative liver function. The perioperative risk of patients with diseased livers is influenced more by the individual hepatocellular function than by the extent of the liver resection.

Schlüsselwörter

Leberresektion - Morbidität - Parenchymreserve

Key words

Liver resection - morbidity - liver remnant

Literatur

• 1 Shimada M, Takenaka K, Gion T. et al . Prognosis of recurrent hepatocellular carcinoma: a 10-year surgical experience in Japan.  Gastroenterology. 1996;  111 720
• 2 Kokudo N, Miki Y, Sugai S. et al . Genetic and histological assessment of surgical margins in resected liver metastases from colorectal carcinoma: minimum surgical margins for successful resection.  Arch Surg. 2002;  137 833
• 3 Minagawa M, Makuuchi M, Torzilli G. et al . Extension of the frontiers of surgical indications in the treatment of liver metastases from colorectal cancer: long-term results.  Ann Surg. 2000;  231 487
• 4 Melendez J, Ferri E, Zwillman M. et al . Extended hepatic resection: a 6-year retrospective study of risk factors for perioperative mortality.  J Am Coll Surg. 2001;  192 47
• 5 El-Serag H B, Mason A C, Key C. Trends in survival of patients with hepatocellular carcinoma between 1977 and 1996 in the United States.  Hepatology. 2001;  33 62
• 6 Choti M A, Sitzmann J V, Tiburi M F. et al . Trends in long-term survival following liver resection for hepatic colorectal metastases.  Ann Surg. 2002;  235 759
• 7 Poon R T, Fan S T, Lo C M. et al . Extended hepatic resection for hepatocellular carcinoma in patients with cirrhosis: is it justified?.  Ann Surg. 2002;  236 602
• 8 Belghiti J, Pateron D, Panis Y. et al . Resection of presumed benign liver tumours.  Br J Surg. 1993;  80 380
• 9 Charny C K, Jarnagin W R, Schwartz L H. et al . Management of 155 patients with benign liver tumours.  Br J Surg. 2001;  88 808
• 10 Lortat-Jacob J L, Robert H G, Henry C. Excision of the right lobe of the liver for a malignant secondary tumor.  Arch Mal Appar Dig Mal Nutr. 1952;  41 662
• 11 Foster J H, Berman M M. Solid liver tumors.  Major Probl Clin Surg. 1977;  22 1
• 12 Belghiti J, Di Carlo I, Sauvanet A. et al . A ten-year experience with hepatic resection in 338 patients: evolutions in indications and of operative mortality.  Eur J Surg. 1994;  160 277
• 13 Cohnert T U, Rau H G, Buttler E. et al . Preoperative risk assessment of hepatic resection for malignant disease.  World J Surg. 1997;  21 396
• 14 Akashi K, Mizuno S, Isaji S. Comparative study of perioperative management of hepatic resection.  Dig Dis Sci. 2000;  45 1988
• 15 Imamura H, Seyama Y, Kokudo N. et al . One thousand fifty-six hepatectomies without mortality in 8 years.  Arch Surg. 2003;  138 1198
• 16 Jarnagin W R, Gonen M, Fong Y. et al . Improvement in perioperative outcome after hepatic resection: analysis of 1 803 consecutive cases over the past decade.  Ann Surg. 2002;  236 397
• 17 Okamoto E, Kyo A, Yamanaka N, Tanaka N, Kuwata K. Prediction of the safe limits of hepatectomy by combined volumetric and functional measurements in patients with impaired hepatic function.  Surgery. 1984;  95 586
• 18 Torzilli G, Makuuchi M, Inoue K. et al . No-mortality liver resection for hepatocellular carcinoma in cirrhotic and noncirrhotic patients: is there a way? A prospective analysis of our approach.  Arch Surg. 1999;  134 984
• 19 Aldrighetti L, Arru M, Caterini R. et al . Impact of advanced age on the outcome of liver resection.  World J Surg. 2003;  27 1149
• 20 Wakabayashi H, Nishiyama Y, Ushiyama T, Maeba T, Maeta H. Evaluation of the effect of age on functioning hepatocyte mass and liver blood flow using liver scintigraphy in preoperative estimations for surgical patients: comparison with CT volumetry.  J Surg Res. 2002;  106 246
• 21 Shoup M, Gonen M, D’Angelica M. et al . Volumetric analysis predicts hepatic dysfunction in patients undergoing major liver resection.  J Gastrointest Surg. 2003;  7 325
• 22 Limanond P, Raman S S, Lassman C. et al . Macrovesicular hepatic steatosis in living related liver donors: correlation between CT and histologic findings.  Radiology. 2004;  230 276
• 23 Ito T, Kiuchi T, Egawa H. et al . Surgery-related morbidity in living donors of right-lobe liver graft: lessons from the first 200 cases.  Transplantation. 2003;  76 158
• 24 Ozawa K, Ida T, Yamada T, Honjo I. Significance of glucose tolerance as prognostic sign in hepatectomized patients.  Am J Surg. 1976;  131 541
• 25 Ikeda Y, Shimada M, Hasegawa H. et al . Prognosis of hepatocellular carcinoma with diabetes mellitus after hepatic resection.  Hepatology. 1998;  27 1567
• 26 Little S A, Jarnagin W R, DeMatteo R P. et al . Diabetes is associated with increased perioperative mortality but equivalent long-term outcome after hepatic resection for colorectal cancer.  J Gastrointest Surg. 2002;  6 88
• 27 Blanchard A, Hurni M, Ruchat P, Stumpe F, Fischer A, Sadeghi H. Incidence of deep and superficial sternal infection after open heart surgery. A ten years retrospective study from 1981 to 1991.  Eur J Cardiothorac Surg. 1995;  9 153
• 28 Fong Y, Fortner J, Sun R L, Brennan M F, Blumgart L H. Clinical score for predicting recurrence after hepatic resection for metastatic colorectal cancer: analysis of 1 001 consecutive cases.  Ann Surg. 1999;  230 309
• 29 Vauthey J N, Chaoui A, Do K A. et al . Standardized measurement of the future liver remnant prior to extended liver resection: methodology and clinical associations.  Surgery. 2000;  127 512
• 30 Miyagawa S, Kawasaki S. Präoperative portale Embolisation zur Induktion von Leberhypertrophie.  Chirurg. 2001;  72 770
• 31 Lan A K, Luk H N, Goto S. et al . Stress response to hepatectomy in patients with a healthy or a diseased liver.  World J Surg. 2003;  27 761
• 32 Levy I, Sherman M. Staging of hepatocellular carcinoma: assessment of the CLIP, Okuda, and Child-Pugh staging systems in a cohort of 257 patients in Toronto.  Gut. 2002;  50 881
• 33 Ercolani G, Grazi G L, Ravaioli M. et al . Liver resection for hepatocellular carcinoma on cirrhosis: univariate and multivariate analysis of risk factors for intrahepatic recurrence.  Ann Surg. 2003;  237 536
• 34 Poon R T, Fan S T, Wong J. Selection criteria for hepatic resection in patients with large hepatocellular carcinoma larger than 10 cm in diameter.  J Am Coll Surg. 2002;  194 592
• 35 Wayne J D, Lauwers G Y, Ikai I. et al . Preoperative predictors of survival after resection of small hepatocellular carcinomas.  Ann Surg. 2002;  235 722
• 36 Yamamoto Y. Leberresektion in Zirrhose.  Chirurg. 2001;  72 784
• 37 Brinkmann A, Calzia E, Trager K, Radermacher P. Monitoring the hepato-splanchnic region in the critically ill patient. Measurement techniques and clinical relevance.  Intensive Care Med. 1998;  24 542
• 38 Kooby D A, Fong Y, Suriawinata A. et al . Impact of steatosis on perioperative outcome following hepatic resection.  J Gastrointest Surg. 2003;  7 1034
• 39 Madoff D C, Hicks M E, Abdalla E K, Morris J S, Vauthey J N. Portal vein embolization with polyvinyl alcohol particles and coils in preparation for major liver resection for hepatobiliary malignancy: safety and effectiveness - study in 26 patients.  Radiology. 2003;  227 251
• 40 Urata K, Kawasaki S, Matsunami H. et al . Calculation of child and adult standard liver volume for liver transplantation.  Hepatology. 1995;  21 1317
• 41 Ladurner R, Brandacher G, Riedl-Huter C. et al . Percutaneous portal vein embolisation in preparation for extended hepatic resection of primary nonresectable liver tumours.  Dig Liver Dis. 2003;  35 716
• 42 Elias D, Ouellet J F, De Baere T, Lasser P, Roche A. Preoperative selective portal vein embolization before hepatectomy for liver metastases: long-term results and impact on survival.  Surgery. 2002;  131 294
• 43 Bismuth H, Adam R, Levi F. et al . Resection of nonresectable liver metastases from colorectal cancer after neoadjuvant chemotherapy.  Ann Surg. 1996;  224 509
• 44 Giacchetti S, Itzhaki M, Gruia G. et al . Long-term survival of patients with unresectable colorectal cancer liver metastases following infusional chemotherapy with 5-fluorouracil, leucovorin, oxaliplatin and surgery.  Ann Oncol. 1999;  10 663
• 45 Adam R, Avisar E, Ariche A. et al . Five-year survival following hepatic resection after neoadjuvant therapy for nonresectable colorectal.  Ann Surg Oncol. 2001;  8 347
• 46 Vogl T J, Mack M G, Balzer J O. et al . Liver metastases: neoadjuvant downsizing with transarterial chemoembolization before laser-induced thermotherapy.  Radiology. 2003;  229 457
• 47 Adam R, Laurent A, Azoulay D, Castaing D, Bismuth H. Two-stage hepatectomy: A planned strategy to treat irresectable liver tumors.  Ann Surg. 2000;  232 777
• 48 Panis Y, Ribeiro J, Chretien Y, Nordlinger B. Dormant liver metastases: an experimental study.  Br J Surg. 1992;  79 221
• 49 Elias D, De Baere T, Roche A, Mducreux, Leclere J, Lasser P. During liver regeneration following right portal embolization the growth rate of liver metastases is more rapid than that of the liver parenchyma.  Br J Surg. 1999;  86 784
• 50 Melendez J A, Arslan V, Fischer M E. et al . Perioperative outcomes of major hepatic resections under low central venous pressure anesthesia: blood loss, blood transfusion, and the risk of postoperative renal dysfunction.  J Am Coll Surg. 1998;  187 620
• 51 Capussotti L, Polastri R. Operative risks of major hepatic resections.  Hepatogastroenterology. 1998;  45 184
• 52 Kooby D A, Stockman J, Ben-Porat L. et al . Influence of transfusions on perioperative and long-term outcome in patients following hepatic resection for colorectal metastases.  Ann Surg. 2003;  237 860
• 53 Jones R M, Moulton C E, Hardy K J. Central venous pressure and its effect on blood loss during liver resection.  Br J Surg. 1998;  85 1058
• 54 Huguet C, Gavelli A, Chieco P A. et al . Liver ischemia for hepatic resection: where is the limit?.  Surgery. 1992;  111 251
• 55 Clavien P A, Selzner M, Rudiger H A. et al . A prospective randomized study in 100 consecutive patients undergoing major liver resection with versus without ischemic preconditioning.  Ann Surg. 2003;  238 843
• 56 Belghiti J, Hiramatsu K, Benoist S, Massault P, Sauvanet A, Farges O. Seven hundred forty-seven hepatectomies in the 1990s: an update to evaluate the actual risk of liver resection.  J Am Coll Surg. 2000;  191 38
• 57 Belghiti J, Kabbej M, Sauvanet A, Vilgrain V, Panis Y, Fekete F. Drainage after elective hepatic resection. A randomized trial.  Ann Surg. 1993;  218 748
• 58 Lai O F, Chow P K, Tan S. et al . Changes in prostaglandin and nitric oxide levels in the hyperdynamic circulation following liver resection.  J Gastroenterol Hepatol. 2000;  15 895
• 59 Thasler W E, Bein T, Jauch K W. Perioperative effects of hepatic resection surgery on hemodynamics, pulmonary fluid balance, and indocyanine green clearance.  Langenbecks Arch Surg. 2002;  387 271