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.

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