Palliativchirurgie beim kolorektalen Karzinom – welche Faktoren können bei der Wahl des operativen Vorgehens helfen?

Zusammenfassung

Hintergrund Das chirurgische Vorgehen beim kolorektalen Karzinom (KRK) in der Palliativsituation lässt sich nur unzureichend standardisieren. Die vorliegende Studie wurde zur Identifikation von Kriterien für den Entscheid hinsichtlich Resektion des Malignoms mit oder ohne primäre Anastomose initiiert.

Patienten/Material und Methoden In einer unizentrischen retrospektiven Analyse wurden 103 Patienten nach palliativer Resektion eines KRK mit oder ohne zeitgleiche Anastomose untersucht. Durch univariate und logistische Regressionsanalyse erfolgte die Beurteilung des Einflusses von insgesamt 40 Faktoren auf die postoperative Morbidität und Mortalität.

Ergebnisse In 46 Fällen wurde eine Darmresektion mit primärer Anastomose, in 57 Fällen eine Diskontinuitätsresektion durchgeführt. Die postoperative Morbidität betrug insgesamt 44,7%, die Letalität 17,5%. Nach einzeitiger Resektion und Anastomose erhöhte ein Nikotinabusus (OR 4,2; p = 0,044), eine Hypalbuminämie (OR 4,0; p = 0,012), eine Kachexie (OR 3,9; p = 0,034), ein ASA-Score > 2 (OR 3,7; p = 0,030) und ein(e) Leberumbau/-zirrhose (OR 3,6; p = 0,031) das Risiko für postoperative Komplikationen. Die Hypalbuminämie (OR 1,8; p = 0,036), Kachexie (OR 1,8; p = 0,043), Anämie (OR 1,5; p = 0,038) und ein bekannter Alkoholabusus (OR 1,9; p = 0,023) wurden als unabhängige Risikofaktoren für die frühpostoperative Mortalität identifiziert. Nach Diskontinuitätsresektion führten eine Niereninsuffizienz (OR 2,1; p = 0,042) und Kachexie (OR 1,5; p = 0,045) zum signifikanten Anstieg des Risikos für die postoperative Morbidität, ein Alkoholabusus (OR 1,8; p = 0,041) für die Letalität. Eine Hypalbuminämie (OR 2,8; p = 0,019) und ein ASA-Score > 2 (OR 2,6; p = 0,004) steigerten nach Resektion und Rekonstruktion das Risiko für Majorkomplikationen entsprechend Clavien-Dindo, eine vorbestehende Niereninsuffizienz (OR 1,6; p = 0,023) das Risiko nach Diskontinuitätsresektion. In der univariaten Analyse wurden nach Tumorresektion und Rekonstruktion zusätzlich noch ein ASA-Score > 2 (p = 0,038), in beiden Gruppen mit und ohne primäre Anastomose eine dringliche Operation als signifikante Parameter mit Einfluss auf die Letalität ermittelt (p = 0,010 und p = 0,017).

Schlussfolgerung Palliative Resektionen kolorektaler Karzinome haben eine hohe Morbidität und Mortalität. Bei vorbestehendem Alkoholabusus und dringlicher Operationsindikation sollte ein intensiveres Monitoring erfolgen. Bei Anämie, Kachexie, Hypalbuminämie sowie ASA-Score > 2 stellt möglicherweise die Diskontinuitätsresektion den geeigneteren Eingriff dar.

Abstract

Background The surgical procedure for patients with colorectal cancer (CRC) in the palliative situation cannot be adequately standardised. The present study was initiated to identify criteria for the decision for resection of the malignancy with or without anastomosis.

Patients/Material and Methods In a unicentric retrospective analysis, 103 patients after palliative resection with or without anastomosis due to CRC were examined. Using univariate and logistic regression analysis, the influence of a total of 40 factors on postoperative morbidity and mortality was assessed.

Results In 46 cases, resection with primary anastomosis and in 57 cases a discontinuity resection was performed. Postoperative morbidity was 44.7% and mortality 17.5%. After one-stage resection with anastomosis, nicotine abuse (OR 4.2; p = 0.044), hypalbuminaemia (OR 4.0; p = 0.012), ASA score > 2 (OR 3.7; p = 0.030) and liver remodelling/cirrhosis (OR 3.6; p = 0.031) increased the risk for postoperative complications. Hypalbuminaemia (OR 1.8; p = 0.036), cachexia (OR 1.8; p = 0.043), anaemia (OR 1.5; p = 0.038) and known alcohol abuse (OR 1.9; p = 0.023) were identified as independent risk factors for early postoperative mortality. After discontinuity resection, renal failure (OR 2.1; p = 0.042) and cachexia (OR 1.5; p = 0.045) led to a significant increase in the risk of postoperative morbidity, alcohol abuse (OR 1.8; p = 0.041) in mortality. Hypalbuminaemia (OR 2.8; p = 0.019) and an ASA score > 2 (OR 2.6; p = 0.004) after resection and reconstruction increased the risk of major complications according to Clavien-Dindo, while pre-existing renal failure (OR 1.6; p = 0.023) increased the risk after discontinuity resection. In univariate analysis, an ASA score > 2 (p = 0.038) after simultaneous tumour resection and reconstruction, and urgent surgery in both groups with or without primary anastomosis were additionally identified as significant parameters with a negative influence on mortality (p = 0.010 and p = 0.017).

Conclusion Palliative resections of colorectal carcinomas have high morbidity and mortality. Especially in cases of pre-existing alcohol abuse and/or urgent indication for surgery, more intensive monitoring should be performed. In the case of anaemia, cachexia, hypalbuminemia and an ASA score > 2, discontinuity resection may be the more appropriate procedure.

Schlüsselwörter

kolorektales Karzinom - Morbidität - Mortalität - Palliativmedizin

Key words

colorectal carcinoma - morbidity - mortality - palliative medicine

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