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Allgemein- und Viszeralchirurgie up2date 2022; 16(04): 313-331
DOI: 10.1055/a-1739-8909
Leber, Galle, Pankreas, Milz

Operative Therapiestrategien bei primären Lebertumoren, hepatozellulären und Cholangio- inkl. Gallenblasenkarzinomen

Was muss der Chirurg wissen?
Silvio Nadalin
,
Maren Peters
,
Alfred Königsrainer
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Primäre Lebertumoren (i. e. hepatozelluläres Karzinom und Cholangiokarzinom) haben eine sehr schlechte Prognose und sind eine der häufigsten Krebstodesursachen. Die einzige kurative Therapieoption stellt nach wie vor die radikale Resektion dar. Im Folgenden sollen sowohl das allgemeine chirurgische resektive Vorgehen als auch spezifische diagnostische und chirurgische Strategien bei den einzelnen Tumorentitäten und -subtypen beschrieben werden.
Kernaussagen

Allgemein

  • Bei primären Lebertumoren ist die chirurgische Therapie nach wie vor die einzige radikale Behandlungsoption.

  • Zur Planung der optimalen Therapie (operativ, lokal-ablativ und systemtherapeutisch) sollte eine Vorstellung im interdisziplinären Tumorboard erfolgen.

  • Umfangreiche Kenntnisse der biliären und vaskulären Anatomie der Leber sind maßgebend.

  • Die Beurteilung der Resektabilität von Lebertumoren sollte durch einen in der hepatobiliären Chirurgie erfahrenen Chirurgen erfolgen.

  • Die gefürchtetste Komplikation nach Resektion ist ein PHLV, welchem durch eine adäquate präoperative Evaluation von Lebervolumen, -funktion, -qualität und Patientenzustand (inkl. Komorbiditäten und Ernährungszustand) vorgebeugt werden kann.

  • Bei Vorliegen einer mechanischen Cholestase ist es notwendig, die zukünftige Restleber präoperativ zu entlasten.

  • Bei fortgeschrittenen Befunden sowie einer Infiltration der Lebergefäße oder des Gallengangs sollte eine operative Versorgung nur an einem tertiären Leberzentrum erfolgen.

Hepatozelluläres Karzinom

  • Die MRT-Bildgebung ist die Diagnostik der Wahl.

  • In selektionierten Fällen ist bei einem HCC eine Resektion über die BCLC-0-A-Kriterien möglich.

  • Eine PVTT ist keine absolute Kontraindikation zur Resektion.

Cholangiokarzinom

  • Die MRT-Untersuchung (MRCP + Primovist) ist beim CCA die Diagnostik der Wahl.

  • Beim phCCA ist häufig eine erweiterte Resektion sowie eine entsprechend komplexe biliäre und vaskuläre Rekonstruktion notwendig.

  • Beim iCCA stellen Multifokalität, Lymphknotenmetastasen und Gefäßinvasion wichtige prognoserelevante Faktoren dar.

  • Eine systematische Lymphadenektomie sollte standardmäßig durchgeführt werden.

Gallenblasenkarzinom

  • Bei Tis- und T1a-Gallenblasentumoren ist eine Cholezystektomie ausreichend.

  • Beim Gallenblasenkarzinom im Stadium ≥ T1b sollte eine zusätzliche Leberresektion mit systematischer Lymphadenektomie erfolgen.

Schlüsselwörter

hepatozelluläres Karzinom - Cholangiokarzinom - Gallenblasenkarzinom - chirurgische Therapie


Publication History

Article published online:
03 August 2022

© 2022. Thieme. All rights reserved.

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