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.

Leberresektion - Morbidität - Parenchymreserve

Liver resection - morbidity - liver remnant

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