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Zentralbl Chir 2012; 137(6): 559-564
DOI: 10.1055/s-0032-1328008
Technical Note
Georg Thieme Verlag KG Stuttgart · New York

Die Technik der Hepatikojejunostomie mit T-Drainage bei der Rekonstruktion schmalkalibriger Gallengänge nach Pankreaskopfresektion

Hepaticojejunostomy after Pancreatic Head Resection – Technical Aspects for Reconstruction of Small and Fragile Bile Ducts with T-Tube Drainage
T. Herzog
1   Chirurgische Klinik, St. Josef Hospital, Ruhr Universität Bochum, Deutschland
,
O. Belyaev
1   Chirurgische Klinik, St. Josef Hospital, Ruhr Universität Bochum, Deutschland
,
W. Uhl
1   Chirurgische Klinik, St. Josef Hospital, Ruhr Universität Bochum, Deutschland
,
M. H. Seelig
2   Klinik für Allgemein-, Visceral-, Thorax-, und Gefäßchirurgie, Kliniken des Main-Taunus Kreises, Bad Soden, Deutschland
,
A. Chromik
1   Chirurgische Klinik, St. Josef Hospital, Ruhr Universität Bochum, Deutschland
› Author Affiliations
Further Information

Publication History

Publication Date:
21 December 2012 (online)

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Zusammenfassung

Hintergrund: Nach Pankreaskopfresektion ist die Rekonstruktion eines schmalen Gallengangs technisch anspruchsvoll und mit einer erhöhten Rate an Gallefisteln assoziiert. Ob sich die „schwierige“ biliodigestive Anastomose sicher mit einer transanastomotisch ausgeleiteten T-Drainage in der Anastomose durchführen lässt, wurde bisher nicht untersucht. Material und Methoden: Nach Pankreaskopfresektion erfolgte die Standardrekonstruktion mit einer End-zu-Seit-Hepatikojejunostomie mit PDS 5/0, welche 15–25 cm distal der Pankreatikojejunostomie angelegt wurde. Bei Patienten mit einem schmalen (< 5 mm) oder dünnwandigen Gallengang erfolgte die Rekonstruktion mit PDS 6/0 sowie einer transanastomotisch ausgeleiteten T-Drainage. Ergebnisse: Die Einlage der T-Drainage in die Hepatikojejunostomie ist technisch einfach und ermöglicht unmittelbar postoperativ eine radiologische Dichtigkeitsprüfung der Anastomose. Tritt im Verlauf eine Gallefistel auf, so ermöglicht die externe Galleableitung über die T-Drainage in ausgewählten Fällen ein konservatives Management mit erfolgreicher Defektheilung der Anastomose. Dadurch lassen sich Revisionsoperationen vermeiden, die ohne T-Drainage erforderlich wären. Inwieweit dies im Verlauf zu revisionspflichtigen Stenosen führt, bedarf weiterer Untersuchungen. Schlussfolgerung: Bei einer schwierigen Hepatikojejunostomie lassen sich Gallefisteln durch die Einlage einer transanastomotisch ausgeleiteten T-Drainage zwar sicher nicht vermeiden, allerdings ermöglicht die externe Galleableitung einen konservativen Behandlungsversuch, wodurch Revisionsoperationen vermieden werden können. Daher ist bei einer schwierigen Hepatikojejunostomie die Einlage einer T-Drainage in die Hepatikojejunostomie empfehlenswert.

Abstract

Background: After pancreatic head resection the reconstruction of small and fragile bile ducts is technically demanding, resulting in more postoperative bile leaks. One option for the reconstruction is the placement of a T-tube drainage at the site of the anastomosis. Material and Methods: Standard reconstruction after pancreatic head resection was an end-to-side hepaticojejunostomy with PDS 5.0, 15–25 cm distally from the pancreaticojejunostomy. For patients with a small bile duct diameter (≤ 5 mm) or a fragile bile duct wall the reconstruction was performed with PDS 6.0 and a T-tube drainage at the side of the anastomosis. Results: The reconstruction with a T-tube drainage at the site of the anastomosis is technically easy to perform and offers the opportunity for immediate visualisation of the anastomosis in the postoperative period by application of water soluble contrast medium. If a bile leak occurs, biliary deviation through the T-tube drainage can enable a conservative management without revisional laparotomy in selected patients. Whether or not a conservative management of postoperative bile leaks will lead to more bile duct strictures is a subject for further investigations. Conclusion: A T-tube drainage at the site of the anastomosis can probably not prevent postoperative bile leaks from a difficult hepaticojejunostomy, but in selected patients it offers the opportunity for a conservative management resulting in less re-operations. Therefore we recommend the augmentation of a difficult hepaticojejunostomy with a T-tube drainage.

Schlüsselwörter

Hepatikojejunostomie - Pankreaschirurgie - postoperative Komplikation - chirurgische Technik - Whipple-Operation - T-Drainage

Key words

hepaticojejunostomy - pancreatic surgery - postoperative complications - surgical technique - Whipple procedure - T-tube drainage
 

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