Postoperatives Leberversagen nach erweiterten Leberresektionen – eine Übersicht, gestützt durch eine retrospektive Single-Center-Analyse

Zusammenfassung

Hintergrund: Postoperatives Leberversagen (PHLF) ist eine der schwerwiegendsten Komplikationen nach größeren Leberresektionen und ein wichtiger Faktor in Bezug auf die perioperative Morbidität und Mortalität. Trotz vieler Fortschritte im Verständnis und der Abstufung des PHLF existieren in der Literatur äußerst heterogene Definitionen, was eine Identifikation von Hochrisikopatienten erschwert. In dieser Studie analysierten wir die Ergebnisse erweiterter Leberresektionen und potenzieller Risikofaktoren für PHLF basierend auf Patientendaten eines Universitätsklinikums. Ziel der Untersuchung war es, einen Überblick der wesentlichen Aspekte in der Vermeidung des PHLFs in Verbindung mit intraoperativen Kernpunkten und einer optimierten postoperativen Behandlung zu entwickeln. Methoden: Daten von 202 Patienten, die sich einer großen, elektiven Leberresektion an einem Universitätsklinikum zwischen 04/1989 und 09/2009 unterzogen, wurden analysiert (135 Hemihepatektomien rechts, 39 Hemihepatektomien links, 28 erweiterte Hemihepatektomien rechts). Nach Balzan et al. „50/50-criteria“ wurde PHLF definiert als Quick < 50 % und Serumbilirubin > 50 µmol/l am postoperativen Tag 5 (POD 5) oder als Tod durch primäres oder sekundäres Leberversagen. Ergebnisse: Die 30-Tage-Mortalität und die Gesamtkrankenhausmortalität betrugen 4,95 bzw. 8,91 %. 28 (14 %) Patienten entwickelten ein PHLF, von denen 16 (57 %) verstarben. Im Vergleich zu den Patienten mit normaler postoperativer Leberfunktion waren mehrere prä- und intraoperative Faktoren in beiden Gruppen signifikant unterschiedlich: z. B. primäres Lebermalignom (p < 0,001), erweiterte Leberresektion (p < 0,001), OP-Dauer (p < 0,001) und Notwendigkeit zur intraoperativen Transfusion von Erythrozytenkonzentraten (p < 0,02) oder gefrorenen Frischplasmen (p < 0,001). Schlussfolgerung: Obwohl Fortschritte in der Hepatobiliärchirurgie zu verzeichnen sind, bleibt das PHLF eine ernsthafte Komplikation, insbesondere bei Patienten mit erweiterten Leberresektionen. Eine sorgfältige und optimierte präoperative Risikostratifizierung ist erforderlich, um Hochrisikopatienten für PHLF vorab zu identifizieren.

Abstract

Background: Posthepatectomy liver failure (PHLF) is one of the most serious complications after major liver resections and an important factor in terms of perioperative morbidity and mortality. Despite many advances in the understanding and grading of PHLF, the definitions found in literature are very heterogeneous, which complicates the identification of high-risk patients. In this study we analysed the results of extended liver resections and potential risk factors for PHLF based on patient data derived from our tertiary referral centre. The aim of the study was to gain an overview of the essential aspects in the prevention of PHLF combined with key intraoperative issues and postoperative treatment strategies. Methods: We analysed data from 202 patients who underwent extended elective liver resections at our centre between April 1989 and September 2009 (135 right hemihepatectomies, 39 left hemihepatectomies, 28 right trisectionectomies). According to Balzanʼs “50/50 criteria”, PHLF was defined as prothrombin time (PT) < 50 % combined with serum bilirubin (SB) > 50 micromol/L on postoperative day (POD) 5 or as death due to primary or secondary liver failure. Results: Thirty-day mortality and overall in-hospital mortality were 4.95 and 8.91 %, respectively. Twenty-eight (14 %) patients developed PHLF and 16 (57 %) patients died. Compared to patients with normal postoperative liver function, several significant pre- and intraoperative factors for PHLF were identified, e.g. primary malignant liver tumour (p < 0.001), extended liver resection (p < 0.001), time of surgery (p < 0.001) and intraoperative transfusion of packed RBC (p < 0.02) or FFP (p < 0.001). Conclusion: Although progress has been made in hepatobiliary surgery, PHLF remains a serious complication, especially after extended liver resections. Careful, optimised preoperative risk stratification is required to identify patients at risk for PHLF.

Schlüsselwörter

postoperatives Leberversagen - hepatobiliäre Chirurgie - erweiterte Leberresektionen - Hemihepatektomie - Risikofaktoren

Key words

posthepatectomy liver failure - hepatobiliary surgery - extended liver resection - hemihepatectomy - risk factors

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