Prädiktion der perioperativen Mortalität bei Patienten mit fortgeschrittener Lebererkrankung und abdominalchirurgischen Eingriffen anhand unterschiedlicher Score- und Testsysteme

Zusammenfassung

Patienten mit fortgeschrittener Lebererkrankung weisen im Vergleich zu Lebergesunden eine erhöhte Morbidität und Mortalität nach Leberresektion und nicht hepatischen abdominalchirurgischen Eingriffen auf. Weiterhin stellt das Auftreten eines postoperativen Leberversagens ein relevantes klinisches Problem dar. Zur Einschätzung der perioperativen Mortalität und der hepatischen Funktion stehen Scoring-Systeme, verschiedene klinische Parameter sowie statische und dynamische Leberfunktionstests zur Verfügung. In letzter Zeit gewinnt komplementär zur Child-Turcotte-Pugh-Klassifikation der Einsatz des Model-for-End-Stage-Liver-Disease-Systems (MELD-System) zunehmend an Bedeutung. Patienten im Child-Turcotte-Pugh-Stadium C und einem MELD-Score > 14 gelten in der Regel als inoperabel. Bei Patienten im Child-Turcotte-Pugh-Stadium B und einem MELD-Score > 8 – 14 sollte ein operativer Eingriff sorgfältig abgewogen werden. Patienten im Child-Turcotte-Pugh-Stadium A und einem MELD-Score ≤ 8 weisen ein geringes perioperatives Risiko auf. Obgleich bisher nicht fest etabliert, können zur Planung insbesondere leberchirurgischer Eingriffe bei Patienten mit Leberzirrhose im Stadium A (MELD-Score ≤ 8) dynamische Testverfahren wichtige Informationen über die zu erwartende residuelle hepatische Funktion bringen. Dabei erscheinen nach aktueller Datenlage die Indocyaningrün-Clearance (ICG-Clearance) und der Monoethylglycinxylid-Test (MEGX-Test) am besten geeignet.

Abstract

Patients with advanced liver disease show increased morbidity and mortality after hepatic resection and non-hepatic digestive surgery. Furthermore, postoperative liver failure is associated with a poor outcome, representing an important clinical problem. For evaluation of the perioperative mortality and the hepatic function, several scoring systems, clinical parameters, and static and dynamic tests are available. Recently, the Model for End-Stage Liver Disease (MELD) has been shown to provide a complementary predictive value to the widely used Child Turcotte Pugh score. Patients with Child Turcotte Pugh class C cirrhosis and MELD scores > 14 are generally not considered for surgical intervention. Patients with Child Turcotte Pugh class B cirrhosis and MELD scores > 8 – 14 have an increased perioperative risk and the indication for surgery should be assessed carefully. In patients with Child Turcotte Pugh class A cirrhosis and MELD scores of ≤ 8, perioperative mortality is low. Although not routinely used, dynamic tests can provide additional information on the expected residual hepatic function in patients with Child Turcotte Pugh class A cirrhosis and MELD scores of ≤ 8 in whom hepatic resection is needed. Besides other dynamic tests, the indocyanine green (ICG) clearance and the monoethylglycinxylid (MEGX) clearance tests have been satisfactorily evaluated.

Schlüsselwörter

Leber - kolorektales Karzinom - Darm

Key words

liver - colorectal carcinoma - intestine

Literatur

• 1 Child C G, Turcotte J G. Surgery and portal hypertension.  Major Probl Clin Surg. 1964;  1 1-85
• 2 Pugh R N, Murray-Lyon I M, Dawson J L. et al . Transection of the oesophagus for bleeding oesophageal varices.  Br J Surg. 1973;  60 646-649
• 3 Garrison R N, Cryer H M, Howard D A. et al . Clarification of risk factors for abdominal operations in patients with hepatic cirrhosis.  Ann Surg. 1984;  199 648-655
• 4 Friedman L S. The risk of surgery in patients with liver disease.  Hepatology. 1999;  29 1617-1623
• 5 Mansour A, Watson W, Shayani V. et al . Abdominal operations in patients with cirrhosis: still a major surgical challenge.  Surgery. 1997;  122 730-735; discussion 735 – 736
• 6 del Olma J A, Flor-Lorente B, Flor-Civera B. et al . Risk factors for nonhepatic surgery in patients with cirrhosis.  World J Surg. 2003;  27 647-652
• 7 Angermayr B, Cejna M, Karnel F. et al . Child-Pugh versus MELD score in predicting survival in patients undergoing transjugular intrahepatic portosystemic shunt.  Gut. 2003;  52 879-885
• 8 Schepke M, Roth F, Fimmers R. et al . Comparison of MELD, Child-Pugh, and Emory model for the prediction of survival in patients undergoing transjugular intrahepatic portosystemic shunting.  Am J Gastroenterol. 2003;  98 1167-1174
• 9 Salerno F, Merli M, Cazzaniga M. et al . MELD score is better than Child-Pugh score in predicting 3-month survival of patients undergoing transjugular intrahepatic portosystemic shunt.  J Hepatol. 2002;  36 494-500
• 10 Kamath P S, Wiesner R H, Malinchoc M. et al . A model to predict survival in patients with end-stage liver disease.  Hepatology. 2001;  33 464-470
• 11 Botta F, Giannini E, Romagnoli P. et al . MELD scoring system is useful for predicting prognosis in patients with liver cirrhosis and is correlated with residual liver function: a European study.  Gut. 2003;  52 134-139
• 12 Freeman Jr R, Wiesner R H, Harper A. et al . The new liver allocation system: moving toward evidence-based transplantation policy.  Liver Transpl. 2002;  8 851-858
• 13 Sakka S G. Assessing liver function.  Curr Opin Crit Care. 2007;  13 207-214
• 14 Teh S, Nagorney D, Stevens S. et al . Risk Factors for Mortality after Surgery in Patients With Cirrhosis.  Gastroenterology. 2007;  132 1261-1269
• 15 Dimick J B, Cowan J A, Knol J A. et al . Hepatic resection in the United States: indications, outcomes, and hospital procedural volumes from a nationally representative database.  Arch Surg. 2003;  138 185-191
• 16 Rädle Jr J, Rau B, Kleinschmidt S. et al . Operative Risk in Patients with Liver and Gastrointestinal Diseases.  Dtsch Arztebl. 2007;  104 A1914-A1921
• 17 Jarnagin W R, Gonen M, Fong Y. et al . Improvement in perioperative outcome after hepatic resection: analysis of 1,803 consecutive cases over the past decade.  Ann Surg. 2002;  236 397-406; discussion 406 – 397
• 18 Schroeder R A, Marroquin C E, Bute B P. et al . Predictive indices of morbidity and mortality after liver resection.  Ann Surg. 2006;  243 373-379
• 19 Ercolani G, Cucchetti A, Cescon M. et al . Predictive indices of morbidity and mortality after liver resection.  Ann Surg. 2006;  244 635-637; author reply 637
• 20 Farnsworth N, Fagan S P, Berger D H. et al . Child-Turcotte-Pugh versus MELD score as a predictor of outcome after elective and emergent surgery in cirrhotic patients.  Am J Surg. 2004;  188 580-583
• 21 Befeler A S, Palmer D E, Hoffman M. et al . The safety of intra-abdominal surgery in patients with cirrhosis: model for end-stage liver disease score is superior to Child-Turcotte-Pugh classification in predicting outcome.  Arch Surg. 2005;  140 650-654; discussion 655
• 22 Northup P G, Wanamaker R C, Lee V D. et al . Model for End-Stage Liver Disease (MELD) predicts nontransplant surgical mortality in patients with cirrhosis.  Ann Surg. 2005;  242 244-251
• 23 Teh S, Christein J, Donohue J. et al . Hepatic Resection of Hepatocellular Carcinoma in Patients with Cirrhosis: Model of End-Stage Liver Disease (MELD) score predicts Perioperative Mortality.  J Gastrointest Surg. 2005;  9 1207-1215
• 24 Cucchetti A, Ercolani G, Cescon M. et al . Recovery from liver failure after hepatectomy for hepatocellular carcinoma in cirrhosis: meaning of the model for end-stage liver disease.  J Am Coll Surg. 2006;  203 670-676
• 25 O’Leary J, Friedman L. Predicting Surgical Risk in Patients with Cirrhosis: From Art to Science.  Gastroenterology. 2007;  132 1609-1611
• 26 Mullin E J, Metcalfe M S, Maddern G J. How much liver resection is too much?.  Am J Surg. 2005;  190 87-97
• 27 Kanzler S, Teufel A, Galle P R. Liver function test to predict hepatic failure after liver resection – expensive and without clinical relevance?.  Zentralbl Chir. 2007;  132 267-273
• 28 Bruix J, Castells A, Bosch J. et al . Surgical resection of hepatocellular carcinoma in cirrhotic patients: prognostic value of preoperative portal pressure.  Gastroenterology. 1996;  111 1018-1022
• 29 Zorzi D, Laurent A, Pawlik T M. et al . Chemotherapy-associated hepatotoxicity and surgery for colorectal liver metastases.  Br J Surg. 2007;  94 274-286
• 30 Blum H, Farthmann E H. Der Patient mit Hepatopathie.  Chirurg. 1997;  68 763-769
• 31 Keegan M T, Plevak D J. Preoperative assessment of the patient with liver disease.  Am J Gastroenterol. 2005;  100 2116-2127
• 32 Fujioka H, Kawashita Y, Kamohara Y. et al . Utility of technetium-99m-labeled-galactosyl human serum albumin scintigraphy for estimating the hepatic functional reserve.  J Clin Gastroenterol. 1999;  28 329-333
• 33 Kubota K, Makuuchi M, Kusaka K. et al . Measurement of liver volume and hepatic functional reserve as a guide to decision-making in resectional surgery for hepatic tumors.  Hepatology. 1997;  26 1176-1181
• 34 Fan S T, Lai E C, Lo C M. et al . Hospital mortality of major hepatectomy for hepatocellular carcinoma associated with cirrhosis.  Arch Surg. 1995;  130 198-203
• 35 Lam C M, Fan S T, Lo C M. et al . Major hepatectomy for hepatocellular carcinoma in patients with an unsatisfactory indocyanine green clearance test.  Br J Surg. 1999;  86 1012-1017
• 36 Imamura H, Seyama Y, Kokudo N. et al . One thousand fifty-six hepatectomies without mortality in 8 years.  Arch Surg. 2003;  138 1198-1206; discussion 1206
• 37 Lau H, Man K, Fan S T. et al . Evaluation of preoperative hepatic function in patients with hepatocellular carcinoma undergoing hepatectomy.  Br J Surg. 1997;  84 1255-1259
• 38 Statland B E, Demas T, Danis M. Letter: Caffeine accumulation associated with alcoholic liver disease.  N Engl J Med. 1976;  295 110-111
• 39 Park G J, Katelaris P H, Jones D B. et al . Validity of the 13C-caffeine breath test as a noninvasive, quantitative test of liver function.  Hepatology. 2003;  38 1227-1236
• 40 Redaelli C A, Dufour J F, Wagner M. et al . Preoperative galactose elimination capacity predicts complications and survival after hepatic resection.  Ann Surg. 2002;  235 77-85
• 41 Salerno F, Borroni G, Moser P. et al . Prognostic value of the galactose test in predicting survival of patients with cirrhosis evaluated for liver transplantation. A prospective multicenter Italian study. AISF Group for the Study of Liver Transplantation. Associazione Italiana per lo Studio del Fegato.  J Hepatol. 1996;  25 474-480
• 42 Oellerich M, Armstrong V W. The MEGX test: a tool for the real-time assessment of hepatic function.  Ther Drug Monit. 2001;  23 81-92
• 43 Ercolani G, Grazi G L, Calliva R. et al . The lidocaine (MEGX) test as an index of hepatic function: its clinical usefulness in liver surgery.  Surgery. 2000;  127 464-471
• 44 Ravaioli M, Grazi G L, Principe A. et al . Operative risk by the lidocaine test (MEGX) in resected patients for HCC on cirrhosis.  Hepatogastroenterology. 2003;  50 1552-1555
• 45 Huang Y S, Chiang J H, Wu J C. et al . Risk of hepatic failure after transcatheter arterial chemoembolization for hepatocellular carcinoma: predictive value of the monoethylglycinexylidide test.  Am J Gastroenterol. 2002;  97 1223-1227
• 46 Addario L, Scaglione G, Tritto G. et al . Prognostic value of quantitative liver function tests in viral cirrhosis: a prospective study.  Eur J Gastroenterol Hepatol. 2006;  18 713-720
• 47 Merkel C, Bolognesi M, Bellon S. et al . Aminopyrine breath test in the prognostic evaluation of patients with cirrhosis.  Gut. 1992;  33 836-842
• 48 Schneider A R, Caspary W F, Stein J. (13)C-breath tests for the assessment of liver function.  Z Gastroenterol. 2004;  42 269-275