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

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

• Literatur

• 1 Antolovic D, Koch M, Galindo L et al. Hepaticojejunostomy–analysis of risk factors for postoperative bile leaks and surgical complications. J Gastrointest Surg 2007; 11: 555-561
• 2 de Castro SM, Kuhlmann KF, Busch OR et al. Incidence and management of biliary leakage after hepaticojejunostomy. J Gastrointest Surg 2005; 9: 1163-1171 discussion 1171–1173
• 3 Akamatsu N, Sugawara Y, Hashimoto D. Biliary reconstruction, its complications and management of biliary complications after adult liver transplantation: a systematic review of the incidence, risk factors and outcome. Transpl Int 2011; 24: 379-392
• 4 Chok KS, Ng KK, Poon RT et al. Impact of postoperative complications on long-term outcome of curative resection for hepatocellular carcinoma. Br J Surg 2009; 96: 81-87
• 5 Karsten TM, Coene PP, van Gulik TM et al. Morphologic changes of extrahepatic bile ducts during obstruction and subsequent decompression by endoprosthesis. Surgery 1992; 111: 562-568
• 6 Herzog T, Belyaev O, Hessam S et al. Bacteribilia with resistant microorganisms after preoperative biliary drainage – the influence of bacteria on postoperative outcome. Scand J Gastroenterol 2012; 47: 827-835
• 7 Miethke T. [Increasing therapeutic challenges through multi-resistant bacteria in the hospital]. Zentralbl Chir 2012; 137: 279-283
• 8 Abdallah AA, Krige JE, Bornman PC. Biliary tract obstruction in chronic pancreatitis. HPB (Oxford) 2007; 9: 421-428
• 9 Fernandez-del Castillo C, Targarona J, Thayer SP et al. Incidental pancreatic cysts: clinicopathologic characteristics and comparison with symptomatic patients. Arch Surg 2003; 138: 427-433 discussion 433–434
• 10 Weiss S, Schmidt SC, Ulrich F et al. Biliary reconstruction using a side-to-side choledochocholedochostomy with or without T-tube in deceased donor liver transplantation: a prospective randomized trial. Ann Surg 2009; 250: 766-771
• 11 Kobayashi T, Sato Y, Yamamoto S et al. Characteristics of biliary reconstruction, using a T-tube, as compared to those with other methods, in left-lobe adult living-donor liver transplantation. J Hepatobiliary Pancreat Surg 2007; 14: 177-182
• 12 Sicklick JK, Camp MS, Lillemoe KD et al. Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients. Ann Surg 2005; 241: 786-792 discussion 793–795
• 13 Lillemoe KD, Pitt HA, Cameron JL. Current management of benign bile duct strictures. Adv Surg 1992; 25: 119-174
• 14 Riediger C, Muller MW, Michalski CW et al. T-Tube or no T-tube in the reconstruction of the biliary tract during orthotopic liver transplantation: systematic review and meta-analysis. Liver Transpl 2010; 16: 705-717
• 15 Koch M, Garden OJ, Padbury R et al. Bile leakage after hepatobiliary and pancreatic surgery: a definition and grading of severity by the International Study Group of Liver Surgery. Surgery 2011; 149: 680-688
• 16 Herzog T, Belyaev O, Muller CA et al. Bacteribilia after preoperative bile duct stenting: a prospective study. J Clin Gastroenterol 2009; 43: 457-462
• 17 Standop J, Glowka T, Schmitz V et al. Operative re-intervention following pancreatic head resection: indications and outcome. J Gastrointest Surg 2009; 13: 1503-1509
• 18 Reed jr. DN, Vitale GC, Wrightson WR et al. Decreasing mortality of bile leaks after elective hepatic surgery. Am J Surg 2003; 185: 316-318
• 19 Ferrero A, Russolillo N, Vigano L et al. Safety of conservative management of bile leakage after hepatectomy with biliary reconstruction. J Gastrointest Surg 2008; 12: 2204-2211
• 20 Hasegawa K, Makuuchi M, Kubota K et al. Reconstruction of small and fragile bile ducts without mucosa-to-mucosa anastomosis. Arch Surg 2000; 135: 596-599
• 21 Sondenaa K, Kubota K, Sano K et al. Successful reconstruction of segmental or subsegmental bile ducts after resection of hilar bile ducts: short- and long-term results. Hepatogastroenterology 2004; 51: 1278-1281
• 22 Laukkarinen J, Sand J, Leppiniemi J et al. A novel technique for hepaticojejunostomy for nondilated bile ducts: a purse-string anastomosis with an intra-anastomotic biodegradable biliary stent. Am J Surg 2010; 200: 124-130
• 23 Wagholikar GD, Sikora SS, Pandey R et al. Morphological changes in bile ducts following preoperative biliary stenting. Indian J Gastroenterol 2003; 22: 166-169
• 24 Cortes A, Sauvanet A, Bert F et al. Effect of bile contamination on immediate outcomes after pancreaticoduodenectomy for tumor. J Am Coll Surg 2006; 202: 93-99
• 25 Buchler MW, Wagner M, Schmied BM et al. Changes in morbidity after pancreatic resection: toward the end of completion pancreatectomy. Arch Surg 2003; 138: 1310-1314 discussion 1315
• 26 Kobayashi T, Sato Y, Yamamoto S et al. Long-term follow-up study of biliary reconstructions and complications after adult living donor liver transplantation: feasibility of duct-to-duct reconstruction with a T-tube stent. Transplant Proc 2009; 41: 265-267
• 27 Kuroda Y, Suzuki Y, Ku Y et al. Biliary-enteric anastomosis by means of a single layer of serosubmucosal sutures without T-tube drainage. Arch Surg 1996; 131: 637-639 discussion 640
• 28 Nuno J, Vicente E, Turrion VS et al. Biliary tract reconstruction after liver transplantation: with or without T-tube?. Transplant Proc 1997; 29: 564-565
• 29 Wills VL, Gibson K, Karihaloot C et al. Complications of biliary T-tubes after choledochotomy. ANZ J Surg 2002; 72: 177-180
• 30 Gharaibeh KI, Heiss HA. Biliary leakage following T-tube removal. Int Surg 2000; 85: 57-63
• 31 Leonardi MI, Ataide EC, Boin IF et al. Role of choledochojejunostomy in liver transplantation. Transplant Proc 2005; 37: 1126-1128
• 32 Klein AS, Savader S, Burdick JF et al. Reduction of morbidity and mortality from biliary complications after liver transplantation. Hepatology 1991; 14: 818-823
• 33 Kubota K, Takayama T, Sano K et al. Small bile duct reconstruction of the caudate lobe in living-related liver transplantation. Ann Surg 2002; 235: 174-177
• 34 Cai X, Lin H, Yu H et al. Novel sutureless cholangiojejunostomy: initial experience with 11 cases. Am J Surg 2008; 195: 273-276
• 35 House MG, Cameron JL, Schulick RD et al. Incidence and outcome of biliary strictures after pancreaticoduodenectomy. Ann Surg 2006; 243: 571-576 discussion 576–578