Blutungskomplikationen in der Leberchirurgie und bei der Lebertransplantation

Zusammenfassung

Nachdem über Leberresektionen und Lebertransplantationen erst in den 60er Jahren berichtet wurde, werden diese heutezutage häufig durchgeführt und stellen sichere Verfahren dar. Aufgrund der technischen Weiterentwicklung der Leberchirurgie sind lebensbedrohliche intraoperative Blutungen selten geworden. Durch entsprechende präoperative Vorbereitung und blutsparende Resektionsverfahren können Blutungen weitgehend vermieden werden. Bei der LTx hat sicherlich die Standardisierung der Transplantationstechnik zu dieser positiven Entwicklung beigetragen. In den Vordergrund sind in der Leberchirurgie Störungen der endogenen Hämostase durch den teilweisen oder kompletten Ausfall der Leberfunktion getreten. Durch den Abfall der in der Leber synthetisierten Gerinnungsfaktoren und Kofaktoren kann es zu erheblichen perioperativen Blutverlusten kommen. Einer präoperativ bestehenden Leberfunktionsstörung kommt hierbei große Bedeutung zu. Diese erfordert dann postoperativ ein engmaschiges Monitoring und eine adaptierte Therapie. Durch die Verbesserung der operativen Ergebnisse wurden die Indikationen zur Leberresektion und -transplantation ausgeweitet: es werden sowohl erweiterte Resektionen als auch Resektionen bei Patienten mit vorbestehendem Leberparenchymschaden durchgeführt, Lebertransplantationen werden zunehmend in einem früheren Erkrankungsstadium vorgenommen. Voraussetzung für diese Ausweitung von Indikation und Resektionsausmaß sind eine verbesserte perioperative Betreuung und ein exaktes Verständnis der perioperativen Veränderungen im Leberstoffwechsel. Nicht zuletzt wurden diese Kenntnisse im Rahmen der Lebertransplantation mit temporärem Ausfall der Lebersyntheseleistung gewonnen.

Summary

In the 1960ies, only a few liver resections and transplantations have been reported. Since then, liver surgery has been developed, and today both are frequently conducted and safe procedures. Serious intraoperative hemorrhage has become rare due to the improved techniques of liver surgery: bleeding complications can be prevented by an appropriate preoperative preparation of the patient, blood saving resection techniques, and the standardization of the liver transplantation procedure. However, liver resections and transplantations can result in a mostly reversible partial or complete liver insufficiency, causing disorders in the endogenous hemostasis with decreased coagulation factors and co-factors, which can be a major reason for perioperative hemorrhage. Patients with a preoperatively reduced liver function therefore require an intensive postoperative monitoring and an individual treatment. Due to the improved results from liver surgery, the indications for liver resections and transplantations have been extended: today, resections are conducted in more advanced disease stages as well as in patients with a reduced liver function; liver transplantations are conducted in an earlier disease stage. An improved perioperative treatment and a better understanding of the perioperative changes and disorders in the metabolism of the liver are the basis for these extended indications. Due to the improvements in the treatment of these perioperative changes the results from liver surgery have been improved and the indications for liver resections and transplantations have been extended.

Schlüsselwörter

Leberresektion - Lebertransplantation

Keywords

Liver resection - liver transplantation

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