Funktionsdiagnostik vor Leberresektion - teuer und ohne klinische Relevanz?

Zusammenfassung

Ein Leberversagen nach Leberteilresektion ist eine gefürchtete postoperative Komplikation, die mit einer schlechten Prognose einhergeht. Pathophysiologisch führt eine inadäquate funktionelle Reserve der Restleber zu einer zunehmenden Verschlechterung der verbliebenen Leberfunktion, zu einer Hemmung der Leberregeneration und somit zu einem Fortschreiten des Leberversagens. Um das Risiko einer Leberteilresektion besser abschätzen zu können bzw. die funktionelle Reserve der Leber präoperativ möglichst exakt zu quantifizieren, sind zahlreiche Leberfunktionsteste entwickelt worden. Die meisten Funktionsteste evaluieren metabolische Leberfunktionen wie Zytochrom p 450-abhängige Stoffwechselfunktionen der Leber oder aber die Extraktion und biliäre Exkretion von Farbstoffen. Nuklearmedizinische Untersuchungen erlauben neben der Visualisierung der Leber auch ein Abschätzen des hepatozellulären Volumens, welches ein besserer Prädiktor der funktionellen Leberreserve zu sein scheint, verglichen mit der reinen Lebervolumetrie. Bislang kann allerdings kein Leberfunktionstest für sich alleine sichere Grenzen der Resektabilität aufzeigen, sodass Leberfunktionsteste im klinischen Alltag derzeit keinen festen Platz haben. Sofern eine Lebergrunderkrankung ausgeschlossen ist, wird in der klinischen Praxis die Resektabilität vorwiegend von volumetrischen Erwägungen und der technischen Machbarkeit der Resektion geleitet. Bei Verdacht auf eine Lebererkrankung sollte präoperativ die Lebergrunderkrankung diagnostiziert und in ihrer Schwere anhand der Child-Pugh-Turcott-Klassifikation bewertet werden. Resektive Verfahren sollten lediglich bei Child-Pugh-A-Patienten mit normalem Bilirubinwert und ohne portale Hypertension in Betracht gezogen werden.

Abstract

Hepatic failure after liver resection is a complication that is dreaded by surgeons and has a poor outcome. Inadequate functional reserve of the remaining liver parenchyma leads to the inability to regenerate and finally to the progression of liver failure. In order to predict the functional reserve of the remaining liver parenchyma, many different liver function tests have been established. Basis for most liver function assessments are metabolic liver functions such as cytochrome p 450 dependent pathways or the extraction and biliary excretion of dye. Nuclear imaging of the liver parenchyma does not only allow visualisation of the liver but also accumulation of information on hepatocyte volume that might be a better predictor for the hepatic reserve and the regenerative capacity compared to the liver volume alone. However, to date no single method has been proven to be able to predict safe limits of resectability. If an underlying liver disease is excluded the resectability is mostly limited by volumetric analysis and technical feasibility of liver resection. In patients with underlying liver disease cirrhosis should be excluded. In case of liver cirrhosis, only Child-Pugh-Turcott A patients with normal bilirubin levels and without portal hypertension should be considered for liver resection.

Schlüsselwörter

Leberresektion - Leberfunktionstest - MEGX-Test - Indigocyanin-clearance - Leberversagen

Key words

fuctional reserve - hepatic resection - indocyanine clearance - MEGX-test - liver failure

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