Zentralbl Chir 2007; 132(4): 267-273
DOI: 10.1055/s-2007-981197
Originalarbeiten und Übersichten

© Georg Thieme Verlag Stuttgart · New York

Funktionsdiagnostik vor Leberresektion - teuer und ohne klinische Relevanz?

Liver Function Test to Predict Hepatic Failure after Liver Resection - Expensive and without Clinical Relevance?S. Kanzler1 , A. Teufel1 , P. R. Galle1
  • 1I. Medizinische Klinik und Poliklinik, Johannes-Gutenberg-Universität, Mainz
Further Information

Publication History

Publication Date:
27 August 2007 (online)

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.

Literatur

  • 1 Abei M, Tanaka E, Tanaka N. et al . Clinical significance of the trimethadione tolerance test in chronic hepatitis: a useful indicator of hepatic drug metabolizing capacity.  J Gastroenterol. 1995;  30 478-484
  • 2 Armuzzi A, Candelli M, Zocco M A. et al . Review article: breath testing for human liver function assessment.  Aliment Pharmacol Ther. 2002;  16 1977-1996
  • 3 Asano M, Ozawa K, Tobe T. Postoperative prognosis as related to blood ketone body ratios in hepatectomized patients.  Eur Surg Res. 1983;  15 302-311
  • 4 Behrns K E, Tsiotos G G, DeSouza N F. et al . Hepatic steatosis as a potential risk factor for major hepatic resection.  J Gastrointest Surg. 1998;  2 292-298
  • 5 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
  • 6 Chijiiwa K, Watanabe M, Nakano K. et al . Biliary indocyanine green excretion as a predictor of hepatic adenosine triphosphate levels in patients with obstructive jaundice.  Am J Surg. 2000;  179 161-166
  • 7 Clowes Jr  G H, McDermott W V, Williams L F. et al . Amino acid clearance and prognosis in surgical patients with cirrhosis.  Surgery. 1984;  96 675-685
  • 8 Didolkar M S, Fitzpatrick J L, Elias E G. et al . Risk factors before hepatectomy, hepatic function after hepatectomy and computed tomographic changes as indicators of mortality from hepatic failure.  Surg Gynecol Obstet. 1989;  169 17-26
  • 9 Dimick J B, Cowan Jr  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
  • 10 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
  • 11 Fabris L, Jemmolo R M, Toffolo G. et al . The monoethylglycinexylidide test for grading of liver cirrhosis.  Aliment Pharmacol Ther. 1999;  13 67-75
  • 12 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
  • 13 Froomes P R, Ghabrial H, Morgan D J. et al . The effect of oxygen supplementation on the arterial ketone body ratio in human cirrhosis.  Digestion. 2002;  66 257-261
  • 14 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
  • 15 Furuya K N, Durie P R, Roberts E A. et al . Glycine conjugation of para-aminobenzoic acid (PABA): a quantitative test of liver function.  Clin Biochem. 1995;  28 531-540
  • 16 Furuya K N, Durie P R, Roberts E A, Soldin S J, Verjee Z, Yung-Jato L, Giesbrecht E, Ellis L. Glycine conjugation of para-aminobenzoic acid (PABA): a quantitative test of liver function.  Clin Biochem. 1995;  28 531-540
  • 17 Galizzi J, Long R G, Billing B H. et al . Assessment of the (14C) aminopyrine breath test in liver disease.  Gut. 1978;  19 40-45
  • 18 Gill R A, Goodman M W, Golfus G R. et al . Aminopyrine breath test predicts surgical risk for patients with liver disease.  Ann Surg. 1983;  198 701-704
  • 19 Hanazaki K, Wakabayashi M, Sodeyama H. et al . Arterial ketone body ratio does not correlate with ischemic changes during major hepatectomy.  Hepatogastroenterology. 1998;  45 145-149
  • 20 Helmreich-Becker I, Schirmacher P, Denzer U, Hensel A, Meyer zum Buschenfelde K H, Lohse A W. Minilaparoscopy in the diagnosis of cirrhosis: superiority in patients with Child-Pugh A and macronodular disease.  Endoscopy. 2003;  35 55-60
  • 21 Hemming A W, Scudamore C H, Shackleton C R. et al . Indocyanine green clearance as a predictor of successful hepatic resection in cirrhotic patients.  Am J Surg. 1992;  163 515-518
  • 22 Herold C, Heinz R, Niedobitek G. et al . Quantitative testing of liver function in relation to fibrosis in patients with chronic hepatitis B and C.  Liver. 2001;  21 260-265
  • 23 Herold C, Heinz R, Radespiel-Troger M. et al . Quantitative testing of liver function in patients with cirrhosis due to chronic hepatitis C to assess disease severity.  Liver. 2001;  21 26-30
  • 24 Huo T I, Wu J C, Lui W Y. et al . Differential mechanism and prognostic impact of diabetes mellitus on patients with hepatocellular carcinoma undergoing surgical and nonsurgical treatment.  Am J Gastroenterol. 2004;  99 1479-1487
  • 25 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
  • 26 Ishikawa A, Fukao K, Tsuji K. et al . Trimethadione tolerance tests for the assessment of feasible size of hepatic resection in patients with hepatocellular carcinoma.  J Gastroenterol Hepatol. 1993;  8 426-432
  • 27 Jarnagin W, 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;  236 397-407
  • 28 Jaeck D, Bachellier P, Guiguet M. et al . Long-term survival following resection of colorectal hepatic metastases. Association Francaise de Chirurgie.  Br J Surg. 1997;  84 977-980
  • 29 Kawasaki S, Makuuchi M, Miyagawa S. et al . Results of hepatic resection for hepatocellular carcinoma.  World J Surg. 1995;  19 31-34
  • 30 Kinoshita K, Ukikusa M, Iwaisako K. et al . Preoperative assessment of hepatic function: utility of a new convenient two-compartment model analysis using galactosyl human serum albumin scintigraphy.  J Gastroenterol Hepatol. 2003;  18 99-104
  • 31 Kubo S, Nishiguchi S, Shuto T. et al . Effects of continuous hepatitis with persistent hepatitis C viremia on outcome after resection of hepatocellular carcinoma.  Jpn J Cancer Res. 1999;  90 162-170
  • 32 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
  • 33 Kudo M, Vera D R, Stadalnik R C. et al . In vivo estimates of hepatic binding protein concentration: correlation with classical indicators of hepatic functional reserve.  Am J Gastroenterol. 1990;  85 1142-1148
  • 34 Kwon A H, Matsui Y, Ha-Kawa S K. et al . Functional hepatic volume measured by technetium-99m-galactosyl-human serum albumin liver scintigraphy: comparison between hepatocyte volume and liver volume by computed tomography.  Am J Gastroenterol. 2001;  96 541-546
  • 35 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
  • 36 Lebel S, Nakamachi Y, Hemming A. et al . Glycine conjugation of para-aminobenzoic acid (PABA): a pilot study of a novel prognostic test in acute liver failure in children.  J Pediatr Gastroenterol Nutr. 2003;  36 62-71
  • 37 Lindner P, Cahlin C, Friman S, Hafstrom L, Rizell M, Olausson M. Treatment of patients with liver metastases from colorectal cancer. More patients can benefit from the treatment!.  Lakartidningen. 2003;  100 2684-2688
  • 38 Makuuchi M, Kosuge T, Takayama T. et al . Surgery for small liver cancers.  Semin Surg Oncol. 1993;  9 298-304
  • 39 Merkel C, Gatta A, Zoli M. et al . Prognostic value of galactose elimination capacity, aminopyrine breath test, and ICG clearance in patients with cirrhosis. Comparison with the Pugh score.  Dig Dis Sci. 1991;  36 1197-1203
  • 40 Minagawa M, Makuuchi M, Takayama T. et al . Selection criteria for repeat hepatectomy in patients with recurrent hepatocellular carcinoma.  Ann Surg. 2003;  238 703-710
  • 41 Miyagawa S, Makuuchi M, Kawasaki S. et al . Changes in serum amylase level following hepatic resection in chronic liver disease.  Arch Surg. 1994;  129 634-638
  • 42 Mullin E J, Metcalfe M S, Maddern G J. How much liver resection is too much?.  Am J Surg. 2005;  190 87-97
  • 43 Nagasue N, Kohno H, Tachibana M. et al . Prognostic factors after hepatic resection for hepatocellular carcinoma associated with Child-Turcotte class B and C cirrhosis.  Ann Surg. 1999;  229 84-90
  • 44 Nakamura H, Tanaka E, Kaneko M. et al . The clinical importance of the trimethadione tolerance test as a method for quantitative assessment of hepatic functional reserve in patients with biliary atresia.  J Clin Pharm Ther. 2001;  26 417-424
  • 45 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
  • 46 Oellerich M, Burdelski M, Ringe B. et al . Functional state of the donor liver and early outcome of transplantation.  Transplant Proc. 1991;  23 1575-1578
  • 47 Okamoto E, Kyo A, Yamanaka N. et al . Prediction of the safe limits of hepatectomy by combined volumetric and functional measurements in patients with impaired hepatic function.  Surgery. 1984;  95 586-592
  • 48 Okochi O, Kaneko T, Sugimoto H. et al . ICG pulse spectrophotometry for perioperative liver function in hepatectomy.  J Surg Res. 2002;  103 109-113
  • 49 Ozawa K, Ida T, Yamada T. et al . Significance of glucose tolerance as prognostic sign in hepatectomized patients.  Am J Surg. 1976;  131 541-546
  • 50 Park G J, Katelaris P H, Jones D B. et al . Validity of the C-caffeine breath test as a noninvasive, quantitative test of liver function.  Hepatology. 2003;  38 1227-1236
  • 51 Redaelli C A, Dufour J, Wagner M. et al . Preoperative galactose elimination capacity predicts complications and survival after hepatic resection.  Ann Surg. 2002;  235 77-85
  • 52 Reding R, Wallemacq P, de Ville de Goyet J. et al . The unreliability of the lidocaine / monoethylglycinexylidide test for assessment of liver donors.  Transplantation. 1993;  56 323-326
  • 53 Satoh K, Yamamoto Y, Nishiyama Y. et al . 99mTc-GSA liver dynamic SPECT for the preoperative assessment of hepatectomy.  Ann Nucl Med. 2003;  17 61-67
  • 54 Sawamura T, Kawasato S, Shiozaki Y. et al . Decrease of a hepatic binding protein specific for asialoglycoproteins with accumulation of serum asialoglycoproteins in galactosamine-treated rats.  Gastroenterology. 1981;  81 527-533
  • 55 Scott N R, Stambuk D, Chakraborty J. et al . Caffeine clearance and biotransformation in patients with chronic liver disease.  Clin Sci. 1988;  74 377-384
  • 56 Sitzmann J V, Greene P S. Perioperative predictors of morbidity following hepatic resection for neoplasm. A multivariate analysis of a single surgeon experience with 105 patients.  Ann Surg. 1994;  219 13-17
  • 57 Schmidt L E, Ott P, Tygstrup N. Galactose elimination capacity as a prognostic marker in patients with severe acetaminophen-induced hepatotoxicity: 10 years' experience.  Clin Gastroenterol Hepatol. 2004;  2 418-424
  • 58 Stewart G D, O'Suilleabhain C B, Madhavan K K. et al . The extent of resection influences outcome following hepatectomy for colorectal liver metastases.  Eur J Surg Oncol. 2004;  30 370-376
  • 59 Suehiro T, Sugimachi K, Matsumata T. et al . Protein induced by vitamin K absence or antagonist II as a prognostic marker in hepatocellular carcinoma. Comparison with alpha-fetoprotein.  Cancer. 1994;  73 2464-2471
  • 60 Sugai Y, Komatani A, Hosoya T. et al . Response to percutaneous transhepatic portal embolization: new proposed parameters by 99mTc-GSA SPECT and their usefulness in prognostic estimation after hepatectomy.  J Nucl Med. 2000;  41 421-425
  • 61 Takenaka K, Kanematsu T, Fukuzawa K. et al . Can hepatic failure after surgery for hepatocellular carcinoma in cirrhotic patients be prevented?.  World J Surg. 1990;  14 123-127
  • 62 Tanaka E, Inomata S, Yasuhara H. The clinical importance of conventional and quantitative liver function tests in liver transplantation.  J Clin Pharm Ther. 2000;  25 411-419
  • 63 Yamanaka N, Okamoto E, Kuwata K, Tanaka N. A multiple regression equation for prediction of posthepatectomy liver failure.  Ann Surg. 1984;  200 658-663
  • 64 Yamanaka N, Okamoto E, Oriyama T. et al . A prediction scoring system to select the surgical treatment of liver cancer. Further refinement based on 10 years of use.  Ann Surg. 1994;  219 342-346
  • 65 Yumoto Y, Umeda M, Ohshima K. et al . Estimation of remnant liver function before hepatectomy by means of technetium-99m-diethylenetriamine-pentaacetic acid galactosyl human albumin.  Cancer Chemother Pharmacol. 1994;  33 S 1-S 6

Priv. Doz. Dr. S. Kanzler

I. Medizinische Klinik und Poliklinik · Johannes-Gutenberg-Universität Mainz

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Email: Kanzler@mail.uni-mainz.de