Chirurgie (Heidelberg, Germany)最新文献

Klatskin tumors are cholangiocarcinomas which arise at the biliary bifurcation (perihilar cholangiocarcinoma). Due to the close anatomical relationship to the liver parenchyma, portal bifurcation and hepatic arteries, the treatment of these tumors represents a major challenge. The only curative treatment option so far is the complete surgical removal of the affected bile ducts. This often warrants an en bloc liver resection sometimes in combination with resection and reconstruction of the portal vein and occasionally of the hepatic artery. A regional lymphadenectomy is mandatory. The operations are technically challenging and associated with a significant perioperative morbidity up to 50-60% and mortality of around 10%.

The treatment of patients with liver diseases represents an important challenge in the German healthcare system. The strategy of centralization of complex surgical interventions has the aim to improve the quality of treatment, to optimize postoperative outcomes and to minimize complications by the bundling of professional competence, infrastructure and resources. Although centralization has the potential to improve the results of treatment, it is simultaneously accompanied by substantial challenges with respect to availability of resources, hospital structures and personal treatment. A thorough planning and sufficient investments are necessary so that this strategy can sustainably be implemented in the practice.

The preoperative estimation of the volumetric and especially functional future liver remnant (FLR) is of particular importance before major liver resections to avoid posthepatectomy liver failure (PHLF). A postoperative regeneration of the liver is only possible if there is sufficient functional FLR. Laboratory parameter scores, such as the combined aspartate aminotransferase to platelet ratio index (APRI)/albumin-bilirubin grade (ALBI) score, can provide an initial assessment of the risk of PHLF. Other functional tests, such as the ICG-R15 test, the LiMAx® (Humedics GmbH, Berlin, Germany) test or scintigraphic procedures (e.g. technetium 99m mebrofenin secretion) can be used in the event of abnormal findings in order to assess liver function more precisely. In the case of inhomogeneous parenchymal quality, for example after portal vein embolization (PVE), knowledge of the segmental functional distribution is essential. This can be done by functional imaging techniques, such as the technetium 99m mebrofenin scintigraphy examinations in combination with magnetic resonance imaging (MRI). Although not yet approved for functional testing, MRI with the hepatocyte-specific contrast agent gadolinium provides a practicable surrogate parameter for parallel three-dimensional (tumor) imaging. This procedure is already well validated. In the future, deep learning algorithms will enable automated analyses of segmental liver function; however, surgical expertise remains decisive for assessing resectability. As a guideline the rule of thumb is at least 30% parenchymal reserve in patients with a healthy liver and 40% in risk constellations. This article provides an overview of current concepts and diagnostic procedures for the preoperative assessment of sufficient parenchymal reserve.

Minimally invasive procedures have been slowly gaining ground in liver surgery since the 1990s but have recently become increasingly more established. In Germany they are now used in around a quarter of all resections for colorectal metastases and much more often in specialized centers. In addition to less blood loss, the advantages include faster postoperative recovery with a correspondingly shorter hospital stay and all this with an oncological safety comparable to open procedures. Robotics provide additional advantages over laparoscopy, especially in complex resections such as posterosuperior segments or vascular and biliary reconstruction. At the same time, artificial intelligence, 3D reconstructions and augmented reality are becoming increasingly more important for planning, navigation and intraoperative safety. Robotics in particular will serve as a technical platform for the increasing digitalization and integration of modern imaging. Despite these advances, open surgery will remain the standard for selected highly complex procedures in the near future.

Background: While standardized treatment recommendations exist for colorectal liver metastases, non-colorectal liver metastases (NCRLM) remain a treatment challenge due to the heterogeneous biology and the lack of evidence-based guidelines.

Material and methods: This review article considers current systematic reviews, retrospective cohort studies and meta-analyses addressing surgical resection and local ablation of NCRLM.

Results: Retrospective data show that selected patients with NCRLM can benefit from local treatment. Favorable prognostic factors include a limited number of oligometastases, achievement of an R0 resection and the absence of extrahepatic tumor manifestations.

Discussion: In view of the limited evidence base, recent advances in minimally invasive surgery and modern systemic treatment, prospective studies are essential to validly define the oncological relevance of local treatment strategies for liver metastases.