„In-situ-Split“- (ISS) Leberresektion: Neue Aspekte zu Technik und Indikation

Zusammenfassung

Die Kombination von rechtsseitiger Pfortaderligatur mit kompletter Parenchymdissektion („In-situ-Split“, ISS) zur Hypertrophieinduktion des links-lateralen Leberlappens ist eine neue Strategie, um primär funktionell irresektable Lebertumoren in einen resektablen Zustand zu überführen. Bislang vorhandene Daten zeigen eine Vergrößerung der Restleber innerhalb eines Zeitraums von 7(− 9) Tagen um bis zu 60–80 %. Ein derart invasives Konzept mit 2 operativen Eingriffen innerhalb kurzer Zeit wirft naturgemäß viele Fragen auf. Unter Einbeziehung der wenigen bislang vorhandenen Literatur zum ISS sowie eigener Erfahrungen mit dieser Prozedur werden technische Diskussionspunkte wie u. a. die Adhäsionsprophylaxe durch Fremdmaterial an der Resektionsfläche, die Möglichkeit der laparoskopischen Primäroperation sowie die Wahl des optimalen Zeitpunkts für die Komplettierungsoperation erörtert. Ferner diskutieren wir Aspekte bezüglich Umfang und Intensität der präoperativ notwendigen Diagnostik. Abschließend werden offene Fragen hinsichtlich der Indikationsstellung wie beispielsweise der Einfluss vorangegangener Chemotherapie oder die Anwendung des ISS bei Patienten mit Leberzirrhose angerissen. Die Darstellung von Chancen und Risiken des neuen Konzepts im Kontext von Indikation und technischer Durchführung soll dazu beitragen, einer größeren Zahl von Patienten mit marginal oder primär irresektablen Lebertumoren die potenziell kurative Option des „In-situ-Splits“ zu ermöglichen.

Abstract

The combination of right portal vein ligation with complete parenchyma dissection (“in-situ split”, ISS) for rapid hypertrophy induction of the left-lateral liver lobe is a novel strategy to convert primarily irresectable liver tumours into a resectable stage. Available data so far show a 60–80 % growth induction of the remnant liver within 7(− 9) days. Certainly, a novel concept that comprises two operations within a very short time period raises questions. Based on the very few literature reports that have been published so far, as well as our own experience, we here discuss technical issues such as the use of a plastic sheet on the resection margin, the possibility of laparoscopic dissection and the timing of the second operation. Moreover, aspects of the preoperative diagnostic work-up that is necessary are assessed. Finally, open questions, e.g., concerning the influence of preoperative chemotherapy and the use of ISS in patients with cirrhosis are evaluated. In summary, the assessment of chances and risks of this novel concept with regard to indication and technical issues helps to provide the potentially curative option of the “in-situ split” procedure to more patients with marginal or even irresectable liver tumours.

Schlüsselwörter

zweizeitige Leberresektion - Resektabilität - In-situ-Split - Hypertrophie - Technik - Indikation

Key words

liver resection in two steps - resectability - in-situ splitting - hypertrophy - technique - indication

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