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DOI: 10.1055/s-0029-1224612
© Georg Thieme Verlag Stuttgart ˙ New York
Zeitlicher Ablauf von Leber- und Darmresektion bei Patienten mit kolorektalem Karzinom und synchronen Lebermetastasen
Timing of Resection in Patients with Colorectal Carcinoma and Synchronous Liver MetastasesPublication History
Publication Date:
15 September 2009 (online)
![](https://www.thieme-connect.de/media/zblchir/200905/lookinside/thumbnails/10.1055-s-0029-1224612-1.jpg)
Zusammenfassung
Der zeitliche Ablauf der Therapie von synchronen Lebermetastasen wird zunehmend differenziert. Goldstandard ist zwar weiterhin in der Mehrzahl der Fälle eine primäre Resektion des Darmtumors mit sekundärer Leberresektion 6 Wochen später. Bei kleinen Leberresektionen, d. h. atypischer Resektion oder Resektion von 1–2 Segmenten kann aber die Leberresektion durchaus simultan mit der Darmresektion erfolgen. Dies gilt insbesondere bei rechtsseitig gelegenen Primärtumoren. Voraussetzung ist eine geringe Komorbidität des Patienten. Große Leberresektionen in Kombination mit großen Darmresektionen führen zu einer erhöhten postoperativen Morbidität und Mortalität. Sie sollten nur in ausgesuchten Einzelfällen durchgeführt werden. Voraussetzung ist ferner eine spezielle Erfahrung des Operateurs in kolorektaler und hepatobiliärer Chirurgie. Wenn synchrone Lebermetastasen nahe an einer wichtigen anatomischen Struktur liegen, sollte primär die Leberresektion und erst sekundär die Darmresektion erfolgen. Gleiches gilt bei technischer Operabilität der Lebermetastasen, aber zu geringem verbleibendem Lebervolumen. Auch dann sollte unter Einsatz der bekannten Techniken zunächst versucht werden, die Leber chirurgisch zu sanieren. Das Risiko einer zwischenzeitlich auftretenden Komplikation von Seiten des Darmtumors ist minimal. Im Zweifelsfall kann im Rahmen der primären Leberresektion ein Anus praeter angelegt werden. Bei begrenzten, primär nicht kurativ oder nicht sicher kurativ resezierbaren synchronen Lebermetastasen sollte primär eine neoadjuvante systemische Chemotherapie durchgeführt werden. Bei Ansprechen der Metastasen erfolgt dann zunächst die Leberresektion. Die Resektion des Primärtumors steht an dritter Stelle. Entscheidend ist bei diesem Vorgehen die enge Kooperation zwischen Onkologen und Chirurgen, da das Fenster für eine chirurgische Therapie begrenzt ist. Der Nutzen einer primären Chemotherapie vor einer Leberresektion bei resektablen synchronen Lebermetastasen ist bisher nicht belegt.
Abstract
Timing of surgical therapy in patients with synchronous colorectal liver metastases is becoming more complex. The standard therapy for most of the patients remains resection of the colorectal cancer first followed 6 weeks later by liver resection. Simultaneous colon and liver resection is safe and advisable in cases of minor liver resections and right-sided colon tumours. Major liver resections in combination with resection of the colorectal cancer carry the risk of increased postoperative morbidity and mortality. They should be considered for selected patients only. A prerequisite is, in addition, special expertise of the operating surgeon in colorectal as well as in hepatobiliary surgery. If the synchronous liver metastases are near to essential anatomic structures, the liver resection should be performed before the bowel resection. The same holds if the metastases are technically resectable, but the future liver remnant seems to be too small. Using well known techniques, the future liver remnant should be increased and the liver metastases resected before treatment of the colonic primary tumour. The risk for local complications is very low when leaving the colorectal tumour in situ during treatment of liver metastases. When synchronous liver metastases are technically not resectable or carry a high risk of an R1 resection, patients should be treated first with systemic neoadjuvant chemotherapy. If sufficient downsizing of the metastases can be achieved, liver resection should be performed before bowel resection. A close cooperation between the oncologist and the hepatobiliary surgeon is most important, since the window for curative surgery is rather limited in these patients. In patients with resectable synchronous liver metastases, the advantage of a neoadjuvant chemotherapy has not been proven yet.
Schlüsselwörter
kolorektales Karzinom - Leberresektion - synchrone Lebermetastasen - Darmresektion - Timing
Key words
colorectal carcinoma - liver resection - synchronous liver metastases - bowel resection - timing
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Prof. U. T. Hopt
Universitätsklinikum der Albert-Ludwigs-Universität · Chirurgische Klinik · Freiburg · Abteilung Allgemein- und Viszeralchirurgie
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