Viszeralchirurgie 2004; 39(2): 114-121
DOI: 10.1055/s-2004-818767
Originalarbeit

© Georg Thieme Verlag Stuttgart · New York

Besonderheiten der Anästhesie und Intensivmedizin bei Lebereingriffen

Anaesthesia and Intensive Care for Major Liver ResectionL. Frey1 , A. Chouker1 , M. Thiel1
  • 1Klinik für Anästhesiologie, Klinikum Großhadern, Ludwig-Maximilians-Universität München
Further Information

Publication History

Publication Date:
21 April 2004 (online)

Zusammenfassung

Operative Eingriffe an der Leber sind heute zu einer erfolgreichen Therapie maligner und benigner Erkrankungen der Leber geworden. Trotz Ausdehnung der Indikationsstellung, steigender Invasivität der Eingriffe und zunehmendem Alter der Patienten hat die perioperative Morbidität und Mortalität stetig abgenommen. Ursächlich hierfür sind enorme Fortschritte auf den Gebieten der Chirurgie, der Anästhesie und der postoperativen Intensivmedizin während der letzten beiden Jahrzehnte. Im Folgenden sollen Besonderheiten der präoperativen Evaluation und Vorbereitung, der Narkoseführung und intraoperativen Überwachung unter Berücksichtigung hämodynamischer Auswirkungen spezieller chirurgischer Techniken (vaskuläre Clampingverfahren), sowie intensivmedizinische Aspekte der postoperativen Therapie beschrieben werden.

Abstract

Hepatectomy has become an established and succesful therapy of malignant and benign liver diseases. Major progress made in the fields of surgery, anaesthesia and intensive care has led to a continuous decrease in perioperative morbidity and mortality despite of extention of indications, degree of invasiveness and increasing age of patients undergoing major liver surgery. In this review, we will report on pecularities of preoperative patient evaluation, anaesthetic management including discussion of hemodynamic side effects of different methods of hepatic vascular occlusion, and summarize liver specific aspects of postoperative intensive care medicine.

Literaturverzeichnis

  • 1 Holt D R, Thiel D V, Edelstein S, Brems J J. Hepatic resections.  Arch Surg. 2000;  135 1353-1358
  • 2 Belghiti J, Hiramatsu K, Benoist S, Massault P, Sauvanet A, Farges O. Seven hundred forty-seven hepatectomies in the 1990s: an update to evaluate the actual risk of liver resection.  J Am Coll Surg. 2000;  191 38-46
  • 3 Pringle J H. Notes on the arrest of hepatic hemorrhage due to trauma.  Annals of Surgery. 1908;  48 541-549
  • 4 Jarnagin W R, Gonen M, Fong Y. et al . Improvement in perioperative outcome after hepatic resection: analysis of 1803 consecutive cases over the past decade.  Ann Surg. 2002;  236 397-406
  • 5 Yeh C N, Chen M F, Lee W C, Jeng L B. Prognostic factors of hepatic resection for hepatocellular carcinoma with cirrhosis: univariate and multivariate analysis.  J Surg Oncol. 2002;  81 195-202
  • 6 Torzilli G, Makuuchi M, Inoue K. et al . No-mortality liver resection for hepatocellular carcinoma in cirrhotic and noncirrhotic patients: is there a way? A prospective analysis of our approach.  Arch Surg. 1999;  134 984-992
  • 7 Ziser A, Plevak D J, Wiesner R H, Rakela J, Offord K P, Brown D L. Morbidity and mortality in cirrhotic patients undergoing anesthesia and surgery.  Anesthesiology. 1999;  90 42-53
  • 8 Vagvolgyi A, Takacs I, Arkossy P, Peter M, Sapy P. Near total hepatectomy in two steps for surgical treatment of liver metastasis of colorectal tumor.  Hepatogastroenterology. 2003;  50 2176-2178
  • 9 Cherqui D, Benoist S, Malassagne B, Humeres R, Rodriguez V, Fagniez P L. Major liver resection for carcinoma in jaundiced patients without preoperative biliary drainage.  Arch Surg. 2000;  135 302-308
  • 10 Behrns K E, Tsiotos G G, DeSouza N F, Krishna M K, Ludwig J, Nagorney D M. Hepatic steatosis as a potential risk factor for major hepatic resection.  J Gastrointest Surg. 1998;  2 292-298
  • 11 Lui W Y, Chau G Y, Wu C W, King K L. Surgical resection of hepatocellular carcinoma in elderly cirrhotic patients.  Hepatogastroenterology. 1999;  46 640-645
  • 12 http://www.dgai.de/06pdf/06_0_01voruntersuchung.pdf.2004
  • 13 Powell Jackson P, Greenway B, Williams R. Adverse effects of exploratory laparotomy in patients with unsuspected liver disease.  Br J Surg. 1982;  69 449-451
  • 14 Hargrove M D. Chronic active hepatitis: possible adverse effect of exploratory laparotomy.  Surgery.. 1970;  68 771-773
  • 15 Garrison R N, Cryer H M, Howard D A, Polk H C. Clarification of risk factors for abdominal operations in patients with hepatic cirrhosis.  Ann Surg. 1984;  199 648-655
  • 16 Mansour A, Watson W, Shayani V, Pickleman J. Abdominal operations in patients with cirrhosis: still a major surgical challenge.  Surgery. 1997;  122 730-735
  • 17 Bernardi M, Calandra S, Colantoni A. et al . Q-T interval prolongation in cirrhosis: prevalence, relationship with severity, and etiology of the disease and possible pathogenetic factors.  Hepatology. 1998;  27 28-34
  • 18 Dec G W, Kondo N, Farrell M L, Dienstag J, Cosimi A B, Semigran M J. Cardiovascular complications following liver transplantation.  Clin Transplant. 1995;  9 463-471
  • 19 Thasler W E, Bein T, Jauch K W. Perioperative effects of hepatic resection surgery on hemodynamics, pulmonary fluid balance, and indocyanine green clearance.  Langenbecks Arch Surg. 2002;  387 271-275
  • 20 Yanaga K, Takenaka K, Yamamoto K. et al . Cardiac complications after hepatic resection.  Br J Surg. 1996;  83 1448-1451
  • 21 Chassot P G, Delabays A, Spahn D R. Preoperative evaluation of patients with, or at risk of, coronary artery disease undergoing non-cardiac surgery.  Br J Anaesth. 2002;  89 747-759
  • 22 Eagle K A, Berger P B, Calkins H. et al . ACC/AHA Guideline Update for Perioperative Cardiovascular Evaluation for Noncardiac Surgery - Executive Summary. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Committee to Update the 1996 Guidelines on Perioperative Cardiovascular Evaluation for Noncardiac Surgery).  Anesth Analg. 2002;  94 1052-1064
  • 23 Wilson S H, Fasseas P, Orford J L. et al . Clinical outcome of patients undergoing non-cardiac surgery in the two months following coronary stenting.  J Am Coll Cardiol. 2003;  42 234-240
  • 24 Posner K L, Van Norman G A, Chan V. Adverse cardiac outcomes after noncardiac surgery in patients with prior percutaneous transluminal coronary angioplasty.  Anesth Analg.. 1999;  89 553-560
  • 25 Kuo P C, Plotkin J S, Johnson L B. et al . Distinctive clinical features of portopulmonary hypertension.  Chest. 1997;  112 980-986
  • 26 Gerbes A L, Gülberg V. [Hepatorenal syndrome].  Dtsch Med Wochenschr. 2003;  128 (Suppl 2) S 93-S 95
  • 27 Noldge G, Pannen B, Armbruster K, Geiger K. [Anesthesia in liver insufficiency].  Anasthesiol Intensivmed Notfallmed Schmerzther. 1993;  28 520-525
  • 28 Nöldge-Schomburg G F, Pannen B H, Geiger K. [Anesthesia and the liver].  Anaesthesist. 1996;  45 567-583
  • 29 Purcell P N, Branson R D, Hurst J M, Davis K, Johnson D J. Gut feeding and hepatic hemodynamics during PEEP ventilation for acute lung injury.  J Surg Res. 1992;  53 335-341
  • 30 Giebler R, Kollenberg B, Pohlen G, Peters J. Effect of positive end-expiratory pressure on the incidence of venous air embolism and on the cardiovascular response to the sitting position during neurosurgery.  Br J Anaesth. 1998;  80 30-35
  • 31 Hatano Y, Murakawa M, Segawa H, Nishida Y, Mori K. Venous air embolism during hepatic resection.  Anesthesiology. 1990;  73 1282-1285
  • 32 Lee S Y, Choi B I, Kim J S, Park K S. Paradoxical air embolism during hepatic resection.  Br J Anaesth. 2002;  88 136-138
  • 33 Ichai C, Levraut J, Baruch I, Samat-Long C, Leverve X, Grimaud D. Hypocapnia does not alter hepatic blood flow or oxygen consumption in patients with head injury.  Crit Care Med. 1998;  26 1725-1730
  • 34 Nielsen V G, Baird M S, Brix A E, Matalon S. Extreme, progressive isovolemic hemodilution with 5 % human albumin, PentaLyte, or Hextend does not cause hepatic ischemia or histologic injury in rabbits.  Anesthesiology. 1999;  90 1428-1435
  • 35 Ishiyama S, Seo N, Iizawa H. et al . [The hemodynamics during hemodilution and its influence on the liver functions after hepatectomy for hepatocellular carcinoma with liver cirrhosis].  Nippon Geka Gakkai Zasshi. 1991;  92 957-963
  • 36 Kainuma M, Kimura N, Nonami T. et al . The effect of dobutamine on hepatic blood flow and oxygen supply-uptake ratio during enflurane nitrous oxide anesthesia in humans undergoing liver resection.  Anesthesiology. 1992;  77 432-438
  • 37 Marx G, Leuwer M, Holtje M. et al . Low-dose dopexamine in patients undergoing hemihepatectomy: an evaluation of effects on reduction of hepatic dysfunction and ischaemic liver injury.  Acta Anaesthesiol Scand. 2000;  44 410-416
  • 38 Sharpe D A, Mitchel I M, Kay E A, McGoldrick J P, Munsch C M, Kay P H. Enhancing liver blood flow after cardiopulmonary bypass: the effects of dopamine and dopexamine.  Perfusion. 1999;  14 29-36
  • 39 Smithies M, Yee T H, Jackson L, Beale R, Bihari D. Protecting the gut and the liver in the critically ill: effects of dopexamine.  Crit Care Med. 1994;  22 789-795
  • 40 Krentz A J, Freedman D, Greene R, McKinley M, Boyle P J, Schade D S. Differential effects of physiological versus pathophysiological plasma concentrations of epinephrine and norepinephrine on ketone body metabolism and hepatic portal blood flow in man.  Metabolism. 1996;  45 1214-1220
  • 41 Kaiho T, Tanaka T, Tsuchiya S. et al . Hepatic resection under in situ hypothermic hepatic perfusion.  Hepatogastroenterology. 2003;  50 761-765
  • 42 Sansoe G, Ferrari A, Baraldi E. et al . Dopaminergic control of renal tubular function in patients with compensated cirrhosis.  Dig Dis Sci. 2002;  47 392-400
  • 43 Bellomo R, Chapman M, Finfer S, Hickling K, Myburgh J. Low-dose dopamine in patients with early renal dysfunction: a placebo-controlled randomised trial. Australian and New Zealand Intensive Care Society (ANZICS) Clinical Trials Group.  Lancet. 2000;  356 2139-2143
  • 44 Sutherland F, Harris J. Claude Couinaud: a passion for the liver.  Arch Surg. 2002;  137 1305-1310
  • 45 Mariette D, Smadja C, Naveau S, Borgonovo G, Vons C, Franco D. Preoperative predictors of blood transfusion in liver resection for tumor.  Am J Surg. 1997;  173 275-279
  • 46 Shinozuka N, Koyama I, Arai T. et al . Autologous blood transfusion in patients with hepatocellular carcinoma undergoing hepatectomy.  Am J Surg. 2000;  179 42-45
  • 47 Kajikawa M, Nonami T, Kurokawa T. et al . Autologous blood transfusion for hepatectomy in patients with cirrhosis and hepatocellular carcinoma: use of recombinant human erythropoietin.  Surgery. 1994;  115 727-734
  • 48 Matot I, Scheinin O, Jurim O, Eid A. Effectiveness of acute normovolemic hemodilution to minimize allogeneic blood transfusion in major liver resections.  Anesthesiology. 2002;  97 794-800
  • 49 Lutz J T, Valentin-Gamazo C, Gorlinger K, Malago M, Peters J. Blood-transfusion requirements and blood salvage in donors undergoing right hepatectomy for living related liver transplantation.  Anesth Analg. 2003;  96 351-355
  • 50 Hansen E. [Wound blood irradiation in oncologic procedures - safe and effective?].  Anaesthesist. 2001;  50 (Suppl 1) S 30-S 33
  • 51 Lentschener C, Benhamou D, Mercier F J. et al . Aprotinin reduces blood loss in patients undergoing elective liver resection.  Anesth Analg. 1997;  84 875-881
  • 52 Cohen D M, Norberto J, Cartabuke R, Ryu G. Severe anaphylactic reaction after primary exposure to aprotinin.  Ann Thorac Surg. 1999;  67 837-838
  • 53 Jones R M, Moulton C E, Hardy K J. Central venous pressure and its effect on blood loss during liver resection.  Br J Surg. 1998;  85 1058-1060
  • 54 Buell J F, Koffron A, Yoshida A. et al . Is any method of vascular control superior in hepatic resection of metastatic cancers? Longmire clamping, pringle maneuver, and total vascular isolation.  Arch Surg. 2001;  136 569-575
  • 55 Zografos G N, Kakaviatos N D, Skiathitis S, Habib N. Total vascular exclusion for liver resections: pros and cons.  J Surg Oncol. 1999;  72 50-55
  • 56 Smyrniotis V E, Kostopanagiotou G G, Gamaletsos E L. et al . Total versus selective hepatic vascular exclusion in major liver resections.  Am J Surg. 2002;  183 173-178
  • 57 Man K, Fan S T, Ng I O, Lo C M, Liu C L, Wong J. Prospective evaluation of Pringle maneuver in hepatectomy for liver tumors by a randomized study.  Ann Surg. 1997;  226 704-711
  • 58 Smyrniotis V E, Kostopanagiotou G G, Contis J C. et al . Selective Hepatic Vascular Exclusion versus Pringle Maneuver in Major Liver Resections: Prospective Study.  World J Surg. 2003;  27 765-769
  • 59 Smyrniotis V E, Kostopanagiotou G G, Gamaletsos E L. et al . Total versus selective hepatic vascular exclusion in major liver resections.  Am J Surg. 2002;  183 173-178
  • 60 Eyraud D, Richard O, Borie D C. et al . Hemodynamic and hormonal responses to the sudden interruption of caval flow: insights from a prospective study of hepatic vascular exclusion during major liver resections.  Anesth Analg. 2002;  95 1173-1178
  • 61 Selzner N, Rudiger H, Graf R, Clavien P A. Protective strategies against ischemic injury of the liver.  Gastroenterology. 2003;  125 917-936
  • 62 Torzilli G, Makuuchi M, Inoue K. The vascular control in liver resection: revisitation of a controversial issue.  Hepatogastroenterology. 2002;  49 28-31
  • 63 Imamura H, Seyama Y, Kokudo N. et al . One thousand fifty-six hepatectomies without mortality in 8 years.  Arch Surg. 2003;  138 1198-1206
  • 64 Yeh D C, Wu C C, Ho W M. et al . Bacterial translocation after cirrhotic liver resection: a clinical investigation of 181 patients.  J Surg Res. 2003;  111 209-214
  • 65 Farges O, Malassagne B, Flejou J F, Balzan S, Sauvanet A, Belghiti J. Risk of major liver resection in patients with underlying chronic liver disease: a reappraisal.  Ann Surg. 1999;  229 210-215
  • 66 D'Amico D, Cillo U. Impact of severe infections on the outcome of major liver surgery: a pathophysiologic and clinical analysis.  J Chemother. 1999;  11 513-517
  • 67 Kaiser A B. Antimicrobial prophylaxis in surgery.  N Engl J Med. 1986;  315 1129-1138
  • 68 Makino Y, Yamanoi A, Kimoto T, El Assal O N, Kohno H, Nagasue N. The influence of perioperative blood transfusion on intrahepatic recurrence after curative resection of hepatocellular carcinoma.  Am J Gastroenterol. 2000;  95 1294-1300
  • 69 Stephenson K R, Steinberg S M, Hughes K S, Vetto J T, Sugarbaker P H, Chang A E. Perioperative blood transfusions are associated with decreased time to recurrence and decreased survival after resection of colorectal liver metastases.  Ann Surg. 1988;  208 679-687
  • 70 Borromeo C J, Stix M S, Lally A, Pomfret E A. Epidural catheter and increased prothrombin time after right lobe hepatectomy for living donor transplantation.  Anesth Analg. 2000;  91 1139-1141
  • 71 Laffi G, La Villa G, Pinzani M, Marra F, Gentilini P. Arachidonic acid derivatives and renal function in liver cirrhosis.  Semin Nephrol. 1997;  17 530-548
  • 72 Hochwald S N, Burke E C, Jarnagin W R, Fong Y, Blumgart L H. Association of preoperative biliary stenting with increased postoperative infectious complications in proximal cholangiocarcinoma.  Arch Surg. 1999;  134 261-266
  • 73 Martinez C, Albet C, Agundez J A. et al . Comparative in vitro and in vivo inhibition of cytochrome P450 CYP1A2, CYP2D6, and CYP3A by H2-receptor antagonists.  Clin Pharmacol Ther. 1999;  65 369-376
  • 74 Weiman A, Jauch K W, Kemen M, Hiesmayr J M. DGEM-Leitlinie Enterale Ernährung.  Aktuel Ernaehr Med. 2003;  28 S51-S60

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Klinik für Anästhesiologie, Klinikum Großhadern

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81377 München

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