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DOI: 10.1055/s-0031-1283887
Kriterien der Resektabilität von malignen extrahepatischen Gallengangstumoren
Criteria for the Resectability of Malignant Extrahepatic Bile Duct TumoursPublication History
Publication Date:
16 February 2012 (online)
Zusammenfassung
Hintergrund: Karzinome der extrahepatischen Gallenwege sind bei der Erstdiagnose häufig fortgeschritten. Die Resektion stellt die einzige potenziell kurative Behandlung dar. Es gibt große Unterschiede in den publizierten Resektionsraten.
Methodik: In diesem Artikel werden die Kriterien der Resektabilität maligner extrahepatischer Gallengangstumoren anhand einer umfassenden Literaturrecherche mittels PubMed erarbeitet, welche die Ergebnisse aus randomisierten, kontrollierten Studien (RCT), Übersichtsarbeiten, Metaanalysen und Kohortenstudien einschließt.
Ergebnisse: Eine detaillierte präoperative Diagnostik und die Erfahrung des Chirurgen sind entscheidend für die Definition der Resektabilität. Klatskintumoren: Regionäre N1-Lymphknotenmetastasen sind keine Kontraindikation für eine Resektion. Eine erweiterte Lymphadenektomie bei paraaortaler Metastasierung ist nur bei selektionierten Patienten indiziert. Der Stellenwert der Lebertransplantation nach neoadjuvanter RCT (sog. Mayo-Klinik-Protokoll) bei nicht resektablen Tumoren muss in weiteren Studien evaluiert werden. Die R1-Resektion bietet einen signifikanten Benefit gegenüber dem palliativen Stenting. Distale Cholangiokarzinome: Der Befall der regionären Lymphknoten ist keine Kontraindikation zur Resektion. Der Verdacht auf eine Infiltration der mesenterico-portalen Venen ist keine Kontraindikation zur Resektion. Die Segmentresektion von V. portae / V. mes. sup. ist sicher und erhöht die Morbidität und Mortalität nicht. Eine Resektion bei Tumorinfiltration des Truncus coeliacus oder der A. mes. sup. ist onkologisch nicht sinnvoll. Zum Wert einer palliativen R1 / R2-Resektion gibt es keine Evidenz.
Schlussfolgerung: Aus anatomischen Gründen liegen die Resektionsraten beim distalen Cholangiokarzinom höher als beim Klatskintumor. Die Beurteilung, ob eine kurative Resektion möglich ist, erfordert insbesondere beim Klatskintumor eine detaillierte präoperative Diagnostik und Konditionierung des Patienten.
Abstract
Background: Most cholangiocarcinomas of the extrahepatic bile duct are diagnosed at an advanced stage. Surgery represents the only potentially curative treatment. An assessment as to whether a curative resection is possible is based on the experience of the treating physicians.
Methods: The present guidelines are based on comprehensive literature surveys in PubMed, including results from randomised controlled trials, systematic reviews and meta-analyses, and cohort studies.
Results: The experience of the surgeon is determining for defining criteria for resection. The surgical standards for treating Klatskin tumours are extended liver resections. Liver transplantation after neoadjuvante chemo / radiation therapy offers good results. N1 regional lymph node metastases are not a contraindication for resection. R1 resection is justified as a very efficient palliative procedure. The surgical standard for treating distal cholangiocarcinoma is the partial pancreatoduodenectomy. Infiltration of the mesenterico-portal veins or regional lymph nodes is not a contraindication for resection. However, resection has not been shown to provide survival benefit if the coeliac trunk or the superior mesenteric artery is infiltrated. There is no evidence for or against a palliative R1/R2 resection.
Conclusions: For anatomic reasons, the resection rates for distal cholangiocarcinoma are higher than those for Klatkin tumours. The decision as to whether or not a curative resection is possible, especially for Klatskin tumour, requires detailed preoperatzive diagnostics and a conditioning of the patient.
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