Resektion Hilusnaher Gallengangscarcinome statt palliativer Gallenwegsdrainage

Abstract

Instead of the widely recommended approach of treating hilar carcinoma of the bile ducts by simple palliative biliary drainage, step by step a policy of primarily aiming at resection for cure has been adopted. So far in 11 out of 22 patients excision of the tumor was possible by resection of the hepatic duct confluence; in 4 cases a left hemihepatectomy had to be added because of carcinomatous infiltration of the left liver lobe or the left hepatic artery. The multiple bile duct openings remaining after resection of such tumors were reconstructed to one or two orifices and a bi- or unilateral Roux-en-Y cholangiojejunal anastomosis performed. In further 3 cases orthotopic liver transplantation was necessary to remove all visibly infiltrated tissue. In the remaining 8 patients because of documented extrahepatic carcinomatous spread palliative biliary drainage by a percutaneous U-tube or an endoprothesis was indeed considered the only reasonable measure. Despite the relatively high resectional rate of 60% and the extensive operations performed early mortality was confined to one patient who succumbed to septic endocarditis 6 weeks after the operation. At present the longest postoperative interval without recurrence amounts to $$3{\raise0.5ex\hbox{$\scriptstyle 1$}\kern-0.1em/\kern-0.15em\lower0.25ex\hbox{$\scriptstyle 2$}}$$ years. Nine patients free of recurrent disease are in perfect health; in 3 patients in whom a recurrence was observed after 1/2, $$1{\raise0.5ex\hbox{$\scriptstyle 1$}\kern-0.1em/\kern-0.15em\lower0.25ex\hbox{$\scriptstyle 2$}}$$ and 2 years meanwhile palliation was perfect. In contrast all patients with unresected tumors but carrying draining stents suffered from cholangitis and after $$1{\raise0.5ex\hbox{$\scriptstyle 1$}\kern-0.1em/\kern-0.15em\lower0.25ex\hbox{$\scriptstyle 2$}}$$ years all but one had died. In conclusion resectional therapy for hilar carcinoma seems possible with acceptable risk. Since only resection can provide potential cure and also palliation was better than that achieved by draining tubes a more agressive attitude to the treatment of these lesions is advocated from our experience. Bei 11 von 22 Patienten mit Gallengangscarcinomen im Leberhilus konnte eine Resektion des tumortragenden Gallenwegsabschrrittes durchgeführt werden; 4mal wurde diese mit einer erweiterten linksseitigen Hemihepatektomie kombiniert. In 3 Fällen war eine orthotope Lebertransplantation nötig. Bei den übrigen 8 Patienten konnte lediglich eine palliative Gallenwegsdrainage angelegt werden. Im vorgestellten Krankengut der Resektionen traten keine primär operativ letalen Komplikationen auf, die längste bisher beobachtete Überlebenszeit beträgt jetzt $$3{\raise0.5ex\hbox{$\scriptstyle 1$}\kern-0.1em/\kern-0.15em\lower0.25ex\hbox{$\scriptstyle 2$}}$$ Jahre. Der Gesamtverlauf nach Resektion gestaltete sich insgesamt wesentlich günstiger als der nach palliativer Drainageoperation. Da somit eine Tumorexstirpation auch von Hiluscarcinomen mit akzeptablem Risiko durchzuführen ist und nur sie zumindest potentiell Heilungsaussichten bieten kann, wird entgegen der bisher weit verbreiteten palliativen Behandlung der zentralen Hiluscarcinome durch einfache Gallenwegsdrainage das Resektionsvorgehen, soweit individuell möglich, empfohlen.