Chirurgische Therapie hepatischer Infektionen mit Echinococcus granulosus

 

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Zusammenfassung

Einleitung: Die zystische Echinokokkose (CE) ist eine weltweite Zoonose, aber in westlichen Industrienationen relativ selten. Die Operation ist die Therapie der Wahl, aber das technische Vorgehen ist uneinheitlich und evidenzbasierte Daten sind lückenhaft. Die Zystektomie und resezierende Verfahren (Perizystektomie, Segmentresektion, Hemihepatektomie) stehen zur Verfügung. Ziel der Studie: Deskriptive Analyse des Patientenkollektivs einer deutschen Universitätsklinik (Anamnese, Zystenlokalisation, Operationsverfahren, Morbidität, Letalität, Krankenhausaufenthaltsdauer und Langzeitverlauf). Methode: Retrospektive Analyse der Krankenblätter und Fragebogenauswertung aller Patienten mit CE, die in einem Zeitraum von 16 Jahren operiert wurden. Ergebnisse: Bei 64 Patienten lagen 101 parasitäre Zysten vor, die mit 67 Operationen entfernt wurden. Die Zysten hatten ein Volumen von durchschnittlich ca. 400 ml (10 - 2200 ml). 86 Zysten lagen in der Leber, 15 extrahepatisch. Die parasitären Läsionen wurden durch Hemihepatektomie rechts (n = 4), Lebersegmentresektion (n = 9), Perizystektomie (n = 24), Zystektomie (n = 34) und Zystojejunostomie (n = 1) beseitigt. In der ersten Hälfte des Untersuchungszeitraums überwogen resezierende Verfahren (81 %), in der zweiten Hälfte wurde die Zystektomie bevorzugt (82 %). Die Krankenhausletalität betrug 0 %. Die postoperative Morbidität nach resezierenden Operationsverfahren bzw. Zystektomie lag bei 47 bzw. 17 %. Nach Zystektomie trat kein Rezidiv auf, nach resezierenden Operationsverfahren vier (2 × nach Hemihepatektomie nach 4 bzw. 7 Jahren sowie 1 × nach Lebersegmentresektion und 1 × nach Zystojejunostomie nach jeweils 2 Jahren). Je ausgedehnter das Operationsverfahren, desto länger war der Krankenhausaufenthalt. Schlussfolgerung: Die Zystektomie empfiehlt sich als operatives Verfahren der Wahl, denn sie ist sicher, einfach, effektiv und erfüllt alle Kriterien einer rationalen chirurgischen Therapie der zystischen Echinokokkose: vollständige Elimination des Parasiten, keine intraoperative Parasitenverschleppung vor allem bei Verwendung des Aarons-Trichters und möglichst geringe Zerstörung gesunden Gewebes. Bei Zysten an der Leberoberfläche sollte die Perizystektomie angewendet werden.

Abstract

Introduction: Cystic echinococcosis (CE) is a world-wide zoonosis but is relatively rare in Western industrial countries. Surgery is the treatment of choice. However, the technical procedure varies and evidence-based knowledge is fragmentary. Cystectomy and partial resection of the liver (pericystectomy, segmental resection, hemihepatectomy) are the procedures under debate. Objective: We present a descriptive analysis of the patients suffering from CE (anamnesis, cyst location, procedures, morbidity, lethality, hospital stay, and long-term follow-up). Methods: A retrospective analysis was made of the medical records and questionnaires of patients surgically treated within a period of 16 years at a German university hospital. Results: Sixty-four patients had 101 parasitic cysts which were treated by 67 operations. The average volume of the cysts was about 400 ml (range 10 - 2200 ml). Eighty-six cysts were located within the liver and 15 in extrahepatic sites. The parasitic lesions were removed by hemihepatectomy (n = 4), segmental liver resection (n = 9), pericystectomy (n = 24), cystectomy (n = 34), and cysto-jejunostomy (n = 1). During the first half of the observation period resective procedures were preferred (81 %) whereas during the second half cystectomy predominated (82 %). Lethality was 0 %. Postoperative morbidity after resective procedures and cystectomy was 47 % and 17 %, respectively. Relapses were not observed after cystectomy, but occurred in four cases following resective procedures (twice after hemihepatectomy, 4 and 7 years later, respectively; once after segmental liver resection and once following cysto-jejunostomy, both 2 years after the respective procedure). The more extensive the surgical procedure the longer was the hospital stay. Conclusion: Cystectomy should be performed as the procedure of choice because it proved to be safe, simple, effective, and meets all criteria of the surgical treatment for hydatid disease, i. e., complete elimination of the parasite, no intra-operative spillage especially by the use of Aaron’s cone, and saving healthy tissue. Pericystectomy should be used for peripheral liver cysts only partially surrounded by liver tissue.

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PD Dr. med. K. Buttenschoen

Abt. für Viszerale und Transplantationschirurgie, Universität Ulm

Steinhövelstraße 9

89075 Ulm

Phone: 07 31/5 00-2 72 06

Fax: 07 31/5 00-2 72 14

Email: klaus.buttenschoen@medizin.uni-ulm.de