Prädiktion der perioperativen Mortalität bei Patienten mit fortgeschrittener Lebererkrankung und abdominalchirurgischen Eingriffen anhand unterschiedlicher Score- und Testsysteme

 

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Zusammenfassung

Patienten mit fortgeschrittener Lebererkrankung weisen im Vergleich zu Lebergesunden eine erhöhte Morbidität und Mortalität nach Leberresektion und nicht hepatischen abdominalchirurgischen Eingriffen auf. Weiterhin stellt das Auftreten eines postoperativen Leberversagens ein relevantes klinisches Problem dar. Zur Einschätzung der perioperativen Mortalität und der hepatischen Funktion stehen Scoring-Systeme, verschiedene klinische Parameter sowie statische und dynamische Leberfunktionstests zur Verfügung. In letzter Zeit gewinnt komplementär zur Child-Turcotte-Pugh-Klassifikation der Einsatz des Model-for-End-Stage-Liver-Disease-Systems (MELD-System) zunehmend an Bedeutung. Patienten im Child-Turcotte-Pugh-Stadium C und einem MELD-Score > 14 gelten in der Regel als inoperabel. Bei Patienten im Child-Turcotte-Pugh-Stadium B und einem MELD-Score > 8 – 14 sollte ein operativer Eingriff sorgfältig abgewogen werden. Patienten im Child-Turcotte-Pugh-Stadium A und einem MELD-Score ≤ 8 weisen ein geringes perioperatives Risiko auf. Obgleich bisher nicht fest etabliert, können zur Planung insbesondere leberchirurgischer Eingriffe bei Patienten mit Leberzirrhose im Stadium A (MELD-Score ≤ 8) dynamische Testverfahren wichtige Informationen über die zu erwartende residuelle hepatische Funktion bringen. Dabei erscheinen nach aktueller Datenlage die Indocyaningrün-Clearance (ICG-Clearance) und der Monoethylglycinxylid-Test (MEGX-Test) am besten geeignet.

Abstract

Patients with advanced liver disease show increased morbidity and mortality after hepatic resection and non-hepatic digestive surgery. Furthermore, postoperative liver failure is associated with a poor outcome, representing an important clinical problem. For evaluation of the perioperative mortality and the hepatic function, several scoring systems, clinical parameters, and static and dynamic tests are available. Recently, the Model for End-Stage Liver Disease (MELD) has been shown to provide a complementary predictive value to the widely used Child Turcotte Pugh score. Patients with Child Turcotte Pugh class C cirrhosis and MELD scores > 14 are generally not considered for surgical intervention. Patients with Child Turcotte Pugh class B cirrhosis and MELD scores > 8 – 14 have an increased perioperative risk and the indication for surgery should be assessed carefully. In patients with Child Turcotte Pugh class A cirrhosis and MELD scores of ≤ 8, perioperative mortality is low. Although not routinely used, dynamic tests can provide additional information on the expected residual hepatic function in patients with Child Turcotte Pugh class A cirrhosis and MELD scores of ≤ 8 in whom hepatic resection is needed. Besides other dynamic tests, the indocyanine green (ICG) clearance and the monoethylglycinxylid (MEGX) clearance tests have been satisfactorily evaluated.

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Dr. Wolf Peter Hofmann

Medizinische Klinik 1, Klinikum der Johann-Wolfgang-Goethe-Universität

Theodor-Stern-Kai 7

60590 Frankfurt am Main

Phone: ++ 49/69/63 01 48 40

Fax: ++ 49/69/63 01 64 48

Email: hofmann@med.uni-frankfurt.de