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Viszeralarterienrekonstruktionen mit Homografts bei Resektionen des Pankreas

Reconstruction of visceral arteries with homografts in excision of the pancreas

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Zusammenfassung

Hintergrund

Die einzige Heilungschance für Patienten mit Pankreaskarzinom ist derzeit die chirurgische Therapie mit Erzielen einer R0-Situation. Oft besteht aufgrund lokaler Progression und durch Infiltration von Gefäßen Inoperabilität. In kleinen Patientengruppen wurde bereits der Versuch unternommen durch Resektion und Rekonstruktion der Viszeralarterien bei fortgeschrittenem Tumor die Operabilität zu erhöhen. Ein klarer Vorteil konnte bisher nicht durchgehend gezeigt werden.

Methoden

Seit 2001 führen wir „en bloc“-Resektionen bei Pankreaskarzinomen mit langstreckigen Infiltrationen der Viszeralgefäße durch, nachdem wir zunächst Erfahrungen mit der Resektion im Bereich der Pfortader und der Resektion und direkten Rekonstruktion bei Arterieninfiltration gesammelt haben. Die Gefäßrekonstruktion erfolgte bei 10 Patienten mit Anlage eines arteriellen Homografts als Interponat. Dabei wurde bei 6 Patienten sowohl die A. hepatica als auch die A. mesenterica superior langstreckig ersetzt. In der perioperativen Phase verstarb 1 Patient an einer fulminanten Blutung. Bei 1 Patienten entwickelten sich schwere Diarrhöen. In der 3–18 Monate bisher dauernden Nachbeobachtung haben 2 Patienten entweder Lebermetastasen oder ein Lokalrezidiv entwickelt.

Schlussfolgerungen

Mit der erweiterten Resektion und Gefäßrekonstruktion mit arteriellen Homografts kann bei ausgewählten Patienten mit lokal fortgeschrittenem Pankreaskarzinom die Operabilität mit Erzielen einer R0-Situation erreicht werden. Die Rekonstruktion der Viszeralarterien ist ohne ischämische Probleme für die Leber und den Dünndarm durchführbar. Perioperative Komplikationen waren selten.

Abstract

Background

At present, surgical treatment with R(0) resection offers the only chance of cure for patients suffering from pancreatic cancer. Carcinomas of the pancreas are frequently diagnosed at an inoperable stage because of local tumor progression by vessel wall infiltration. In a small series of patients, efforts have been made to increase curative resection rates for advanced pancreatic cancer by excision and reconstruction of the involved visceral arteries. Whether this provides clinical benefit remains uncertain.

Methods

Since 2001 we have been employing “en bloc” tumor resection for advanced pancreatic carcinomas with extended infiltration of visceral vessels. Technical experience was gained priorly by performing portal vein resection as well as arterial excision and reconstruction by direct anastomosis in the presence of malignant wall infiltration. A total of ten patients underwent vascular reconstruction by arterial homograft interposition. In six of ten cases, combined extended reconstructions of the hepatic and superior mesenteric arteries were performed. One patient died during the perioperative course due to fulminant bleeding. One patient developed severe diarrhea. During a 3- to 18-month follow-up, one case of liver metastasis and one case of local tumor recurrence were documented.

Conclusions

In selective cases, operability and R(0) resection can be achieved in advanced pancreatic cancer by performing extended resection procedures with vascular reconstruction using arterial homografts. Vascular substitution of visceral arteries can be conducted without ischemic disturbances of the small bowel and liver. Only a few perioperative complications were observed.

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Authors and Affiliations

  1. Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Campus Virchow Klinikum, Charité, Humboldt-Universität, Berlin

    U. Settmacher, J:M. Langrehr, I. Husmann, R. Eisele, M. Bahra, M. Heise & P. Neuhaus

  2. Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Campus Virchow Klinikum, Charité, Augustenburgerplatz 1, 13353 , Berlin

    U. Settmacher

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  1. U. Settmacher
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  2. J:M. Langrehr
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  3. I. Husmann
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  4. R. Eisele
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Correspondence to U. Settmacher.

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Settmacher, U., Langrehr, J., Husmann, I. et al. Viszeralarterienrekonstruktionen mit Homografts bei Resektionen des Pankreas. Chirurg 75, 1199–1206 (2004). https://doi.org/10.1007/s00104-004-0899-4

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