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Chirurgische Behandlung benigner Läsionen und Strikturen der Gallenwege

Surgical treatment of benign lesions and strictures of the bile ducts

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Zusammenfassung

Gutartige Strikturen der Gallenwege resultieren in 90% der Fälle aus chirurgischen Eingriffen.Meist sind sie Folge von Operationen an der Gallenblase und entstehen in diesem Zusammenhang bei brüsken Manipulationen am Ductus choledochus. Häufig sind Menschen in jüngerem Lebensalter betroffen, die insbesondere bei unbehandelten Strikturen Sekundärkomplikationen wie eine Cholangitis oder sekundäre biliäre Zirrhose mit den schwerwiegenden Folgen der portalen Hypertension bis hin zum Ausfall der Leberfunktion mit letalem Ausgang erleiden. Obwohl in einigen Situationen die sofortige Versorgung durch eine End-zu-End-Anastomose der Gangstrukturen beschrieben wird, ist diese lediglich für glatte Schnittverletzungen des Ductus choledochus sinnvoll. Gute Langzeitergebnisse werden in 86% mit der Anlage einer ausgeschalteten und nach Roux-Y eingeleiteten Hepatikojejunostomie erzielt. Grundsätzlich ist die sicherste Art und Weise, eine Komplikation zu vermeiden, und oberste chirurgische Maxime die strenge Indikationsstellung des Ersteingriffes. Am besten beschränkt man sich bei der Entscheidung zur Operation nur auf symptomatische Gallenblasensteine.

Abstract

Benign strictures of the biliary ducts are treated surgically in 90% of cases. Usually they caused by trauma to the choledochous duct during gallbladder operations. Younger patients are frequently affected and, particularly if the strictures go untreated, can suffer from secondary complications such as cholangitis or secondary biliary cirrhosis with the serious dangers of portal hypertension and even hepatic failure and death. Although immediate treatment by end-to-end anastomosis has sometimes been described, this method is reasonable only for smooth cuts to the choledochous duct. Good long-term results have been achieved in 86% of cases with Roux-en-Y hepaticojejunostomy. In general, the best way to avoid complications is the all-important surgical maxim of correct indication for the primary operation. The best course is to limit the decision for surgery to symptomatic gallstones.

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Notes

  1. Nach dem Tübinger Anatomen Hubert v. Luschka werden aberrierende Gallengänge, welche zumeist eine Verbindung zwischen dem rechten D. hepaticus und dem D. cysticus oder auch mit der Gallenblase direkt herstellen, so benannt. Anm. des Übersetzers.

Literatur

  1. Bismuth H 1982 Postoperative strictures of the bile duct. In: Blumgart LH (ed) The biliary tract. Clinical surgery international. Churchill Livingstone, Edinburgh, p 209–218

  2. Sicklick JK, Camp MS, Lillemoe KD et al. (2005) Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy; perioperative results in 200 patients. Ann Surg 241(5): 786–795

    Article  PubMed  Google Scholar 

  3. Boerma D, Rauws EA, Keulemans YCA et al. (2001) Impaired quality of life 5 years after bile duct injury during laparoscopic cholecystectomy: a prospective analysis. Ann Surg 234(6): 750–757

    Article  PubMed  Google Scholar 

  4. Grey-Turner RJ (1944) Injuries to the main bile duct. Lancet 1: 621–622

    Article  Google Scholar 

  5. Moossa AR, Mayer D, Stabile B (1990) Iatrogenic injury to the bile duct: Who how where? Arch Surg125: 1028–1031

    Google Scholar 

  6. Buell JF, Cronin DC, Funaki B et al. (2002) Devastating and fatal complications associated with combined vascular and bile duct injuries during cholecystectomy. Arch Surg 137: 703–710

    Article  PubMed  Google Scholar 

  7. Chapman WC, Abecassis M, Jarnagin W et al. (2003) Bile duct injuries 12 years after the introduction of laparoscopic cholecystectomy. J Gastrointest Surg 3: 412–416

    Article  Google Scholar 

  8. Kern KA (1997) Malpractice litigation involving laparoscopic cholecystectomy. Cost cause, and consequences. Arch Surg 134(4): 392–397

    Google Scholar 

  9. Carroll BJ,Birth M,Phillips EH (1998) Common bile duct injuries during laparoscopic cholecystectomy that result in litigation. Surg Endosc 12: 310–314

    Article  PubMed  Google Scholar 

  10. Dolan JP, Diggs BS, Sheppard BC, Hunter JG (2005) Ten-year trend in the national volume of bile duct injuries requiring operative repair. Surg Endoscop 19: 967–973

    Article  Google Scholar 

  11. Flum DR, Cheadle A, Prela C et al. (2003) Bile duct injury during cholecystectomy and survival in Medicare beneficiaries. JAMA 2902168–2173

  12. Deziel DJ, Millikan KW, Economou SG et al. (1993) Complications of laparoscopic cholecystectomy: a national survey of 4,292 hospitals and an analysis of 77,604 cases. Am J Surg 165(1): 9–14

    PubMed  Google Scholar 

  13. A prospective analylsis of 1518 laparoscopic cholecystectomies (1991) The southern surgeons club. NEJM 324(16): 1073–1078

    PubMed  Google Scholar 

  14. Orlando R, Russell JC, Lynch J, Mattie A (1993) Laparoscopic cholecystectomy. A state-wide experience. The Connecticut laparoscopic registry. Arch Surg 128(5): 494–499

    PubMed  Google Scholar 

  15. Davidoff AM, Pappas TN, Murray EA et al. (1992) Mechanism of major biliary injury during laparoscopic cholecystectomy. Ann Surg 215(3): 196–202

    PubMed  Google Scholar 

  16. Strasberg SM, Hertl M, Soper NJ (1995) An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 180(1): 101–125

    PubMed  Google Scholar 

  17. Way L, Stewart L, Gantert W et al. (2003) Causes and prevention of laparoscopic bile duct injuries: analysis of 252 cases from a human factors and cognitive psychology perspective. Ann Surg 237(4): 460–469

    Article  PubMed  Google Scholar 

  18. Way LW (1992) Bile duct injury during laparoscopic cholecystectomy. Ann Surg 215(3): 195

    PubMed  Google Scholar 

  19. Strasberg SM (2005) Biliary injury in laparoscopic surgery; part2. Changing the culture of cholecystectomy. J Am Coll Surg 201(4): 604–611

    Article  PubMed  Google Scholar 

  20. Hunter JG (1991) Avoidance of bile duct injury during laparoscopic cholecystectomy. Am J Surg 161: 71–76

    Article  Google Scholar 

  21. Moossa AR (1990) Bile duct injury: some myths and realities. In: Najarian JS, Delancey JP (eds) Progress in Hepatic, Biliary and Pancreatic Surgery. Year Book Medical Publishers, Chicago, pp 173–218

  22. Bismuth H, Majno PE (2001) Biliary strictures: Classicfication based on the principles of surgical treatment. World J Surg 5: 1241–1244

    Article  Google Scholar 

  23. Stewart L, Way LW (1995) Bile duct injuries during laparoscopic cholecystectomy Factors that influence the result of treatment. Arch Surg 30(10): 1123–1129

    Google Scholar 

  24. Chapman WC, Halevy A, Blumgart LH, Benjamin IS (1995) Postcholecystectomy bile duct stricture. management and outcome in 130 patients. Arch Surg 130: 597–604

    PubMed  Google Scholar 

  25. Flum DR, Dellinger EP, Cheadle A et al. (2003) Intraoperative cholangiography and risk of common bile duct injury during cholecystectomy. JAMA 289 (13): 1639–1644

    Article  PubMed  Google Scholar 

  26. Pelligrini CA, Thomas MJ, Way LW (1984) Recurrent biliary stricture. patterns of recurrence and outcome of surgical therapy. Am J Surg 147: 175–180

    Article  PubMed  Google Scholar 

  27. Csendes A, Díaz JC, Burdiles P et al. (1989) Late results of immediate primary end to end repair in accidental section of the common bile duct. Surg Gynaecol Obstetr 168: 125–130

    Google Scholar 

  28. Thomson BN, Parks RW, Madhavan KK et al. (2005) Early specialist repair of biliary injury.Br J Surg 93(2): 216–220

    Article  Google Scholar 

  29. Andrén-Sandberg A, Johansson S, Bengmark S (1985) Accidental lesions of the common bile duct at cholecystectomy. II Results and treatment. Ann Surg 201: 452–455

    PubMed  Google Scholar 

  30. Bismuth H, Franco D, Corlette MB, Hepp J (1978) Long term results of roux-en-y hepaticojejunostomy.Surg Gynecol Obstetr 146(2): 161–167

    Google Scholar 

  31. Lillemoe KD, Pitt HA, Cameron JL (1990) Postoperative bile duct strictures. Surg Clinics North Am 70(6): 1355–1381

    Google Scholar 

  32. Warren KW, Mountain JC, Midell AI (1971) Management of strictures of the biliary tract. Surg Clin North Am 51(3): 711–731

    PubMed  Google Scholar 

  33. Pitt HA, Miyamoto T, Parapatis SK et al. (1882) Factors influencing the outcome in patients with postoperative biliary strictures. Am J Surg 144: 14–21

    Article  Google Scholar 

  34. Mercado MA Chan C, Tielve M, Hinojosa CA (2003) Acute bile duct injury. The need for a high repair. Surg Endoscop 17: 1351–1355

    Article  Google Scholar 

  35. Terblanche J, Worthley CS, Spence RA, Krige JEJ (1990) High or low hepaticojejunostomy for bile duct strictures? Surgery 108(5): 828–834

    PubMed  Google Scholar 

  36. Vellar ID (1999) The blood supply of the biliary ductal system and its relevance to vasculobiliary injuries following cholecystectomy. Aust N Z J Surg 69(11): 816–820

    Article  PubMed  Google Scholar 

  37. Terblanche J, Allison HF, Northover JMA (1983) An ischemic basis for biliary strictures. Surgery 94(1): 52–57

    PubMed  Google Scholar 

  38. Hepp J, Couinaud C (1956) L’abord et l’utilisation du canal hépatique gauche dans les rêparations de la voie biliaire principale. Presse Med 23: 947–948

    Google Scholar 

  39. Mercado MA, Chan C, Orozco H et al. (2002) To stent or not to stent bilioenteric anastamosis after iatrogenic injury. A dilemma not answered? Arch Surg 137: 60–63

    Article  PubMed  Google Scholar 

  40. Buell JF, Cronin DC, Funaki B et al. (2002) Devastating and fatal complications associated with combined vascular and bile duct injuries during cholecystectomy. Arch Surg 137: 703–710

    Article  PubMed  Google Scholar 

  41. Mathisen O. Soreide O, Bergan A (2002) Laparoscopic cholecystectomy: bile duct vascular injuries: management and outcome. Scand J Gastroenterol 37(4): 476–481

    Article  PubMed  Google Scholar 

  42. Strasberg SM (2005) Biliary injury in laparascopic surgery: Part 1. Processes used in determination of standard of care in misidentification injuries. J Am Coll Surg 201(4): 598–603

    Article  PubMed  Google Scholar 

  43. van Sonnenberg E, D’Agostino HB, Easter DW et al. (1993) Complications of laparoscopic cholecystectomy: coordinated radiologic and surgical management in 21 patients. Radiology 188: 399–404

    PubMed  Google Scholar 

  44. Nuzzo, Gennaro (2002) Le Lesioni Iatrogene Della Via Biliare Principale. 104. Congresso Della Società Italiana Di Chirurgia Roma 13–16 Ottobre 2002. Ed Soc Ital Chir

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Correspondence to A. R. Moossa.

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Übersetzt und bearbeitet von PD Dr. C. Schuhmacher, Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar, München

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Tracey, J.Y., Moossa, A.R. Chirurgische Behandlung benigner Läsionen und Strikturen der Gallenwege. Chirurg 77, 315–324 (2006). https://doi.org/10.1007/s00104-006-1168-5

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