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Verschluss des Pankreasstumpfes bei Links- und Segmentresektion

Naht, Stapler, Deckung oder Anastomose?

Closure of pancreas stump after distal and segmental resection

Suture, stapler, coverage or anastomosis?

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Zusammenfassung

Nach Pankreaslinks- und Pankreassegmentresektionen stellt die postoperative Pankreasfistel die häufigste Komplikation dar und tritt mit einer Häufigkeit von bis zu 50 % auf. Es gibt eine Vielzahl technischer Variationen der Pankreasstumpfversorgung zur Reduktion der Fistelraten bei der Linksresektion. Viele dieser Verfahren wurden nur in retrospektiven Analysen getestet und die Evidenz für oder gegen die Verwendung verschiedener Techniken ist niedrig. Mit guter Evidenz wurden die Gleichwertigkeit der Skalpell- gegenüber der Staplerresektion und die Reduktion klinisch relevanter Komplikationen mit einem Ligamentum-falciforme-Patch gezeigt. Mehrere retrospektive Analysen berichteten über gute Ergebnisse mittels Anastomosierung des Pankreasstumpfes im Sinne einer Pankreatikojejunostomie. In einer kürzlich publizierten, randomisierten Studie konnten diese Ergebnisse jedoch nicht nachvollzogen werden. Da bei der laparoskopischen Pankreaslinksresektion standardmäßig die Staplerresektion durchgeführt wird, beschäftigen sich viele aktuelle Studien mit einer Verbesserung der Staplertechnik. Hierbei sind vor allem eine individuelle Kompressionszeit sowie eine Netzverstärkung der Staplerreihe zu nennen. Da die Pankreassegmentresektion eine relativ seltene Operation ist, sind kaum größere Studien zur Anastomosierungs-/Verschlusstechnik verfügbar. Prinzipiell wird eine Anastomosierung des distalen Pankreasrestes analog zur partiellen Duodenopankreatektomie durchgeführt und der Pankreasstumpf zum Kopf hin wie bei der Pankreaslinksresektion verschlossen. Insgesamt ist die hohe postoperative Fistelrate nach Linksresektion ein bestehendes, großes klinisches Problem. Weitere Studien mit potenziell verbesserten Techniken sind notwendig, um eine standardisierbare, relevante Fistelreduktion zu erreichen.

Abstract

Postoperative pancreatic fistulas represent the most frequent complication after distal and segmental pancreatectomy and occur with a frequency of up to 50 %. There are many technical variations of pancreatic stump treatment for reduction of fistula rates after distal resection. Most of these techniques have only been analyzed in retrospective studies and the evidence for or against a specific technique is low. Several retrospective trials have been conducted with good results to compare suturing with stapled closure of the remnant and to assess the effect of a vascularized falciform ligament patch in reducing postoperative pancreatic fistula; however, in a recently published randomized trial, which analyzed closure of the remnant with a pancreaticojejunostomy compared to standard closure, these results could not be confirmed. Because stapler resection and closure is the most commonly used technique in laparoscopic distal pancreatectomy, there are a large number of studies which assessed various novel methods of improving stapling. Extended stapler compression time and mesh augmentation of the stapler line can be valid methods to reduce fistula rates. Central pancreatectomy is a relatively rarely used procedure where the right-sided pancreatic remnant is closed in the same fashion as during distal pancreatectomy and the left-sided remnant is connected to the intestines with a pancreaticojejunostomy or pancreaticogastrostomy. In conclusion, postoperative pancreatic fistula rates are still a relevant clinical problem after distal pancreatectomy and further studies on potentially improved novel techniques are required.

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Authors and Affiliations

  1. Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland

    C. W. Michalski, P. Tramelli, M. W. Büchler &  T. Hackert

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  1. C. W. Michalski
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  2. P. Tramelli
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  3. M. W. Büchler
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  4. T. Hackert
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Correspondence to T. Hackert.

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Interessenkonflikt

C. W. Michalski, P. Tramelli, M. W. Büchler und T. Hackert geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Michalski, C.W., Tramelli, P., Büchler, M.W. et al. Verschluss des Pankreasstumpfes bei Links- und Segmentresektion. Chirurg 88, 25–29 (2017). https://doi.org/10.1007/s00104-016-0301-3

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