Zusammenfassung
Hintergrund: Bei der intrathorakalen Anastomoseninsuffizienz nach Resektionen am oberen Gastrointestinaltrakt sind sowohl die operative als auch die konservative Therapie problematisch und mit hoher Morbidität und Letalität assoziiert. Endoskopische Behandlungsverfahren haben sich in den letzten Jahren in dieser Situation zunehmend etabliert. Im Folgenden sollen unsere Ergebnisse bei der endoskopischen Behandlung mediastinaler Anastomoseninsuffizienzen dargestellt werden. Patienten: 27 konsekutive Patienten wurden mit einer symptomatischen, intrathorakalen Anastomoseninsuffizienz nach Ösophagusresektion (n=19), nach erweiterter Gastrektomie (n=6) bzw. nach limitierter Resektion eines Kardiakarzinoms (n=1) sowie nach Resektion eines epiphrenischen Divertikels (n=1) endoskopisch therapiert. Die Insuffizienzgröße schwankte zwischen 10% und 70%. Nachdem zunächst die Insuffizienzen endoskopisch gespült und debridiert wurden, erfolgte bei sauberen Wundverhältnissen (nach durchschnittlich 16,8 Tagen) der endoskopische Fistelverschluss durch Fibrinkleber (n=9) oder durch Clips (n=2) bei kleinerer Insuffizienz (<30%) bzw. durch Stentimplantation (n=11), Stentimplantation nach erfolgloser Fibrinklebung (n=3) bzw. Stentimplantation und Endoclipping (n=1) bei Insuffizienzen >30%. Simultan wurde die suffiziente Drainage der Insuffizienzhöhle sichergestellt. Ergebnisse: Bei 25 von 27 Patienten konnte die mediastinale Anastomoseninsuffizienz erfolgreich endoskopisch behandelt werden. Ein Patient verstarb unter der endoskopischen Therapie im septischen Multiorganversagen, ein weiterer Patient entwickelte eine chronisch-persistierende Fistel. Zwei Stentdislokationen und 4 Anastomosenstenosen wurden im Verlauf als Prozedur-assoziierte Komplikationen beobachtet. Schlussfolgerung: Symptomatische, intrathorakale Anastomoseninsuffizienzen bis zu einer Größe von 70% lassen sich effektiv und sicher interventionell-endoskopisch behandeln. Nach intermittierender endoskopischer Spülbehandlung mit Debridement der Anastomoseninsuffizienz lassen sich kleinere Fisteln (<30%) durch Fibrinklebung oder durch Endoclips effektiv verschließen. Bei Insuffizienzen >30% bietet sich die Implantation geeigneter Stents an.
Abstract
Background: Surgery, as well as conservative treatment, in patients with clinically apparent intrathoracic anastomotic leaks are often associated with poor results and carry a high morbidity and mortality. This report describes our results with the endoscopic treatment of intrathoracic anastomotic leakages. Patients: 27 consecutive patients presenting with clinically apparent intrathoracic anastomotic leak, caused by resection of an epiphrenic diverticulum (n=1), esophagectomy for esophageal cancer (n=19), limited resection for carcinoma of the gastroesophageal junction (n=1) or gastrectomy for gastric cancer (n=6) were endoscopically treated. The extent of the dehiscences ranged from about 10-70%. After endoscopic lavage and debridement of the leakage (mean duration: 16,8 days) the leaks were closed with fibrin clue (n=9) or endoclips (n=2) in cases of smaller leaks or by stent placement (n=11), stent placement after unsuccessful fibrin clue injections (n=3) or stent placement and endoclipping (n=1) in patients with a large leakage. Simultaneously the periesophageal mediastinum was drained by chest drains. Results: 25 of 27 patients were successfully treated endoscopically. Under endoscopic treatment one patient died due to septic multiorgan failure. Another patient developed a refractory, persistent leak. Procedure related complications (stent migration, anastomotic stenosis) were obtained in 6 patients. Conclusion: An endoscopic approach is successful and safe to treat symptomatic intrathoracic anastomotic leaks smaller than 70% of the circumference. An endoscopic lavage and debridement of the leak, prior to leak closure, seems to be helpful to reduce mediastinal and pleural inflammation. In patients with smaller leaks (<30%) fibrin clue injections and endoclipping is recommended. Patients with a dehiscence from 30-70% of the circumference profit from stent placement.
Schlüsselwörter
Anastomoseninsuffizienz - Fibrinkleber - Stent - Plastikstent - Endoskopie
Key words
Anastomotic leak - fibrin clue - stent - plastic stent - endoscopic treatment
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Dr. med. Daniel Schubert
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