Lymphokutane Fisteln, Chylaszites sowie Chylothorax im Komplikationsspektrum chirurgischer Eingriffe: Ursachen, Diagnostik und Therapie

Zusammenfassung

Die Lymphorrhö bzw. Chylorrhö ist eine seltene aber ernsthafte Komplikation nach Interventionen und operativen Eingriffen. Sie führt zu einem signifikanten Anstieg der perioperativen Morbidität und Letalität. Bei der lymphokutanen Fistel stehen vor allem lokale Probleme wie Wundheilungsstörungen und Infektionen im Vordergrund. Chylaszites und Chylothorax können unbehandelt zu schweren nutritiven und metabolischen Störungen bis hin zur Immunsuppression führen. Die Diagnose bereitet aufgrund des charakteristischen Aussehens chylöser Flüssigkeit sowie durch den laborchemischen Nachweis von Triglyzeriden und Chylomikronen wenig Schwierigkeiten. Bei der initialen Behandlung wird in der Regel konservativen Maßnahmen (Dränage, Kompressionsverbände, totale parenterale Ernährung, spezielle enterale Diät) der Vorzug gegeben. Nachteilig ist jedoch die zum Teil erhebliche Behandlungsdauer. Operative Therapien werden bei inadäquatem Ansprechen auf konservative Therapien empfohlen. Jedoch bergen chirurgische Revisionseingriffe die Gefahr erneuter Komplikationen und sind ihrerseits mit einer erhöhten Morbidität und Letalität assoziiert. Vielversprechend sind neuere alternative Therapieansätze (Gabe von Octreotid bzw. Etilefrin, lokale Bestrahlung, Sklerosierungstherapie, V.A.C.-Verbände sowie die perkutane Embolisation des Ductus thoracicus), mit denen konservative Behandlungsstrategien sinnvoll ergänzt und chirurgische Re-Eingriffe vermieden werden können. Von außerordentlicher Bedeutung ist die Prävention der Lymphorrhö bei der Primäroperation. Die vorliegende Arbeit gibt einen systematischen Überblick über aktuell verfügbare diagnostische und therapeutische Möglichkeiten bei der Behandlung der lymphokutanen Fistel, des Chylaszites und Chylothorax als häufigste Entitäten der Lymphorrhö.

Abstract

Lymphorrhea is an uncommon but potentially life-threatening complication following surgical procedures which strongly influences the outcome of surgical patients. Persistent lymphocutaneous fistula is mainly associated with an increased risk of local infections and wound complications. Chylous ascites and chylothorax can result in malnutrition, metabolic deterioration and immunosuppression that increase postsurgical morbidity. Diagnosis can easily be made by the characteristic milky-beige appearance of chylous fluid. Laboratory investigation of the drainage fluid (chylomicrons, triglycerides) enables to confirm diagnosis. Initial therapy favors conservative measures including drainage, pressure dressings, total parenteral nutrition and diet modifications. But this takes sometimes several weeks to control the chylous leak and leads to prolonged hospitalisation. Surgical options are only recommended if conservative therapy fails. However, surgical re-interventions are associated with significant incidence of morbidity and mortality. In addition, surgery may occasionally fail to identify the leak. Some promising new techniques have recently been introduced (application of octreotide or etilefrine, low-dose radiotherapy, use of sclerosing agents, subatmospheric pressure dressings or percutaneous embolization of cisterna chyli), which - alone or in combination with well-established conservative measures - may have the potential to avoid surgical re-interventions. Prevention of lymphorrhea during primary operation is of major importance. The present study focusses on current diagnostic and therapeutic options in the treatment of lymphocutaneous fistula, chylous ascites and chylothorax as the most frequent entities of lymphorrhea.

Schlüsselwörter

Lymphorrhö - lymphokutane Fistel - Chylaszites - Chylothorax - postoperative Komplikation

Key words

lymphorrhea - lymphocutaneous fistula - chylous ascites - chylothorax - postoperative complication

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