Komplikationen und Komplikationsmanagement in der Ösophaguschirurgie

Zusammenfassung

Hintergrund: Prävention, frühe Erkennung und adäquates Management von perioperativen Komplikationen in der resezierenden Ösophagus­chi­rurgie sind die Schlüssel zur Erhöhung der Sicherheit dieser komplexen Eingriffe. Erkennung, Diagnostik, Management und Behandlung: Im Vorfeld der Operation kann die Erfassung und ggf. Vorbehandlung von spezifischen Risikofaktoren die Komplikationsrate deutlich senken. Die subtile Anwendung präoperativer Score-Systeme kann bei Patienten mit hohem operativen Risiko in der Abwägung von Nutzen und Risiko gegen eine Indikationsstellung zur Operation sprechen. Die Patienten werden dann alternativen Behandlungsverfahren zugewiesen. Die Anastomoseninsuffizienz ist die häufigste technische chirurgische Komplikation. Eine exakte Nahttechnik unter Vermeidung von Spannung und von Perfusionsminderung des Magen-, ­Kolon- oder Dünndarminterponates kann die Rate derartiger Insuffizienzen senken. Die häufigste nicht chirurgische Komplikation ist die postoperative Pneumonie, welche durch effektive Schmerztherapie wie Periduralkatheter und entsprechende Techniken der postoperativen Beatmung verhindert und behandelt werden sollte. Von entscheidender Bedeutung ist die frühestmögliche Erkennung postoperativer Komplikationen. Das Auftreten postoperativer Tachyarrhythmien hat sich als häufiger und früher Indikator für derartige Komplikationen erwiesen. Die Behandlung der Komplikationen umfasst konservative, interventionelle – z. B. endoskopische Stentversorgung bei gedeckter Nahtinsuffizienz – und operative Maßnahmen wie etwa die Reoperation bei nicht gedeckter Leckage mit Pleuraanschluss. Alle anderen chirurgischen Komplikationen wie Blutung, tracheobronchiale Leckagen oder Chylothorax sind selten und erfordern spezielle therapeutische Maßnahmen. Schlussfolgerung: Nicht allein der Beitrag der Chirurgie ent­scheidet über eine hohe oder niedrige Komplikationsrate bei der Ösophaguschirurgie. Es konnte klar gezeigt werden, dass das inter­disziplinäre Management von Komplikationen nach Ösophagektomien in High-Volume-Zentren sehr viel effektiver ist und zu einer geringeren Mortalität führt als in Kliniken mit niedriger Fallzahl und folglich geringeren Erfahrung mit diesen komplexen Operationen. 

Abstract

Background: Prevention, early recognition and an adequate management of perioperative complications in resectional oesophageal surgery are the keys to an increased safety of these complex procedures. Recognition, Diagnostics, Management and Treatment: Preoperative registration and – if re­quired – pretreatment of specific risk factors can consid­erably decrease the complication rate. The precise implementation of significant preoperative score systems in patients with high operative risk can lead to a negative risk-benefit consideration concerning the indication for an operation. The patients will then be assigned to an alternative treatment process. Anastomotic leakage is the most frequent technical-surgical complication. A precise suturing technique with the prevention of tension and the avoidance of reduction of ­perfusion of the conduit (stomach, colon, small intestine) can reduce the rate of such insufficiencies. The most frequent non-surgical complica­tion is postoperative pneumonia, which can be avoided or combated through effective pain-re­liev­ing ther­apy like peridural anaesthesia and specific techniques of postoperative ventilation. It is of vital importance to identify, at the earliest possible timepoint, complications that might emerge after the operation. The occurrence of postoperative tachyarrhythmia has proven to be a frequent and early indicator of such compli­cations. The treatment of complications after oesoph­a­geal resections includes adequate conservative, interventional, e. g., endoscopic placement of a stent in cases of covered insufficiency of the suture line, and operative procedures like re-oper­ation in cases of uncovered leakage with pleural connection. All the other surgical complications like haemorrhage, tracheobronchial leak­ages or chylothorax are rarely seen and demand specific therapeutic procedures. Conclusion: It is not only the surgery that determines a high or low complication rate in oesophageal resectional procedures. It has clearly been proved that interdisciplinary management of complications after oesophagectomy is much more effective in high-volume centres, leading to a lower mortality, than in sur­gical departments with a lower case rate and thus with less ­ex­perience in such complex operations. 

Schlüsselwörter

Ösophagektomie - Komplikationen - Management - Prävention - Diagnostik - Behandlung

Key words

oesophagectomy - complications - management - prevention - diagnostics - treatment

Literatur

• 1 Bollschweiler E, Schröder W, Hölscher A H et al. Preoperative risk analysis in patients with adenocarcinoma or squamous cell carcinoma of the oesophagus.  Brit J Surg. 2000;  87 1106-1110
• 2 Greer S E, Goodney P P, Sutton J E et al. Neoadjuvant chemoradiotherapy for esophageal carcinoma: A meta-analysis.  Surgery. 2005;  137 172-177
• 3 Fiorica F, Di B D, Schepsis F et al. Preoperative chemoradiotherapy for oesophageal cancer: a systemic review and meta-analysis.  Gut. 2004;  53 925-930
• 4 Khuri S F, Henderson W G, DePalma R G et al. Determinants of long-term survival after major surgery and the adverse effect of postoperative complications.  Ann Surg. 2005;  242 326-343
• 5 Schröder W, Bollschweiler E, Hölscher A H et al. Preoperative risk analysis – a reliable predictor of postoperative outcome after transthoracic esophagectomy?.  Langenbecks Arch Surg. 2006;  391 455-460
• 6 Imdahl A, Munzar T, Farthman E H et al. Perioperative risk factors in esophageal cancer: a retrospective study of independent variables.  Zentralbl Chir. 1993;  118 190-196
• 7 Hölscher A H. Clinical management of esophageal cancer in 2005. Special Issue.  Chinese-German JCO. 2005;  Supplement 199-264
• 8 Schneider P M, Baldus S E, Hölscher A H et al. Histomorphologic tumor regres­sion and lymph node metastases determine prognosis following neoadjuvant radiochemotherapy for esophageal cancer. Implications for response classification.  Ann Surg. 2005;  242 684-692
• 9 Hulscher J BF, Van Sandick J W, van Lanschot J et al. Extended transtho­racic resection compared with limited transhiatal resection for adenocarcinoma of the esophagus.  New Engl J Med. 2002;  347 1662-1669
• 10 Whooley B P, Law S, Murthy S C et al. Analysis of reduced death and complication rates after esophageal resection.  Ann Surg. 2001;  233 338-344
• 11 Hölscher A H, Bollschweiler E, Bumm R et al. Prognostic factors of resected adenocarcinoma of the esophagus.  Surgery. 1995;  118 845-855
• 12 Lerut T, Nafteux P, Moons J et al. Three-field lymphadenectomy for carcinoma of the esophagus and gastroesophageal junction in 174 R0 resections: Impact on staging, disease-free survival and outcome.  Ann Surg. 2004;  240 962-974
• 13 Hölscher A H, Schneider P M, Schröder W et al. Laparoscopic ischemic conditioning of the stomach for esophageal replacement.  Ann Surg. 2007;  245 241-246
• 14 Liebermann-Meffert D MI, Siewert J R et al. Vascular anatomy of the gastric tube used for esophageal reconstruction.  Ann Thorac Surg. 1992;  54 1110-1115
• 15 Hölscher A H. Surgery techniques: Conduit preparation and route of reconstruction. In: Jobe BA, Thomas CR, Hunter JG, eds. Esophageal Cancer. Principles and Practice demos. New York: MEDICAL; 2009
• 16 Schröder W, Stippel D, Hölscher A H et al. Postoperative recovery of microcirculation after gastric tube formation.  Langenbecks Arch Surg. 2004;  389 267-271
• 17 Boyle N H, Pearce A, Hunter D et al. Scanning laser Doppler flowmetry and intraluminal recirculating gas tonometry in the assessment of gastric and jejunal perfusion during oesophageal resection.  Brit J Surg. 1998;  85 1407-1411
• 18 Karl R C, Schreiber R, Boulware D et al. Factors affecting morbidity, mortality and survival in patients undergoing Ivor Lewis esophagectomy.  Ann Surg. 2000;  231 635-643
• 19 Ando N, Ozawa S, Kitagawa Y et al. Improvement in the results of sur­gical treatment of advanced squamous esophageal carcinoma during 15 consecutive years.  Ann Surg. 2000;  232 225-232
• 20 Hölscher A H, Schröder W, Bollschweiler E et al. Wie sicher ist die hoch intrathorakale Ösophagogastrostomie?.  Chirurg. 2003;  74 726-733
• 21 Fumagalli U, Rosati R, Caputo M et al. Diaphragmatic acute massive herniation after laparoscopic gastroplasty for esophagectomy.  Dis Esophagus. 2006;  19 40-43
• 22 Vallböhmer D, Hölscher A H, Schröder W et al. Diaphragmatic hernia after conventional or laparoscopic-assisted transthoracic esophagec­tomy.  Ann Thorac Surg. 2007;  84 1847-1853
• 23 Briel J W, Tamhankar A P, Hagen J A et al. Prevalence and risk factors for ischemia, leak and stricture of esophageal anastomosis: gastric pull-up versus colon interposition.  J Am Coll Surg. 2004;  198 536-541
• 24 DeMeester S R. Colon interposition following esophagectomy.  Dis Esophagus. 2001;  14 169-172
• 25 Siewert J R, Hölscher A H. Eingriffe beim Ösophaguskarzinom und Eingriffe beim Adenokarzinom des gastroösophagealen Übergangs. In: Gschnitzer F, Kern E, Schweiberer L, Hrsg. Breitner: Chirurgische Ope­rationslehre, 2. Auflage, Band IV: Siewert JR, Hrsg. Chirurgie des Abdomens 2. München, Wien, Baltimore: Urban & Schwarzenberg; 1989: 17–54 und 109–119
• 26 Gutschow C, Schröder W, Hölscher A H et al. Merendino procedure with preservation of the vagus for early carcinoma of the gastroesophageal junction.  Zentralbl Chir. 2004;  129 276-281
• 27 Law S, Suen D TK, Wong K H et al. A single-layer, continuous, hand-sewn method for esophageal anastomosis.  Arch Surg. 2005;  140 33-39
• 28 Walther B, Johansson J, Johnsson F et al. Cervical or thoracic anastomosis after esophageal resection and gastric tube reconstruction: A prospective randomized trial comparing sutured neck anastomosis with stapled intrathoracic anastomosis.  Ann Surg. 2003;  238 803-814
• 29 Deschamps C. Perioperative complications: anastomotic leak. 10th World Congress of the ISDE, Adelaide 2006, Book of Abstracts. New York: Springer; 2006: 54
• 30 Aly A, Jamieson G G, Devitt P G et al. Antireflux anastomosis following esophagectomy.  ANZ J Surg. 2004;  74 434-438
• 31 Tilanus H W. Postoperative complications. The use of a jejunostomy for feeding. 10th World Congress of the ISDE, Adelaide 2006; Book of Abstracts. New York: Springer; 2006: 54
• 32 Cense H A, Lagarde S M, de Jong K et al. Association of no epidural analgesia with postoperative morbidity and mortality after transthoracic esophageal cancer resection.  J Am Coll Surg. 2006;  202 395-400
• 33 Schäfer H, Engert A, Hölscher A H et al. Perioperative granulocyte colony-stimulating factor does not prevent severe infections in patients undergoing esophagectomy for esophageal cancer. A randomized placebo-controlled clinical trial.  Ann Surg. 2004;  240 68-75
• 34 Stippel D, Taylan C, Hölscher A H. Supraventricular tachyarrhythmias as early indicator of a complicated course after esophagectomy.  Dis Esophagus. 2005;  18 267-273
• 35 Leers J M, Hölscher A H, Metzger R et al. Endoscopic therapy for esophageal perforation or anastomotic leak with a self-expandable metallic stent.  Surg Endosc. 2009;  23 2258-2262
• 36 Deitmar S, Anthoni C, Senninger N. Are leukocytes and CRP early indicators for anastomotic leakage after esophageal resection?.  Zentralbl Chir. 2009;  134 83-89
• 37 Meyer T, Merkel S, Hohenberger W et al. Changes and complication rate in surgery for thoracic esophageal carcinoma.  Zentralbl Chir. 2003;  128 631-639
• 38 Crestanello J A, Deschamps C, Cassivi S D et al. Selective management of intrathoracic anastomotic leak after esophagectomy.  J Thorac Cardiovasc Surg. 2005;  129 254-260
• 39 Schubert D, Pross M, Lippert H et al. Endoscopic treatment of medias­tinal anastomotic leaks.  Zentralbl Chir. 2006;  131 369-375
• 40 Schubert D, Scheidbach H, Kuhn R et al. Endoscopic treatment of tho­racic esophageal anastomotic leaks by using silicone-covered, self-expanding polyester stents.  Gastroint Endosc. 2005;  61 891-896
• 41 Michelet P, D’Journo X B, Roch A et al. Perioperative risk factors for anas­tomotic leakage after esophagectomy: influence of thoracic epidural analgesia.  Chest. 2005;  128 3461-3466
• 42 Korst R J, Port J L, Lee P C et al. Intrathoracic manifestations of cervical anastomotic leaks after transthoracic esophagectomy for carcinoma.  Ann Thorac Surg. 2005;  80 1185-1190
• 43 Page R D, Shackcloth M J, Russell G N et al. Surgical treatment of anastomotic leaks after oesophagectomy.  Eur J Cardiothorac Surg. 2005;  27 337-343
• 44 Junemann-Ramirez M, Awan M Y, Khan Z M. Anastomotic leakage post-esophagogastrectomy for esophageal carcinoma: retrospective analysis of predictive factors, management and influence on longterm survival in a high volume center.  Eur J Cardiothorac Surg. 2005;  27 3-7
• 45 Toth I, Szucs G, Kiss J I et al. Surgical complications of esophageal resections: our experience with 168 operations.  Magy Seb. 2004;  57 201-208
• 46 Mariette C, Taillier G, Van Seuningen I et al. Factors affecting postoperative course and survival after en bloc resection for esophageal carci­noma.  Ann Thorac Surg. 2004;  78 1177-1183
• 47 Peracchia A, Bonavina L, Bona D et al. Evolution of anastomotic techniques in oesophageal surgery: experience at the Milan University Department of Surgery.  Chir Ital. 2004;  56 307-312
• 48 Alanezi K, Urschel J D. Mortality secondary to esophageal anastomotic leak.  Ann Thorac Cardiovasc Surg. 2004;  10 71-75
• 49 Walther B, Johansson J, Johnsson F et al. Cervical or thoracic anastomosis after esophageal resection and gastric tube reconstruction: A prospective randomized trial comparing sutured neck anastomosis with stapled intrathoracic anastomosis.  Ann Surg. 2003;  238 803-814
• 50 Davis P A, Law S, Wong J. Colonic interposition after esophagectomy for cancer.  Arch Surg. 2003;  138 303-308
• 51 Griffin S M, Lamb P J, Dresner S M et al. Diagnosis and management of a mediastinal leak following radical esophagectomy.  Br J Surg. 2001;  88 1346-1351
• 52 Orringer M B, Marshall B, Iannettoni M D. Transhiatal esophagectomy for treatment of benign and malignant esophageal disease.  World J Surg. 2001;  25 196-203
• 53 McManus K, Anikin V, McGuigan J. Total thoracic esophagectomy for oesophageal carcinoma: has it been worth it?.  Eur J Cardiothorac Surg. 1999;  16 261-265
• 54 Kohl P, Honore P, Gielen J L et al. Surgery of esophageal cancer in Liege. I. A study of mortality and perioperative morbidity.  Rev Med Liege. 1998;  53 187-192
• 55 Anikin V A, McManus K G, Graham A N et al. Total thoracic esophagec­tomy for esophageal cancer.  J Am Coll Surg. 1997;  185 525-529
• 56 Fahn H J, Wang L S, Huang M S, et al. Leakage of intrathoracic oesophagovisceral anastomosis in adenocarcinoma of the gastric cardia: changes in serial APACHE II scores and their prognostic significance.  Eur J Surg. 1997;  163 345-350
• 57 Pierie J P, De Graaf P W, Poen H et al. End-to-side and end-to-end anastomosis give similar results in cervical esophagogastrostomy.  Eur J Surg. 1995;  161 893-896
• 58 Fok M, Wong J. Cancer of the oesophagus and gastric cardia. Standard esophagectomy and anastomotic technique.  Ann Chir Gynaecol. 1995;  84 179-183
• 59 Lam K H, Lim S T, Wong J et al. Chylothorax following resection of the oesophagus.  Br J Surg. 1979;  66 105-109
• 60 Bolger C, Walsh T N, Tanner W A et al. Chylothorax after esophagectomy.  Br J Surg.. 1991;  78 587-588
• 61 Dougenis D, Walker W S, Cameron E W et al. Management of chylothorax complicating extensive esophageal resection.  Surg Gynecol Obstet. 1992;  174 501-506
• 62 Svanes K, Stangeland L, Viste A et al. Morbidity, ability to swallow, and survival, after esophagectomy for cancer of the oesophagus and cardia.  Eur J Surg. 1995;  161 669-675
• 63 Alexiou C, Watson M, Beggs D et al. Chylothorax following esophagogastrectomy for malignant disease.  Eur J Cardiothorac Surg. 1998;  14 460-466
• 64 Dugue L, Sauvanet A, Farges O et al. Output of chyle as an indicator of treatment for chylothorax complicating esophagectomy.  Br J Surg. 1998;  85 1147-1149
• 65 Merigliano S, Molena D, Ruol A et al. Chylothorax complicating esophagectomy for cancer: a plea for early thoracic duct ligation.  J Thorac Cardiovasc Surg. 2000;  119 453-457
• 66 Shackcloth M J, Poullis M, Lu J et al. Preventing of chylothorax after esoph­agectomy by routine pre-operative administration of oral cream.  Eur J Cardiothorac Surg. 2001;  20 1035-1036
• 67 Swanson S J, Batirel H F, Bueno R et al. Transthoracic esophagectomy with radical mediastinal and abdominal lymph node dissection and cervical esophagogastrostomy for esophageal carcinoma.  Ann Thorac Surg. 2001;  72 1918-1925
• 68 Rao D V, Chava S P, Sahni P et al. Thoracic duct injury during esophagec­tomy: 20 years experience at a tertiary care center in a developing country.  Dis Esophagus. 2004;  17 141-145