Duodenalperforation nach EST/EPT: Wann operieren?[*]

Zusammenfassung

Die Duodenalperforation nach EST/EPT ist mit ca. 1 % eine nicht seltene, leider nicht ganz vermeidbare Komplikation. Sie wird bei deutlicher Manifestation eines retroperitonealen Luftaustrittes allein leicht übertherapiert. Bei versteckten, nicht wahrgenommenen Zeichen nimmt sie leicht einen tückischen Verlauf. Es wird zwischen kontinenter (gedeckter) und inkontinenter (offener) Perforation differenziert. Die Therapie wird weniger nach dem initialen klinischen Befund, mehr nach dem Verlauf in der Bildgebung (Sonographie und KM-CT) innerhalb der ersten 24 Stunden entschieden. Neben Beobachtung und konservativen Maßnahmen sind endoskopische Interventionen wie Re-ERCP mit nasobiliärer Ablaufsonde (kontinente Perforation) in hohem Maße erfolgversprechend, sofern sie baldmöglichst zum Einsatz kommen. Bei progredient kompliziertem Verlauf (inkontinente Perforation) muss frühzeitig, d. h. rechtzeitig vor Eintritt septischer Komplikationen operiert werden. Operation heißt: Gallenwegsrevision mit T-Drain und Drainage des Retroperitoneums. Eine Notfalloperation in der Sepsis hat eine hohe Mortalität und wäre bei sorgfältiger Befunderhebung, sorgfältiger Befundkontrolle und frühzeitigem chirurgischem Konsil in den meisten Fällen vermeidbar. Spätabszesse erfordern eine Spätintervention.

Abstract

EST/EPT is charged with a certain amount of duodenal perforations, ranging about 1 %, a complication not completely avoidable. Post-EST/EPT-perforation may be overtreated by overrating some impressive signs, such as obvious retroperitoneal or mediastinal air leakages. Otherwise, with more discrete or equivocal symptoms, duodenal perforation may be overlooked, undervalued and may take a disastrous course. There is a substantial therapeutic difference in continent and incontinent leakages. Definitive therapeutic decisions are not made by the initial clinical symptoms alone, but mainly by close observation of the clinical course and the change of findings in ultrasound and CT within the first 24 hours post EST/EPT. In continent perforations, conservative treatment and endoscopic interventions such as re-ERCP and nasobiliary drainages are highly effective, if they come to work as soon as possible. In cases of productive leakages and progressive complicative signs, it has to be operated upon urgently, before the onset of septic forebodings. Operation means open surgery with open revision of the CBD, T-tube-drain and retroperitoneal drainage, not the closure of the retroperitoneal leak at first hand. Emergency laparotomy in septic situations has a high mortality about 50 %, this should and could be avoided by careful investigation, strong clinical controls and early surgical consultation in all cases.

Schlüsselwörter

Duodenalperforation durch EST/EPT - endoskopische Therapie - chirurgische Therapie

Key words

Duodenal perfortation by EST/EPT - endoscopic therapy - surgical therapy

1 Nach einem Vortrag während des 34. Kongresses der Deutschen Gesellschaft für Endoskopie und bildgebende Verfahren (DGE-BV), München (18.-21.3.2004)

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1 Nach einem Vortrag während des 34. Kongresses der Deutschen Gesellschaft für Endoskopie und bildgebende Verfahren (DGE-BV), München (18.-21.3.2004)