RSS-Feed abonnieren
DOI: 10.1055/s-2006-949532
© J. A. Barth Verlag in Georg Thieme Verlag KG
Endoskopische Therapieoptionen bei mediastinaler Anastomoseninsuffizienz
Endoscopic Treatment of Mediastinal Anastomotic LeaksPublikationsverlauf
Publikationsdatum:
06. November 2006 (online)
![](https://www.thieme-connect.de/media/zblchir/200605/lookinside/thumbnails/10.1055-s-2006-949532-1.jpg)
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
Literatur
- 1 Alanezi K, Urschel JD. Mortality secondary to esophageal anastomotic leak. Ann Thorac Cardiovasc Surg. 2004; 10 71-75
- 2 Beitler AL, Urschel JD. Comparison of stapled and hand-sewn esophagogastric anastomoses. Am J Surg. 1998; 175 337-340
- 3 Crestanello JA, Deschamps C, Cassivi SD, Nichols FC, Allen MS, Schleck C, Pairolero PC. Selective management of intrathoracic anastomotic leak after esophagectomy. J Thorac Cardiovasc Surg. 2005; 129 254-260
- 4 Doniec JM, Schniewind B, Kahlke V, Kremer B, Grimm H. Therapy of anastomotic leaks by means of covered self-expanding metallic stents after esophagogastrectomy. Endoscopy. 2003; 35 652-658
- 5 Dumonceau JM, Deviere J. Treatment of Boerhaave's syndrome using the Ultraflex self-expandable stent. Gastrointest Endosc. 2000; 51 773-774
- 6 Eubanks PJ, Hu E, Nguyen D, Procaccino F, Eysselein VE, Klein SR. Case of Boerhaave's syndrome successfully treated with a self-expanding metallic stent. Gastrointest Endosc. 1999; 49 780-783
- 7 Evrard S, Le Moine O, Lazaraki G, Dormann A, El Nakadi I, Deviere J. Self-expanding plastic stents for benign esophageal lesions. Gastrointest Endosc. 2004; 60 894-900
- 8 Fernandez FF, Richter A, Freudenberg S, Wendl K, Manegold BC. Treatment of endoscopic esophageal perforation. Surg Endosc. 1999; 13 962-966
- 9 Gelbmann CM, Ratiu NL, Rath HC, Rogler G, Lock G, Scholmerich J, Kullmann F. Use of self-expandable plastic stents for the treatment of esophageal perforations and symptomatic anastomotic leaks. Endoscopy. 2004; 36 695-699
- 10 Griffin S, Desai J, Charlton M, Townsend E, Fountain SW. Factors influencing mortality and morbidity following esophageal resection. Eur J Cardiothoracic Surg. 1989; 3 419-424
- 11 Griffin SM, Lamb PJ, Dresner SM, Richardson DL, Hayes N. Diagnosis and management of a mediastinal leak following radical oesophagectomy. Br J Surg. 2001; 88 1346-1351
- 12 Groitl H, Horbach T. Endoscopic treatment of anastomosis insufficiency and perforation in the esophagus with fibrin. Langenbecks Arch Chir Suppl Kongressbd. 1996; 113 753-754
- 13 Hunerbein M, Stroszczynski C, Moesta KT, Schlag PM. Treatment of thoracic anastomotic leaks after esophagectomy with self-expanding plastic stents. Ann Surg. 2004; 240 801-807
- 14 Langer FB, Wenzl E, Prager G, Salat A, Miholic J, Mang T, Zacherl J. Management of postoperative esophageal leaks with the Polyflex self-expanding covered plastic stent. Ann Thorac Surg. 2005; 79 398-403
- 15 Mohan V, Kozarek RA. Placement of conventional and expandable stents for malignant esophageal stenoses. Techniques Gastrointest Endosc. 2001; 3 166-175
- 16 Patil PK, Patel SG, Mistry RC, Deshpande RK, Desai PB. Cancer of the esophagus: esophagstric anastomotic leak - a retrospective study of predisposing factors. J Surg Oncol. 1992; 49 163-167
- 17 Pross M, Manger T, Reinheckel T, Mirow L, Kunz D, Lippert H. Endoscopic treatment of clinically symptomatic leaks of thoracic esophageal anastomoses. Gastrointest Endosc. 2000; 51 73-76
- 18 Rabago LR, Castro JL, Joya D, Herrera N, Gea F, Mora P. et al . Esophageal perforation and postoperative fistulae of the upper digestive tract treated endoscopically with the application of Tissucol. Gastroenterol Hepatol. 2000; 23 82-86
- 19 Raijman I, Siddique I, Ajnani J, Lynch P. Palliation of malignant dysphagia and fistulae with coated expandable metal stents: experience with 101 patients. Gastrointest Endosc. 1998; 48 172-179
- 20 Ramirez FC, Dennert B, Zierer ST, Samowski RA. Esophageal self-expandable metallic stents-indications, practice, techniques, and complications: results of a national survey. Gastrointest Endosc. 1997; 45 360-364
- 21 Roy-Choudhury SH, Nicholson AA, Wedgewood KR, Mannion RAJ, Sedman PC, Royston CMS. et al . Symptomatic malignant gastroesophageal anastomotic leak: management with covered metallic esophageal stents. Am J Roentgenol. 2001; 176 161-165
- 22 Sauvanet A, Baltar J, Le Mee J, Belghiti J. Diagnosis and conservative management of intrathoracic leakage after oesophagectomy. Br J Surg. 1998; 85 1446-1449
- 23 Schubert D, Kuhn R, Lippert H, Pross M. Selfexpandable metal stent for the treatment of a large anastomotic insufficiency after esophageal resection. Z Gastroenterol. 2003; 41 181-184
- 24 Schubert D, Scheidbach H, Kuhn R, Wex C, Weiss G, Eder F, Lippert H, Pross M. Endoscopic treatment of thoracic esophageal anastomotic leaks by using silicone-covered, self-expanding polyester stents. Gastrointest Endosc. 2005; 61 891-896
- 25 Siersema PD, Homs MY, Haringsma J, Tilanus HW, Kuipers EJ. Use of large-diameter metallic stents to seal traumatic nonmalignant perforations of the esophagus. Gastrointest Endosc. 2003; 58 356-361
- 26 Siersema PD. Treatment of esophageal perforations and anastomotic leaks: the endoscopist is stepping into the arena. Gastrointest Endosc. 2005; 61 897-900
- 27 Siewert JR, Stein HJ, Bartels H. Anastomotic leaks in the upper gastrointestinal tract. Chirurg. 2004; 75 1063-1070
- 28 Song HY, Park SI, Do YS, Yoon HK, Sung KB, Sohn KH. et al . Expandable metallic stent placement in patients with benign esophageal strictures: results of a long term follow up. Radiology. 1997; 203 131-136
- 29 Urschel JD. Esophagogastrostomy anastomotic leak complicating esophagectomy: a review. Am J Surg. 1995; 169 324-340
- 30 Vakil N, Gross U, Bethge N. Human tissue response to metal stents. Gastrointest Endosc Clin North Am. 1999; 9 359-365
- 31 Viste A, Geir E, Soreide O. Stomach cancer: a prospective study of anastomotic failure following total gastrectomy. Acta Chir Scand. 1987; 153 303-306
- 32 Yuasa N, Hattori T, Kobayashi Y, Miyata K, Hayashi Y, Seko H. Treatment of spontaneous esophageal rupture with a covered self-expanding metal stent. Gastrointest Endosc. 1999; 49 777-780
Korrespondenzadresse
Dr. med. Daniel Schubert
Klinik für Allgemein- Viszeral- und Gefäßchirurgie·Otto von Guericke-Universität
Magdeburg
Leipziger Straße 44
39120 Magdeburg
Telefon: +49/391/67 15 50 0
Fax: +49/391/67 15 57 0
eMail: schubertdr@hotmail.com