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
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Univ.-Prof. Dr. A. H. Hölscher
Universitätsklinikum Köln · Klinik und Poliklinik für Allgemein-, Viszeral- und Tumorchirurgie
Kerpener Str. 62
50924 Köln
Deutschland
eMail: arnulf.hoelscher@uk-koeln.de
