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Endoskopisches Komplikationsmanagement im hepatobiliopankreatischen System und Tracheobronchialbaum

Endoscopic management of complications in the hepatobiliary and pancreatic system and the tracheobronchial tree

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Zusammenfassung

Die endoskopischen Methoden stellen heutzutage ein wertvolles Tool zur Behandlung postoperativer Komplikationen der hepatobiliopankreatischen und Thoraxchirurgie dar. Bei Gallenleckagen nach Cholezystektomie, Leberresektion oder Lebertransplantation ist die endoskopische Druckentlastung der Gallengänge die Therapie der Wahl. Postoperative Gallengangsstenosen können auch in den meisten Fällen erfolgreich endoskopisch durch Ballondilatation und Implantation unterschiedlicher Endoprothesen behandelt werden. Im Fall der Pankreasfisteln, insbesondere nach zentralen oder distalen Resektionen, kann die endoskopische Entlastung des Pankreasgangs viel zur zügigen Heilung beitragen. Zudem bietet die interventionelle Endosonographie eine wichtige therapeutische Option zur transgastralen Drainage postoperativer Flüssigkeitsansammlungen, die oft eine Pankreasfistel begleiten. Mehrere Behandlungsalternativen wurden auch zur bronchoskopischen Versorgung bronchopleuraler und tracheoösophagealer Fisteln beschrieben, die zur zügigen Linderung der Symptomatik und oft zum definitiven Verschluss der Fistel führen.

Abstract

Endoscopic methods are nowadays a priceless tool for the treatment of postoperative complications after hepatobiliary, pancreatic and thoracic surgery. Endoscopic decompression of the biliary tract is the treatment of choice for biliary duct leakage after cholecystectomy, hepatic resection or liver transplantation. Postoperative biliary duct stenosis can also be successfully treated by endoscopic balloon dilatation and implantation of various endoprostheses in most of the patients. In the case of pancreatic fistulas, especially those occurring after central or distal pancreatic resections, endoscopic decompression of the pancreatic duct can significantly contribute to rapid healing. Additionally, interventional endosonography provides a valuable treatment option for transgastric drainage of postoperative fluid collections, which often accompany a pancreatic fistula. Various treatment alternatives have been described for the bronchoscopic treatment of bronchopleural and tracheoesophageal fistulas, which often lead to the rapid alleviation of symptoms and often to the definitive closure of the fistula.

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  1. Zentrale Interdisziplinäre Endoskopie, Chirurgische Klinik, Medizinische Fakultät Mannheim, Universität Heidelberg, Theodor-Kutzer-Ufer 1–3, 68167, Mannheim, Deutschland

    Konstantinos Kouladouros &  Georg Kähler

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K. Kouladouros: A. Finanzielle Interessen: K. Kouladouros gibt an, dass kein finanzieller Interessenkonflikt besteht. – B. Nichtfinanzielle Interessen: Oberarzt, Zentrale Interdisziplinäre Endoskopie, Chirurgische Klinik, Universitätsmedizin Mannheim.

G. Kähler: A. Finanzielle Interessen: Referentenhonorar oder Kostenerstattung als passiver Teilnehmer: Vortrags- und Gutachtenhonorare : Falk Foundation, Microtech Europe, Köhler Chemie GmbH; Aesculap AG, Thieme-Verlag, Springer-Verlag, Elsevier-Verlag, DBFK Südwest, EKW Concept GmbH, Bildungswerk Gesundheit, ecomed, HTGF Bonn, Baxter Healthcare, Erbe Elektromedizin GmbH, GBUK Ltd. UK. – Bezahlter Berater/interner Schulungsreferent/Gehaltsempfänger o. ä.: Vortrags- und Gutachtenhonorare : Falk Foundation, Microtech Europe, Köhler Chemie GmbH; Aesculap AG, Thieme-Verlag, Springer-Verlag, Elsevier-Verlag, DBFK Südwest, EKW Concept GmbH, Bildungswerk Gesundheit, ecomed, HTGF Bonn, Baxter Healthcare, Erbe Elektromedizin GmbH, GBUK Ltd. UK. – B. Nichtfinanzielle Interessen: 2010 bis 2021 Leiter der Zentralen Interdisziplinären Endoskopie (ZIE) des Universitätsklinikum Mannheim, seit 2021 stellv. Leiter der ZIE, 2015 bis 2016 Präsident der Deutschen Gesellschaft für Endoskopie und bildgebende Verfahren, seit 2019 Gründungsvorsitzender der AG Metabolische Endoskopie der DEG-BV, seit 2018 Beiratsmitglied der Chirurgischen Arbeitsgemeinschaft Endoskopie und Sonographie der DGAV, seit 2014 Gründer und Geschäftsführer der Trans-Duodenal Concepts GmbH Mannheim.

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Nach welchem Eingriff treten die meisten postoperativen Gallenleckagen, die endoskopisch behandelt werden, auf?

Hemihepatektomie rechts

Cholezystektomie

Lebertransplantation

Hemihepatektomie links

Pankreatoduodenektomie

Die Therapie der ersten Wahl bei den meisten postoperativen Gallenleckagen ist …

die Endosonographie.

die perkutane transhepatische Cholangiodrainage (PTCD).

die operative Revision.

die sonographische Drainage.

die endoskopische retrograde Cholopankreatikographie (ERCP).

Welche Aussage zu den Grundprinzipien der Therapie der Gallenleckage ist richtig?

Die Leckage kann mittels endoskopischer retrograder Cholopankreatikographie (ERCP) oder Magnetresonanzcholangiopankreatikographie (MRCP) nur selten genau lokalisiert werden.

Das gallige Sekret kann über die intraoperativ eingelegten Drainagen nicht drainiert werden.

Ziel der endoskopischen Therapie ist die Druckentlastung im Gallengangssystem.

Ziel der endoskopischen Therapie ist der Verschluss des Defektes im Gallengangssystem.

Das gallige Sekret kann mithilfe interventionell eingebrachter Drainagen nicht ausreichend drainiert werden.

Die häufigste Lokalisation einer Gallenleckage nach Cholezystektomie ist …

der Zystikusstumpf.

der Luschka-Gallengang.

der Ductus hepatocholedochus (DHC).

die intrahepatischen Gallengänge.

das Gallenblasenbett.

Welche endoskopische Methode kann zur Entlastung des Drucks im Gallengangssystem nicht eingesetzt werden?

Selbstexpandierende Metallgitterstents (SEMS)

Ballondilatation

Plastikstents

Nasobiliäre Sonde

Biliäre Sphinkterotomie

Welche Therapie ist in der Regel bei kompletter Durchtrennung des Ductus hepatocholedochus (DHC) oder der Lappengallengänge notwendig?

Endoskopische retrograde Cholopankreatikographie (ERCP) mit biliärer Sphinkterotomie

Perkutane transhepatische Cholangiodrainage (PTCD)

Operative Revision

ERCP mit Implantation von Endoprothesen

ERCP mit Ballondilatation

Welche Aussage zu den postoperativen Stenosen nach Lebertransplantation ist falsch?

Alle Gallengangsstenosen, die in der Bildgebung nach Lebertransplantation auffallen, sind behandlungsbedürftig.

Die Inzidenz der symptomatischen Stenosen liegt zwischen 5–32 %.

Die ischämischen Stenosen sind hauptsächlich in den proximalen und intrahepatischen Gallengängen lokalisiert.

Therapie der Wahl für die Anastomosenstenosen ist das Multistenting.

Die Anastomosenstenosen sind in der Regel kurz und narbig.

Welche Aussage zu den Pankreasfisteln ist korrekt?

Die Fisteln Grad C nach der International Study Group for Pancreatic Fistulas (ISGPF) sind die häufigsten.

Die Fisteln Grad C nach ISGPF wurden in der revidierten Klassifikation von 2016 aufgrund ihrer fehlenden klinischen Bedeutung in „biochemische Leckagen“ umbenannt.

Die Therapie der Wahl bei Fisteln Grad A nach ISGPF ist die endoskopische Druckentlastung des Pankreasgangs.

Bei Fisteln Grad B nach ISGPF ist in der Regel eine operative Revision notwendig.

Die Fisteln Grad A nach ISGPF bedürfen keiner spezifischen Therapie.

Welche Aussage bezüglich der endosonographischen Drainage postoperativer Flüssigkeitsverhalte ist richtig?

Der Verhalt kann mit dem longitudinalen Echoendoskop nur erschwert eingestellt werden.

Die transgastrale Entlastung postoperativer Flüssigkeitsverhalte ist in ca. 50 % erfolgreich.

Die transgastral eingelegten Stents können belassen werden.

Über den transgastralen Zugang kann keine Nekrosektomie, in der Kavität erfolgen.

Zur Entlastung des Verhalts können Pigtail-Stents oder LAMS („lumen apposing metal stents“) eingesetzt werden.

Welche der folgenden Therapiemodalitäten kann zum Verschluss einer bronchopleuralen Fistel nicht eingesetzt werden?

Injektion von Ethanol

Vorhofseptumokkluder

Injektion von Fibrinkleber

Endoskopische Unterdrucktherapie

Stents

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Kouladouros, K., Kähler, G. Endoskopisches Komplikationsmanagement im hepatobiliopankreatischen System und Tracheobronchialbaum. Chirurgie 94, 469–484 (2023). https://doi.org/10.1007/s00104-022-01735-3

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