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Die onkologische Ösophagusresektion und -rekonstruktion

Offen, Hybrid, MIC oder Robotik?

Oncologic esophageal resection and reconstruction

Open, hybrid, minimally invasive or robotic?

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Zusammenfassung

Zunehmend werden minimalinvasive Resektionen in der onkologischen Chirurgie des Ösophaguskarzinoms eingesetzt. Die neue deutsche S3-Leitlinie konstatiert, dass sowohl die Ösophagektomie als auch die Rekonstruktion des Ösophagus minimalinvasiv oder in Kombination mit offenen Prozeduren (Hybridtechnik) ausgeführt werden kann. Auf die aktuelle Wertigkeit der unterschiedlichen Techniken von der komplett minimalinvasiven Ösophagektomie über die Hybridoperation bis zur Robotik wird dabei nicht eingegangen. Ziel dieser Übersichtsarbeit ist der kritische Vergleich der unterschiedlichen Techniken anhand aktueller Evidenz. Minimalinvasive Verfahren der onkologischen Ösophagusresektion sind in erfahrenen Händen sicher und zeigen zahlreiche Vorteile der postoperativen Rekonvaleszenz auf. Die laparoskopische Gastrolyse mit intraabdomineller Lymphadenektomie und muskelschonender, anterolateraler Minithorakotomie (auch via VATS als Single-port-Technik) im Sinne eines Hybridverfahrens führt ebenfalls zu einer deutlichen Reduktion der postoperativen Morbidität und bietet die Möglichkeit der erweiterten mediastinalen Lymphadenektomie, welche thorakoskopisch einer hohen Expertise bedarf. Die Robotikösophagektomie wird derzeit in Deutschland nur in wenigen Kliniken durchgeführt. Hinzuweisen ist auf die fehlende Evidenz für die Ösophaguschirurgie anhand von Studien sowie die hohen Investitions- und Betriebskosten des Robotiksystems.

Abstract

Minimally invasive resections are increasingly employed in oncologic surgery for esophageal carcinoma. The new German S3 guideline states that esophagectomy, as well as reconstruction of the esophagus, can be performed minimally invasively or in combination with open techniques (hybrid). However, the current value of different techniques – ranging from complete minimally invasive esophagectomy over hybrid to robotic surgery – remains unregarded.

This review provides a critical comparison of these techniques based on current evidence. Minimally invasive procedures of oncologic esophageal resection are safe in experienced hands and show numerous advantages with regard to postoperative reconvalescence. Laparoscopic gastrolysis with intra-abdominal lymphadenectomy and muscle sparing as well as anterolateral mini-thoracotomy (also via VATS as single-port technique) as a hybrid method also result in a relevant reduction of postoperative mortality and offer the possibility of extended mediastinal lymphadenectomy, which requires a high level of expertise when performed thoracoscopically. At present, robotic esophagectomy is applied in only a few clinics in Germany. A lack of evidence based on studies for esophageal surgery, as well as high acquisition and operating costs of the robotic system, have to be taken into account.

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Authors and Affiliations

  1. Klinik für Viszeral-, Transplantations-, Thorax- und Gefäßchirurgie, Universitätsklinikum Leipzig, Liebigstr. 20, 04103, Leipzig, Deutschland

    I. Gockel

  2. Klinik für Allgemein- und Viszeralchirurgie, Sana Klinikum Offenbach GmbH, Offenbach, Deutschland

    D. Lorenz

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Correspondence to I. Gockel.

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I. Gockel und D. Lorenz geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Gockel, I., Lorenz, D. Die onkologische Ösophagusresektion und -rekonstruktion. Chirurg 88, 496–502 (2017). https://doi.org/10.1007/s00104-016-0364-1

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