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Anastomosentechniken am Pankreas

Technical aspects of pancreatoenteric anastomosis

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Zusammenfassung

Fortschritte in der Pankreaschirurgie haben in den letzten beiden Jahrzehnten die Letalitätsraten nach Whipple-Operationen in spezialisierten Zentren auf Werte unter 3–5% sinken lassen. Dennoch bleibt die Morbidität, die vor allem durch Insuffizienzen der pankreatoenterischen Anastomose verursacht und als Pankreasfistel klinisch manifest wird, mit 30–50% immer noch sehr hoch. In zahlreichen Studien wurde daher versucht die „ideale Pankreasanastomose“ zu identifizieren. Zu den am häufigsten verwendeten Methoden gehören die End-zu-Seit-Duct-to-Mucosa-Pankreatikojejunostomie, die End-zu-End-Invaginations-Pankreatojejunostomie und die End-zu-Seit-Pankreatogastrostomie. In kontrolliert randomisierten Studien wurden je nach Anastomosentechnik Pankreasfistelraten zwischen 4% und 20% erreicht, ohne dass eine individuelle Methode in mehreren unabhängigen Studien einen signifikanten Vorteil aufweisen konnte. Ein großes Problem bei der Bewertung der Studien stellt die Heterogenität der Definitionen für eine Pankreasfistel dar. Allerdings bemühen sich jüngere Studien hier um die Verwendung allgemein anerkannter Definitionen und klarer Studienendpunkte, um zukünftig die Frage nach der „idealen Pankreasanastomose“ zu beantworten.

Abstract

Advances in pancreatic surgery during the last two decades have resulted in significant improvement of patient outcome leading to mortality rates as low as 3–5% following Whipple’s procedure in specialized centers. However, morbidity remains considerably high at 30–50% which is primarily caused by insufficiency of the pancreato-enteric anastomosis which becomes manifested as a pancreatic fistula. Therefore, numerous studies have aimed to identify the ideal pancreatic anastomosis. The most frequently used techniques comprise end-to-end duct-to-mucosa pancreaticojejunostomy, end-to-end invagination pancreatojejunostomy as well as end-to-side pancreatogastrostomy. In randomized controlled trials the frequency of pancreatic fistulas ranges between 4% and 20% depending on the particular technique. However, no single technique was able to demonstrate a significant superiority in several independent studies. The heterogeneity of definitions for pancreatic fistula represents the main problem in evaluating and comparing clinical studies on pancreato-enteric anastomosis. However, recent clinical trials applied commonly accepted definitions for pancreatic fistula as well as precise study endpoints to address the question of the ideal pancreatic anastomosis.

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Abbreviations

95%-CI:

95%-Konfidenzintervall

DtM:

Duct-to-Mucosa

DtM-PJ:

Duct-to-Mucosa-Pankreatikojejunostomie

EzE:

End-zu-End

EzS:

End-zu-Seit

EzS-DtM-PJ:

End-zu-Seit-Duct-to-Mucosa-Pankreatikojejunostomie

EzS-Inv-PJ:

End-zu-Seit-Invaginations-Pankreatojejunostomie

Inv-PJ:

Invaginations-Pankreatojejunostomie

ISGPF:

International Study Group for Pancreatic Fistula

PEA:

pankreatoenterische Anastomose

PG:

Pankreatogastrostomie

PJ:

Pankreatojejunostomie/Pankreatikojejunostomie

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  1. Klinik für Allgemein- und Viszeralchirurgie, St.-Josef-Hospital, Klinikum der Ruhr-Universität Bochum, Gudrunstraße 56, 44791, Bochum, Deutschland

    A.M. Chromik, D. Sülberg, O. Belyaev &  W. Uhl

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  1. A.M. Chromik
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Chromik, A., Sülberg, D., Belyaev, O. et al. Anastomosentechniken am Pankreas. Chirurg 82, 14–25 (2011). https://doi.org/10.1007/s00104-010-1903-9

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