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Diagnostik und Definition der Nahtinsuffizienz aus chirurgischer Sicht

Diagnosis and definition of anastomotic leakage from the surgeon’s perspective

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Zusammenfassung

Die Nahtinsuffizienzraten der verschiedenen Anastomosen im Gastrointestinaltrakt variieren beträchtlich. Trotzdem gibt es Gemeinsamkeiten und allgemeine Konzepte zur Diagnostik und zum Management. Frühzeitige Diagnostik und rechtzeitige, konsequente Therapie müssen unser Handeln bestimmen, um unnötigen Schaden von unseren Patienten abzuwenden. Die Diagnostik von Nahtinsuffizienzen in der Viszeralchirurgie orientiert sich am Zeitverlauf und an der klinischen Symptomatik des Patienten und sollte bei Verdacht rasch eingeleitet werden. Einen hohen Stellenwert haben heute abhängig von der Lokalisation der Insuffizienz die Computertomographie mit oraler oder rektaler Kontrastmittelgabe und die Endoskopie. Beide Verfahren gewähren die Möglichkeit einer unmittelbaren Therapie.

Erst durch die Implementierung einheitlicher Definitionen von Nahtinsuffizienzen und anderen Komplikationen lassen sich chirurgische Therapien vergleichen und nachhaltig weiterentwickeln. In den letzten Jahren wurden Konsensusdefinitionen für postoperative Komplikationen, insbesondere der Nahtinsuffizienzen von Gallengangs-, Pankreas- und kolorektalen Anastomosen erarbeitet. Die Definitionen basieren auf einer im Vergleich zur Serumkonzentration 3fach erhöhten Bilirubin- (Galleleckage) oder Amylasekonzentration (Pankreasfistel) in der Drainageflüssigkeit, bzw. auf einem anastomosennahen Darmwanddefekt mit Kommunikation der intra- und extraluminalen Kompartimente (kolorektale Insuffizienz). Die Definitionen berücksichtigen jeweils 3 Schweregrade A–C, wobei ab Grad B eine Änderung des klinischen Managements erfolgt und Grad-C-Komplikationen in der Regel eine Reoperation erfordern. Konsensusdefinitionen für Insuffizienzen nach Ösophagogastrostomie oder -jejunostomie oder nach Dünndarmanastomosen sind derzeit nicht publiziert.

Zur Optimierung der Studienvergleichbarkeit empfehlen die Autoren die Verwendung der vorgestellten Konsensusdefinitionen im klinischen und wissenschaftlichen Alltag.

Abstract

The leak rates of different gastrointestinal anastomoses vary considerably but despite this there are common and general concepts for diagnosis and management. Early diagnosis and timely consistent therapy must guide management to prevent harm to the patients. Diagnosis of anastomotic leaks is coupled to clinical signs of the patients and should be initiated promptly. Dependent on the localization of the leak, computed tomography with administration of oral or rectal contrast dye and endoscopy are of high diagnostic value. Both procedures guarantee the option of drainage or stenting through interventional drains or stent placement. Only the implementation of uniform definitions of anastomotic leaks enables surgeons to compare and to improve surgical treatment. Over recent years consensus definitions of postoperative complications including bile leak, pancreatic fistula and colorectal leak have been formulated. These definitions are based on a 3-fold increase of bilirubin (bile leak) or amylase levels (pancreatic fistula) in abdominal drainage fluid compared to serum levels or on an intestinal wall defect with communication of the intraluminal and extraluminal compartments (colorectal anastomosis). The definitions each describe three severity grades A–C. A change of clinical management is required in grade B whereas grade C usually requires a re-operation. Comparable consensus definitions for anastomotic leaks following esophagogastrostomy or esophagojejunostomy or following small bowel anastomosis have not been established. The authors strongly recommend implementation of the presented consensus definitions into clinical and academic daily practice.

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  1. Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland

    T. Welsch, M. von Frankenberg, J. Schmidt & M.W. Büchler

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  1. T. Welsch
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  2. M. von Frankenberg
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  3. J. Schmidt
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T. Welsch und M. von Frankenberg haben gleichermaßen zu dieser Arbeit beigetragen.

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Welsch, T., von Frankenberg, M., Schmidt, J. et al. Diagnostik und Definition der Nahtinsuffizienz aus chirurgischer Sicht. Chirurg 82, 48–55 (2011). https://doi.org/10.1007/s00104-010-1916-4

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