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Endoskopische Vakuumtherapie von Perforationen und Anastomoseninsuffizienzen des Ösophagus

Endoscopic vacuum therapy of perforations and anastomotic insufficiency of the esophagus

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Zusammenfassung

Hintergrund

Die hohe Letalität und Morbidität von ösophagealen Defekten sind eine klinische Herausforderung in der Behandlung dieser Krankheitsbilder. Die endoskopische Vakuumtherapie wurde in den letzten Jahren als innovatives chirurgisch-endoskopisches Verfahren zur Therapie von Ösophagusleckagen entwickelt.

Ziel der Arbeit

Alle Patienten der Klinik für Allgemein-, Viszeral-, Thorax- und Gefäßchirurgie des Marienkrankenhauses Hamburg GmbH, bei welchen transmurale Ösophagusdefekte mit der endoskopischen Vakuumtherapie behandelt wurden, werden retrospektiv betrachtet.

Material und Methoden

Von 11/2006 bis 10/2013 behandelten wir insgesamt 35 Patienten mit endoskopischer Vakuumtherapie. In diesem Patientengut finden sich 21 Patienten mit ösophagealer Anastomoseninsuffizienz, 7 Patienten mit einer iatrogenen Perforation nach flexibler oder starrer Endoskopie und 7 Patienten mit anderen Defektgenesen.

Zur Behandlung werden Drainagen, bestehend aus einem offenporigen Polyurethanschaum und einem Drainageschlauch, endoskopisch ösophageal platziert. Die Drainagen können defektüberdeckend intraluminal im Ösophagus eingelegt werden. Ebenso können die Drainagen durch einen Defekt hindurch intrakavitär-extraluminal in einer paraösophagealen Wundhöhle positioniert werden. Mittels einer elektronisch kontrollierten Vakuumpumpe wird ein kontinuierlicher, spezifischer Unterdruck von 125 mmHg an die Drainage angelegt. Dieser Unterdruck wird über mehrere Tage aufrechterhalten. Ösophaguslumen oder Wundhöhle kollabieren durch den Unterdruck. Die nach intraluminal gerichtete Drainagewirkung erfolgt zeitgleich mit dem Defektverschluss. Im mehrtägigen Abstand werden regelmäßige endoskopische Drainagewechsel vorgenommen, bis eine stabile sekundärheilende, intrakorporale Wundsituation bzw. der Defektverschluss erreicht ist.

Ergebnisse

Bei 32 von 35 Patienten (91,4 %) wurde eine Abheilung der Defekte nach einer medianen Behandlungsdauer von 11 (4–78) Tagen erreicht. In 20 von 21 Fällen ösophagealer Anastomoseninsuffizienz wurde nach einem Median von 11 (4–46) Tagen Therapie eine Abheilung erreicht. Die 7 Patienten, die aufgrund einer iatrogenen Perforation behandelt wurden, waren alle (100 %) nach einer medianen Behandlungszeit von 5 (4–7) Tagen geheilt. In einem Fall trat eine Rezidivfistel 75 Tage nach Vakuumtherapie auf. Die 90-Tages-Letalität unseres Kollektivs von 35 Patienten betrug 5,7 %.

Diskussion

Die Ergebnisse dieser retrospektiven Studie unterstreichen den zunehmenden Stellenwert der endoskopischen Vakuumtherapie als ein geeignetes Behandlungsverfahren zur Therapie von Ösophagusdefekten aller Größen, Höhenlokalisationen und Infektsituationen.

Abstract

Background

The high morbidity and mortality of esophageal defects show that the clinical challenge in the treatment of this disease still remains. An innovative method which has been developed in recent years for esophageal leakage is endoscopic vacuum therapy.

Objectives

A retrospective analysis of all patients treated for esophageal perforation with endoscopic vacuum therapy in our department was carried out.

Methods

From November 2006 to October 2013 a total of 35 patients were treated with this method and of these 21 had anastomotic leakage, 7 had iatrogenic perforation due to flexible or rigid endoscopy and 7 patients had esophageal defects of various other origins. Drainage systems with an open pore polyurethane tip were placed using a standard endoscope. The vacuum drainage may be positioned either in the esophageal lumen onto the defect or through the defect into the extraluminal wound cavity. The intraluminal or intracavitary vacuum drainage is connected to an electronically controlled vacuum device and a continuous negative pressure of 125 mmHg is maintained for several days. The esophageal lumen or wound cavity collapses around the drainage resulting in intraluminal evacuation and closure of the defect. Under endoscopic monitoring the vacuum system is changed regularly until stable secondary healing of the intracorporeal wound or closure of the transmural defect is achieved.

Results

In 32 out of 35 patients (91.4 %) healing of defects was achieved after median treatment duration of 11 days (range 4–78 days). The postoperative anastomotic leakage healed in 20 out of 21 patients (95.2 %) after a median of 11 days (range 4–46 days) of therapy. The defects in the 7 patients who were treated for iatrogenic perforation all healed (100 %) after a median treatment time of 5 days (range 4–7 days). There was one case of a recurrent fistula 75 days after treatment. The 90-day mortality in this series of 35 patients was 5.7 %.

Discussion

The results of this retrospective study emphasize the increasing importance of endoscopic vacuum therapy in the current literature as an endoscopic treatment method in the management of esophageal perforation and anastomotic leakage.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. T. Schorsch und C. Müller haben keinen Interessenkonflikt. G. Loske ist als Berater für Lohmann&Rauscher GmbH & Co. KG tätig. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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Authors and Affiliations

  1. Klinik für Allgemein-, Viszeral-, Thorax-, und Gefäßchirurgie, Katholisches Marienkrankenhaus, GmbH, Alfredstr. 9, 22087, Hamburg, Deutschland

    T. Schorsch, C. Müller &  G. Loske

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  1. T. Schorsch
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  2. C. Müller
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  3. G. Loske
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Correspondence to G. Loske.

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Schorsch, T., Müller, C. & Loske, G. Endoskopische Vakuumtherapie von Perforationen und Anastomoseninsuffizienzen des Ösophagus. Chirurg 85, 1081–1093 (2014). https://doi.org/10.1007/s00104-014-2764-4

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