Klinische Anastomosenprobleme in der Pankreaschirurgie

 

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Zusammenfassung

Trotz bedeutender Fortschritte in der chirurgischen Technik und im perioperativen Management zählen Pankreasresektionen zu den sehr komplikationsträchtigen Eingriffen (postoperative Morbiditätsrate 30-50 %). Hauptverantwortlich hierfür sind Komplikationen im Bereich der Pankreasanastomose. Eine Vielzahl von Rekonstruktionstechniken nach partieller Duodenopankreatektomie wurde beschrieben, wobei sich bisher kein signifikanter Vorteil einer Anastomosentechnik sicher belegen lässt. Weltweit ist jedoch die Pankreatikojejunostomie die häufigste Rekonstruktionstechnik und wird vorwiegend in Form einer End-zu-Seit-Anastomose durchgeführt. Eine postoperative prophylaktische Verabreichung von Somatostatinanaloga wie Octreotid kann insbesondere bei weichem, nicht fibrosiertem Pankreasrest empfohlen werden. Die Wirksamkeit von endoluminalen Stents oder externen Pankreasgangdränagen ist jedoch nicht bewiesen. Als häufigste Komplikation nach Pankreasresektionen gilt die Gastroparese, die sich meist konservativ behandeln lässt. Ihr liegen jedoch oft weitere lokale Komplikationen zugrunde (Pankreasfistel, Abszess, Anastomoseninsuffizienz). Alle septischen Komplikationen nach Pankreasresektion können zu späten postoperativen Arrosionsblutungen führen, die sich bei einer Anastomoseninsuffizienz auch als späte endoluminale Blutungen bemerkbar machen können und einer sofortigen Abklärung bedürfen (sentinel bleed). Revisionsoperationen treten jedoch bei zunehmend besseren interventionell-radiologischen Verfahren (CT-gesteuerte Dränagen, Gefäßembolisation) in den Hintergrund, da sie mit einem erhöhten operativen Risiko verbunden sind. Nur in seltenen Fällen muss eine Restpankreatektomie bei Anastomoseninsuffizienz oder Blutung erfolgen.

Abstract

Regardless of significant progress in surgical technique and perioperative management, pancreatic surgery still has a morbidity rate of 30 to 50 %. The main cause of postoperative complications remains the pancreatic anastomosis. Therefore, many different surgical techniques were developed, but none was definitely proven to be significantly better than others. Pancreaticojejunostomy seems to be the most established technique world-wide for pancreatico-intestinal reconstruction, and end-to-side anastomosis has become popular. Prophylactic use of Octreotid can be recommended particularly for soft pancreatic tissue without fibrosis. However, the benefit of ductal stents or external drainage of the pancreatic duct is not proven. Delayed gastric emptying remains the most common surgical complication after pancreatic surgery and should be treated conservatively. However, gastrostasis might often be a result of other local complications, such as pancreatic fistula, abscess and anastomotic leakage. Septic complications may all result in late postoperative haemorrhage which may occur as sentinel bleed, and which always needs an immediate diagnostic work up. Relaparotomies for local complications have become less frequent since interventional radiology has emerged (CT-guided drainage, transarterial embolization) and salvage- pancreatectomy has become a rare procedure in cases of anastomotic dehiscence or bleeding.

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Dr. A. Kleespies

Chirurgische Klinik und Poliklinik - Großhadern · Ludwig-Maximilians-Universität München

Marchioninistraße 15

81377 München

Germany

Phone: +49 / 89 / 70 95 27 91

Fax: +49 / 89 / 70 95 65 77

Email: axelkleespies@aol.com