Endoskopische Vakuum-Schwamm-Therapie bei Leckagen im Verdauungstrakt

Zusammenfassung

Anastomosenleckagen stellen eine gefürchtete Komplikation nach Operationen am oberen und unteren Gastrointestinaltrakt dar, die mit hoher Morbidität und Mortalität vergesellschaftet sind. Eine neue Therapiemodalität stellt die endosko­pische Vakuum-Schwamm-Therapie dar. Hierbei macht man sich die positiven Effekte des vakuum­assistierten Verschlusses (Vacuum Assisted Clo­sure, V.A.C.) zunutze, der eine etablierte The­rapiemodalität zur Behandlung ausgedehnter ­infizierter Hautdefekte darstellt. Für die Behandlung von rektalen Anastomoseninsuffizienzen steht ein kommerziell erhältliches Schwammsystem (Endosponge®) zur Verfügung. Auch am oberen Gastrointestinaltrakt wird die endoskopische Vakuum-Schwamm-Therapie erfolgreich eingesetzt, wenngleich die Schwammapplikation sich technisch anspruchsvoller gestaltet. Die endoskopische Vakuum-Schwamm-Therapie stellt hier eine neue wesentliche Alternative zur Stent­anlage bei thorakalen Anastomoseninsuffizien­zen dar. Weitere Anwendungsmöglichkeiten dieser innovativen Methode sind zu erwarten.

Abstract

Anastomotic leakage in the upper and lower intestinal tract is associated with high morbidity and mortality. Endoscopic vacuum assisted closure (E-V.A.C.) is a new innovative endoscopic therapeutic option. E-V.A.C. transfers the positive effects of vacuum assisted closure (V.A.C.) on infected cutaneous wounds to infected cavities that can only be reached endoscopically. For the treatment of rectal insufficiency, a commer­cially available vacuum system (Endosponge®) is available. In the upper gastrointestinal tract the method has been applied successfully for the treatment of intrathoracic anastomotic leakages. E-V.A.C. might be an important alternative to stent placement in intrathoracic anastomotic leakage. Additional indications for the application of E-V.A.C. are expected to be developed within the near future.

Schlüsselwörter

Anasomoseninsuffizienz - enterale Stents - endoskopische Vakuum-Schwamm-Therapie

Key words

anastomotic leakage - stent - endoscopic vacuum assisted closure

Literatur

• 1 Vikatmaa P, Juutilainen V, Kuukasjarvi P et al. Negative pressure wound therapy: a systematic review on effectiveness and safety.  Eur J Vasc ­Endovasc Surg. 2008;  36 438-448
• 2 Thompson J T, Marks M W. Negative pressure wound therapy.  Clin Plast Surg. 2007;  34 673-684
• 3 Holle G, Riedel K, von Gregory H et al. Vacuum-assisted closure therapy: Current status and basic research.  Unfallchirurg. 2007;  110 490-504
• 4 Weidenhagen R, Gruetzner K U, Wiecken T et al. Endoscopic vacuum-assisted closure of anastomotic leakage following anterior resection of the rectum: a new method.  Surg Endosc. 2008;  22 1818-1825
• 5 Glitsch A, von Bernstorff W, Seltrecht U et al. Endoscopic transanal ­vacuum-assisted rectal drainage (ETVARD): an optimized therapy for major leaks from extraperitoneal rectal anastomoses.  Endoscopy. 2008;  40 192-199
• 6 van Koperen P J, Berge Henegouwen M I, Rosman C et al. The Dutch multicenter experience of the Endo-Sponge treatment for anastomotic leakage after colorectal surgery.  Surg Endosc. 2009;  23 1379-1383
• 7 Mees S T, Palmes D, Mennigen R et al. Endo-vacuum assisted closure treatment for rectal anastomotic insufficiency.  Diseases of the Colon & Rectum. 2008;  51 404-410
• 8 Lee Y, Fujita H, Yamana H et al. Factors affecting leakage following esophageal anastomosis.  Surg Today. 1994;  24 24-29
• 9 Faller J. Surgery for esophageal and cardia cancer in Hungary: a nationwide retrospective five-year survey.  Surg Today. 1996;  26 368-372
• 10 Lang H, Piso P, Stukenborg C et al. Management and results of proximal anastomotic leaks in a series of 1114 total gastrectomies for gastric carcinoma.  Eur J Surg Oncol. 2000;  26 168-171
• 11 Miller J D, Jain M K, de Gara C J et al. Effect of surgical experience on ­results of esophagectomy for esophageal carcinoma.  J Surg Oncol. 1997;  65 20-21
• 12 Ikeguchi M, Oka S, Gomyo Y et al. Postoperative morbidity and mortality after gastrectomy for gastric carcinoma.  Hepatogastroenterology. 2001;  48 1517-1520
• 13 Schubert D, Scheidbach H, Kuhn R et al. Endoscopic treatment of tho­racic esophageal anastomotic leaks by using silicone-covered, self-expanding polyester stents.  Gastrointest Endosc. 2005;  61 891-896
• 14 Dai Y Y, Gretschel S, Dudeck O et al. Treatment of oesophageal anastomotic leaks by temporary stenting with self-expanding plastic stents.  Br J Surg. 2009;  96 887-891
• 15 Roy-Choudhury S H, Nicholson A A, Wedgwood K R et al. Symptomatic malignant gastroesophageal anastomotic leak: management with covered metallic esophageal stents.  AJR Am J Roentgenol. 2001;  176 161-165
• 16 Doniec J M, Schniewind B, Kahlke V et al. Therapy of anastomotic leaks by means of covered self-expanding metallic stents after esophago­gastrectomy.  Endoscopy. 2003;  35 652-658
• 17 Gelbmann C M, Ratiu N L, Rath H C et al. Use of self-expandable plastic stents for the treatment of esophageal perforations and symptomatic anastomotic leaks.  Endoscopy. 2004;  36 695-699
• 18 Hunerbein M, Stroszczynski C, Moesta K T et al. Treatment of thoracic anastomotic leaks after esophagectomy with self-expanding plastic stents.  Ann Surg. 2004;  240 801-807
• 19 Truong S, Bohm G, Klinge U et al. Results after endoscopic treatment of postoperative upper gastrointestinal fistulas and leaks using combined Vicryl plug and fibrin glue.  Surg Endosc. 2004;  18 1105-1108
• 20 Langer F B, Wenzl E, Prager G et al. Management of postoperative esophageal leaks with the Polyflex self-expanding covered plastic stent.  Ann Thorac Surg. 2005;  79 398-403
• 21 Radecke K, Gerken G, Treichel U. Impact of a self-expanding, plastic esophageal stent on various esophageal stenoses, fistulas, and leak­ages: a single-center experience in 39 patients.  Gastrointest Endosc. 2005;  61 812-818
• 22 Peters J H, Craanen M E, van der Peet D L et al. Self-expanding metal stents for the treatment of intrathoracic esophageal anastomotic leaks following esophagectomy.  Am J Gastroenterol. 2006;  101 1393-1395
• 23 Kauer W K, Stein H J, Dittler H J et al. Stent implantation as a treatment option in patients with thoracic anastomotic leaks after esophagec­tomy.  Surg Endosc. 2008;  22 50-53
• 24 Tuebergen D, Rijcken E, Mennigen R et al. Treatment of thoracic esophageal anastomotic leaks and esophageal perforations with endoluminal stents: efficacy and current limitations.  J Gastrointest Surg. 2008;  12 1168-1176
• 25 Wedemeyer J, Schneider A, Manns M P et al. Endoscopic vacuum-assist­ed closure of upper intestinal anastomotic leaks.  Gastrointest Endosc. 2008;  67 708-711
• 26 Wedemeyer J, Brangewitz M, Kubicka S et al. Management of major postsurgical gastroesophageal intrathoracic leaks with an endoscopic vacuum-assisted closure system.  Gastrointest Endosc. 2009;  ,  [Epub ahead of print]
• 27 Loske G, Muller C. Vacuum therapy of an esophageal anastomotic leakage – a case report.  Zentralblatt fur Chirurgie. 2009;  134 267-270
• 28 Seifert H, Biermer M, Schmitt W et al. Transluminal endoscopic ne­crosec­tomy after acute pancreatitis: a multicenter study with long-term follow-up (the GEPARD Study).  Gut. 2009;  58 1260-1266