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DOI: 10.1055/s-0042-119304
Der postoperative Enterothorax – Fallserie und Literaturanalyse
Diaphramatic Herniation of Abdominal Contents: Case Series and Review of the LiteraturePublication History
Publication Date:
16 March 2017 (online)
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Zusammenfassung
Hintergrund Ein Enterothorax mit Hernierung von Darmanteilen durch einen Zwerchfelldefekt ist eine seltene postoperative Komplikation, die sowohl in der frühen postoperativen Phase wie auch erst Monate nach dem Primäreingriff auftreten kann. Die Diagnose erfordert in praktisch allen Fällen eine operative Therapie mit Reposition der hernierten Strukturen und Verschluss des Zwerchfelldefekts. Das Ziel der hier vorliegenden Arbeit war die Beschreibung einer größeren Fallserie einer seltenen Komplikation und das Herausarbeiten von therapierelevanten Besonderheiten sowie die Durchsicht der relevanten Literatur zum Thema.
Material und Methoden Die Daten der an unserem Zentrum aufgrund eines postoperativen Enterothorax therapierten Patienten wurden retrospektiv ausgewertet. Insbesondere der Zeitpunkt des Auftretens und die Art der klinischen Symptome, die operative Therapie und die postoperative Morbidität wurden analysiert.
Ergebnisse Von März 2007 bis Oktober 2014 wurden 20 Patienten aufgrund eines postoperativen Enterothoraxes operiert. In 6 Fällen (30 %) handelte es sich hierbei um eine frühe postoperative Komplikation (im Mittel am 10. postoperativen Tag), bei 14 Patienten (70 %) wurde der Enterothorax erst verzögert (im Mittel 42 Monate nach der Primäroperation) auffällig. Die Varianz der klinischen Symptome war breit, in der Mehrzahl der Fälle präsentierten sich die Patienten jedoch mit einer Ileussymptomatik oder neu aufgetretener Dyspnoe. Bei 2 Patienten (10 %) war die Diagnose ein Zufallsbefund ohne klinische Symptome. Eine Computertomografie (CT) erfolgte bei 70 % (n = 14), ein Röntgenthorax bei 30 % (n = 6) der Patienten zur Diagnosestellung. Eine unverzügliche Laparotomie erfolgte in 15 % (n = 3) der Fälle. Der Zwerchfelldefekt betraf in 75 % der Fälle (n = 15) die linke Seite. Die operative Therapie erfolgte bei allen Patienten über eine Laparotomie. Der Zwerchfellverschluss erfolgte bei 70 % der Patienten (n = 14) durch eine Direktnaht, bei 6 Patienten (30 %) erfolgte eine Augmentation (Netz- bzw. Gewebe-Patch). Die gesamte postoperative Morbidität lag bei 55 %, bei elektiver Operationsplanung bei 0 %, ein Patient verstarb im weiteren postoperativen Verlauf.
Schlussfolgerung Ein postoperativer Enterothorax kann frühzeitig nach der Primäroperation oder auch erst Jahre danach auftreten. Eine operative Therapie sollte auch bei asymptomatischen Verläufen zeitnah erfolgen, um weitere Komplikationen zu vermeiden.
Abstract
Background An enterothorax with herniation of bowel segments through a diaphragmatic defect is a rare postoperative complication, which can occur in the early postoperative period as well as several months or even years after the primary procedure. In virtually all cases, this diagnosis requires surgical treatment with reposition of the herniated structures and closure of the diaphragmatic defect. The aim of this study was to describe a larger case series of a rare complication and to present a review of the literature.
Material and Methods The data of all patients treated for postoperative enterothorax at our centre were retrospectively analysed with a special focus on time of occurrence, type of clinical symptoms, surgical treatment and postoperative morbidity.
Results From March 2007 to October 2014, twenty patients underwent surgery due to postoperative enterothorax. Six cases (30 %) were early postoperative complications (mean 10th postoperative day); in 14 patients (70 %) the enterothorax presented with delay (mean 42 months after primary surgery). The variance of the clinical symptoms was wide, but in the majority of cases, patients presented with symptoms of ileus or new-onset dyspnoea. In two patients (10 %) the diagnosis was an incidental finding without clinical symptoms. Computed tomography (CT) was performed in 70 % (n = 14), chest X-rays in 30 % (n = 6) of patients for diagnosis. Immediate laparotomy was performed in 15 % (n = 3) of cases. The diaphragmatic defect involved the left side in 75 % of cases (n = 15). Surgical treatment was performed via laparotomy in all patients. The diaphragm was closed by a direct suture in 70 % of patients (n = 14); in six patients (30 %) an augmentation (mesh or tissue patch) was added. Overall postoperative morbidity was 55 %; for elective operations it was 0 %. One patient died in the further postoperative course.
Conclusion Postoperative enterothorax may occur early or years after primary surgery. Surgical treatment should be performed in a timely manner even in asymptomatic patients to avoid further complications.
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