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Perioperatives Management der transthorakalen Ösophagektomie

Grundlagen der interdisziplinären Patientenversorgung und neue Konzepte zur beschleunigten postoperativen Erholung

Perioperative management of transthoracic oesophagectomies

Fundamentals of interdisciplinary care and new approaches to accelerated recovery after surgery

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Zusammenfassung

Lokal fortgeschrittene Karzinome des Ösophagus werden gegenwärtig multimodal therapiert. Kernelement des kurativen Therapieansatzes ist die Ösophagektomie. Als Standardeingriff wird in spezialisierten Zentren die transthorakale En-bloc-Ösophagektomie durchgeführt. Die Rekonstruktion der intestinalen Passage erfolgt meist durch Schlauchmagen, der entweder thorakal oder zervikal an den verbleibenden Ösophagus anastomosiert wird. Dieser thorakoabdominale Eingriff ist mit einer klinisch relevanten postoperativen Morbidität verbunden, nicht zuletzt auch wegen der oft multiplen Vorerkrankungen der operierten Patienten. Für ein optimales Ergebnis sind eine sorgfältige interdisziplinäre Patientenauswahl, präoperative Risikoevaluation und Konditionierung erforderlich. Die Erfahrung des Zentrums korreliert invers mit der Komplikationsrate. Die führende chirurgische Komplikation ist die Anastomoseninsuffizienz, die endoskopisch-interventionell diagnostiziert und in aller Regel mithilfe endoskopischer Therapieverfahren behandelt wird. Auf der Seite der nichtchirurgischen Komplikationen dominieren pulmonale Infektionen. Eine thorakale Periduralanästhesie (PDA) und ein perfusionsorientiertes Volumenmanagement können die Rate an pulmonalen Komplikationen senken. Die Patienten werden lungenprotektiv beatmet und frühzeitig extubiert. Ösophagektomien sollen in Zentren mit hoher Fallzahl in enger chirurgischer und anästhesiologisch-intensivmedizinischer Kooperation durchgeführt werden. Enhanced-recovery-after-surgery-Programme beinhalten ein weiteres Potenzial zur schnelleren postoperativen Rekonvaleszenz der Patienten. Dieser Übersichtsbeitrag beschreibt die grundlegenden Aspekte des interdisziplinären perioperativen Managements der transthorakalen Ösophagektomie.

Abstract

Locally advanced carcinomas of the oesophagus require multimodal treatment. The core element of curative therapy is transthoracic en bloc oesophagectomy, which is the standard procedure carried out in most specialized centres. Reconstruction of intestinal continuity is usually achieved with a gastric sleeve, which is anastomosed either intrathoracically or cervically to the remaining oesophagus. This thoraco-abdominal operation is associated with significant postoperative morbidity, not least because of a vast array of pre-existing illnesses in the surgical patient. For an optimal outcome, the careful interdisciplinary selection of patients, preoperative risk evaluation and conditioning are essential. The caseload of the centres correlates inversely with the complication rate. The leading surgical complication is anastomotic leakage, which is diagnosed endoscopically and usually treated with the aid of endoscopic procedures. Pulmonary infections are the most frequent non-surgical complication. Thoracic epidural anaesthesia and perfusion-orientated fluid management can reduce the rate of pulmonary complications. Patients are ventilated protecting the lungs and are extubated as early as possible. Oesophagectomies should only be performed in high-volume centres with the close cooperation of surgeons and anaesthesia/intensive care specialists. Programmes of enhanced recovery after surgery (ERAS) hold further potential for the patient’s quicker postoperative recovery. In this review article the fundamental aspects of the interdisciplinary perioperative management of transthoracic oesophagectomy are described.

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Authors and Affiliations

  1. Klinik für Allgemein-, Viszeral- und Tumorchirurgie, Uniklinik Köln, Köln, Deutschland

    R. Lambertz, M. Bludau & W. Schröder

  2. Klinik für Anästhesiologie und Operative Intensivmedizin, Uniklinik Köln, Kerpenerstr. 62, 50937, Köln, Deutschland

    H. Drinhaus, D. Schedler &  T. Annecke

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  1. R. Lambertz
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  2. H. Drinhaus
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  3. D. Schedler
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  4. M. Bludau
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Correspondence to T. Annecke.

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R. Lambertz, H. Drinhaus, D. Schedler, M. Bludau und W. Schröder geben an, dass kein Interessenkonflikt besteht. T. Annecke erhält Forschungsunterstützung durch die Firmen Pulsion (Sachmittel), Köhler Chemie (Sachmittel) und Cytosorbents.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Lambertz, R., Drinhaus, H., Schedler, D. et al. Perioperatives Management der transthorakalen Ösophagektomie. Anaesthesist 65, 458–466 (2016). https://doi.org/10.1007/s00101-016-0179-y

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