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Intrathorakale Anastomoseninsuffizienz nach Ösophagus- und Kardiaresektion

Definition und Validierung der neuen CAES-Klassifikation

Intrathoracic anastomotic leakage following esophageal and cardial resection

Definition and validation of a new severity grading classification

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Zusammenfassung

Hintergrund und Fragestellung

Die Anastomoseninsuffizienz ist nach wie vor die Hauptursache für Mortalität nach Ösophagus- und Kardiaresektion. Da sich in Deutschland die Endoskopie als erste diagnostische Maßnahme beim Verdacht auf eine Insuffizienz etabliert hat, hat die CAES auf der Basis des endoskopischen Befundes eine Definition und Schweregradklassifikation der Insuffizienz nach Ösophagusresektion entwickelt und validiert.

Material und Methoden

Der 2010 publizierte und 2013 validierte Vorschlag der internationalen Studiengruppe für die Insuffizienz nach anteriorer Rektumresektion diente als Basis für die intrathorakale Anwendung. Die Schwere der Insuffizienz sollte anhand der Bedeutung für das klinische Management bewertet werden: Typ I konservatives Management, Typ II interventionell radiologisch oder endoskopische Therapie und Typ III chirurgische Revision. Im Unterschied zur Rektumklassifikation wurde eine Unterteilung des Typ III in eine Kategorie ohne (Typ IIIa) und mit Diskontinuitätsresektion (Typ IIIb) vorgenommen. Die Validierung erfolgte anhand eines 10-Jahres-Kollektivs aus den Unikliniken Heidelberg und Tübingen.

Ergebnisse

Im Zeitraum 2006 bis 2015 wurden alle 92 Patienten, die nach Ösophagus- und Kardiaresektion eine Insuffizienz entwickelten, in das Kollektiv eingeschlossen. Wir fanden einen signifikanten Anstieg der IMC/ICU-Tage mit aufsteigenden Typen der Klassifikation (p < 0,0143). Weiterhin fand sich eine signifikante Korrelation sowohl mit der allgemeinen Klassifikation postoperativer Komplikationen nach Clavien-Dindo als auch mit der Mortalität (p < 0,001).

Diskussion

Standardisierte Parameter sind die Voraussetzung, um Ergebnisse zwischen Kliniken und Studien vergleichen zu können. Die Validierung der hier vorgeschlagenen Klassifikation zeigt, dass die Differenzierung zwischen den Gruppen durch die Korrelationen zu Intensivaufenthalt, Clavien-Dindo und Mortalität untermauert wird und damit in Zukunft zur besseren Vergleichbarkeit der Daten zu Insuffizienz nach Ösophagusresektion beiträgt.

Abstract

Background

Anastomotic leakage is still the most frequent cause of postoperative mortality following esophageal and cardial surgery. The German Advanced Surgical Study Group recommended that endoscopy should be the first diagnostic method if leakage is suspected. The German Surgical Endoscopy Association developed and validated a definition and severity classification of anastomotic leakage following esophageal and cardial resection.

Material and methods

In 2010 the international study group on insufficiency published a definition and severity grading of anastomotic leakage following anterior resection of the rectum, which was validated in 2013. The severity of anastomotic leakage should be graded according to the impact on clinical management: type I requires only conservative management, type II requires interventional radiological or endoscopic treatment and type III requires surgical revision. In contrast to the rectal classification type III is divided into a category without (type IIIa) or with (type IIIb) conduit resection and diversion. The validation was carried out on a 10-year collective from the university hospitals in Heidelberg and Tübingen.

Results

From 2006–2015 all 92 patients who developed an anastomotic leakage following esophageal and cardial resection were enrolled in the study. We found a significant increase in the length of stay in the intensive care unit (ICU) with increasing classification type (p < 0.0143). Furthermore, there was a significant correlation with the general classification of postoperative complications according to Clavien-Dindo as well as with mortality (p < 0.001).

Discussion

Standardized parameters are the prerequisite to be able to compare the results between hospitals and studies. The validation of the suggested classification shows that the differentiation between the groups is substantiated by the correlation to the length of ICU stay, Clavien-Dindo and mortality and will therefore contribute to a better comparability of data on leakage following esophageal resection in the future.

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Authors and Affiliations

  1. Klinik für Allgemein‑, Viszeral- und Transplantationschirurgie, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland

    A. Schaible, T. Schmidt, M. Diener & U. Hinz

  2. Klinik für Gastroenterologie, Infektionskrankheiten und Vergiftung, Universitätsklinikum Heidelberg, Heidelberg, Deutschland

    P. Sauer

  3. Viszeral- und Transplantationschirurgie, Universitätsklinik für Allgemeine, Tübingen, Deutschland

    D. Wichmann & A. Königsrainer

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  1. A. Schaible
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  2. T. Schmidt
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  3. M. Diener
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  4. U. Hinz
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  5. P. Sauer
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Correspondence to A. Schaible.

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Interessenkonflikt

A. Schaible, T. Schmidt, M. Diener, U. Hinz, P. Sauer, D. Wichmann und A. Königsrainer geben an, dass kein Interessenkonflikt besteht.

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

Additional information

CAES – Chirurgische Arbeitsgemeinschaft für Endoskopie und Sonografie der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV)

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Schaible, A., Schmidt, T., Diener, M. et al. Intrathorakale Anastomoseninsuffizienz nach Ösophagus- und Kardiaresektion. Chirurg 89, 945–951 (2018). https://doi.org/10.1007/s00104-018-0738-7

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