Roboterchirurgie am Ösophagus

 

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Zusammenfassung

Hintergrund: Die abdominothorakale Ösophagusresektion nach Ivor Lewis zählt zu den komplexen viszeralchirurgischen Eingriffen. In den letzten Jahren wurden zunehmend Teilschritte in minimalinvasiver Technik durchgeführt, jedoch ist insbesondere die intrathorakale Anastomose bei dem heutigen Stand der apparativen und technischen Mittel nach wie vor eine Herausforderung. Wir berichten detailliert über den Einsatz des Da Vinci-Robotersystems und unsere Technik bei der Ösophaguschirurgie. Material und Methoden: In einer prospektiven Datensammlung erfolgte die Auswertung der im Universitätsklinikum Schleswig-Holstein, Campus Kiel, im Zeitraum von November 2013 bis November 2015 durchgeführten roboterassistierten Ösophagusoperationen. Ergebnisse: Insgesamt 56 Patienten unterzogen sich einer roboterassistierten Operation an der Speiseröhre, wobei 43 Ivor-Lewis-, 10 McKeown-Prozeduren bei Karzinomen sowie 3 Enukleationen von Leiomyomen durchgeführt wurden. Bei 53 (93,4 %) der Patienten konnte ein R0-Resektionsstatus erreicht werden, die mittlere Lymphknotenausbeute betrug 23 (14–75). 45 der Patienten (80,5 %) wurden neoadjuvant vorbehandelt. Die mittlere OP-Zeit betrug 412 min (120–610). Eine Konversion auf ein offenes Verfahren war bei 19 (34,1 %) notwendig, wobei dies überwiegend (17 Patienten) im thorakalen Teil der Operation notwendig war. Bei 43 Patienten wurde eine intrathorakale Ösophagogastrostomie angelegt; bei der initial angelegten Seit-zu-Seit-Ösophagogastrostomie entwickelten 4 von 5 Patienten eine Leckage, sodass die Technik auf ein handgenähtes Verfahren umgestellt wurde (Leckage bei 3 von 20 Patienten). Andere Majorkomplikationen waren eine Leckage im Magenschlauch bei 2 (3,6 %), eine bronchotracheale Fistel bei 2 (3,6 %), mesenteriale Ischämie bei 1 (1,8 %), Peritonitis durch dislozierte Ernährungssonde bei 1 (1,8 %), pulmonale Komplikationen bei 19 (34 %) der Patienten. Vier (7,1 %) der Patienten verstarben postoperativ aufgrund einer Lungenarterienembolie, eines Myokardinfarkts sowie eines septischen Kreislaufversagens. Schlussfolgerung: Die roboterassistierte minimalinvasive Ösophagusresektion kann technisch und onkologisch sinnvoll angewandt werden. Die Einführung dieser Technik sollte in einem strukturierten Programm mit einer kritischen und intensiven Evaluation eigener Ergebnisse und einem Austausch mit anderen Gruppen erfolgen. Dadurch können „Pitfalls“ vermieden werden und eine schnellere Lernkurve erreicht werden. Weitere technische Entwicklungen und Erfahrungen könnten dazu führen, dass diese Technik zunehmende Anwendung findet.

Abstract

Background: Abdominothoracic oesophageal resections, also known as Ivor Lewis procedures, are complex visceral surgery procedures. In recent years, substeps have increasingly been performed using minimally invasive techniques. However, intrathoracic anastomosis is still a challenge given the instrumental and technological possibilities available to date. This article provides a detailed description of the use of the Da Vinci robotic system and our techniques in oesophageal surgery. Methods: In a prospective data collection, we analysed the robotic-assisted oesophageal surgeries performed at the University Hospital of Schleswig-Holstein, Campus Kiel, between November 2013 and November 2015. Results: A total of 56 patients underwent robotic-assisted oesophageal surgery, with 43 patients undergoing the Ivor Lewis technique, 10 patients undergoing the McKeown procedure and 3 patients undergoing enucleation of a leiomyoma. A complete tumour resection (R0 margin) was achieved in 53 patients (93.4 %); the mean number of resected lymph nodes was 23 (14–75). Forty-five (80.5 %) patients received an induction therapy. Mean operative time was 412 min (120–610); mean hospital stay was 19 days (4–145). A conversion to open surgery was necessary in 19 (34.1 %) cases, most notably in the thoracic part of the surgical procedure (17 patients). Forty-three patients received intrathoracic oesophagogastrostomy; 4 out of 5 patients with an initial side-to-side anastomosis developed a leakage, whereupon the technique was switched to a hand-sewn procedure (leakage in 3 out of 20 patients). Other major morbidities included leakage of the gastric conduit in 2 patients (3.6 %), airway fistula in 2 patients (3.6 %), mesenteric ischaemia in one patient (1.8 %), and peritonitis due to a dislocated feeding tube in one other patient. Pulmonary complications occurred in 19 patients (34 %). Four patients (7.1 %) died of pulmonary embolism, heart attack, and septic organ failure. Conclusion: Robotic-assisted, minimally invasive oesophagectomy is a feasible and useful approach for oncological surgery. This technique should be implemented in a structured program with an extensive and critical evaluation of the usersʼ own results and an exchange with other experienced work teams. This helps to avoid pitfalls and to speed up the learning curve. Further technological developments and increasing experience might lead to a more widespread use of this technique.

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