Endoskopische Therapie von Leckagen im Gastrointestinaltrakt, an den Gallenwegen und im Pankreas

Zusammenfassung

Die Therapie von Perforationen, Leckagen und Fisteln im Gastrointestinaltrakt war früher eine Domäne der Chirurgie. Heute ist in vielen Fällen eine weniger invasive endoskopische Therapie möglich. Der Endoskopiker hat die Möglichkeit, Perforationen als Folge endoskopischer Untersuchungen, Bougierungen und Resektionen während des Eingriffs unmittelbar zu verschließen. Im Ösophagus ist die effektive Therapie von Perforationen und Anastomoseninsuffizienzen durch die temporäre Platzierung von gecoverten Stents gut etabliert. Mit herkömmlichen Metallclips lassen sich kleinere Leckagen und Fisteln im Ösophagus und Magen-Darm-Trakt verschließen. Die seit Kurzem verfügbaren Over-the-scope-Clips und spezielle Fasszangen und Anker ermöglichen einen sichereren Vollwandverschluss im oberen Gastrointestinaltrakt und im Rektosigmoid. Die endoskopisch geführte Vakuum-Schwammtherapie ist bei rektalen Anastomoseninsuffizienzen etabliert und wird zunehmend auch bei Leckagen im Bereich des Ösophagus eingesetzt. Bei Gallenwegsleckagen nach endoskopischen oder chirurgischen Gallenwegseingriffen reicht meist die effektive interne Galleableitung mittels temporärem Stenting des Gallengangs aus. In einigen Fällen ist ein Verschluss durch gecoverte Metallstents oder mittels Coils erforderlich. Pankreasleckagen stellen ein therapeutisches Problem dar und können multimodale Therapien mit Stenting, Verklebung und Coils erforderlich machen.

Abstract

Surgery has been the mainstay of therapy in patients with gastrointestinal perforations, leakage or fistulas. New techniques for endoscopic closure of gastrointestinal perforations provide tools for an effective treatment by less invasive procedures. Temporary placement of covered self-expanding stents is an established therapy for oesophageal perforations and anastomotic leaks. Using conventional endoclips small perforations and leaks in the oesophagus and gastrointestinal tract may be closed. With the new over-the-scope-clips a more effective endoscopic full wall closure is possible in the upper gastrointestinal tract and the rectum. Endoscopically guided endoluminal vacuum therapy using polyurethane sponges is an established method for treating rectal leaks and is now increasingly used also in oesophageal leaks. Biliary leakage following endoscopic or surgical interventions is effectively treated with temporary bile stenting in most cases, but closure using metal stents or coiling may be necessary. Pancreatic leaks are a major therapeutic problem and may require multimodal therapies.

Schlüsselwörter

Perforationen - Anastomoseninsuffizienzen - endoskopische Behandlung - Over-the-scope-Clips - Vakuum-Schwammtherapie - Stenting

Key words

perforations - anastomotic leaks - endoscopic treatment - over-the-scope-clip - stenting

Literatur

• 1 Eroglu A, Turkyilmaz A, Aydin Y et al. Current management of esophageal perforation: 20 years experience.  Dis Esophagus. 2009;  22 374-380
• 2 Sepesi B, Rymond D P, Peters J H. Esophageal perforation: surgical, endoscopic and medical management strategies.  Curr Opin Gastroenterol. 2010;  26 379-383
• 3 Qadeer M A, Dumot J A, Vargo J J et al. Endoscopic clips for closing esophageal perforations: case report and pooled analysis.  Gastrointest Endosc. 2007;  66 605-611
• 4 Pohl J, Borgulya M, Lorenz D et al. Endoscopic closure of postoperative esophageal leaks with a novel over-the-scope clip system.  Endoscopy. 2010;  42 757-759
• 5 Fritscher-Ravens A, Hampe J et al. Clip closure versus endoscopic suturing versus thoracoscopic repair of an iatrogenic esophageal perforation: a randomized, comparative, long-term survival study in a porcine model.  Gastrointest Endosc. 2010;  72 1020-1026
• 6 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
• 7 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;  79 398-404
• 8 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
• 9 Johnsson E, Lundell L, Liedman B. Sealing of esophageal perforation or ruptures with expandable metallic stents: a prospective controlled study on treatment efficacy and limitations.  Dis Esophagus. 2005;  18 262-266
• 10 Freeman R K, Van Woerkom J M, Ascioti A J. Esophageal stent placement for the treatment of iatrogenic intrathoracic esophageal perforation.  Ann Thorac Surg. 2007;  83 2003-2008
• 11 Freeman R K, Ascioti A J, Wozniak T C. Postoperative esophageal leak management with the Polyflex esophageal stent.  J Thorac Cardiovasc Surg. 2007;  133 333-338
• 12 Salminen P, Gullichsen R, Laine S. Use of self-expandable metal stents for the treatment of esophageal perforations and anastomotic leaks.  Surg Endosc. 2009;  23 1526-1530
• 13 Dai Y, S C hopra S, Kneif S et al. Management of esophageal anastomotic leaks, perforations, and fistulae with self-expanding plastic stents.  J Thorac Cardiovasc Surg. 2010; 
• 14 Bakken J C, Wong Kee Song L M, Groen P C et al. Use of a fully covered self-expandable metal stent for the treatment of benign esophageal diseases.  Gastrointest Endosc. 2010;  72 712-720
• 15 Van Heel N C, Haringsma de J, Spaander M C et al. Short-term esophageal stenting in the management of benign perforations.  Am J Gastroenterol. 2010;  105 1515-1520
• 16 Eloubeidi M A, Lopes T L. Novel removable internally fully covered self-expanding metal esophageal stent: feasibility, technique of removal, and tissue response in humans.  Am J Gastroenterol. 2009;  104 1374-1381
• 17 Cerná M, Köcher M, Válek V et al. Covered Biodegradable Stent: New Therapeutic Option for the Management of Esophageal Perforation or Anastomotic Leak.  Cardiovasc Intervent Radiol. 2011; 
• 18 Wedemeyer J, Schneider A, Manns M P et al. Endoscopic vacuum-assisted closure of upper intestinal anastomotic leaks.  Gastrointest Endosc. 2008;  67 708-711
• 19 Wedemeyer J, Helfritz F A, Brangewitz M et al. Endoskopische Vakuum-Schwamm-Therapie bei Leckagen im Verdauungstrakt.  Endoskopie heute. 2010;  23 41-45
• 20 Loske G, Schorsch T, Müller C. Endoscopic vacuum sponge therapy for esophageal defects.  Surg Endosc. 2010;  24 2531-2535
• 21 Ahrens M, Schulte T, Egberts J et al. Drainage of esophageal leakage using endoscopic vacuum therapy: a prospective pilot study.  Endoscopy. 2010;  42 693-698
• 22 Schmidt S C, Strauch S, Rösch T et al. Management of esophageal perforations.  Surg Endosc. 2010;  24 2809-2813
• 23 Abbas G, Schuchert M J, Pettiford B L et al. Contemporaneous management of esophageal perforation.  Surgery. 2009;  146 749-755
• 24 Fujishiro M, Yahagi N, Kakushima N et al. Successful nonsurgical management of perforation complicating endoscopic submucosal dissection of gastrointestinal epithelial neoplasms.  Endoscopy. 2006;  38 1001-1006
• 25 Kirschniak A, Kratt T, Stüker D et al. A new endoscopic over-the-scope clip system for treatment of lesions and bleeding in the GI tract: first clinical experiences.  Gastrointest Endosc. 2007;  66 162-167
• 26 Seebach L, Bauerfeind P, Gubler C. „Sparing the surgeon”: clinical experience with over-the-scope clips for gastrointestinal perforation.  Endoscopy. 2010;  42 1108-1111
• 27 Von Renteln D, Vassiliou M C, Rothstein R I. Randomized controlled trial comparing endoscopic clips and over-the-scope clips for closure of natural orifice transluminal endoscopic surgery gastrotomies.  Endoscopy. 2009;  41 1056-1061
• 28 Sumiyama K, Gostout C J, Rajan E et al. Endoscopic full-thickness closure of large gastric perforations by use of tissue anchors.  Gastrointest Endosc. 2007;  65 134-139
• 29 Von Renteln D, Schmidt A, Riecken B et al. Gastric full-thickness suturing during EMR and for treatment of gastric-wall defects.  Gastrointest Endosc. 2008;  67 738-744
• 30 Wedi E, Menke D, Hochberger J. Endoskopischer Verschluss eines intraoperativ perforierten Duodenaldivertikels mit einem „Over-the-Scope-Clip” (OTSC) – Ein Fallbericht.  Endoskopie heute. 2010;  23 224-226
• 31 Frieling T, Heise J, Wassilew S W. Multiple colon ulcerations, perforation and death during treatment of malignant melanoma with sorafenib.  Dtsch Med Wochenschr. 2009;  134 1464-1466
• 32 Panteris V, Haringsma J, Kuipers J. Colonoscopy perforation rate, mechanisms and outcome: from diagnostic to therapeutic colonoscopy.  Endoscopy. 2009;  41 941-951
• 33 Rabeneck L, Paszat L F, Hilsden R J et al. Bleeding and perforation after outpatient colonoscopy and their risk factors in usual clinical practice.  Gastroenterology. 2008;  135 1899-1906
• 34 Lohsiriwat V. Colonoscopic perforation: incidence, risk factors, management and outcome.  World Gastroenterol. 2010;  16 425-430
• 35 Luning T H, Keemers-Gels M E, Barendregt W B et al. Colonoscopic perforations: a review of 30 366 patients.  Surg Endosc. 2007;  21 994-997
• 36 Damore L J, Rantis P C, Vernava A M et al. Colonoscopic perforations. Etiology, diagnosis, and management.  Dis Colon Rectum. 1996;  39 1308-1314
• 37 Anderson M L, Pasha T M, Leighton J A. Endoscopic perforation of the colon: lessons from a 10-year study.  AmJ Gastroenterol. 2000;  95 3418-3422
• 38 Cobb W S, Heniford B T, Sigmon L B et al. Colonoscopic perforations: incidence management and outcomes.  Am Surg. 2004;  70 750-757
• 39 Iqbal C W, Chun Y S, Farley D R. Colonoscopic perforations: a retrospective review.  J Gastrointest Surg. 2005;  9 1229-1235
• 40 Dafnis G, Ekbom A, Pahlman L et al. Complications of diagnostic and therapeutic colonoscopy within a defined population in Sweden.  Gastrointest Endosc. 2001;  54 302-330
• 41 Tulchinsky H, Madhala-Givon O, Wasserberg N et al. Incidence and management of colonoscopic perforations: 8 years’ experience World.  J Gastroenterol. 2006;  12 4211-4213
• 42 Frieling T. Das akute Abdomen aus internistischer Sicht.  Dtsch Med Wochenschr. 2009;  134 246-250
• 43 Waye J D, Kahn O, Auerbach M E. Complications of colonoscopy and flexible sigmoidoscopy.  Gastrointest Endosc Clin N Am. 1996;  6 343-377
• 44 Yoshikane H, Hidano H, Sakakibara A et al. Endoscopic repair by clipping of iatrogenic colonic perforation.  Gastrointest Endosc. 1997;  46 464-466
• 45 Magdeburg R, Collet P, Post S et al. Endoclipping of iatrogenic colonic perforation to avoid surgery.  Surg Endosc. 2008;  22 1500-1504
• 46 Taku K, Sano Y, Fu K I et al. Iatrogenic perforation at therapeutic colonoscopy: should the endoscopist attempt closure using endoclips or transfer immediately to surgery?.  Endoscopy. 2006;  38 428
• 47 Heldwein W, Dollhopf M, Rosch T et al. The Munich Polypectomy Study (MUPS): prospective analysis of complications and risk factors in 4000 colonic snare polypectomies.  Endoscopy. 2005;  37 1116-1122
• 48 Mana F, De Vogelaere K, Urban D. Iatrogenic perforation of the colon during diagnostic colonoscopy: endoscopic treatment with clips.  Gastrointest Endosc. 2001;  54 258-259
• 49 Ahlawat S, Al-Kawas F H. Invagination of the muscularis propria in a polyp stalk: a rare cause of post-polypectomy perforation of the colon.  Endoscop. 2007;  39 (Suppl 1) E78-79
• 50 Trecca A, Gaj F. Large iatrogenic colonic perforation repaired endoscopically with Triclip.  Tech Coloproctol. 2007;  11 87
• 51 Dhalla S S. Endoscopic repair of a colonic perforation following polypectomy using an endoclip.  Can J Gastroenterol. 2004;  18 105-106
• 52 Taku K, Sano Y, Fu K I et al. Iatrogenic perforation associated with therapeutic colonoscopy: a multicenter study in Japan.  J Gastroenterol Hepatol. 2007;  22 1409-1414
• 53 Barbagallo F, Castello G, Latteri S et al. Successful endoscopic repair of an unusual colonic perforation following polypectomy using an endoclip device.  World J Gastroenterol. 2007;  13 2889-2891
• 54 Ahlawat S K, Charabaty A, Benjamin S. Rectal perforation caused by retroflexion maneuver during colonoscopy: closure with endoscopic clips.  Gastrointest Endosc. 2008;  67 771-773
• 55 Raju G S. Endoscopic closure of gastrointestinal leaks.  Am J Gastroenterol. 2009;  104 1315-1320
• 56 Trecca A, Gagliardi G. Our experience with endoscopic repair of large colonoscopic perforations and review of the literature.  Tech Coloproctol. 2008;  12 315-321
• 57 Celestino C, Harz C, Decaestecker J et al. Endoscopic treatment of an iatrogenic perforation of the colon by using endoloop.  Gastrointest Endosc. 2006;  64 653-654
• 58 Mangiavillano B, Viaggi P, Masci E. Endoscopic closure of acute iatrogenic perforations during diagnostic and therapeutic endoscopy in the gastrointestinal tract using metallic clips: a literature review.  J Dig Dis. 2010;  11 12-18
• 59 Von Renteln D, Schmidt A, Vassiliou M C et al. Endoscopic closure of large colonic perforations using an over-the-scope clip: a randomized controlled porcine study.  Endoscopy. 2009;  41 481-486
• 60 Chopra S S, Mrak K, Hünerbein M. The effect of endoscopic treatment on healing of anastomotic leaks after anterior resection of rectal cancer.  Surgery. 2009;  145 182
• 61 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
• 62 Glitsch A, Bernstorff von 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
• 63 Mees S T, Palmes D, Mennigen R et al. Endo-vacuum assisted closure treatment for rectal anastomotic insufficiency.  Dis Colon Rectum. 2008;  51 404-410
• 64 Van de Sande S, Bossens M, Parmentier Y et al. National survey on cholecystectomy related bile duct injury--public health and financial aspects in Belgian hospitals 1997.  Acta Chir Belg. 2003;  103 168-180
• 65 Buanes T, Waage A, Mjaland O et al. Bile leak after cholecystectomy significance and treatment: results from the National Norwegian Cholecystectomy Registry.  Int Surg. 1996;  81 276-279
• 66 Prakash K, Jacob G, Lekha V et al. Laparoscopic cholecystectomy in acute cholecystitis.  Surg Endosc. 2002;  16 180-183
• 67 Lau W Y, Lai E C, Lau S H. Management of bile duct injury after laparoscopic cholecystectomy: a review.  ANZ J Surg. 2010;  80 75-81
• 68 Selvaggi F, Cappello G, Astolfi A et al. Endoscopic therapy for type B surgical biliary injury in a patient with short cystic duct.  G Chir. 2010;  31 229-232
• 69 Kauvar D S, Braswell A, Brown B D et al. Influence of resident and attending surgeon seniority on operative performance in laparoscopic cholecystectomy.  J Surg Res. 2006;  132 159-163
• 70 Kaffes A J, Hourigan L, De Luca N et al. Impact of endoscopic intervention in 100 patients with suspected postcholecystectomy bile leak.  Gastrointest Endosc. 2005;  61 269-275
• 71 Sandha G S, Bourke M J, Haber G B et al. Endoscopic therapy for bile leak based on a new classification: results in 207 patients.  Gastrointest Endosc. 2004;  60 567-574
• 72 Katsinelos P, Paroutoglou G, Beltsis A et al. Endobiliary endoprosthesis without sphincterotomy for the treatment of biliary leakage.  Surg Endosc. 2004;  8 165-166
• 73 Elmi F, Silverman W B. Nasobiliary tube management of postcholecystectomy bile leaks.  J Clin Gastroenterol. 2005;  39 441-444
• 74 Kiltz U, Baier J, Adamek R J. Selective embolization of a bile leak after operative resection of an echinococcal cyst.  Dtsch Med Wochenschr. 1999;  124 650-652
• 75 Vu D N, Strub W M, Nguyen P M. Biliary duct ablation with N-butyl cyanoacrylate.  J Vasc Interv Radiol. 2006;  17 63-69
• 76 Tsukamoto T, Hirohashi K, Osugi H et al. Percutaneous management of bile duct injuries after cholecystectomy.  Hepatogastroenterology. 2002;  49 113-115
• 77 Schelhammer F, Dahl vom S, Heintges T et al. A multimodal approach in coil embolization of a bile leak following cholecystectomy.  Cardiovasc Intervent Radiol. 2007;  30 529-530
• 78 Oliva V L, Nicolet V, Soulez G et al. Biliomas developing after laparoscopic biliary surgery: percutaneous management with embolization of biliary leaks.  J Vasc Interv Radiol. 1997;  8 469-473
• 79 Hunt J A, Gallagher P J, Heintze S W et al. Percutaneous microcoil embolization of intraperitoneal intrahepatic and extrahepatic biliary fistulas.  Aust N Z J Surg. 1997;  67 424-427
• 80 Sandroussi C, Lemech L D, Grunewald B et al. Late complication following coil embolization of a biliary leak.  ANZ J Surg. 2005;  75 614-615
• 81 Ryan M E, Geenen J E, Lehman G A et al. Endoscopic intervention for biliary leaks after laparoscopic cholecystectomy: a multicenter review.  Gastrointest Endosc. 1998;  47 261-266
• 82 Sicklick J K, Camp M S, Lillemoe K D et al. Surgical management of bile duct injuries sustained during laparoscopic cholecystectomy: perioperative results in 200 patients.  Ann Surg. 2005;  241 786-795
• 83 Boerma D, Rauws E AJ, Gulik T M et al. Endoscopic stent placement for pancreaticocutaneous fistula after surgical drainage of the pancreas.  Br J Surg. 2000;  87 1506-1509
• 84 Kim H S, Lee D K, Kim I W et al. The role of endoscopic retrograde pancreatography in the treatment of traumatic pancreatic duct injury.  Gastrointest Endosc. 2001;  54 49-55
• 85 Lau S T, Simchuk E J, Kozarek R A et al. A pancreatic leak should be sought to direct treatment in patients with acute pancreatitis.  Am J Surg. 2001;  181 411-415
• 86 Martin F M, Rossi R L, Munson J L. Management of pancreatic fistulas.  Arch Surg. 1989;  124 571-573
• 87 Roder J D, Stein H J, Böttcher K A et al. Stented versus nonstented pancreaticojejunostomy after pancreatoduodenectomy.  Ann Surg. 1999;  229 41-48
• 88 Rieder van B, Krampulz D, Adolf J et al. Endoscopic pancreatic sphincterotomy and stenting for preoperative prophylaxis of pancreatic fistula after distal pancreatectomy.  Gastrointest Endosc. 2010;  72 543-545
• 89 Fockens P. EUS in drainage of pancreatic pseudocysts.  Gastrointest Endosc. 2002;  56 S93-S97
• 90 Costamagna G, Mutignari M, Ingrosso M et al. Endoscopic treatment of postsurgical external pancreatic fistulas.  Endoscopy. 2001;  33 317-322
• 91 Kozarek R A, Ball T J, Patterson D J et al. Endoscopic transpapillary therapy for disrupted pancreatic duct and peripancreatic fluid collections.  Gastroenterology. 1991;  100 1362-1370
• 92 Labori K J, Trondsen E, Buanes T et al. Endoscopic sealing of pancreatic fistula: four case reports and review of the literature.  Scand J Gastroenterol. 2009;  44 1491-1496
• 93 Lüthen R, Jaklin P, Cohnen M. Permanent closure of a pancreatic duct leak by endoscopic coiling.  Endoscopy. 2007;  39 (S1) E21-E22
• 94 Meining A, Feussner H, Swain P et al. Natural-orifice transluminal endoscopic surgery (NOTES) in Europe: summary of the working group reports of the Euro-NOTES meeting 2010.  Endoscopy. 2011;  43 140-143
• 95 Honore C, Vibert E, Hoti E et al. Management of excluded segmental bile duct leakage following liver resection.  HPB (Oxford). 2009;  11 364-369
• 96 Zyromski N J, Lillemoe K D. Current management of biliary leaks.  Adv Surg. 2006;  40 21-46
• 97 Ponsky J L. Endoscopic approaches to common bile duct injuries.  Surg Clin North Am. 1996;  76 505-513