Magen- und Duodenalperforation: Welchen Stellenwert hat die laparoskopische Chirurgie?

 

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Zusammenfassung

Einleitung: Die Magen- und Duodenalperforation stellt eine lebensbedrohliche Komplikation der Ulkuskrankheit mit der sofortigen Indikation zur operativen Versorgung dar. Inwieweit die Laparoskopie in dieser Akutsituation ein geeignetes Verfahren darstellt, soll die vorliegende Untersuchung zeigen.
Material und Methoden: Die Daten aller Patienten, die innerhalb eines Zeitraums von 15 Jahren (01/1996–12/2010) wegen eines perforierten Magen- oder Duodenalulkus laparoskopisch operiert worden waren, wurden prospektiv erfasst und hinsichtlich Alter, Geschlecht, Perforationslokalisation, Diagnostik, Klinik, Operationsverfahren, intra- und postoperativen Komplikationen sowie postoperativem Verlauf retrospektiv analysiert.
Ergebnisse: Im Beobachtungszeitraum wurden 45 Patienten mit einer Magen- oder Duodenalperforation laparoskopisch operiert. Das mediane Lebensalter bei Operation betrug 58 (18–91) Jahre. Eine NSAR-Medikation bestand bei 11 (24,4 %) Patienten. Die Perforation lag bei 12 (26,7 %) Patienten präpylorisch, bei 10 (22,2 %) postpylorisch, bei je 1 (2,2 %) Patienten an der kleinen und an der großen Kurvatur, bei 18 (40,0 %) an der Vorder- und 3 (6,7 %) an der Hinterwand. In 2 Fällen bestand eine vorangegangene operative Versorgung im Oberbauch. Nach primärer diagnostischer Laparoskopie wurde bei 20 (44,4 %) Patienten die Indikation zur Konversion gestellt. Im Verlauf der laparoskopisch beendeten Operationen wurden bei 18/25 (72,0 %) Patienten eine Übernähung und bei 7/25 (37,8 %) Patienten eine Ulkusexzision durchgeführt. Nach Konversionen wurde bei 7/20 (35,0 %) Patienten eine Übernähung, bei 10/20 (50,0 %) Patienten eine Ulkusexzision und bei 3/20 (15,0 %) Patienten ein resezierender Eingriff durchgeführt. Die mediane Operationszeit betrug 105 (40–306) Minuten und die mittlere Verweildauer 11 (4–66) Tage. Der Intensivaufenthalt lag im Median bei 2 (0–37) Tagen. Majorkomplikationen bestanden bei 11 (24,4 %) Patienten. Hierbei sind im Wesentlichen Relaparotomien (n = 7; 15,6 %) und Nachblutungen (n = 4; 8,9 %) zu nennen. Minorkomplikationen waren in 8 (17,8 %) Fällen zu beobachten. Die Letalität betrug 11,1 % (n = 5).
Schlussfolgerung: Die laparoskopische Versorgung von Magen- und Duodenalperforationen stellt eine minimalinvasive therapeutische Option für die definitive Versorgung dieser lebensbedrohlichen Erkrankung dar. Die Indikation für ein laparoskopisches Vorgehen ist jedoch individuell zu stellen und wird in entscheidendem Maß von der laparoskopischen Erfahrung des Operateurs bestimmt.

Abstract

Introduction: The gastric and duodenal perforations are a life-threatening complication of peptic ulcer disease with the indication for immediate surgical intervention. To which extent laparoscopy is a suitable method in an acute situation was examined in the present investigation. Materials and Methods: The data of all patients within a period of 15 years (01/1996–12/2010) who were operated laparoscopically because of a perforated gastric or duodenal ulcer, were collected prospectively in terms of age, gender, localisation of perforation, diagnostics, symptoms, surgical procedures, intraoperative and postoperative complications and postoperative course, and were analysed retrospectively. Results: During the observation period 45 patients were operated laparoscopically due to gastric or duodenal perforation. The median age at operation was 58 (18–91) years. An NSAID medication was present in 11 (24.4 %) patients. The perforation was juxtapyloric in 12 (26.7 %) patients, postpyloric in 10 (22.2 %) patients, one (2.2 %) patient in each small and greater curvature, in 18 (40.0 %) at the front and in three (6.7 %) patients on the rear wall. In two cases, previous surgical treatment in the upper abdomen was performed. After primary diagnostic laparoscopy, an indication for conversion was seen in 20 (44.4 %) patients. During laparoscopically completed operations simple suturing was done in 18/25 (72.0 %) patients and excision and suturing was performed in 7/25 (37.8 %) patients. After conversion simple suturing was observed in 7/20 (35.0 %) patients, whereas in 10/20 (50.0 %) patients excision and suturing was performed. 3/20 (15.0 %) patients underwent a resective operation. The median operative time was 105 (40–306) minutes and mean hospitalisation 11 (4–66) days. The ICU stay was in median 2 (0–37) days. Major complications were seen in 11 (24.4 %) patients, namely re-laparotomy (n = 7; 15.6 %) and haemorrhage (n = 4; 8.9 %). Minor complications were observed in 8 (17.8 %) of cases. The mortality rate was 11.1 % (n = 5).
Conclusion: The laparoscopic treatment of gastric and duodenal perforations is a minimally invasive therapeutic option for the definitive treatment of this life-threatening disease. The indication for a laparoscopic approach has to be considered individually and depends to a decisive extent on the experience of the laparoscopic surgeon.

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