Management der postoperativ prolongierten Parenchymfistel

Zusammenfassung

Eine protrahierte Parenchymfistel ist eine der häufigsten postoperativen Komplikationen in der Thoraxchirurgie. Für elektive lungenresezierende Eingriffe wird in der Literatur von einer postoperativen protrahierten Parenchymfistel ab einer Dauer von 5 – 7 Tagen gesprochen. Es bestehen mehrere prädiktive Faktoren für die Ausbildung einer protrahierten Fistel, die sich in präoperative, wie beispielsweise die obstruktive Lungenerkrankung, und intraoperative Risikofaktoren, wie pleurale Adhäsionen oder fusionierte Fissuren, unterteilen lassen. Die Therapie der postoperativen protrahierten Parenchymfistel ist sehr individuell und unterscheidet sich unter Umständen je nach Patient erheblich. Es existieren 4 größere Bausteine als Therapieoptionen, die in ihrer Abfolge und Nutzung einen großen Behandlungsspielraum ermöglichen: eine intensivierte konservative Therapie, eine Installation von sklerosierenden Agenzien oder Eigenblut, endoskopische Verfahren oder eine chirurgische Revision. Die Vermeidung, Erkennung und Therapie einer postoperativen protrahierten Parenchymfistel sind alltägliche Aspekte der thoraxchirurgischen Arbeit mit hoher klinischer Relevanz. Neben einigen standardisierten Abläufen wie der Risikoidentifizierung und der diagnostischen Aufarbeitung bei einer protrahierten Fistel ist die Behandlung sehr individuell und erfordert eine große Expertise des behandelnden Chirurgen. Zu einer erfolgversprechenden, zielführenden Therapie scheint es empfehlenswert, sich innerhalb einer Klinik auf eine bestimmte standardisierte Therapieabfolge zu einigen.

Abstract

Prolonged air leak is one of the most common postoperative complications in thoracic surgery. For elective partial lung resections, postoperative air leak lasting longer than 5 – 7 days is arbitrarily defined as prolonged. There are several predictive factors for the development of prolonged air leak that can be subdivided as either preoperative, such as obstructive pulmonary disease, or intraoperative risk factors, such as pleural adhesions or fused fissures. The treatment of postoperative prolonged air leak is performed on an individual basis for each patient and may vary considerably. Four major treatment options can be varied in sequence and use: intensified conservative therapy, installation of sclerosing agents or autologous blood, endoscopic procedures and surgical revision. Prevention, detection and treatment of postoperative prolonged air leak are common aspects of thoracic surgery with high clinical relevance. In contrast to standardised procedures in risk identification and diagnostic work-up, the treatment of prolonged air leak is performed on an individual basis and requires a great deal of surgical expertise. For effective targeted therapy, it seems advisable to agree on a specific standardised therapy sequence within a clinic.

Schlüsselwörter

Parenchymfistel - Luftleckage - Thoraxchirurgie - endobronchiale Ventile

Key words

air leak - thoracic surgery - endobronchial valves

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