M Müller

Influenceable surgical and anesthesiological risk factors for the development of cardiac and pulmonary complications in laparoscopic surgery of the colon

Einleitung: Aufgrund der demografischen Verschiebung der Altersstruktur der Bevölkerung werden zunehmend ältere, multimorbide Patienten operiert, die ein wesentlich höheres Risiko für das Auftreten intraund postoperativer Komplikationen aufweisen. Neben der Identifikation von patientenbezogenen, schwer beeinflussbaren Risikofaktoren werden beeinflussbare intraoperative Faktoren auf chirurgischer und anästhesiologischer Seite kaum untersucht. Ziel dieser Untersuchung war es, solche Risikofaktoren für die Entwicklung der postoperativen Morbidität zu definieren. Methode: In einem Zeitraum von 44Monaten führten wir bei 157Männern und 209 Frauen mit einem medianen Alter von 63 Jahren einen laparoskopischen Koloneingriff durch. Dokumentiert wurden prospektiv ASA-Klassifikation, POSSUMScore, Facharztstatus des Anästhesisten, Wechsel in der Anästhesie, intraoperative Überwachungsmaßnahmen, Narkoseverfahren, Blutdruckund Pulsschwankungen während der Operation, Schockindex > 1, Substitution von Erythrozytenkonzentraten und FFPs sowie intraoperative chirurgische Komplikationen. Postoperativ wurden therapiebedürftige allgemeine, insbesondere kardiale und pulmonale Komplikationen sowie chirurgische Komplikationen, insbesondere Wundinfekte und Nachblutungen, dokumentiert. Die Datenanalyse erfolgte mittels SPSS. Ergebnisse: Intraoperative Überwachungsmaßnahmen fanden sich häufiger in höheren ASA-Stadien, wobei im Stadium ASA IV in 17% kein ZVK und in 33% kein arterieller Zugang gelegt wurden. Ein ähnlicher Zusammenhang mit dem POSSUMScore konnte nicht festgestellt werden. Patienten, die von Anästhesisten in der Weiterbildung betreut wurden, hatten in 6,7% kardiale Komplikationen und mussten in 13,1% nachbeatmet werden gegenüber 2% kardialen Komplikationen Abstract !INTRODUCTION Due to the demographic shift in the age structure of the population, increasingly older, multimorbid patients are operated who have a substantially higher risk for the occurrence of intra- and postoperative complications. Apart from the identification of patient-referred, hardly influenceable risk factors, influenceable intraoperative surgical and anesthesiological risk factors have hardly ever been examined. The aim of this investigation was therefore to identify influenceable risk factors for the development of post-operative morbidity. METHODS In a period of 44 months, we performed a laparoscopic colon resection in 157 men and 209 women with a mean age of 63 years. The ASA classification, POSSUM score, status of the anesthesiologist, change of the anesthesiologist, intraoperative monitoring, kind of anaesthesia, fluctuations of blood pressure and pulse during the operation, shock-index > 1, substitution of erythrocyte concentrates and FFPs as well as intraoperative surgical complications were documented prospectively. Postoperative general complications requiring therapy, in particular, cardiac and pulmonal problems as well as surgical complications, in particular, infections and hemorrhages, were documented. The data analysis was performed using the program package SPSS. RESULTS Intraoperative monitoring was more frequently used in higher ASA stages, whereas for ASA stage IV no central venous line was used in 17 % and no arterial catheter was placed in 33 %. a similar tendency concerning the POSSUM score could not be determined. Patients cared for by junior surgeons exhibited cardiac complications in 6.7 % and 13.1 % had to be mechanically ventilated postoperatively versus 2 % of cardiac complications and 9 % mechanical ventilation among those managed by specialists. An increase in postoperative complications could also be found when a change in anesthesia took place. During treatment by an assistant in case of emergencies, in cases where intraoperative substitution of erythrocytes or an operation lasting more than two hours, more cardiac complications and a higher rate of mechanical respiration was observed than during treatment by a specialist. A mechanical respiration was significantly more necessary in higher ASA stages (p < 0.01), in an operation lasting more than 2 hours (p < 0.01), in cases with the occurrence of intraoperative bleeding complications (p < 0.01), procedures with a lower status of the anesthesiologist (p < 0.01) and in procedures with a change of the anesthesiologist (p < 0.05). CONCLUSION Factors such as overweight, ASA classification or urgency cannot be changed. Surgical factors such as a standardisation of the operation technique with reduction of the operating time and careful staunching of bleeding can help to reduce postoperative complications. Anesthesiologists can also help by avoiding a change of the anesthesiologist as well as by preference of specialists in patients with higher ASA stages and in emergency cases.

[Intrathoracic thoracoscopic anastomosis in minimally invasive oesophageal resection - technical tips].

INTRODUCTION Minimally invasive oesophageal resections are being increasingly propagated. However, a leakage of the cervical anastomosis, occurring in up to 30 % of the cases, remains a severe disadvantage. By means of a case report, a new alternative technique of intrathoracic thoracoscopic anastomosis is described. PATIENT AND METHOD After the customary laparoscopic abdominal performance of lymph-node dissection, a gastric conduit was performed in a 73-year-old patient with an adenocarcinoma of the gastro-oesophageal junction. After that the oesophagus had been resected thoracoscopically and an intrathoracic side-to-side/functional end-to-end anastomosis between the gastric conduit and oesophagus was performed with linear staplers. RESULTS There were no postoperative complications. CONCLUSION The intrathoracic thoracoscopic oesophagogastrostomy seems to be an oncologically adequate procedure that has less complications than the other laparoscopic-thoracoscopic techniques described so far. However, further studies are necessary to prove this conclusively.