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Levosimendan is a calcium sensitizer and opens adenosine triphosphate-dependent potassium channels. Since 20 years, it is approved for acute decompensated heart failure. It has been tested in many clinical trials for treatment of at-risk patients in cardiac surgery, right ventricular failure, pulmonary hypertension, weaning of extracorporeal systems, cardiogenic shock, septic shock, ARDS and others.Levosimendan has diverse positive effects next to positive inotropy. It improves ventriculoarterial coupling, increases peripheral perfusion, increases kidney glomerular filtration rate, coronary blood flow and it reduces preload and afterload as well as pulmonary capillary wedge pressure.Due to the opening of potassium channels, it also acts on mitochondria resulting in organ protection. Levosimendan acts anti-apoptotic. These positive effects were described in many small studies. Although this sounds like a promising drug for a variety of settings, results of several multicentre randomized placebo-controlled studies were frustrating. This review resumes some facts of levosimendan in different diseases.

Background and study aims: Management of esophago-jejunal anastomotic leakages (EJAL) following gastrectomy is challenging. Endoscopic negative pressure therapy (ENPT) is an emerging effective tool for treatment of gastrointestinal and anastomotic leaks. We have been using ENPT as first line therapy for EJAL after oncological gastric resections since 2018. The aim of the study was to present our results with this strategy in a case series. Methods: Nine consecutive patients were treated with ENPT for EJAL after oncological gastrectomy between 01.2018 and 12.2019. A retrospective analysis of patients’ and treatment-related data was performed. Results: Time to leakage detection was 6.00 ± 2.49 days after surgery. After 14.78 ± 9.66 days of ENPT, 6.25 ± 3.65 endoscopies and 38.11 ± 16.46 days of hospitalization, endoscopic treatment with ENPT combined with surgical debridement and drainage for sepsis control was effective in eight of nine patients. In one patient with a complete anastomotic dehiscence, treatment was changed to a stent-based therapy combined with surgery. Conclusions: ENPT is a new and promising option in the complication management of patients with anastomotic insufficiencies following oncological gastrectomy. It can be recommended in combination with limited surgery to preserve the anastomosis and provide sepsis control. The time interval to diagnosis and the size of the insufficiency are important for the success of ENPT in patients with EJAL.

ZusammenfassungIn den letzten Jahren hat sich die Rolle des Anästhesisten vom „Narkosearzt“ zum perioperativen Mediziner und Risikospezialisten enorm gewandelt. Die Patienten sind älter, multimorbide und werden zu immer umfangreicheren Eingriffen und Interventionen aufgeboten. Sozioökonomische Aspekte haben an Bedeutung zugenommen. Der Anästhesist ist als Wegbereiter eines guten Outcomes in nahezu alle perioperativen Prozesse involviert: präoperative Evaluation, Festlegung und Optimierung der prä- und intraoperativen Bedingungen, moderne intraoperative Anästhesieführung sowie eine postoperative, medizinisch indizierte, effektive und effiziente Behandlung der teilweise hochkomplexen Patienten. Die einzelnen perioperativen Prozessschritte auf diesem Weg werden in Anlehnung an etablierte Leitlinien und die Zunahme der gegenwärtigen Anforderungen beleuchtet. Schließlich wird ein besonderer Akzent auf die Erkenntnis gelegt, dass der perioperative Prozess nicht mit dem Operationsende abgeschlossen ist – postoperatives Outcome ist nicht zuletzt von postoperativen Komplikationen auf der Normalstation negativ beeinflusst. Das Risiko für Todesfälle nach Komplikationen, „Failure to rescue“, sollte frühzeitig erkannt und umgehend behandelt werden.

Introduction: Endoscopic negative pressure therapy (ENPT) is an effective new method to treat patients with anastomotic insufficiencies of the upper gastrointestinal tract. Development of an esophagobronchial fistula in situation of postesophagectomy anastomotic insufficiency is a rare but challenging and potentially life-threatening complication. In cases of contact to the respiratory tract ENPT is non-operatively because of air leakage. Case Report: We report about a patient with a bronchial fistula going out from an esophago-mediastinal cave caused by an anastomotic insufficiency. Five steps to an optimal endoscopic treatment were needed. Finally a combination of endobronchial stenting and active drainage of the mediastinal cave and the stomach was used. Discussion: Successful outcome in this case is attributable to good interdisciplinary communication of all attending physicians and the imaginative combined usage of endoscopic devices.