Chirurgische Behandlung von Paravasaten

Zusammenfassung

Hintergrund: Paravasate gehören zu den häufigsten iatrogenen Verletzungen. Ziel dieser Studie war es, die operative Versorgung von Patienten mit Paravasaten zu untersuchen und Rückschlüsse für die zukünftige Versorgung zu ziehen. Material und Methoden: Zwischen 1999 und 2009 wurden 24 Patienten mit Nekrosen nach Paravasaten in unserer Klinik behandelt. Die Fälle wurden retrospektiv analysiert. Die Nekrose verursachenden Substanzen und die Lokalisation wurden mit der Anzahl der Eingriffe, Komplexität der Rekonstruktion ins Verhältnis gesetzt. Ergebnisse: Chemotherapeutika (83 %, n = 20), Kontrastmittel (8 %, n = 2), Antibiotika (4 %, n = 1) und Insulin (4 %, n = 1) waren die auslösenden Noxen. Zu 70 % war die obere Extremität, zu 30 % der Thorax betroffen. In 38 % kam es bei liegendem Port zum Paravasat. 2 ± 1,5 Operationen waren zur vollständigen Sanierung notwendig. Ein Patient verstarb an einer Sepsis auf dem Boden des infizierten Nekroseareals, der andere postoperativ an Rechtsherzversagen bei pulmonaler Vorschädigung. Schlussfolgerung: Ein Großteil der Paravasate lässt sich konservativ therapieren. Liegt ein toxisches Paravasat vor oder droht aufgrund des Gewebedrucks eine Minderperfusion, ist eine sofortige chirurgische Sanierung erforderlich, um eine Zerstörung tieferer Gewebeschichten zu verhindern. 

Abstract

Objective: Extravasations account for most iatrogenic injuries. The aim of the study was to analyse the results of surgery in patients with extravasations and to draw conclusions for future treatment. Materials and Methods: 24 patients with soft-tissue defects after extravasations were treated between 1999 and 2009 in our hospital. The cases were analysed retrospectively. We looked at the drugs causing tissue necrosis and the localisation in relation to the number of interventions and reconstruction complexity. Results: In 83 % (n = 20) of cases tissue necrosis was caused by chemotherapeutic agents, in 8 % (n = 2) by contrast mediums and in 4 % (n = 1) by antibiotics and insulin. 70 % of the cases involved the upper extremity, in 30 % the thoracic wall was affected. 38 % of the extravasations occurred over venous access ports. In mean 2 ± 1.5 interventions were necessary for defect coverage. Two patients died as a direct result of the extravasations, one due to sepsis originating from an infected necrosis area and one due to right-heart failure with prior pulmonary damage. Conclusion: Most extravasations can be treated without surgery. In cases of toxic extravasations or pressure-caused ischaemia rapid surgical intervention is necessary to prevent the necrosis progressing to deeper tissue layers. 

Schlüsselwörter

Paravasat - Chemotherapie - Defektdeckung - Weichteildefekt - Kontrastmittel

Key words

extravasation - chemotherapy - defect closure - soft-tissue defect - contrast medium

• Literatur

• Schrijvers DL. Extravasation: a dreaded complication of chemotherapy. Ann Oncol 2003; 14 Suppl 3: iii26-iii30
• Ener RA, Meglathery SB, Styler M. Extravasation of systemic hemato-oncological therapies. Ann Oncol 2004; 15: 858-862
• Wang CL, Cohan RH, Ellis JH et al. Frequency, management, and outcome of extravasation of nonionic iodinated contrast medium in 69 657 intravenous injections. Radiology 2007; 243: 80-87
• Federle MP, Chang PJ, Confer S et al. Frequency and effects of extravasation of ionic and nonionic CT contrast media during rapid bolus injection. Radiology 1998; 206: 637-640
• Sistrom CL, Gay SB, Peffley L. Extravasation of iopamidol and iohexol during contrast-enhanced CT: report of 28 cases. Radiology 1991; 180: 707-710
• Jordan K, Behlendorf T, Mueller F et al. Anthracycline extravasation injuries: management with dexrazoxane. Ther Clin Risk Manag 2009; 5: 361-366
• Jordan K, Grothe W, Schmoll HJ. [Extravasation of chemotherapeutic agents: prevention and therapy]. Dtsch Med Wochenschr 2005; 130: 33-37
• Thakur JS, Chauhan CG, Diwana VK et al. Extravasational side effects of cytotoxic drugs: A preventable catastrophe. Indian J Plast Surg 2008; 41: 145-150
• Schaverien MV, Evison D, McCulley SJ. Management of large volume CT contrast medium extravasation injury: technical refinement and literature review. J Plast Reconstr Aesthet Surg 2008; 61: 562-565 discussion 565
• Mouridsen HT, Langer SW, Buter J et al. Treatment of anthracycline extravasation with Savene (dexrazoxane): results from two prospective clinical multicentre studies. Ann Oncol 2007; 18: 546-550
• Damert HG, Lenz-Scharf O, Altmann S et al. [Soft-tissue defects on the dorsum of the hand by extravasation of the cytostatic agents: surgical options of treatment]. Handchir Mikrochir Plast Chir 2007; 39: 409-413
• Goertz O, Baerreiter S, Ring A et al. Determination of microcirculatory changes and angiogenesis in a model of frostbite injury in vivo. J Surg Res 2009; Aug 11 [Epub ahead of print]
• Cicchetti S, Jemec B, Gault DT. Two case reports of vinorelbine extravasation: management and review of the literature. Tumori 2000; 86: 289-292
• Olver IN, Aisner J, Hament A et al. A prospective study of topical dimethyl sulfoxide for treating anthracycline extravasation. J Clin Oncol 1988; 6: 1732-1735
• Hasinoff BB. Chemistry of dexrazoxane and analogues. Semin Oncol 1998; 25: 3-9
• Langer SW, Sehested M, Jensen PB. Treatment of anthracycline extravasation with dexrazoxane. Clin Cancer Res 2000; 6: 3680-3686
• Bertelli G, Dini D, Forno GB et al. Hyaluronidase as an antidote to extravasation of Vinca alkaloids: clinical results. J Cancer Res Clin Oncol 1994; 120: 505-506
• Langer SW, Thougaard AV, Sehested M et al. Treatment of anthracycline extravasation in mice with dexrazoxane with or without DMSO and hydrocortisone. Cancer Chemother Pharmacol 2006; 57: 125-128
• Mader I, Fürst-Weger P, Mader R et al. www.paravasate.at (Stand: 5.11.2010)
• Stanley A. The National Extravasation Information Service. http://www.extravasation.org.uk/home.html. (Stand: 5.11.2010)
• Jordan K, Behlendorf T, Surov A et al. Venous access ports: frequency and management of complications in oncology patients. Onkologie 2008; 31: 404-410
• Langstein HN, Duman H, Seelig D et al. Retrospective study of the management of chemotherapeutic extravasation injury. Ann Plast Surg 2002; 49: 369-374
• Schulmeister L. Managing vesicant extravasations. Oncologist 2008; 13: 284-288
• Bozkurt AK, Uzel B, Akman C et al. Intrathoracic extravasation of antineoplastic agents: case report and systematic review. Am J Clin Oncol 2003; 26: 121-123
• von Heimburg D, Pallua N. [Early and late treatment of iatrogenic injection damage]. Chirurg 1998; 69: 1378-1382
• Fallscheer P, Kammer E, Roeren T et al. Injury to the upper extremity caused by extravasation of contrast medium: a true emergency. Scand J Plast Reconstr Surg Hand Surg 2007; 41: 26-32
• Tsai YS, Cheng SM, Ng SP et al. Squeeze maneuver: an easy way to manage radiological contrast-medium extravasation. Acta Radiol 2007; 48: 605-607
• Vandeweyer E, Heymans O, Deraemaecker R. Extravasation injuries and emergency suction as treatment. Plast Reconstr Surg 2000; 105: 109-110
• Cohan RH, Bullard MA, Ellis JH et al. Local reactions after injection of iodinated contrast material: detection, management, and outcome. Acad Radiol 1997; 4: 711-718