Bedeutung und Wertigkeit der Duplexsonographie postoperativ in der Tumor- und Transplantationschirurgie des Abdomens

Zusammenfassung

Die postoperative Duplexsonographie in der Tumor- und Transplantationschirurgie des Abdomens sieht sich mit spezifischen Problemen konfrontiert, im Vergleich zur etablierten, also auch standardisierten, Duplexsonographie der extrakraniellen Hirngefäße oder der Extremitäten-versorgenden Gefäße. Die fehlende standardisierte Untersuchungstechnik und der Mangel an Normwerten sind dabei ebenso anzuführen wie die erheblichen anatomischen Varianten einzelner Gefäße, so dass eine erhebliche inter- aber auch intraindividuelle Streuung einzelner Messergebnisse vorliegen kann. Postoperative Gegebenheiten wie das initiale Pneumoperitoneum oder ein anhaltender Meteorismus, aber auch eine vorbestehende Adipositas erschweren zusätzlich die duplexsonographische Untersuchung in den oftmals kritischen ersten Tagen nach Transplantation oder Tumoroperation. Hieraus erwächst die Erkenntnis, dass diese Untersuchungstechnik „nichts für Anfänger”, also in der Tat untersucherabhängig ist. Dennoch hat die Duplexsonographie im vergangenen Jahrzehnt insbesondere in der Transplantationschirurgie eine zentrale Position eingenommen, trotz der „Konkurrenz” mit digitaler Subtraktionsangiographie, dynamischen CT- und NMR-Verfahren und verschiedenen nuklearmedizinischen Untersuchungsmethoden. Dank stetig verbesserter Technik liefern moderne Duplexsonographie-Geräte eine hervorragende sonomorphologische Darstellung der zu untersuchenden intraabdominellen Strukturen, die durch zusätzliche Verwendung von Echokontrastmittel weiter gesteigert werden kann. Gleichzeitig können am Patientenbett non-invasiv, innerhalb weniger Minuten wertvolle Erkenntnisse zur quantitativen und qualitativen Organperfusion oder Gefäßdurchgängigkeit wiederholt gewonnen werden. In der Transplantationschirurgie kann dabei die duplexsonographisch erfasste, abnorme Organperfusion sowohl Ursache wie auch Folge einer Transplantatfunktionsstörung sein. Demgegenüber sind in der Tumorchirurgie duplexsonographisch erfasste Perfusionsstörungen in erster Linie als mittel- oder unmittelbare Folgen des abgelaufenen Eingriffes zu werten. Eine wesentliche Erweiterung der bis dato relativ beschränkten Verwendung der Duplexsonographie im Rahmen der abdominellen Tumorchirurgie könnte der duplexsonographische Nachweis okkulter Lebermetastasen bei kolorektalem Primärtumor darstellen.

Abstract

Postoperative Doppler ultrasound in both abdominal transplant and tumor surgery is confronted with substantial, site-specific difficulties in comparison to established, i. e. standardised Doppler ultrasound investigations concerning regions such as extracranial cerebral blood vessels or peripheral vessels. A lack of both standardised investigation techniques and standard values as well as considerable anatomical variations of intraabdominal vessels contribute to a substantial inter- and also intraindividual variation of Doppler ultrasound results in this field. Postoperative complications such as ongoing meteorism or intraperitoneal air together with preexisting adipositas may further hamper the Doppler ultrasound investigation in the early, often critical phase following organ transplantation or tumor surgery. Thus, postoperative abdominal Doppler ultrasound is no technique for “beginners” and decidedly observer-dependent to a certain degree. Nonetheless, postoperative Doppler ultrasound has gained a central position in the field of transplant surgery, despite strong competition by digital subtraction angiography, various forms of dynamic CT and MRI investigations and also nuclear medicine methods. Due to improved technology, modern Doppler ultrasound machines are capable of producing high resolution two-dimensional images which may be further enhanced by application of contrast medium. Simultaneously, valuable information concerning quantitative and qualitative organ perfusion or vessel patency may be repeatedly gained within minutes in a bed-side, non-invasive fashion. Abnormal flow patterns observed post-transplant may either be the cause or result of transplant organ dysfunction. On contrast, observed pathological flow patterns following tumor surgery often reflect direct or indirect consequences of the operation. A major extension of the current rather limited use of Doppler ultrasound following abdominal tumor surgery may arise from the ability of Doppler ultrasound to detect occult liver metastases of underlying colorectal cancer.

Schlüsselwörter

Duplexsonographie - Transplantationschirurgie - Abdominalchirurgie

Key words

doppler ultrasound - transplantation surgery - abdominal surgery

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