Indikationsspektrum und perioperatives Management bei i. v.-Portsystemexplantation – Alternative Taurolingabe bei i. v.-Portsysteminfektion

Zusammenfassung

Hinterground: Das Ziel der Studie bestand darin, systematisch zu untersuchen: i) die Gründe und Komplikationen, die zu einer i. v.-Portsystemexplantation führten, ii) eine spezifische Therapieoption (Taurolingabe via i. v.-Portsystem) im Falle einer i. v.-Portsysteminfektion in einer Pilotstudie hinsichtlich Machbarkeit und Wirksamkeit zur Explantationsvermeidung. Patienten und Methoden: Anhand einer prospektiven, unizentrischen Beobachtungsstudie zur Implantation des i. v.-Portsystems (klinischer Alltag) unter Einschluss konsekutiver Patienten reprä­sentativer Anzahl über einen definierten Zeitraum (Design: Fallserie) wurden neben patienten- und interventionsspezifischen Charakteristika: 1. das Ursachenspektrum der i. v.-Port­explantation eruiert; 2. bei einer ausgewählten Patientengruppe aufeinanderfolgender Fälle mit mikrobiologisch nachgewiesener i. v.-Portinfek­tion eine konser­vative, i. v.-Portsystem-erhal­tende, endoluminal-antiseptisch ausgerichtete Lokaltherapie im Sinne der separaten klinischen Anwenderbeobachtung untersucht (Schema: 2 × 5,0 ml Taurolin 2,0 % / d für 3 d) und einer vergleichenden mikrobiologischen Erregerdetektion post applicationem (Blutkultur vs. i. v.-Portkatheter) gegenübergestellt. Ergebnisse: Von 2002–2005 wurden in der Klinik für Allgemein-, Viszeral- und Gefäßchirurgie (Universitätsklinikum Magdeburg) 1588 Portsysteme implantiert. 1. Insgesamt wurden 117 Patienten (69 Frauen vs. 48 Männer; Geschlechtsverhältnis: 1,44 : 1) mit einer Komplikation und indizierter i. v.-Portexplantation eruiert (häufigste Ursache: i. v.-Portinfektionen mit 40 %). 2. Davon wurden 10 Patienten mit Taurolin therapiert und nachuntersucht: Bei 8 von 10 Patienten (Erfolgsrate: 80 %) konnte durch die Taurolin-Gabe eine i. v.-Port­infektion erfolgreich behandelt und eine Entfernung des i. v.-Portsystems bei guter Tolerabilität vermieden werden. Schlussfolgerung: Es ergab sich ein überraschend breites Spektrum von Indikationen für eine i. v.-Portsystemexplantation, wobei teilweise deren scharfe ätiologische Eingrenzung essenziell für die Prävention von Langzeitkonsequenzen ist. Eine i. v.-Portsysteminfektion als Hauptursache für eine indizierte Explantation kann unter engmaschiger klinischer und mikrobiologischer Kontrolle in ausgewählten Fällen durch Taurolin effektiv behandelt werden in Bestätigung anderer Autoren. Die bisher zwingend ­erscheinende Operation zur Entfernung des i. v.-Portsystems kann so umgangen werden. Eine weiterführende systematische Fallserie mit repräsentativer Fallzahl sowie kurz- bis mittelfristige, fallspezifische Verlaufskontrollen sind jedoch empfehlenswert.

Abstract

Background: The aims of this systematic investigation were to analyse i) causes and complications leading to i. v. port-a-cath explantation and ii) a specific therapeutic option (taurolin administration via i. v. port-a-cath) in the case of an i. v. port-a-cath infection in a pilot study with regard to the feasibility and efficacy to finally avoid ­explantation. Patients and Methods: Based on a prospective, unicentre observational study on the implanta­tion of an i. v. port-a-cath (daily surgical practice) enrolling consecutive patients of a representative number and through a defined study period (design, case series), besides patient and interven­tion-associated characteristics, we investigated 1. the spectrum of causes for an i. v. port-a-cath explantation; 2. the option of a conservative i. v. port-a-cath-maintaining, endoluminal, antiseptic local therapy in a selected number of patients with microbiologically detected infection of the i. v. port-a-cath using 2 × 5.0 ml Taurolin 2.0 % / d for 3 d as an accompanying clinical observation of initial therapeutic use and its effect. Thereafter, microbe detection was again compared between blood culture and the port-a-cath catheter. Results: From 2002 to 2005, overall 1588 i. v. port-a-caths were implanted at the Department of ­Gen­eral, Abdominal and Vascular Surgery (University Hospital, Magdeburg, Germany). 1) In ­total, 117 patients (69 females vs. 48 males; sex ratio, 1.44 : 1) with complications and subsequent indication for an explantation of the i. v. port-a-cath were observed (most frequent cause: infec­tion of the i. v. port-a-cath, 40 %). 2) Taken togeth­er, 10 patients underwent systematic administration of taurolin and follow-up investigation: In 8 of 10 patients (success rate, 80 %), the infection of the i. v. port-a-cath could be successfully treated with taurolin ­adminsitration as described and, in addition, the threatening ­explantation of the i. v. port-a-cath could be avoided. Conclusions: There are various indications for the necessary ­explantation of an i. v. port-a-cath, which need to be precisely analysed to avoid long-term consequences. Infection of the i. v. port-a-cath is the main reason for explantation and may be successfully treated with taurolin in selected cases under short-term clinical and microbiological control. The up to now urgently ­in­dicat­ed explantation of an i. v. port-a-cath can thus be circum­vented. However, a further systematic case series with a representative case number and intermediate, case-specific follow-up investigations appear to be desirable.

Schlüsselwörter

intravenöses Portsystem (i. v.-Port) - Infektion - Taurolin - Antibiotikum - Thrombose - totale parenterale Nutrition (TPN)

Key words

i. v. port-a-cath - i. v. port-a-cath infection - taurolin - antibiotics - thrombosis - total parenteral nutrition

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1 Beide Autoren sind gleichberechtigt als Erstautoren an der Erstellung des Manuskriptes beteiligt.