Prophylaxe der venösen Stase und tiefen Venenthrombose bei laparoskopischer Fundoplikatio

Zusammenfassung

In der vorliegenden Untersuchung sollte folgenden Fragestellungen nachgegangen werden:
Auswirkung eines Pneumoperitoneums von 12 mm Hg auf den Femoralvenenabfluss.
Überprüfung der Wirksamkeit von mechanischen Antithrombosemaßnahmen wie intermittierende pneumatische Kompression (IPC), intermittierende elektrische Unterschenkelmuskelstimulation (IEUS) und graduierte Beinkompression durch Bandagen (B) zur Reduktion der venösen Stase.
Überprüfung der Häufigkeit von tiefen Venenthrombosen (TVT) nach laparoskopischer Fundoplikatio mit Hilfe der Venenverschlussplethysmographie.
Patienten und Methodik: 54 Patienten mit elektiver laparoskopischer Fundoplikatio wurden randomisiert drei Gruppen zu je 18 Patienten zugeteilt. Die erste Gruppe erhielt B, die zweite Gruppe IEUS und die dritte Gruppe IPC während der Operation. Die venöse Flussgeschwindigkeit der unteren Extremitäten wurde mit Hilfe des Doppler Ultraschalls während der Operation bestimmt. Außerdem wurde der venöse Abstrom einen Tag vor und einen Tag nach der Operation mit Hilfe der venösen Verschlussplethysmographie gemessen, um so eventuelle tiefe Venenthrombosen auszuschließen.
Ergebnisse: Die Blutflussgeschwindigkeit in den Femoralvenen betrug ohne Pneumoperitoneum in der IPC-Gruppe 20,1 ± 2,4 cm/sek., in der IEUS-Gruppe 20,3 ± 1,4 cm/sek. und in der B-Gruppe 23,9 ± 1,2 cm/sek. Nach Anlage des Pneumoperitoneum (12 mm Hg) und der umgekehrten Trendelenburgposition verringerte sich die Femoralvenenflussgeschwindigkeit in allen Gruppen signifikant: 9,3 ± 0,9 cm/sek. in IPC, 9,4 ± 0,9 cm/sek. in IEUS und 9,2 ± 1,1 cm/sek. in der B-Gruppe (p < 0,05). Durch die Anlage der IPC stieg die maximale Flussgeschwindigkeit in dieser Gruppe auf 17,4 ± 1,9 cm/sek. an, durch die IEUS auf 14,0 ± 1,1 cm/sek., während sie in der B-Gruppe gleich blieb (9,2 ± 1,1 cm/sek.). In der B- Gruppe entwickelte sich eine tiefe Unterschenkelvenenthrombose und eine pulmonalarterielle Mikroembolie, die durch venöse Verschlussplethysmographie bzw. Lungenperfusionscintigraphie einen Tag nach Operation aufgedeckt wurden.
Folgerungen: Die Stase in den Femoralvenen kann bei laparoskopischer Fundoplikatio gering gehalten werden durch Reduzierung des intraabdominellen Drucks während der Operation und Vermeidung einer umgekehrten Trendelenburg-Position. Hinsichtlich der Verhinderung der venösen Stase ist IPC effektiver als IEUS. Die graduierte Beinkompression durch Bandagen ist unter den genannten Bedingungen ineffektiv. Allerdings gelang es mit keiner dieser Maßnahmen, während des Pneumoperitoneum die reduzierte Blutflussgeschwindigkeit bis zu den Ausgangswerten anzuheben. Die Inzidenz tiefer Venenthrombosen und Pulmonalarterienembolien bei laparoskopischer Fundoplikatio betrug in dieser Studie 1,8 %.

Abstract

Aims of the study: first, to study the effect of a pneumoperitoneum (12 mm Hg) on femoral venous outflow, second, to evaluate the efficacy of mechanical antistasis devices: intermittent pneumatic compression (IPC), intermittent electric calf muscle stimulation (IECS) and graded compression leg bandages (LB) in reducing venous stasis, third, to determinate the incidence of deep venous thrombosis (DVT) after laparoscopic fundoplications using venous occlusion plethysmography method.
Patients and methods: 54 patients undergoing elective laparoscopic fundoplications were studied. They were randomized into three groups - 18 patients in each group. The first group received LB, the second group received IECS and the third group IPC during operations. Lower extremity venous blood velocity was evaluated using Doppler ultrasonography during operation. In all 54 patients leg venous outflow was measured 1 day before and 1 day after operation using venous occlusion plethysmography method, in order to detect possible DVT after operation. The blood velocity in the femoral vein without pneumoperitoneum was 20.1 ± 2.4 cm/s in the IPC group, 20.3 ± 1.4 cm/s in the IECS group, and 23.9 ± 1.2 cm/s in the LB group. With the introduction of a pneumoperitoneum (12 mm Hg) and the reverse Trendelenburg position the femoral venous blood velocity was significantly reduced in all groups: 9.3 ± 0.9 cm/s in IPC group, 9.4 ± 0.9 cm/s in IECS group, and 9.2 ± 1.1 cm/s in LB group (p < 0.05). The maximum blood velocity generated by the IPC when a pneumoperitoneum (12 mm Hg) was present was 17.4 ± 1.9 cm/s, and in the IECS group 14.0 ± 1.1 cm/s, whereas in the LB group the blood velocity remained the same (9.2 ± 1.1 cm/s). Calf DVT and pulmonary artery microembolisation developed in one patient of the LB group, detected by venous occlusion plethysmography and lung perfusion scintigraphy methods one day after operation.
Conclusions: The femoral vein stasis which appears in laparoscopic fundoplications can be minimized by reducing the intraabdominal pressure during operation, and avoiding reverse Trendelenburg possition as much as possible. IPC is more effective than IECS in reducing venous stasis induced by the pneumoperitoneum and the reverse Trendelenburg position. Graded compression by leg bandages is ineffective in patients undergoing laparoscopic gastrofundoplication. With a pneumoperitoneum in place, neither device was able to return the depressed blood flow velocity to the values recorded without a pneumoperitoneum. The incidence of DVT and pulmonary embolism after laparoscopic fundoplications was 1.8 % in our study.

Schlüsselwörter

Laparoskopische Gastrofundoplikatio - venöse Stase der unteren Extremitäten - tiefe Venenthrombose

Key words

Laparoscopic gastrofundoplication - lower-extremity venous stasis - deep vein thrombosis (DVT)

Literatur

• 1 Allan A, Williams J T, Bolton J P. et al . The use of graduated compression stockings in the prevention of postoperative deep vein thrombosis.  Br J Surg. 1983;  70 172-174
• 2 Beebe D S, McNevin M P, Crain J M. et al . Evidence of venous stasis after abdominal insufflation for laparoscopic cholecystectomy.  Surg Gynec Obstet. 1993;  176 443-447
• 3 Bergqvist D, Flordal P A, Friberg B. et al . Thromboprophylaxis with a low molecular weight heparin (tinzaparin) in emergency abdominal surgery. A double-blind multicenter trial.  Vasa. 1996;  25 156-160
• 4 Bergqvist D, Lindblad B. The thromboprophylactic effect of graded elastic compression stockings in combination with dextran 70.  Arch Surg. 1984;  119 1329-1331
• 5 Borow M, Goldson H J. Postoperative venous thrombosis: Evaluation of five methods of prophylaxis.  Am J Surg. 1981;  141 245-251
• 6 Bostrom S, Holmgren E, Jonsson O. et al . Post-operative thromboembolism in neurosurgery. A study on the prophylactic effect of calf muscle stimulation plus dextran compared to low-dose heparin.  Acta Neurochir. 1986;  80 83-89
• 7 Browse N L, Negus D. Prevention of postoperative leg vein thrombosis by electrical muscle stimulation. An evaluation with I-labelled fibrinogen.  Br Med J. 1970;  3 615-618
• 8 Butson A RC. Intermittent pneumatic calf compression for prevention of deep venous thrombosis in general abdominal surgery.  Am J Surg. 1981;  142 525-527
• 9 Clarke-Pearson D L, Synan I S, Hinshaw W M. et al . Prevention of postoperative venous thromboembolism by external pneumatic calf compression in patients with gynecologic malignancy.  Obstet Gynecol. 1984;  63 92-98
• 10 Colditz G A, Tuden R, Oster G. Rates of venous thrombosis after general surgery: combined results of randomised clinical trials.  Lancet. 1986;  19 143-146
• 11 Cotton L T, Roberts V C. The prevention of deep vein thrombosis with particular reference to mechanical methods of prevention.  Surgery. 1977;  81 228-235
• 12 Dynamics of blood and lymph flow. In: William F (ed) Ganong, Review of medical physiology. 13th ed. Appelton and Lange, Norwalk 1987; 491
• 13 Doran F SA, Drury M, Siver A. A simple way to combat the venous stasis which occurs in the lower limbs during surgical operations.  Br J Surg. 1964;  51 486-492
• 14 Faghri P D, Van Meerdervort H F, Glaser R M. et al . Electrical stimulation-induced contraction to reduce blood stasis during arthroplasty.  IEEE Trans Rehabil Eng. 1997;  5 62-69
• 15 Faghri P D, Votto J J, Hovorka C F. Venous hemodynamics of the lower extremities in response to electrical stimulation.  Arch Phys Med Rehabil. 1998;  79(7) 842-848
• 16 Ho Y H, Seow-Choen F, Leong A. et al . Randomized, controlled trial of low molecular weight heparin vs. no deep vein thrombosis prophylaxis for major colon and rectal surgery in Asian patients.  Dis Colon Rectum. 1999;  42 196-203
• 17 Ido K, Suzuki T, Kimura K. et al . Lower-extremity venous stasis during laparoscopic cholecystectomy as assessed using color Doppler ultrasound.  Surg Endosc. 1995;  9 310-313
• 18 Ido K, Suzuki T, Taniguchi Y. et al . Femoral vein stasis during laparoscopic cholecystectomy: effects of graded elastic compression leg bandages in preventing thrombus formation.  Gastrointestinal Endoscopy. 1995;  42 151-155
• 19 Jorgensen J O, Gillies R B, Lalak N J. et al . Lower limb venous hemodynamics during laparoscopy: an animal study.  Surg Laparosc and Endosc. 1994;  4 32-35
• 20 Jorgensen J O, Lalak N J, North L. et al . Venous stasis during laparoscopic cholecystectomy.  Surgical laparoscopy and Endoscopy. 1994;  4 128-133
• 21 Lindstrom B, Holmdahl C, Jonsson O. et al . Prediction and prophylaxis of postoperative thromboembolism - a comparison between peroperative calf muscle stimulation with groups of impulses and dextran 40.  Br J Surg. 1982;  69 633-637
• 22 Mellbring G, Palmer K. Prophylaxis of deep vein thrombosis after major abdominal surgery. Comparison between dihydroergotamineheparin and intermittent calf compression and evaluation of added graduated static compression.  Acta Chirurgica Scandinavia. 1986;  152 597-600
• 23 Nicolaides A N, Fernandes J, Fernandes M D, Pollock A V. Intermittent sequential pneumatic compression of the legs in the prevention of venous stasis and postoperative deep venous thrombosis.  Surgery. 1980;  87 69-76
• 24 Oster G, Tuden R, Colditz G A. Prevention of venous thromboembolism after general surgery.  Am J Med. 1987;  82 889-899
• 25 Rosengarten D S, Laird J, Jeyasingh  K, Martin P. The failure of compression stockings (Tubigrip) to prevent deep venous thrombosis after operation.  Br J Surg. 1970;  57 296-299
• 26 Sabri S, Roberts V C, Cotton L T. Prevention of early postoperative deep vein thrombosis by passive exercise of leg during surgery.  Br Med J. 1971;  3 82-83
• 27 Sigel B, Edelstein A L, Savitch L. et al . Type of compression for reducing venous stasis. A study of lower extremities during inactive recumbency.  Arch Surg. 1975;  110 171-175
• 28 Spebar M J, Collins G J, Rich N M. et al . Perioperative heparin prophylaxis of deep venous thrombosis in patients with peripheral vascular disease.  Am J Surg . 1981;  142 649-650
• 29 The Multicenter Trial C ommittee. Dihydroergotamine-heparin prophylaxis of postoperative deep vein thrombosis: A multicenter trial.  JAMA.. 1984;  251 2960-2966
• 30 Torngren S. Low dose heparin and compression stockings in the prevention of postoperative deep venous thrombosis.  Br J Surg. 1980;  67 482-484
• 31 Turpie A GG, Hirsh J, Gent M. et al . Prevention of deep vein thrombosis in potential neurosurgical patients. A randomized trial comparing graduated compression stockings plus intermittent pneumatic compression with control.  Arch Intern Med. 1989;  149 679-681
• 32 Wille-Jorgensen P, Thorup J, Fischer A. et al . Heparin with and without graded compression stockings in the prevention of thromboembolic complications of major abdominal surgery: a randomized trial.  Br J Surg. 1985;  72 579-581
• 33 Zelikovski A, Zucker G, Eliashiv A. et al . A new sequential pneumatic device for the prevention of deep vein thrombosis.  J Neurosurg. 1981;  54 652-664