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.

Laparoskopische Gastrofundoplikatio - venöse Stase der unteren Extremitäten - tiefe Venenthrombose

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

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