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DOI: 10.1055/a-0721-1983
Nicht elektive thoraxchirurgische Operationen bei Patienten mit respiratorischer Insuffizienz und Einsatz einer venovenösen extrakorporalen Membranoxygenierung
Non-Elective Thoracic Surgery in Patients with Respiratory Insufficiency During Support with Veno-Venous Extracorporeal Membrane OxygenationPublikationsverlauf
Publikationsdatum:
15. Oktober 2018 (online)
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Zusammenfassung
Hintergrund Patienten mit schwerer respiratorischer Insuffizienz und venovenöser extrakorporaler Membranoxygenierung (vv-ECMO) benötigen häufig eine diagnostische oder therapeutische thoraxchirurgische Intervention.
Material und Methode Retrospektive Analyse von prospektiv erhobenen Daten (Regensburger ECMO-Register) aller Patienten im Zeitraum von Dezember 2010 bis Dezember 2016, die aufgrund eines akuten Lungenversagens (ALV) mit einer vv-ECMO behandelt wurden und bei denen eine diagnostische oder therapeutische thoraxchirurgische Operation (TCH-OP) durchgeführt wurde. Endpunkte waren die Indikation zur TCH-OP sowie die postoperative Morbidität und Letalität.
Ergebnis Es wurden 418 Patienten (m = 285, 68%; mittleres Alter 50,0 ± 16,5 Jahre) mit einer vv-ECMO behandelt. Die häufigsten Indikationen zur vv-ECMO waren ein ALV bei Pneumonie (59,8%), postoperativ (18,7%), posttraumatisch (9,8%), nach Chemotherapie (2,8%) oder sonstigen Gründen (8,9%). Insgesamt wurden 102 (24,4%) Patienten unter vv-ECMO operiert, davon 29 Patienten (28,4%) thoraxchirurgisch. Die häufigste primäre Indikation für eine TCH-OP war therapeutisch bei Hämatothorax (n = 13; 44,8%), gefolgt von karnifizierender Pneumonie/Lungenabszess (n = 5; 17,2%), Pleuraempyem (n = 3; 10,3%) und sonstigen Ursachen (n = 3; 10,3%). Bei interstitieller Lungenerkrankung unklarer Genese (n = 5; 17,2%) erfolgte eine diagnostische Lungenbiopsie. Bei den Ersteingriffen wurde bei 27 Patienten eine Thorakotomie (93,1%), seltener eine VATS (n = 2; 6,9%) durchgeführt. Mindestens eine Rethorakotomie erfolgte in 15 Patienten (51,7%) und 9 Patienten (31,0%) wurden mehr als 2 × operiert. Die Letalität im Krankenhaus der Patienten mit TCH-OP (44,8%) war höher als die der Patienten ohne TCH-OP (35,7%; p = 0,326).
Schlussfolgerung Die Indikationen für eine thoraxchirurgische Operation bei Patienten mit vv-ECMO sollten streng gestellt werden, da häufig postoperative Komplikationen mit einer hohen Reoperationsrate (58,6%) auftreten. Daher sollte eine ECMO-Therapie nur in spezialisierten Zentren mit thoraxchirurgischer Expertise erfolgen.
Abstract
Introduction Patients with severe respiratory failure and veno-venous extracorporeal membrane oxygenation (vv-ECMO) often require diagnostic or therapeutic thoracic surgery.
Methods Retrospective analysis of prospectively collected data (Regensburg ECMO Registry) on all patients requiring vv-ECMO between December 2010 and December 2016 due to acute lung failure (ALF) with diagnostic or therapeutic thoracic surgery. Endpoints were the indications for thoracic surgery as well as postoperative morbidity and in-hospital mortality.
Results A total of 418 patients (male n = 285, 68%, mean age 50.0 ± 16.5 years) with severe respiratory insufficiency refractory to conventional therapy required vv-ECMO. Indications for vv-ECMO were ALF due to pneumonia (59.8%), postoperative (18.7%), posttraumatic (9.8%), after chemotherapy (2.8%) and others (8.9%). Overall, in 24.4% (n = 102) of patients with vv-ECMO surgery was performed. Of these, 28.4% (n = 29) of patients required thoracic surgery. Primary indications for thoracic surgery were most frequently therapeutic due to hemothorax (n = 13; 44.8%), followed by carnifying pneumonia/pulmonary abscess (n = 5; 17.2%), pleural empyema (n = 3; 10.3%) and others (n = 3; 10.3%). In patients with interstitial lung disease of unknown origin (n = 5; 17.2%), diagnostic pulmonary biopsy was performed. For initial thoracic intervention thoracotomy was carried out in 93.1% (n = 27) of patients, whereas only two patients (6.9%) received thoracoscopy. At least one repeated thoracotomy was performed in 15 patients (51.7%) and nine patients (31.0%) underwent more than two surgeries. In-hospital mortality of patients with thoracic surgery (44.8%) was higher than in patients without thoracic surgery (35.7%; p = 0.326).
Conclusion Thoracic surgery in patients with vv-ECMO warrants strict indications, because postoperative complications are common and surgical revision (58,6%) is often required. Therefore, ECMO therapy should only be carried out in specialised centers with thoracic surgery.
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