Portimplantation als idealer Ausbildungseingriff – eine Analyse von 1423 Eingriffen

Zusammenfassung

Ziel: Ziel der Arbeit war eine Erfassung der Raten an Gesamt-, Früh- und Spätkomplikationen aller zentralvenösen Portsystemimplantationen zwischen 1998 und 2008 an der Chirurgischen Universitätsklinik Rostock. Zusätzlich wurden verschiedene Implantationstechniken bez. Erfolgsrate, Komplikationsrate und OP-Dauer verglichen. Die Ergebnisse wurden in Abhängigkeit des Ausbildungsstands des Operateurs und in Bezug auf verwendete OP-Technik, OP-Dauer, Konversionshäufigkeit und Komplikationen aufgearbeitet. Material und Methoden: Es wurden 1423 Portsystemimplantationen in den Jahren 1998 bis 2008 retrospektiv analysiert. Ergebnisse: Die Rate der Gesamtkomplikationen betrug 13,8 %. Unter den 4,7 % Frühkomplikationen stellte der Pneumothorax die häufigste Komplikation dar. Die Rate an Spätkomplikationen betrug 9,1 %. Hierbei stellte die Infektion mit 4,9 % die allgemeine Hauptkomplikation. Die Katheterdysfunktion war mit 3,5 % die zweithäufigste Komplikation. Insgesamt wurden 1322 Punktionsverfahren und 101 Venae sectiones angewandt. Die OP-Zeiten der Venae sectio im Vergleich zur Punktion sind signifikant länger (46,5 min vs. 38,7 min, p = 0,005). Beim Punktionsverfahren gibt es signifikant mehr Spät- (9,6 % vs. 2 %, p = 0,01) und Gesamtkomplikationen (14,5 % vs. 4 %, p = 0,005). Die primäre Erfolgsrate bei der Venae sectio lag bei 100 %, beim Punktionsverfahren bei 96,8 %. Die Rate an Komplikationen war unabhängig vom Ausbildungsstand der Operateure, jedoch sinkt die Rate an Gesamt- und Spätkomplikationen mit steigender Operationsfrequenz signifikant. Schlussfolgerung: Die Portanlage ist ein einfacher operativer Eingriff trotz vorhandener Komplikationsmöglichkeiten. Die Venae sectio ist hierbei das Verfahren mit den geringsten Komplikationen. Die Rate an Komplikationen ist unabhängig vom Ausbildungsstand des Operateurs. Die Rate an Komplikationen sinkt mit der Operationsfrequenz des Operateurs. Somit ist die Portanlage und insbesondere die Venae sectio im Rahmen einer strukturierten chirurgischen Ausbildung ein idealer Ausbildungseingriff.

Abstract

Aim: The aim of this study was the analysis of total, early and late complications following venous access port implantation between 1998 and 2008 at the Department of Surgery of the University of Rostock, Germany. A comparison between different implantation techniques addressing success rate, complication rate and duration of operation was performed. These results were further analysed in regard to the level of training of the participating surgeons. Material and Methods: A retrospective analysis of 1423 venous access port implantations between 1998 and 2008 was performed. Results: The rate of total complications was 13.8 %. Among 4.7 % early complications pneumothorax was the most common. The rate of late complications was 9.1 %. Most common were infection (4.9 %) followed by dysfunction of the catheter (3.5 %). 1322 venous access port implantations were performed using puncture of the subclavian vein and Seldingerʼs technique. 101 operations were performed by direct access through dissection of the cephalic vein and open introduction of the catheter. Operation time in the open group was significantly longer than in the puncture group (46.5 min vs. 38.7 min, p = 0.005). There were significantly more late complications (9.6 % vs. 2 %, p = 0.01) and total complications (14.5 % vs. 4 %, p = 0.005) in the puncture group vs. the open access group. Primary success rates of open access vs. puncture were 100 % and 96.8 %, respectively. The rate of complications was independent of the experience status of the surgeon. However, the rate of total and late complications significantly decreases with number of performed operations. Conclusion: Venous port implantation is a relatively simple procedure despite its possible complications. An open access technique is safer than puncture. The rate of complications significantly decreases with increasing number of performed operations. Therefore venous port implantation and especially the open access method is an ideal teaching operation in a structured surgical training programme.

Schlüsselwörter

venöse Portsystemimplantation - chirurgische Ausbildung - Komplikationen

Key words

venous access port implantation - surgical training - complications

• Literatur

• 1 Gyves J, Ensminger W, Niederhuber J et al. Totally implanted system for intravenous chemotherapy in patients with cancer. Am J Med 1982; 73: 841-845
• 2 Silberzweig JE, Sacks D, Khorsandi AS et al. Reporting standards for central venous access. Technology Assessment Committee. J Vasc Interv Radiol 2000; 11: 391-400
• 3 Lewis CA, Allen TE, Burke DR et al. Quality improvement guidelines for central venous access. J Vasc Interv Radiol 2003; 14: S231-S235
• 4 Groeger JS, Lucas AB, Thaler HT et al. Infectious morbidity associated with long-term use of venous access devices in patients with cancer. Ann Intern Med 1993; 119: 1168-1174
• 5 Schwarz RE, Coit DG, Groeger JS. Transcutaneously tunneled central venous lines in cancer patients: an analysis of device-related morbidity factors based on prospective data collection. Ann Surg Oncol 2000; 7: 441-449
• 6 Teichgräber UK, Gebauer B, Benter T et al. [Long-term central venous lines and their complications]. Rofo 2004; 176: 944-952
• 7 Kondi ES, Pietrafitta JJ, Barriola JA. Technique for placement of a totally implantable venous access device. J Surg Oncol 1988; 37: 272-277
• 8 Kock HJ, Pietsch M, Krause U et al. Implantable vascular access systems: experience in 1500 patients with totally implanted central venous port systems. World J Surg 1998; 22: 12-16
• 9 Stein M, Wagner RH. [Complications of central venous access devices: outcome analysis of 2359 implantations]. Dtsch Med Wochenschr 2005; 130: 1129-1132
• 10 Jung KH, Moon SB. Cephalic vein cutdown for totally implantable central venous port in children: a retrospective analysis of prospectively collected data. Can J Surg 2014; 57: 21-25
• 11 Harvey WH, Pick TE, Reed K et al. A prospective evaluation of the Port-A-Cath implantable venous access system in chronically ill adults and children. Surg Gynecol Obstet 1989; 169: 495-500
• 12 Wolosker N, Yazbek G, Nishinari K. Totally implantable venous catheters for chemotherapy: experience in 500 patients. Sao Paulo Med J 2004; 122: 147-151
• 13 Mansfield PF, Hohn DC, Fornage BD et al. Complications and failures of subclavian-vein catheterization. N Engl J Med 1994; 331: 1735-1738
• 14 Adamus R, Beyer-Enke S, Otte P et al. [Ultrasound-guided puncture of the subclavian vein to implant central venous ports]. Rofo 2002; 174: 1450-1453
• 15 McGee DC, Gould MK. Preventing complications of central venous catheterization. N Engl J Med 2003; 348: 1123-1133
• 16 Poorter RL, Lauw FN, Bemelman WA et al. Complications of an implantable venous access device (Port-a-Cath) during intermittent continuous infusion of chemotherapy. Eur J Cancer 1996; 32?A: 2262-2266
• 17 Cil BE, Canyigit M, Peynircioglu B et al. Subcutaneous venous port implantation in adult patients: a single center experience. Diagn Interv Radiol 2006; 12: 93-98
• 18 Paleczny J, Banys-Jafernik B, Gazurek K et al. Long-term totally implantable venous access port systems – one center experience. Anaesthesiol Intensive Ther 2013; 45: 215-222
• 19 Sotir MJ, Lewis C, Bisher EW et al. Epidemiology of device-associated infections related to a long-term implantable vascular access device. Infect Control Hosp Epidemiol 1999; 20: 187-191
• 20 Chang L, Tsai JS, Huang SJ et al. Evaluation of infectious complications of the implantable venous access system in a general oncologic population. Am J Infect Control 2003; 31: 34-39
• 21 Barrios CH, Zuke JE, Blaes B et al. Evaluation of an implantable venous access system in a general oncology population. Oncology 1992; 49: 474-478
• 22 Yung B, Campbell IA, Elborn JS et al. Totally implantable venous access devices in adult patients with cystic fibrosis. Respir Med 1996; 90: 353-356
• 23 Zähringer M, Hilgers J, Krüger K et al. [Ultrasound guided implantation of chest port systems via the lateral subclavian vein]. Rofo 2006; 178: 324-329
• 24 Lemmers NW, Gels ME, Sleijfer DT et al. Complications of venous access ports in 132 patients with disseminated testicular cancer treated with polychemotherapy. J Clin Oncol 1996; 14: 2916-2922
• 25 Biffi R, de Braud F, Orsi F et al. Totally implantable central venous access ports for long-term chemotherapy. A prospective study analyzing complications and costs of 333 devices with a minimum follow-up of 180 days. Ann Oncol 1998; 9: 767-773
• 26 Vardy J, Engelhardt K, Cox K et al. Long-term outcome of radiological-guided insertion of implanted central venous access port devices (CVAPD) for the delivery of chemotherapy in cancer patients: institutional experience and review of the literature. Br J Cancer 2004; 91: 1045-1049
• 27 Leinung S, Würl P, Anders K et al. [Port catheter fractures in 361 implanted port systems. Analysis of the causes – possible solutions – review of the literature]. Chirurg 2002; 73: 696-699
• 28 Orsi F, Grasso RF, Arnaldi P et al. Ultrasound guided versus direct vein puncture in central venous port placement. J Vasc Access 2000; 1: 73-77
• 29 Biffi R, Pozzi S, Agazzi A et al. Use of totally implantable central venous access ports for high-dose chemotherapy and peripheral blood stem cell transplantation: results of a monocentre series of 376 patients. Ann Oncol 2004; 15: 296-300
• 30 Linnemann B, Lindhoff-Last E. [Management of catheter-related upper extremity deep vein thrombosis]. Zentralbl Chir 2013; 138 (Suppl. 02) e86-e94
• 31 Schlüter A, Stock K, von Poblozki A et al. [Radiological evaluation of complications of implantable venous access port systems]. Rofo 1999; 171: 324-328
• 32 Herrmann KA, Waggershauser T, Helmberger T et al. [Percutaneous interventional radiologic implantation of intravenous port-catheter systems]. Radiologe 1999; 39: 777-782
• 33 Wildhaber B, Kistler W, Caflisch U. [Experiences with the Port-A-Cath system in children]. Schweiz Med Wochenschr 2000; 130: 732-738
• 34 Debourdeau P, Zammit C, Pavic M et al. [Venous thromboembolism associated with long-term use of central venous catheters in cancer patients]. Rev Med Interne 2007; 28: 471-483
• 35 de Gregorio MA, Miguelena JM, Fernandez JA et al. Subcutaneous ports in the radiology suite: an effective and safe procedure for care in cancer patients. Eur Radiol 1996; 6: 748-752