Pleuraerguss und Aszites – chirurgische und palliative Aspekte

 

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Zusammenfassung

Hintergrund: Pleuraergüsse und Aszites sind unabhängig von der Grunderkrankung mit quälenden Symptomen wie Dyspnoe, Ileus, Erbrechen, Übelkeit und Schmerzen und bei maligner Ursache mit einer limitierten Prognose von wenigen Monaten verbunden. Bei Versagen medikamentöser Therapien kommen chirurgische und experimentelle palliative Therapien zur Anwendung. Methoden: Diese Übersichtsarbeit beinhaltet einen systematischen Review der chirurgischen, experimentellen und palliativen Therapieoptionen. Ergebnisse: Bei malignem Pleuraerguss steht neben der Thorakozentese die permanente transkutane Dränage, der thorakoperitoneale Shunt sowie die Pleurodese über Dränagen oder über eine Thorakoskopie zur Verfügung, die in Abhängigkeit von der Expansionsfähigkeit der Lunge zur Anwendung kommen. Bei chronischen Aszites und Leberzirrhose ist die Anlage eines TIPS das optimale Verfahren. Ansonsten können bei Aszites neben der symptomatischen Parazentese peritoneovenöse Shuntsysteme chirurgisch angelegt werden, die mit hohen Komplikations- und Verschlussraten verbunden sind. Bei malignem Pleuraerguss und Aszites stellt die totale Zytoreduktion und hypertherme Chemoperfusion einen aggressiven chirurgischen Therapieansatz dar, der wenigen geeigneten Patienten vorbehalten bleibt. Bei malignem Aszites stellt die i. p.-Immuntherapie mit Catumaxomab eine neuartige und hoch effektive Option dar, die peritoneale Tumorzellen gezielt zerstören und damit malignen Aszites kontrollieren kann. Schlussfolgerung: Der Behandlung von Pleuraergüssen und Aszites stehen unterschiedliche Optionen zur Verfügung. Eine differenzierte Indikationsstellung und Therapie sind notwendig, um die Lebensqualität und die Prognose zu verbessern.

Abstract

Background: Pleural effusions and ascites are associated with distressing symptoms like dyspnoea, intestinal obstruction, vomiting, nausea and pain. In patients with underlying malignancy, the prognosis is limited to few months. After unsuccessful medical treatment, surgical and experimental palliative treatment is indicated. Methods: This review includes a systematic analysis of surgical, experimental and palliative options. Results: In patients with pleural effusions, thoracocentesis, permanent percutaneous drainage, thoracoperitoneal shunts as well as pleurodesis by tubes or thoracoscopy are available, which will be used depending on the re-expansion of the lung. In patients with ascites, paracentesis is able to control acute symptoms. For long-lasting treatment, portosystemic shunts (TIPS) are favourable for patients with liver cirrhosis. Peritoneovenous shunts can be implanted by laparotomy, but are correlated with high rates of complications and occlusions. In patients with malignancy, pleural effusions and ascites may also be controlled by complete cytoreductive surgery and hyperthermic chemoperfusion. This aggressive surgical concept is limited to single carefully selected patients. In malignant ascites, intraperitoneal immunotherapy by catumaxomab is a novel and highly effective option, which controls ascites by targeted destruction of peritoneal cancer cells. Conclusion: Various options for treatment of pleural effusions and ascites are available. Carful evaluation of the individual patient is necessary to improve quality of life and survival.

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Dr. med. M. A. Ströhlein

Klinikum Köln-Merheim · Universität Witten / Herdecke · Klinik für Viszeral-, Gefäß- und Transplantationschirurgie

Ostmerheimer Str. 200

51109 Köln

Deutschland

Phone: +49 / 2 21 / 89 07 37 70

Fax: +49 / 2 21 / 89 07 85 61

Email: stroehleinm@kliniken-koeln.de