Das abdominelle Kompartment-Syndrom

Zusammenfassung.

Das abdominelle Kompartment wird durch die Bauchdecke, die Rippen, die Wirbelsäule, beide Psoasmuskeln, das Zwerchfell und den Beckenboden begrenzt. Es schließt also das Retroperitoneum mit ein. Anhaltende Druckerhöhungen in diesem Raum können zur Beeinträchtigung der Funktion des Magen-Darmtraktes, der Nieren, des Herz-Kreislaufsystems und der Lungen führen. Diese sind nach Druckentlastung reversibel. Häufige Ursachen für eine intraabdominelle Druckerhöhung sind abdominelle Operationen, Bauchtraumata, diffuse Peritonitis, Aszites und Ödem nach Reanimation. Das Ausmaß der Funktionsstörungen wächst mit steigendem und länger anhaltendem Druck. Die pathophysiologische Situation, in der die intraabdominelle Druckerhöhung unbehandelt zu einem Multiorganversagen führt, wird abdominelles Kompartmentsyndrom genannt. Bei ausbleibendem Erfolg der konservativen Behandlungsmöglichkeiten kann oft nur noch eine operative Dekompression helfen. Anhand tierexperimenteller Untersuchungen und klinischen Erfahrungen lassen sich in Abhängigkeit vom intraabdominellen Druck Empfehlungen zur Therapie geben. Bei entsprechender klinischer Symptomatik sollte der intraabdominelle Druck gemessen werden. Da die Bestimmung des Blaseninnendrucks eine gute Näherung des intraabdominellen Drucks darstellt und ohne großen Aufwand durchführbar ist, können diese Werte problemlos in der medizinische Entscheidungsfindung berücksichtigt werden. Es besteht ein großer Bedarf an kontrollierten Studien, um die klinische Wertigkeit der intraabdominellen Druckerhöhung und des abdominellen Kompartmentsyndroms zu bestimmen.

The Abdominal Compartment Syndrome.

The abdominal compartment is limited by the abdominal wall, Mm. Psoas, vertebral column, diaphragm and the pelvis. Thus the retroperitoneum is included. Elevated intraabdominal pressure may profoundly impair the function of the entire gastrointestinal tract, the cardiovascular, respiratory, and renal system. Reduction of increased intraabdominal pressure may reverse all these adverse effects. The most common causes of elevated intraabdominal pressure are abdominal operations, abdominal trauma, diffuse peritonitis, ascites and peritoneal edema following resuscitation. Excessively increased intraabdominal pressure may result in a total loss of function and may lead to death. Such a condition is called an abdominal compartment syndrome. It usually requires operative decompression. According to animal experiments and clinical experiences suggestions for treatment are given. Diagnostic suspicion of elevated intraabdominal pressure may be confirmed with objective measurements. Since bedside manometry using a Foley catheter provides a valuable estimate of intraabdominal pressure and is easy to perform, intraabdominal pressure values may contribute to medical decision making. At this time there is a great need of controlled clinical trials to point out the importance of increased intraabdominal pressure and the abdominal compartment syndrome.

Schlüsselwörter:

abdominelles Kompartmentsyndrom - - intraabdomineller Druck - - postoperative Komplikationen - - Dekompression - - Übersicht

Key words:

Abdominal compartment syndrome - - Intraabdominal pressure - - Postoperative complications - - Decompression - - Review

Literatur

• 1 Echtermeyer V. Kompartmentsyndrom.  In: Breitner Chirurgische Operationslehre, Traumatologie 1. Gschnitzer,F, Kern,E und Schweiberer,L (Hrsg); Urban & Schwarzenberg, München Wien Baltimore. 1987;  2. Aufl. 211-226
• 2 Hitchings R A. Intraocular Pressure and circulation at the disc in glaucoma.  Acta OphthaImol. Scand.Suppl.. 1997;  220 15-22
• 3 Stone H H, Fulenwider J T. Renal decapsulation in the prevention of postischemic oliguria.  Ann. Surg.. 1977;  186 343-355
• 4 Saul T G. Is ICP monitoring worthwhile?.  CIin. Neurosurg.. 1988;  34 560-571
• 5 Barnes G E, Laine G A, Giam P Y, Smith E E, Granger H J. Cardiovascular responses to elevation of intra-abdominal hydrostatic pressure.  Am. J. Physiol.. 1985;  248 8208-8213
• 6 Rubinson R M, Vasko J S, Doppman J S, Morrow A G. Inferior vena caval obstruction from increased intra-abdominal pressure. Experimental hemodynamic and angiographic observations.  Arch. Surg.. 1967;  94 766-770
• 7 Emerson H. Intra-abdominal pressures.  Arch. Intern. Med.. 1911;  7 764-784
• 8 Wagoner G. Studies an intra-abdominal pressure.  Am. J. Med.. 1926;  171 697-707
• 9 Overholt R H. Intraperitoneal pressure.  Arch.Surg.. 1931;  22 691-703
• 10 Wittmann D H. Compartment syndrome of the abdominal cavity.:  In: Intensive Care Medicine. Irwin,RS, Cerra,FB und Rippe,JM (Hrsg); Lippincott-Raven Publishers, Philadelphia. 1998;  4. Aufl. 1888-1904
• 11 Richardson J D, Trinkle J K. Hemodynamic and respiratory alterations with increased intra-abdominal pressure.  J. Surg. Res.. 1976;  20 401-404
• 12 Bloomfield G L, Dalton J M, Sugermann H J, Ridings P C, DeMaria E J, Bullock R. Treatment of increasing intracranial presure secondary to the acute abdominal compartment sysndrome in a patient with combined abdominal and head trauma.  J.Trauma. 1995;  39 1168-1170
• 13 Josephs L G, Este-McDonald J R, Birkett D, Hirsch E F. Diagnostic laparoscopy increases intracranial pressure.  J.Trauma. 1994;  36 815-819
• 14 Diebel L N, Dulchavsky S A, Wilson R F. Effect of increased intra-abdominal pressure an mesenteric arterial and intestinal mucosal blood flow.  J. Trauma. 1992;  33 45-48
• 15 Diebel L N, Wilson R F, Dulchavsky S A, Saxe J. Effect of increased intraabdominal pressure an hepatic arterial, portal venous, and hepatic microcirculatory blood flow.  J. Trauma. 1992;  33 279-282
• 16 Harman P K, Kron I L, McLachlan H D, Freedlender A E, Nolan S P. Elevated intra-abdominal pressure and renal function.  Ann. Surg.. 1982;  196 594-597
• 17 Caldwell C B, Ricotta J J. Changes in viceral blond flow with elevated intraabdominal pressure.  J. Surg. Res.. 1987;  42 14-20
• 18 McGill S M, Sharratt M T, Sguin J P. Loads an spinal tissues during simultaneous lifting and ventilatory challenge.  Ergonomics.. 1995;  38 1772-1792
• 19 McGill S M, Morman R W, Sharratt M T. The effect of an abdominal belt an trunk muscle activity and intra- abdominal pressure during squat lifts.  Ergonomics. 1990;  33 147-160
• 20 Kelman G R, Swapp G H, Smith I, Benzie R J, Gordon N L. Caridac output and arterial blond-gas tension during laparoscopy.  Br. J. Anaesth.. 1972;  44 1155-1162
• 21 Ivankovich A D, Miletich D J, Albrecht R F, Heyman H J, Bonnet R F. Cardiovascular effects of intraperitoneal insufflation with carbon dioxide and nitrous oxide in the dog.  Anesthesiology. 1975;  42 281-287
• 22 Ho A D, Miletich D J, Albrecht R F, Heyman H J, Bonnet R R. Intraperitoneal carbon dioxide insufflation and cardiopulmonary functions. Laparoscopic cholecystectomy in pigs.  Ann. Surg.. 1992;  127 928-932
• 23 Doppman J, Rubinson R M, Rockoff S D, Vasko J S, Shapiro R, Morrow A G. Mechanism of obstruction of the infradiaphragmatic portion of the inferior vena cava in the presence of increased intra-abdominal pressure.  Invest.Radiol.. 1966;  1 37-53
• 24 Iberti T J, Kelly K M, Gentili D R, Hirsch S, Benjamin E. A simple technique to accurately determine intra-abdominal pressure.  Crit. Care Med.. 1987;  15 1140-1142
• 25 Cullen D J, Coyle J P, Teplick R, Long M C. Cardiovascular, pulmonary, and renal effects of massively increased intra-abdominal pressure in critically ill patients.  Crit. Care Med.. 1989;  17 118-121
• 26 Buchard K W, Ciombor D M, McLeod M K, Slothman G J, Gann D S. Positive and expiratory pressure with increased intra-abdominal pressure.  Surg. Gynecol. Obstet.. 1985;  161 313-318
• 27 Wendt E C. Über den Einfluß des intraabdominellen Druckes auf die Absonderungsgeschwindigkeit des Harnes.  Arch. Heilkunde. 1876;  17 527-546
• 28 Shelly M P, Robinson A A, Hesfor J W, Park G R. Haemodynamic effects following surgical release of increased intra-abdominal pressure.  Br. J. Anaesth.. 1987;  59 800-805
• 29 Mullaue J F, Gliedman M L. Elevation of the pressure in the abdominal inferior vena cava as a cause of a hepatorenal syndrome in cirrhosis.  Surgery. 1966;  59 1135-1146
• 30 Le Roith D, Bark H, Nyska M, Glick S M. The effect of abdominal pressure on plasma antidiuretic hormone levels in dogs.  J. Surg. Res.. 1982;  32 65-69
• 31 Zink J, Greenway C V. Control of ascites absorption in anesthetized cats: effects of intraperitoneal pressure, protein, and furosemide diuresis.  Gastroenterology. 1977;  73 1119-1124
• 32 Bloechle C, Emmermann A, Zornig C. Effect of carbon dioxide pneumoperitoneum an bacteraemia and endotoxaemia in an animal model of peritonitis.  Br. J. Surg.. 1995;  82 1702-1703
• 33 Bloechle C, Emmermann A, Strate T, Scheurlen U J, Schneider C, Achilles E, Wolf M, Mack D, Zornig C, Broelsch C E. Laparoscopic vs open repair of gastric perforation and abdominal lavage of associated peritonitis in pigs.  Surg. Endosc.. 1998;  12 212-218
• 34 Jacobi C A, Ordemann J, Zieren H U, Volk H D, Bauhofer A, Halle E, Muller J M. Increased systemic inflammation after laparotomy vs laparoscopy in an animal model of peritonitis.  Arch.Surg.. 1998;  133 258-262
• 35 Diebel L N, Dulchavsky S A, Brown W J. Splanchnic ischemia and bacterial translocation in the abdominal compartment syndrome.  J. Trauma. 1997;  43 852-855
• 36 Eleftheriadis E, Kotzampassi K, Papanotas K, Heliadis N, Sarris K. Gut ischemia, oxidative stress, and bacterial translocation in elevated abdominal pressure in rats.  World J.Surg.. 1996;  20 11-16
• 37 Gennarelli T A, Champion H R, Sacco W J, Copes W S, Alves W M. Mortality of patients with head injury and extracranial injury treated in trauma centers.  J.Trauma. 1989;  29 1193-1201
• 38 Savino J A, Cerabona T, Agarwal N, Byrne D. Manipulation of ascitic fluid pressure in cirrhotics to optimize hemodynamic and renal function.  Ann.Surg.. 1988;  208 504-511
• 39 Chang M C, Miller P R, D'Agostino R, Meredith J W. Effects of abdominal decompression an cardiopulmonary function and visceral perfusion in patients with intra-abdominal hypertension.  J.Trauma. 1998;  44 440-445
• 40 Wittmann D H, Schein M, Condon R E. Management of secondary peritonitis.  Ann. Surg.. 1996;  224 10-18
• 41 Morino M, Giraudo G, Festa V. Alterations in hepatic function during laparoscopic surgery. An experimental clinical study.  Surg. Endosc.. 1998;  12 968-972
• 42 Sugrue M, Buist M D, Hourihan F, Deane S, Bauman A, Hillman K. Prospective study of intra-abdominal hypertension and renal function after laparotomy.  Br. J. Surg.. 1995;  82 235-238
• 43 Sugrue M, Buist M D, Lee A, Sanchez D J, Hillman K M. Intra-abdominal pressure measurement using a modified nasogastric tube: description and validation of a new technique.  Intensive Care Med.. 1994;  20 588-590
• 44 Iberti T J, Lieber C E, Benjamin E. Determination of intra-abdominal pressure using a transurethral bladder catheter: clinical validation of the technique.  Anesthesiology. 1989;  70 47-50
• 45 Kron I L, Harman P K, Nolan S P. The measurement of intra-abdominal pressure as a criterion for abdominal re-exploration.  Ann. Surg.. 1984;  199 28-30
• 46 Schein M, Wittmann D H, Aprahamian C C, Condon R E. The abdominal compartment syndrome: The physiological and clinical consequences of elevated intra-abdominal pressure.  J. Am. Coll. Surg.. 1995;  180 745-753
• 47 Knauer C M, Lowe H M. Hemodynamics in the cirrhotic patient during paracentesis.  N. Engl. J. Med.. 1967;  276 491-496
• 48 Burch J M, Moore E E, Moore F A, Franciose R. The abdominal compartment syndrome.  Surg. CIin. North Am.. 1996;  76 833-842
• 49 Smith P C, Tweddell J S, Bessey P Q. Alternative approaches to abdominal wound closure in severely injured patients with massive visceral edema.  J. Trauma. 1992;  32 16-20
• 50 Cue J I, Cryer H G, Miller F B, Richardson J D, Polk H CJ. Packing and planned reexploration for hepatic and retroperitoneal hemorrhage: critical refinements of a useful technique.  J.Trauma. 1990;  30 1007-1011
• 51 Fabian T C, Croce M A, Pritchard F E, Minard G, Hickerson W L, Howell R L, Schurr M J, Kudsk K A. Planned ventral hernia. Staged management for acute abdominal wall defects.  Ann. Surg.. 1994;  219 643-650
• 52 Fayman M S, Schein M, Saadia R. Abdominal wall reconstruction after open management of the septic abdomen.  S. Afr. J. Surg.. 1990;  28 62-65
• 53 Livingston D H, Sharma P K, Glantz A I. Tissue expanders for abdominal wall reconstruction following severe trauma: technical note and case reports.  J.Trauma. 1992;  32 82-86
• 54 Richards W O, Scovill W, Shin B, Reed W. Acute renal failure associated with increased intra-abdominal pressure.  Ann. Surg.. 1983;  197 183-187
• 55 Ridings P C, Bloomfield G L, Blocher C R, Sugerman H J. Cardiopulmonary effects of raised intra-abdominal pressure before and after intravascular volume expansion.  J.Trauma. 1995;  39 1071-1075