Der klinische Verlauf nach großen Operationen korreliert mit einer frühen intestinalen Barrierestörung

Introduction: Major surgery is often followed by an overwhelming systemic inflammatory response syndome (SIRS) which is considered to be the major cause of multiorgan dysfunction syndrome (MODS). The »ntestine-sepsis-hypothesis« considers the breakdown of the intestinal barrier followed by bacterial translocation a major step towards the development of SIRS. The present clinical study prospectively investigates the relation of intestinal barrier dysfunction and the risc of multiorgan failure (MOF) after major abdominal and vascular surgery. Materials and methods: 36 patients (68 ± 20 years; m : w 20 : 16) after major elective abdominal and vascular operations (esophagectomies (3), colorectal resections (18), aortic aneurysm operations (15)) were included into this study. Preoperatively and 24, 72 and 120 hours after operation clinical data as well as laboratory exams were performed. Concentrations after oral application of sugar (15 g lactulose; 0.5 g mannitol, 2.0 g rhamnose, 1.0 g xylose) were determined in urine of patients (HPLC). The clinical course was estimated by APACHE II score, MOF was evaluated by Goris-score. Results: According to APACHE II (≥ 10 points) and MOF-score (≥ 5 points) patients with bad prognosis (multiorgan failure, group 1; n = 10) and patients with good prognosis (group 2; n = 26) were differentiated. After enteral application of mono- and disaccharids an increased intestinal permeability measured by mannitol excretion into urine was found 24 hours(significant, p < 0.05 Mann-Whitney U-test, MOF vs. group2: 4.46 ± 1.20 vs. 0.89 ± 0.23) and 72 hours (significant, p < 0.05 MOF vs. group2: 0.88 ± 0.29 vs. 0.24 ± 0.03) postoperatively in the MOF group. This difference was not found 120 hours postoperatively. Mannitol concentration correlated with MOF-score and after 72 hours even with survival probability. Lactulose/rhamnose ratio also showed the tendency of increasing intestinal permeability in the multiorgan failure group, however without significance. ROC-Analysis showed that intestinal permeability 72 hours postoperatively is predictive for survival of patients after extended abdominal and vascular operations. Conclusion: Our results confirm that patients with a multiorgan failure show an increased intestinal permeability in the early phase after large visceral surgery. These observations are consistent with the »ntestine-sepsis-hypothesis« and indicate an important role of intestinal barrier disturbances in the development of MOF after extended abdominal surgery.