Zusammenfassung
Eine valide Einschätzung des präoperativen Ernährungszustandes unserer viszeralchirurgischen Patienten erscheint angesichts der hohen Inzidenz von Mangelernährten zwingend erforderlich. Die verfügbare Datenlage zeigt deutlich, dass Mangelernährung, gemessen mit verschiedenen Werkzeugen, ein unabhängiger Risikofaktor für Morbidität und Mortalität ist, insbesondere in der perioperativen Situation. Ein präoperatives Screening mit anschließender Einleitung einer nutritionellen Konditionierung kann die Morbiditäts-und Mortalitätsrate in viszeralchirurgischen Abteilungen signifikant senken. Die Leitlinien der „European Society for Parenteral and Enteral Nutrition“ wurden 2006 erstellt und finden in den deutschen chirurgischen Abteilungen wenig Anklang, obwohl viele dieser Empfehlungen einen hohen Evidenzgrad aufweisen. Um diese Situation zu verbessern, haben wir in der Universitätsklinik für Viszeralchirugie/Oldenburg einen klinikinternen Behandlungspfad entwickelt. Unsere ersten Ergebnisse bezüglich der systematischen Umsetzung des Konzeptes sind zwar bescheiden, zeigen aber, dass das Konzept applizierbar ist. Der Erfolg der präoperativen Konditionierung hängt von der konsequenten Zusammenarbeit zwischen Hausarzt und behandelnder Klinik ab. Die Gesetzeslage ermöglicht die Kostenübernahme der präopertiven häuslichen Ernährungstherapie durch die Krankenversicherung, dies kann jedoch zu einer Überschreitung des Arzneimittelbudgets einzelner Praxen führen. Diese Überschreitung kann in der Regel durch Nachweis der aktuellen medizinischen Datenlage und durch die gute Dokumentation des Einzelfalls vor der kassenärztlichen Vereinigung gerechtfertigt werden und führt nicht zu Regressen.
Abstract
The incidence of malnutrition in oncological and visceral surgical units can be high. The screening of malnourished patients is very important, especially in the preoperative setting. The available published literature provides crucial knowledge about the risks inherent to malnutrition and subsequent perioperative morbidity and mortality. The preoperative screening of malnourished patients followed by a subsequent renutrition is the key to decreasing rates of postoperative morbidity and mortality. The data and guidelines given by the European Society of Parenteral and Enteral Nutrition (ESPEN) in 2006 for the preoperative nutritional conditioning are clear and give no doubt regarding the necessity of preparation of malnourished patients for elective abdominal surgery. Despite this fact, the observance and application of these guidelines among German surgical units remain low. To fill this void a model of systematic screening and treatment of malnutrition in the preoperative setting for elective abdominal surgery was created and implemented at the university hospital of Oldenburg. A practical treatment regimen was designed to prepare malnourished patients within 2–3 weeks before elective surgery. Initial results regarding the feasibility of preoperative home renutrition therapy were moderate but encouraging. The success of such a conditioning process depends on cooperation between the surgical unit, the general practitioner (GP) and the homecare environment. In the German healthcare system the prescription of home nutrition (i.e. enteral feeding) can lead to the prescription limits of a GP being exceeded and has to be justified to the medical insurance company in each case. This article presents a simple yet applicable way of screening and preparing malnourished patients a few weeks prior to elective surgery. Therefore, simple tools which can be promptly used in daily clinical life, especially in the outpatient surgical consultations prior to elective visceral surgery are proposed.
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Interessenkonflikt. K. Khatib-Chahidi, A. Troja, M. Kramer, M. Klompmaker, H.-R. Raab und D. Antolovic geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.
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Khatib-Chahidi, K., Troja, A., Kramer, M. et al. Präoperatives Management bei Mangelernährten in der Viszeralchirurgie. Chirurg 85, 520–528 (2014). https://doi.org/10.1007/s00104-013-2637-2
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DOI: https://doi.org/10.1007/s00104-013-2637-2