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Operative Verfahrenswahl bei der Divertikelkrankheit

Unter Berücksichtigung der neuesten Therapiestrategien

Choice of operative procedure in diverticular disease

Taking the latest treatment strategies into consideration

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Zusammenfassung

Hintergrund

Bei der operativen Therapie der komplizierten Divertikulitis gibt es unterschiedliche zu berücksichtigende Verfahren, die in Abhängigkeit des CDD(Classification of Diverticular Disease)-Typs und des Zustands des Patienten zu treffen sind.

Fragestellung

Vergleich der operativen Verfahren im Hinblick auf Aspekte wie Morbidität, Mortalität, Wiederherstellungsoperationen und postoperative Lebensqualität.

Material und Methoden

Auswertung, Analyse und Einschätzung der aktuellen Literatur zur operativen Therapie der Divertikelkrankheit.

Ergebnisse

Die laparoskopische Sigmaresektion mit primärer Anastomose gilt heute als Standardverfahren bei der komplizierten Sigmadivertikulitis und ist der offenen Resektion vorzuziehen, da das minimal-invasive Vorgehen in Bezug auf die Inzidenz von Wundinfektionen, intraabdominellen Abszessen sowie dem Auftreten von Fasziendehiszenzen bessere Ergebnisse zeigt. In der Notfallsituation mit freier Perforation und Peritonitis (CDD-Typ 2c1/2) ist die primäre Anastomose mit protektivem Ileostoma gegenüber der Diskontinuitätsresektion nach Hartmann zu favorisieren. Es muss hierbei insbesondere berücksichtigt werden, dass es bei einem Großteil der Patienten nach Hartmann-Operation zu keiner Kontinuitätswiederherstellung kommt. Das „Damage-control“-Verfahren kann bei der frei perforierten Sigmadivertikulitis mit generalisierter Peritonitis (CDD-Typ 2c1/2) angewandt werden. In Einzelfällen kann bei der perforierten Sigmadivertikulitis mit eitriger Peritonitis (CDD-Typ 2c1) die laparoskopische Lavage mit Drainagenanlage erwogen werden.

Schlussfolgerungen

Die operative Verfahrenswahl bei der komplizierten Sigmadivertikulitis bleibt herausfordernd. Randomisiert-kontrollierte Studien zu neuen Therapiestrategien sowie zum roboterassistierten Operieren sollten zukünftig bei der Wahl des Operationsverfahrens berücksichtigt werden.

Abstract

Background

There are various procedures to be considered in the surgical treatment of complicated diverticulitis, which must be selected depending on the classification of diverticular disease (CDD) type and the condition of the patient.

Objective

Comparison of surgical procedures with respect to aspects such as morbidity, mortality, reconstructive surgery and postoperative quality of life.

Material and methods

Evaluation, analysis and assessment of the current literature on surgical treatment of diverticular disease.

Results

Laparoscopic sigmoid resection with primary anastomosis is now considered the standard procedure for complicated sigmoid diverticulitis. It is preferable to open resection because of the better results of the minimally invasive approach with respect to the incidence of wound infections, abdominal abscesses and the occurrence of fascial dehiscence. In an emergency situation with perforation and peritonitis (CDD type 2c1/2), primary anastomosis with protective ileostomy should be favored over discontinuity resection (Hartmann’s procedure). In particular, it must be taken into account that in a large proportion of patients there is no restoration of continuity after Hartmann’s operation. The damage control strategy can be used in perforated sigmoid diverticulitis with generalized peritonitis (CDD type 2c1/2). In individual cases, laparoscopic lavage with insertion of a drainage may be considered as a therapeutic treatment strategy for perforated sigmoid diverticulitis with purulent peritonitis (CDD type 2c1).

Conclusion

Selection of the surgical procedure for complicated sigmoid diverticulitis remains challenging. Randomized controlled trials of new treatment strategies as well as robotic-assisted surgery should be considered in the choice of surgical procedure in the future.

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Authors and Affiliations

  1. Chirurgische Klinik, Universitätsmedizin Mannheim, Medizinische Fakultät, Universität Heidelberg, Theodor-Kutzer-Ufer 1–3, 68167, Mannheim, Deutschland

    A. Betzler, J. Grün, A. Finze & C. Reißfelder

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  1. A. Betzler
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  2. J. Grün
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  3. A. Finze
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  4. C. Reißfelder
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Correspondence to A. Betzler.

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A. Betzler, J. Grün, A. Finze und C. Reißfelder geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autoren keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

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C.T. Germer, Würzburg

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Betzler, A., Grün, J., Finze, A. et al. Operative Verfahrenswahl bei der Divertikelkrankheit. Chirurg 92, 702–706 (2021). https://doi.org/10.1007/s00104-021-01409-6

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