Divertikelkrankheit – Wann ist der Chirurg gefragt?

Zusammenfassung

Für die richtige Indikationsstellung zur Operation bei der Divertikelkrankheit ist eine exakte präoperative Klassifikation obligat. Die Deutsche Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und die Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV) hat 2014 eine S2k Leitlinie Divertikelkrankheit / Divertikulitis erfasst, in der eine neue Klassifikation erarbeitet wurde, aus der sich daraus die operative Therapie gut ableiten lässt. Die unkomplizierte Divertikulitis stellt nur noch in Ausnahmesituationen eine OP-Indikation dar. Die Anzahl der Divertikulitis-Schübe fließt nicht mehr in die Entscheidungsfindung zur Operation ein.

Abstract

In preparation for operations of patients with diverticular disease an adequate medical indication has to be performed. The new classification of sigmoid diverticulitis corresponding to the German guidelines for diverticular disease classification (GGDDC) enables an appropriate strategy for evaluating the indications and selection of the time for surgery. New is, that the uncomplicated form of diverticulitis indicates an operation in exceptional case only. Furthermore the frequency of diverticulitis-exacerbation does not influence the indication for surgery any more.

Schlüsselwörter

Divertikulose - Divertikulitis - Divertikelblutung - Leitlinie - abdominelle Abszessdrainage

Keywords

diverticular disease - diverticulitis - diverticular hemorrhage - guideline - percutanous abscess drainage

• Literatur

• 1 Köhler L, Sauerland S, Neugebauer E. Diagnosis and treatment of diverticular disease: results of a consensus development conference. The Scientific Committee of the European Association for Endoscopic Surgery. Surg Endosc 1999; 13: 430-436
• 2 Jurowich C, Seyfried F, Germer CT. Sigmadivertikulitis: Indikation und Zeitpunkt zur Operation. Chirurg 2014; 85: 304-307
• 3 Leifeld L, Germer CT, Böhm S et al. S2k-Leitlinie Divertikelkrankheit / Divertikulitis. Z Gastroenterol 2014; 52: 663-710
• 4 Andersen JC, Bundgaard L, Elbrønd H et al. Danish national guidelines for treatment of diverticular disease. Dan Med J 2012; 59: C4453
• 5 Rafferty J, Shellito P, Hyman NH et al. Practice parameters for sigmoid diverticulitis. Dis Colon Rectum 2006; 49: 939-944
• 6 Andeweg CS, Mulder IM, Felt-Bersma RJ et al. Guidelines of diagnostics and treatment of acute left-sided colonic diverticulitis. Dig Surg 2013; 30: 278-292
• 7 Shaikh S, Krukowski ZH. Outcome of a conservative policy for managing acute sigmoid diverticulitis. Br J Surg 2007; 94: 876-879
• 8 Tyau ES, Prystowsky JB, Joehl RJ, Nahrwold DL. Acute diverticulitis. A complicated problem in the immunocompromised patient. Arch Surg 1991; 126: 855-859
• 9 Qasabian RA, Meagher AP, Lee R et al. Severe diverticulitis after heart, lung, and heart-lung transplantation. J Heart Lung Transplant 2004; 23: 845-849
• 10 Biondo S, Borao JL, Kreisler E et al. Recurrence and virulence of colonic diverticulitis in immunocompromised patients. Am J Surg 2012; 204: 172-179
• 11 Berger M. Besonderheiten der Divertikulitis beim Diabetiker. In: Schumpelick V, Kasperk R, Hrsg. Divertikulitis. 1.. Aufl. Heidelberg: Springer; 2001: 141-150
• 12 Collins D, Winter DC. Elective resection for diverticular disease: an evidence-based review. World J Surg 2008; 32: 2429-2433
• 13 Chapman JR, Dozois EJ, Wolff BG et al. Diverticulitis: a progressive disease? Do multiple recurrences predict less favorable outcomes?. Ann Surg 2006; 243: 876-833
• 14 Parks TG. Natural history of diverticular disease of the colon. A review of 521 cases. Br Med J 1969; 4: 639-642
• 15 Mueller MH, Glatzle J, Kasparek MS et al. Long-term outcome of conservative treatment in patients with diverticulitis of the sigmoid colon. Eur J Gastroenterol Hepatol 2005; 17: 649-654
• 16 Broderick-Villa G, Burchette RJ, Collins JC et al. Hospitalization for acute diverticulitis does not mandate routine elective colectomy. Arch Surg 2005; 140: 576-583
• 17 Anaya DA, Flum DR. Risk of emergency colectomy and colostomy in patients with diverticular disease. Arch Surg 2005; 140: 681-685
• 18 Ritz JP, Lehmann KS, Frericks B et al. Outcome of patients with acute sigmoid diverticulitis: multivariate analysis of risk factors for free perforation. Surgery 2011; 149: 606-613
• 19 Pittet O, Kotzampassakis N, Schmidt S et al. Recurrent left colonic diverticulitis episodes: more severe than the initial diverticulitis?. World J Surg 2009; 33: 547-552
• 20 Binda GA, Amato A, Serventi A, Arezzo A. Clinical presentation and risks. Dig Dis 2012; 30: 100-107
• 21 Hall J, Hammerich K, Roberts P. New paradigms in the management of diverticular disease. Curr Probl Surg 2010; 47: 680-735
• 22 Siewert B, Tye G, Kruskal J et al. Impact of CT-guided drainage in the treatment of diverticular abscesses: size matters. AJR Am J Roentgenol 2006; 186: 680-686
• 23 Holmer C, Lehmann KS, Engelmann S et al. Microscopic findings in sigmoid diverticulitis – changes after conservative therapy. J Gastrointest Surg 2010; 14: 812-817
• 24 Ambrosetti P, Grossholz M, Becker C et al. Computed tomography in acute left colonic diverticulitis. Br J Surg 1997; 84: 532-534
• 25 Kaiser AM, Jiang JK, Lake JP et al. The management of complicated diverticulitis and the role of computed tomography. Am J Gastroenterol 2005; 100: 910-917
• 26 Hall J. Should elective colectomy be routine following percutaneous drainage of a diverticular abscess?. Dis Colon Rectum 2013; 56: 533-534
• 27 van de Wall BJ, Draaisma WA, Consten EC et al. DIRECT trial. Diverticulitis recurrences or continuing symptoms: Operative versus conservative treatment. A multicenter randomised clinical trial. BMC Surg 2010; 10: 25
• 28 Holmer C, Kreis ME. Divertikelkrankheit – operative Verfahrenswahl. Chirurg 2014; 85: 308-313
• 29 Gonzalez R, Smith CD, Mattar SG et al. Laparoscopic vs open resection for the treatment of diverticular disease. Surg Endosc 2004; 18: 276-280
• 30 Lawrence DM, Pasquale MD, Wasser TE. Laparoscopic versus open sigmoid colectomy for diverticulitis. Am Surg 2003; 69: 499-504
• 31 Klarenbeek BR, Veenhof AA, Bergamaschi R et al. Laparoscopic sigmoid resection for diverticulitis decreases major morbidity rates: a randomized control trial: short-term results of the Sigma Trial. Ann Surg 2009; 249: 39-44
• 32 Guller U, Jain N, Hervey S et al. Laparoscopic vs open colectomy: outcomes comparison based on large nationwide databases. Arch Surg 2003; 138: 1179-1186
• 33 Royds J, O‘Riordan JM, Eguare E et al. Laparoscopic surgery for complicated diverticular disease: a single-centre experience. Colorectal Dis 2012; 14: 1248-1254
• 34 Benn PL, Wolff BG, Ilstrup DM. Level of anastomosis and recurrent colonic diverticulitis. Am J Surg 1986; 151: 269-271
• 35 Thaler K, Baig MK, Berho M et al. Determinants of recurrence after sigmoid resection for uncomplicated diverticulitis. Dis Colon Rectum 2003; 46: 385-388
• 36 Tocchi A, Mazzoni G, Fornasari V et al. Preservation of the inferior mesenteric artery in colorectal resection for complicated diverticular disease. Am J Surg 2001; 182: 162-167
• 37 Sarli L, Pavlidis C, Cinieri FG et al. Prospective comparison of laparoscopic left hemicolectomy for colon cancer with laparoscopic left hemicolectomy for benign colorectal disease. World J Surg 2006; 30: 446-452
• 38 Purkayastha S, Constantinides VA, Tekkis PP et al. Laparoscopic vs. open surgery for diverticular disease: a meta-analysis of nonrandomized studies. Dis Colon Rectum 2006; 49: 446-463
• 39 Abbas S. Resection and primary anastomosis in acute complicated diverticulitis, a systematic review of the literature. Int J Colorectal Dis 2007; 22: 351-357
• 40 Salem L, Flum DR. Primary anastomosis or Hartmann’s procedure for patients with diverticular peritonitis? A systematic review. Dis Colon Rectum 2004; 47: 1953-1964
• 41 Oberkofler CE, Rickenbacher A, Raptis DA et al. A multicenter randomized clinical trial of primary anastomosis or Hartmann’s procedure for perforated left colonic diverticulitis with purulent or fecal peritonitis. Ann Surg 2012; 256: 819-827
• 42 Vermeulen J, Gosselink MP, Busschbach JJ, Lange JF. Avoiding or reversing Hartmann’s procedure provides improved quality of life after perforated diverticulitis. J Gastrointest Surg 2010; 14: 651-657
• 43 Swank HA, Vermeulen J, Lange JF et al. The ladies trial: laparoscopic peritoneal lavage or resection for purulent peritonitis and Hartmann’s procedure or resection with primary anastomosis for purulent or faecal peritonitis in perforated diverticulitis (NTR2037). BMC Surg 2010; 10: 29
• 44 Toorenvliet BR, Swank H, Schoones JW et al. Laparoscopic peritoneal lavage for perforated colonic diverticulitis: a systematic review. Colorectal Dis 2010; 12: 862-867
• 45 Afshar S, Kurer MA. Laparoscopic peritoneal lavage for perforated sigmoid diverticulitis. Colorectal Dis 2012; 14: 135-142
• 46 Rogers AC, Collins D, O’Sullivan GC, Winter DC. Laparoscopic lavage for perforated diverticulitis: a population analysis. Dis Colon Rectum 2012; 55: 932-938
• 47 Swank HA, Mulder IM, Hoofwijk AG et al. Early experience with laparoscopic lavage for perforated diverticulitis. Br J Surg 2013; 100: 704-710
• 48 Angenete E, Thornell A, Burcharth J et al. Laparoscopic Lavage Is Feasible and Safe for the Treatment of Perforated Diverticulitis With Purulent Peritonitis: The First Results From the Randomized Controlled Trial DILALA. Ann Surg 2014;
• 49 Klarenbeek BR, Samuels M, van der Wal MA et al. Indications for elective sigmoid resection in diverticular disease. Ann Surg 2010; 251: 670-674
• 50 McGuire Jr HH. Bleeding colonic diverticula. A reappraisal of natural history and management. Ann Surg 1994; 220: 653-656
• 51 Longstreth GF. Epidemiology and outcome of patients hospitalized with acute lower gastrointestinal hemorrhage: a population-based study. Am J Gastroenterol 1997; 92: 419-424