Zusammenfassung
Das Spektrum der Divertikelkrankheit reicht von einer asymptomatischen Divertikulose bis hin zu einer symptomatischen Erkrankung mit rezidivierenden Verläufen mit der Ausbildung von Fisteln, Stenosen oder aber mit potenziell tödlichen Komplikationen wie einer Perforation oder Blutung. Die laparoskopische Sigmakontinuitätsresektion gilt heute als Standardverfahren bei der komplizierten und rezidivierenden Sigmadivertikulitis. Grundsätzlich sollte bei der chirurgischen Behandlung der Sigmadivertikulitis das gesamte Sigma reseziert und eine spannungsfreie Anastomose im oberen Rektumdrittel angelegt werden. Das Entfernen verbliebener Divertikel oral des Sigmas ist nach aktueller Datenlage nicht erforderlich, da kein Zusammenhang zwischen der Anzahl der Restdivertikel im verbliebenen Kolon mit dem Risiko einer Progression oder eines Rezidivs der Divertikelerkrankung existiert. In der Notfallsituation im Rahmen einer freien Perforation sollte die primäre Anastmose mit protektivem Ileostoma favorisiert werden, da die Ileostomarückverlagerung im Vergleich zur Kontinuitätswiederherstellung nach einer Hartmann-Operation später häufiger möglich ist. Die Sigmadiskontinuitätsresektion nach Hartmann bleibt dagegen Perforationen mit schweren septischen Verläufen vorbehalten. Letztlich sollte jedoch die Therapieentscheidung für eine primäre Anastomose ggf. mit protektivem Stoma oder Hartmann-Resektion von der individuellen Situation des Patienten abhängig gemacht werden. Als Alternative zu den resezierenden Verfahren wird in neueren Studien auch die Möglichkeit der laparoskopischen Lavage und Drainageneinlage bei Patienten mit perforierter Sigmadivertikulitis und generalisierter Peritonitis beschrieben. Bei einer Divertikelblutung und nicht genauer Lokalisierbarkeit der Blutungsquelle sollte zur Vermeidung einer Rezidivblutung eine subtotale Kolektomie mit Ileorektostomie erfolgen.
Abstract
The clinical spectrum of diverticular disease varies from asymptomatic diverticulosis to symptomatic disease with potentially fatal complications, such as perforation or bleeding. Laparoscopic sigmoid resection with restoration of continuity is currently the prevailing modality for treating acute and recurrent sigmoid diverticulitis. The tenets of surgical treatment of diverticulitis are resection of the entire sigmoid and creation of a tension-free anastomosis in the upper rectum. With respect to the required extent of resection according to current data it is not necessary to remove the entire colonic segment bearing diverticula because such a strategy does not reduce the recurrence rate. In the emergency situation due to free perforation a primary anastomosis with defunctioning ileostomy should be favored because the stoma reversal rate after primary anastomosis is higher than after Hartmann’s procedure. The Hartmann procedure should be reserved for perforated diverticulitis with severe septic complications; however, the final treatment decision for primary anastomosis or Hartmann’s procedure should be dependent on the individual patient. There have been a number of recent publications on the use of laparoscopic peritoneal lavage for perforated sigmoid diverticulitis as an alternative to resection surgery. In cases of diverticular bleeding a subtotal colectomy should be performed if the diverticular bleeding site cannot be localized.
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Interessenkonflikt. C. Holmer und M.E. Kreis geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.
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Holmer, C., Kreis, M. Divertikelkrankheit – operative Verfahrenswahl. Chirurg 85, 308–313 (2014). https://doi.org/10.1007/s00104-013-2621-x
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DOI: https://doi.org/10.1007/s00104-013-2621-x