Skip to main content
SpringerLink
Log in

Empfehlungen zur Therapie der Divertikelkrankheit

Recommendations for treatment of diverticular disease

  • Leitthema
  • Published:
Der Chirurg Aims and scope Submit manuscript

Zusammenfassung

Hintergrund

Die Divertikelkrankheit hat in Deutschland erhebliche klinische und gesundheitsökonomische Bedeutung. In den letzten Jahren haben Änderungen in den Therapieempfehlungen zahlreicher internationaler Leitlinien für Diskussion gesorgt. Die deutsche S2k-Leitlinie befindet sich derzeit in Überarbeitung.

Ziel der Arbeit

Die wichtigsten klinischen Aspekte im Management der Divertikelkrankheit werden aus chirurgischer Perspektive zusammengefasst.

Material und Methoden

Die Empfehlungen wurden auf Basis aktueller nationaler und internationaler Leitlinien und einer selektiven Literaturrecherche verfasst.

Ergebnisse

Die akute, unkomplizierte Divertikulitis ohne Risikofaktoren kann ambulant und ohne Einsatz von Antibiotika behandelt werden. Bei Patienten mit einer komplizierten Divertikulitis ist eine stationäre Aufnahme mit parenteraler Antibiotikatherapie indiziert. Bei Makroabszessen kann ab einer Größe von ca. 5 cm eine perkutane Drainage erfolgen. Die Indikation zur umgehenden Sigmaresektion besteht bei der freien Perforation oder bei Versagen der konservativen Therapie. Die elektive Resektion ist bei der chronisch rezidivierenden Divertikulitis mit Komplikationen indiziert; alle weiteren Indikationen werden zunehmend auf Basis der individuellen Lebensqualität des Patienten gestellt.

Diskussion

Die unkomplizierte Divertikulitis kann ambulant und ohne Antibiotika behandelt werden. Die Operationsindikation wird außerhalb der Notfallsituationen zunehmend von der Lebensqualität abhängig gemacht. Eine elektive Sigmaresektion sollte als laparoskopische Operation mit primärer Anastomose nach Vorliegen einer Computertomographie sowie einer totalen Koloskopie erfolgen.

Abstract

Background

Diverticular disease is of major clinical and health economic importance in Germany. Treatment recommendations in many international guidelines have changed significantly in recent years. The German national S2k guidelines are currently being revised.

Objective

To summarize the most important clinical aspects in the management of diverticular disease from a surgical perspective.

Material and methods

The recommendations were compiled based on current national and international guidelines and a selective literature search.

Results

Acute uncomplicated diverticulitis without risk factors can be treated on an outpatient basis without antibiotics. For patients with complicated diverticulitis, hospital admission with parenteral antibiotic treatment is recommended. In the case of abscess formation >5 cm, percutaneous drainage can be performed. The indications for immediate sigmoid resection are free perforation and failure of conservative treatment. Elective resection is indicated in chronic recurrent diverticulitis with complications; all other indications are increasingly based on the individual quality of life of the patient.

Conclusion

Uncomplicated diverticulitis is increasingly being treated on an outpatient basis and without antibiotics. Apart from emergency settings, the indications for surgery are increasingly dependent on the quality of life. Elective sigmoid resection should be performed as laparoscopic surgery with primary anastomosis after obtaining results of computed tomography and total colonoscopy.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1

Literatur

  1. Ahmed O, Jilani D, Sheth S et al (2015) Long-term results of microcoil embolization for colonic haemorrhage: how common is rebleeding? Br J Radiol 88:20150203

    Article  CAS  Google Scholar 

  2. Andersen JC, Bundgaard L, Elbrond H et al (2012) Danish national guidelines for treatment of diverticular disease. Dan Med J 59:C4453

    PubMed  Google Scholar 

  3. Andeweg CS, Mulder IM, Felt-Bersma RJ et al (2013) Guidelines of diagnostics and treatment of acute left-sided colonic diverticulitis. Dig Surg 30:278–292

    Article  CAS  Google Scholar 

  4. Au S, Aly EH (2019) Treatment of uncomplicated acute diverticulitis without antibiotics: a systematic review and meta-analysis. Dis Colon Rectum 62:1533–1547

    Article  Google Scholar 

  5. Binda GA, Bonino MA, Siri G et al (2018) Multicentre international trial of laparoscopic lavage for Hinchey III acute diverticulitis (LLO study). Br J Surg 105:1835–1843

    Article  CAS  Google Scholar 

  6. Bolkenstein HE, Consten ECJ, van der Palen J et al (2019) Long-term outcome of surgery versus conservative management for recurrent and ongoing complaints after an episode of diverticulitis: 5‑year follow-up results of a multicenter randomized controlled trial (DIRECT-trial). Ann Surg 269:612–620

    Article  Google Scholar 

  7. Brandt D, Gervaz P, Durmishi Y et al (2006) Percutaneous CT scan-guided drainage vs. antibiotherapy alone for Hinchey II diverticulitis: a case-control study. Dis Colon Rectum 49:1533–1538

    Article  CAS  Google Scholar 

  8. Chabok A, Pahlman L, Hjern F et al (2012) Randomized clinical trial of antibiotics in acute uncomplicated diverticulitis. Br J Surg 99:532–539

    Article  CAS  Google Scholar 

  9. Daniels L, Unlu C, de Korte N et al (2017) Randomized clinical trial of observational versus antibiotic treatment for a first episode of CT-proven uncomplicated acute diverticulitis. Br J Surg 104:52–61

    Article  CAS  Google Scholar 

  10. Desai M, Fathallah J, Nutalapati V et al (2019) Antibiotics versus no antibiotics for acute uncomplicated diverticulitis: a systematic review and meta-analysis. Dis Colon Rectum 62:1005–1012

    Article  Google Scholar 

  11. Durmishi Y, Gervaz P, Brandt D et al (2006) Results from percutaneous drainage of Hinchey stage II diverticulitis guided by computed tomography scan. Surg Endosc 20:1129–1133

    Article  CAS  Google Scholar 

  12. Elagili F, Stocchi L, Ozuner G et al (2015) Antibiotics alone instead of percutaneous drainage as initial treatment of large diverticular abscess. Tech Coloproctol 19:97–103

    Article  CAS  Google Scholar 

  13. Gallo A, Ianiro G, Montalto M et al (2016) The role of biomarkers in diverticular disease. J Clin Gastroenterol 50(1):S26–28

    Article  CAS  Google Scholar 

  14. Gervaz P, Inan I, Perneger T et al (2010) A prospective, randomized, single-blind comparison of laparoscopic versus open sigmoid colectomy for diverticulitis. Ann Surg 252:3–8

    Article  Google Scholar 

  15. Isacson D, Thorisson A, Andreasson K et al (2015) Outpatient, non-antibiotic management in acute uncomplicated diverticulitis: a prospective study. Int J Colorectal Dis 30:1229–1234

    Article  CAS  Google Scholar 

  16. Jensen DM, Machicado GA, Jutabha R et al (2000) Urgent colonoscopy for the diagnosis and treatment of severe diverticular hemorrhage. N Engl J Med 342:78–82

    Article  CAS  Google Scholar 

  17. Khan RMA, Hajibandeh S, Hajibandeh S (2017) Early elective versus delayed elective surgery in acute recurrent diverticulitis: a systematic review and meta-analysis. Int J Surg 46:92–101

    Article  Google Scholar 

  18. Klarenbeek BR, Veenhof AA, Bergamaschi R et al (2009) Laparoscopic sigmoid resection for diverticulitis decreases major morbidity rates: a randomized control trial: short-term results of the sigma trial. Ann Surg 249:39–44

    Article  Google Scholar 

  19. Lambrichts DPV, Bolkenstein HE, van der Does D et al (2019) Multicentre study of non-surgical management of diverticulitis with abscess formation. Br J Surg 106:458–466

    Article  CAS  Google Scholar 

  20. Lameris W, van Randen A, van Gulik TM et al (2010) A clinical decision rule to establish the diagnosis of acute diverticulitis at the emergency department. Dis Colon Rectum 53:896–904

    Article  Google Scholar 

  21. Lee H, Gachabayov M, Rojas A et al (2020) Systematic review of failure of nonoperative management in complicated sigmoid diverticulitis with abscess. Langenbecks Arch Surg 405(3):277–281. https://doi.org/10.1007/s00423-020-01872-5

    Article  CAS  PubMed  Google Scholar 

  22. Leifeld L, Germer CT, Bohm S et al (2014) S2k guidelines diverticular disease/diverticulitis. Z Gastroenterol 52:663–710

    Article  CAS  Google Scholar 

  23. Lock JF, Galata C, Reissfelder C et al (2020) Operationsindikation und Operationszeitpunkt bei der Divertikelkrankheit. Dtsch Arztebl. (Im Druck)

  24. Martinolich J, Croasdale DR, Bhakta AS et al (2019) Laparoscopic surgery for diverticular fistulas: outcomes of 111 consecutive cases at a single institution. J Gastrointest Surg 23:1015–1021

    Article  Google Scholar 

  25. Mortensen LQ, Burcharth J, Andresen K et al (2017) An 18-year nationwide cohort study on the association between diverticulitis and colon cancer. Ann Surg 265:954–959

    Article  Google Scholar 

  26. Penna M, Markar SR, Mackenzie H et al (2018) Laparoscopic lavage versus primary resection for acute perforated diverticulitis: review and meta-analysis. Ann Surg 267:252–258

    Article  Google Scholar 

  27. Subhas G, Rana G, Bhullar J et al (2014) Percutaneous drainage of a diverticular abscess should be limited to two attempts for a resilient diverticular abscess. Am Surg 80:635–639

    PubMed  Google Scholar 

  28. Toorenvliet BR, Bakker RF, Breslau PJ et al (2010) Colonic diverticulitis: a prospective analysis of diagnostic accuracy and clinical decision-making. Colorectal Dis 12:179–186

    Article  CAS  Google Scholar 

  29. Tursi A, Elisei W, Brandimarte G et al (2010) Predictive value of serologic markers of degree of histologic damage in acute uncomplicated colonic diverticulitis. J Clin Gastroenterol 44:702–706

    Article  Google Scholar 

  30. van Dijk ST, Bos K, de Boer MGJ et al (2018) A systematic review and meta-analysis of outpatient treatment for acute diverticulitis. Int J Colorectal Dis 33:505–512

    Article  Google Scholar 

  31. van Dijk ST, Chabok A, Dijkgraaf MG et al (2020) Observational versus antibiotic treatment for uncomplicated diverticulitis: an individual-patient data meta-analysis. Br J Surg 107(8):1062–1069. https://doi.org/10.1002/bjs.11465

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  32. Vennix S, Morton DG, Hahnloser D et al (2014) Systematic review of evidence and consensus on diverticulitis: an analysis of national and international guidelines. Colorectal Dis 16:866–878

    Article  CAS  Google Scholar 

  33. Vermeulen J, Coene PP, Van Hout NM et al (2009) Restoration of bowel continuity after surgery for acute perforated diverticulitis: should Hartmann’s procedure be considered a one-stage procedure? Colorectal Dis 11:619–624

    Article  CAS  Google Scholar 

  34. You K, Bendl R, Taut C et al (2018) Randomized clinical trial of elective resection versus observation in diverticulitis with extraluminal air or abscess initially managed conservatively. Br J Surg 105:971–979

    Article  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Chirurgische Klinik, Universitätsmedizin Mannheim, Medizinische Fakultät Mannheim, Universität Heidelberg, Heidelberg, Deutschland

    C. Galata &  C. Reißfelder

  2. Klinik und Poliklinik für Allgemein‑, Viszeral‑, Transplantations‑, Gefäß- und Kinderchirurgie, Universitätsklinikum Würzburg, Oberdürrbacher Str. 6, 97080, Würzburg, Deutschland

    J. F. Lock &  C.-T. Germer

Authors
  1. C. Galata
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. J. F. Lock
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. C. Reißfelder
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. C.-T. Germer
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to J. F. Lock.

Ethics declarations

Interessenkonflikt

C. Galata gibt an, dass kein Interessenkonflikt besteht. J.F. Lock, C. Reißfelder und C.-T. Germer erhielten Honorare für die Vorbereitung von wissenschaftlichen Tagungen von der Falk Foundation.

Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

Additional information

Redaktion

T.C. Germer, Würzburg

C. Galata und J.F. Lock teilen sich die Erstautorenschaft.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Galata, C., Lock, J.F., Reißfelder, C. et al. Empfehlungen zur Therapie der Divertikelkrankheit. Chirurg 91, 720–726 (2020). https://doi.org/10.1007/s00104-020-01239-y

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00104-020-01239-y

Schlüsselwörter

Keywords

Search

Navigation