Pl�doyer f�r die prim�re Resektion mit prim�rer Anastomose bei der komplizierten Sigmadiverticulitis

Abstract

Of the 107 patients with complicated diverticulitis operated from 1973-1986 47 were females and 60 males. In 14 of the 107 patients a perforated diverticulitis with diffuse purulent/faecal peritonitis was found, a perforated diverticulitis with localized purulent peritonitis/paracolic abscess in 68 patients and an acute phlegmonous diverticulitis without perforation in 25 patients. Additional pathologic findings were internal fistulae (13 patients), necrotizing fasciitis (3 patients), obstruction (3 patients) and synchronous carcinoma (7 patients). The overall mortality of the 107 patients was 9.3% (= 10 patients) and the morbidity of the 97 survivors 34% (= 33 patients). The mortality of the 14 patients with perforated diverticulitis and diffuse purulent peritonitis was 50% of the 68 patients with perforated diverticulitis and localized purulent peritonitis 4.4% and of the 25 patients with acute phlegmonous diverticulitis 0%. Seven of the 10 patients died after operation of the perforated diverticulitis with diffuse purulent peritonitis - 1 (5) after primary resection with primary anastomosis. 3 (5) after Hartmann procedure, 3 (4) after loop colostomy alone. Three patients died after operation of the perforated diverticulitis with localized purulent peritonitis - 2 (6) after Hartmann procedure, 1 (5) after loop colostomy alone. In spite of forcing the primary resection with primary anastomosis in the years from 1980 - 1986 the mortality decreased for these operations from 35.7% in 1973 - 1979 to 0% in 1980 - 1986. The indication of primary resection with primary anastomosis is justified also for perforated diverticulitis with localized and diffuse peritonitis.

Complicated Diverticulitis of the Sigmoid: A Prospective Study Concerning Primary Resection with Secure Primary Anastomosis

“…Therefore, comparison of the different studies and their results is quite difficult. In the recent literature, there seems to be a change in the surgical treatment of complicated diverticulitis in the last 10–15 years in the direction of primary anastomosis and away from the Hartmann procedure [2, 3, 13]. This has been the standard treatment before in all cases with acute left colonic diverticulitis [26, 27], because the risk of an anastomosis in the presence of acute inflammation was believed to be too high [20].…”

“…August and Wise [7]and Alanis et al [8]were able to show that a colostomy is not absolutely necessary even in cases of pericolonic abscess, localized pelvic abscess and mesenteric phlegmone, but usually is in generalized purulent or fecal peritonitis. In a review of the recent literature, most authors prefer primary anastomosis in patients without large abscess or advanced peritonitis [1, 2, 3, 10, 11, 12, 13, 14, 15], but classification and nomenclature are not used uniformly so that comparison of the results becomes difficult.…”

Outcome of Diffuse Faecal and Purulent Peritonitis following Colonic Perforation

“…Recent reports have suggested that patients undergo ing a direct anastomosis following colonic resection have a better prognosis than patients who undergo a two-stage or a three-stage procedure [5,6], However, such an approach is only suitable in patients in relatively good general condition. When the overall clinical situation is poor, the procedure is Hartmann operation, but a signifi cant mortality has been reported [1.2.…”

Chirurgische Therapie der Kolondivertikulitis – deutsche Erfahrungen

“…War man viele Jahre der Auffassung, daû die Divertikulose des Kolons, die nahezu bei 70% der 50ja È hrigen beobachtet wird, harmlos ist und daû auch Entzu È ndungen einen positiven Spontanverlauf erleben oder konservativ mit Nahrungskarenz und Antibiose erfolg-reich behandelt werden ko È nnen, so belegen inzwischen vorliegende Daten [4,6,14,15,19,20], daû diese Einscha Ètzung die fu È r den Patienten risikoreichere Variante mit einer Letalita È t von etwa 10% darstellt [4,19,20]. Es ist das Verdienst von Wellmann et al [16], daû uns eine Standortbestimmung bezu È glich Diagnostik, Indikationsstellung und chirurgischer Technik bei der Behandlung der Divertikulitis an deutschen Kliniken aus dem Jahr 1994 mit aus heutiger Sicht zum Teil verblu È ffenden Resultaten vorliegt.…”