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Operative Therapie von Divertikeln der Speiseröhre

Endoskopisch oder offen?

Surgical treatment of esophageal diverticula

Endoscopic or open approach?

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Zusammenfassung

Ösophagusdivertikel sind verhältnismäßig selten. Am häufigsten sind Zenker-Divertikel; daneben kommen parabronchiale und epiphrenische Divertikel vor. Parabronchiale Divertikel haben kaum eine klinische Relevanz, während sich die beiden Pulsionsdivertikelarten klinisch meist durch Dysphagie und Regurgitation manifestieren. Etwa 100 Jahre nach der ersten chirurgischen Behandlung haben heute perorale Verfahren (Staplerdissektion und flexibel-endoskopische Schwellenspaltung) eine gewisse Bedeutung erlangt. Beide Verfahren sind weniger invasiv als das offen-chirurgische Vorgehen, scheinen aber mit einer deutlich höheren Rezidivrate behaftet zu sein. Deshalb sollte bei Patienten mit noch entsprechender Lebenserwartung und vertretbarem operativen Risiko nach wie vor die offene Divertikulektomie mit zervikaler Myotomie die Therapie der Wahl sein, insbesondere auch bei Divertikeln des Stadiums I–III nach Brombart, bei denen mit dem peroralen Zugang naturgemäß keine vollständige Myotomie erzielt werden kann. Die klassische Behandlung des epiphrenischen Divertikels besteht in der offenen oder laparoskopischen/thorakoskopischen Divertikulektomie mit vorderer Fundoplastik. Allerdings ist die Insuffizienzrate hoch, sodass zahlreiche Behandlungsalternativen derzeit erprobt werden.

Abstract

Esophageal diverticula are comparatively rare. The majority are Zenker’s diverticula but parabronchial and epiphrenic diverticula can also occur. Parabronchial diverticula are of low clinical relevance, whereas Zenker’s and epiphrenic diverticula both belong to the group of pulsion diverticula and can become clinically apparent by dysphagia and regurgitation. Approximately 100 years after the first surgical treatment, peroral approaches (e.g. stapler dissection and flexible endoscopic diverticulotomy) have now achieved a certain level of importance. Both approaches are less invasive than the open approach but are evidently more prone to recurrences. Accordingly, traditional open diverticulectomy with cervical myotomy should be recommended to patients with a reasonable life expectancy and an acceptable operative risk. This holds particularly true for Brombart stages I–III of the disease, as complete myotomy cannot be achieved via the peroral access. The classical surgical treatment of epiphrenic diverticula is open or laparoscopic/thoracoscopic diverticulectomy with distal myotomy, mostly combined with an anterior partial fundoplication; however, the leakage rate is high and several alternative options are currently being evaluated.

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Authors and Affiliations

  1. Klinik und Poliklinik für Chirurgie, Klinikum rechts der Isar der Technischen Universität München, Ismaninger Straße 22, 81675, München, Deutschland

    H. Feußner, N. Hüser, D. Wilhelm, A. Jell & H. Friess

  2. Institut für Diagnostische und Interventionelle Radiologie, Klinikum rechts der Isar der Technischen Universität München, München, Deutschland

    A. Fingerle

  3. Klinik und Poliklinik für Innere Medizin II, Klinikum rechts der Isar der Technischen Universität München, München, Deutschland

    M. Bajbouj

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  1. H. Feußner
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  2. N. Hüser
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  3. D. Wilhelm
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Correspondence to H. Feußner.

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H. Feußner, N. Hüser, D. Wilhelm, A. Fingerle, A. Jell, H. Friess und M. Bajbouj geben an, dass kein Interessenkonflikt besteht.

Dieser Beitrag beinhaltet keine von den Autoren durchgeführten Studien an Menschen oder Tieren.

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Feußner, H., Hüser, N., Wilhelm, D. et al. Operative Therapie von Divertikeln der Speiseröhre. Chirurg 88, 196–203 (2017). https://doi.org/10.1007/s00104-016-0344-5

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