Die Hartmann-Operation bei perforierter Divertikulitis und maligner linksseitiger kolorektaler Obstruktion und Perforation

 

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Abstract

Hintergrund: Ziel der vorliegenden Übersicht war es zu überprüfen, ob sich in den letzten 10 Jahren aufgrund laparoskopischer Techniken und interventioneller Möglichkeiten das Indikationsspektrum der Hartmann-Operation (HP) in seiner ­gesamten Breite als Notfalleingriff bei perforierter Divertikulitis und obstruierendem oder perforiertem linksseitigen kolorektalen Karzinom laut Studienlage verschoben hat. Perforierte Divertikulitis: Die Kolonresektion mit primärer Anastomose (RPA) und Schutzstoma ist die Methode der Wahl bei perforierter Sigma­divertikulitis. Die HP bleibt älteren Patienten mit zahlreichen Risikofaktoren reserviert sowie Patienten, bei denen aller Voraussicht nach später keine Wiederherstellung der Darmkontinuität infrage kommt. Im Hinchey-Stadium III ist in erfahrenen Zentren die laparoskopische peritoneale Lavage eine echte Alternative zur HP, die prospektiv geprüft werden muss. Linksseitige maligne kolorektale Obstruktion / Perforation: Bei perforiertem kolorektalen Kar­zinom ist die Indikation zur HP im Zweifelsfall großzügig zu stellen. Bei der Obstruktion sollte hingegen versucht werden, primär eine Entlastung des Kolons durch ein Schutzstoma oder bei entsprechender Expertise durch Stentinsertion zu erreichen. Dies führt zu wünschenswert höheren Raten an Elektiveingriffen und RPA. Schlussfolgerung: Die HP stellt für Hochrisiko­patienten weiterhin eine gute Option dar, speziell in der Situation des Bereitschaftsdiensts, wenn nicht immer der erfahrenste Operateur zur Verfügung steht. Kolorektale Spezialisten erzielen aber mit der RPA in dieser Situation keine schlechteren Ergebnisse hinsichtlich Morbidität und Letalität – bei besserer postoperativer Lebensqualität. 

Abstract

Background: This review comments on the question whether laparoscopic techniques and interventional strategies have in the last ten years changed the emergency management of perfo­rated diverticulitis and malignant colorectal obstruction or perforation with regard to the broad spectrum of indications for Hartmann’s proce­dure (HP). Perforated Diverticulitis: Colon resection with primary anastomosis and defunctioning stoma is the optimal strategy for patients with perforated diverticulitis. HP should be considered for older patients with multiple comorbidities, realising that restoration of bowel continuity is no longer an issue. Laparoscopic peritoneal lavage is an alter­native to HP in Hinchey-III diverticulitis with promising results in experienced centers which should be further evaluated. Obstructive / Perforated Left-Sided Colorectal Cancer: In perforated left-sided colorectal cancer HP may be generously indicated. In malignant obstruction, however, a temporary colostomy or ­colonic stenting in case of appropriate expertise has been suggested as preoperative treatment ­before elective surgery, allowing higher rates of RPA. Conclusion: HP remains relevant, especially in high-risk patients and after hours and during the weekend, when the most experienced sur­geon is not always available. However, subspecialised colo­rectal surgeons obtain with single-stage resection in this situation at least comparable results with respect to morbidity and mortality, but better patient quality of life. 

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PD Dr. F. Meyer

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