Leitlinienreport zur aktualisierten S3-Leitlinie der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV) zur Prävention, Diagnostik und Behandlung von Gallensteinen

 

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1. Hintergrund der Leitlinie

Die Entwicklung und Implementierung von nationalen, hochwertigen evidenz- und konsensbasierten Leitlinien ist eine wesentliche Grundlage für eine optimierte und sichere Versorgung unserer Patienten. 15 – 20 % unserer Bevölkerung haben Gallensteine [1] [2] [3] [4], und jährlich werden in Deutschland mehr als 175 000 Cholezystektomien aufgrund einer Cholelithiasis durchgeführt [5] [6]. Das Gallensteinleiden ist damit nach der Refluxerkrankung die gastroenterologische Erkrankung, die die höchsten Kosten verursacht [7]. Folgerichtig wurde bereits 2000 eine erste Leitlinie publiziert, um eine evidenzbasierte und einheitliche Behandlung des Gallensteinleidens zu gewährleisten. 2007 erfolgte eine erste Aktualisierung auf S3-Niveau, deren Gültigkeit 2012 endete. Inzwischen wurden weitere wichtige Leitlinien, Metaanalysen und randomisierte Studien veröffentlicht, die eine erneute Überarbeitung der Leitlinie erforderten.

Die Leitlinie zur Prävention, Diagnostik und Therapie dieser sehr häufigen Erkrankung wurde von der Deutschen Gesellschaft für Verdauungs- und Stoffwechselkrankheiten (DGVS) und der Deutschen Gesellschaft für Allgemein- und Viszeralchirurgie (DGAV) gemeinsam entwickelt. Die bisherigen Leitlinien, die auf die Diagnostik und die Therapie fokussierten, wurden hierbei auch um Empfehlungen zur Prävention des Gallensteinleidens erweitert.

Die Leitlinie ist eine systematisch entwickelte ärztliche Orientierungshilfe mit Handlungs- und Entscheidungsvorschlägen, von denen in begründeten Fällen abgewichen werden kann oder sogar muss. Die Entscheidung, ob einer bestimmten Empfehlung gefolgt wird, trifft der behandelnde Arzt unter Berücksichtigung der individuellen Situation seines Patienten.

1.1 Zielorientierung der Leitlinie

Ziel ist es, die neuen Erkenntnisse zur Definition, Epidemiologie und Resistenzlage sowie Fortschritte in der Diagnostik und Therapie zu bewerten und zu integrieren. Zu Beginn dieser vollständigen Leitlinienaktualisierung wurde daher zunächst der Überarbeitungsbedarf der Leitlinie in folgenden Schritten analysiert und festgelegt.

Festlegung des inhaltlichen Überarbeitungsbedarfs:

• Orientierende Literaturrecherche insbesondere nach Quellen aggregierter Evidenz

• Aufarbeitung der Kommentare und Korrekturvorschläge zur alten Leitlinie

• Expertenbefragung der Leitliniengruppe zum Änderungs- und Ergänzungsbedarf

• Priorisierung des Überarbeitungsbedarfs der alten Leitlinienempfehlung, Festlegung der Evidenzgrundlage und Ergänzung neuer Schlüsselfragen

• Konsentierung durch die Steuergruppe (Koordinator, AG-Leiter und Mandatsträger der eingeladenen Fachgesellschaften)

Dem Entwicklungsprozess lagen wie auch bei den Vorgängerversionen die Anforderungen des Deutschen Instruments zur methodischen Leitlinien-Bewertung (DELBI) zugrunde [8]. Die Methodik der Leitlinie beruht auf dem zurzeit gültigen Regelwerk der AWMF, dem Cochrane Manual Systematische Literaturrecherche für die Erstellung von Leitlinien und dem Leitlinienprogramm der DGVS [9] [10] [11], hierbei ergaben sich einige Änderungen, insbesondere in der Darstellung der angewandten Methodik.

Festlegung des methodischen Überarbeitungsbedarfs:

1. Systematische Literaturrecherche ab 2007, Auswahl und Bewertung der Literatur für prioritäre Fragestellungen

2. Klassifizierung von Studien und Empfehlungen nach den Kriterien der evidenzbasierten Medizin, Erstellen von Evidenztabellen

3. Dokumentation der Evidenzrecherche (Suchstrategien, Trefferquoten, Auswahl der Evidenz und Dokumentation der Ausschlussgründe)

4. Änderung der Empfehlungsgraduierung nach A („soll“), B („sollte“) und 0 („kann“)

5. Formulierung von Qualitätszielen für die Versorgung

6. Dokumentation und Bewertung potenzieller Interessenskonflikte im Leitlinienreport, Offenlegung im Leitlinienreport

1.2 Patientenzielgruppe

Die Leitlinie richtet sich an Erwachsene mit Gallensteinen sowie deren Folgekrankheiten.

1.3 Versorgungsbereich

Die Leitlinie gilt sowohl für die ambulante als auch die stationäre medizinische Versorgung und behandelt Prävention, Diagnostik und Therapie in der primärärztlichen und der spezialfachärztlichen Versorgung.

1.4 Anwenderzielgruppe

Die Leitlinie richtet sich insbesondere an alle an der Beratung, Diagnostik und Therapie der Erkrankung beteiligten Internisten, Gastroenterologen und Chirurgen. Sie soll darüber hinaus aber andere Institutionen und Organisationen wie zum Beispiel Medizinisch-Wissenschaftlichen Fachgesellschaften und Berufsverbänden, Interessenvertretungen der Patienten, Gesundheitspolitischen Einrichtungen und Entscheidungsträgern, Kostenträgern sowie der Öffentlichkeit zur Information über gute medizinische Vorgehensweise dienen.

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