Zusammenfassung
Die sekundäre diffuse Peritonitis weist bis heute eine hohe Morbidität und Mortalität auf. Umso mehr sind die verschiedenen operativen Therapiemöglichkeiten in der evidenzbasierten Überprüfung. So stehen sich mit der laparoskopischen Lavage ohne Resektion des Sepsisfokus bis zur Damage-control-basierten Strategie des initialen Laparostomas mit verzögert durchgeführter Anastomosierung extreme Unterschiede im Behandlungskonzept der diffusen Peritonitis gegenüber. Gelten die Daten für die Peritonitis bei Appendizitis, Cholezystitis und ulzerierten Perforationen des Magens und Duodenums im minimal-invasiven Zugangsweg als vergleichsweise gut evidenzbasiert, so lassen sich für die beiden genannten Verfahren nach wie vor bei derzeit noch schwacher Evidenzstärke keine eindeutigen Empfehlungen ableiten. Die vorliegende Arbeit soll eine Übersicht über die aktuellen Therapieverfahren der diffusen Peritonitis in kritischer Betrachtung ihrer jeweiligen Evidenzlage ermöglichen. Als Schlüsselempfehlung wird dargestellt, dass die Entscheidung für ein Operationsverfahren im Spiegel der aktuellen Datenlage letztlich in Abhängigkeit von der Schwere der abdominellen Sepsis, ihrer Dauer, dem Alter des Patienten und seiner Komorbidität getroffen werden sollte.
Abstract
Secondary diffuse peritonitis still has a high morbidity and mortality even now; therefore, the various strategies and options for the different surgical therapies are undergoing an evidence-based review. Laparoscopic lavage without resection of the focus of sepsis for example is a profoundly different approach in the treatment of diffuse peritonitis from the damage control-based strategy of surgery with initial laparostomy and deferred anastomosis. The evidential data for minimally invasive therapy are comparatively well-reviewed for appendicitis, cholecystitis and ulcerated perforation of the stomach and duodenum. In contrast, the evidence for laparoscopy and minimally invasive surgery with lavage and deferred anastomosis or damage control in secondary peritonitis has improved but is still low and cannot yet be clearly recommended. This article presents an overview of the currently available therapeutic methods for diffuse peritonitis and a critical consideration of the evidence-based data. The key recommendation is that the decision to use a surgical procedure based on the currently available data depends more on the severity of the abdominal sepsis, the duration, the age of the patient and comorbidities than on the individual technique.
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C. Güsgen, R. Schwab und A. Willms geben an, dass kein Interessenkonflikt besteht.
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Güsgen, C., Schwab, R. & Willms, A. Therapiekonzepte der diffusen Peritonitis. Chirurg 87, 34–39 (2016). https://doi.org/10.1007/s00104-015-0104-y
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DOI: https://doi.org/10.1007/s00104-015-0104-y