Positionspapier der DGVS zur endoskopischen Dekompression bei akutem Ileus

Zusammenfassung

Bei Patienten mit paralytischem oder mechanischem Ileus und bildgebend dilatiertem Dünn- oder Dickdarm erscheint eine Dekompression mittels endoskopischer Verfahren erfolgversprechend, wird häufig aber unkritisch und ohne belastbare Evidenz eingesetzt. Vor der Entscheidung zu einem endoskopischen Vorgehen sollte mittels CT-Bildgebung die Klärung erfolgen, ob ein mechanisches Passagehindernis oder ein paralytischer Ileus/eine intestinale Pseudoobstruktion vorliegt. Ein lumenverlegender Tumor sollte dabei identifiziert und in Bezug auf seine Höhe im Kolon lokalisiert werden, weil davon die Wahl des Entlastungsverfahrens abhängt. Bei einer Dilatation des Zoekums auf über 12 cm besteht ein erhöhtes Perforationsrisiko, bei toxischem Megakolon wird ohne gute Evidenz 6 cm im Transversum angegeben.

Die endoskopische Entlastung ist komplikationsbehaftet. Sie sollte, wenn möglich, elektiv und nicht als Notfalleingriff erfolgen. Sie sollte unter CO₂-Insufflation und mit der Möglichkeit der Durchleuchtung durchgeführt werden. Die vorherige Anlage einer nasalen oder oralen Entlastungssonde ist regelhaft und eine Schutzintubation häufig erforderlich. Bei über 90 % der Patienten mit Pseudoobstruktion (Ogilvie-Syndrom) ist ein endoskopisches Vorgehen entbehrlich, weil die konservative Therapie innerhalb von 24 bis 48 Stunden zum Erfolg führt. Das endoskopische Absaugen von Gas und flüssigem Darminhalt als alleinige Maßnahme ist so wenig nachhaltig, dass es im Regelfall mit der Einlage eines Entlastungskatheters kombiniert wird.

Die Einlage von selbstexpandierenden Metallstents zur Dekompression von Tumorstenosen ist meist nur im linksseitigen Kolon und Rektum zu erwägen, mit einem signifikanten Perforations- und Stentmigrationsrisiko verbunden und onkologisch umstritten wegen der möglichen Mobilisation von Tumorzellen und einer erhöhten postoperativen Tumorrezidivrate. Ein primär operatives Vorgehen ist in vielen Fällen zielführender.

Das vorliegende Positionspapier fasst die Vorzüge und Nachteile der verschiedenen Dekompressionsverfahren in unterschiedlichen klinischen Situationen zusammen.

Abstract

In patients with ileus with dilated intestine in imaging studies, endoscopic decompression appears a feasible option. However, its use is often uncritical and without scientific evidence. Before considering endoscopic intervention, CT-imaging should differentiate between mechanical obstruction and paralytic ileus/intestinal pseudo-obstruction. Tumor diagnosis and localisation are essential because the latter determines the choice of the decompression procedure. Coecal dilatation of more than 12 cm indicates an increased risk of perforation. In patients with toxic megacolon, dilation of the transverse colon to more than 6 cm is considered critical without much prospective evidence. Endoscopic decompression has a high complication rate and should be performed electively, and not as an emergency procedure, whenever possible. The use of CO₂ insufflation rather than ambient air is strongly recommended, as is the availability of fluoroscopy. Prior trans-nasal or oral decompression-tube placement is routinely performed, and tracheobronchial intubation frequently required. In over 90 % of patients with pseudo-obstruction, conservative treatment is successful within 24 to 48 hours, and endoscopic decompression is, therefore, unnecessary. Placement of self-expanding metal stents to decompress a tumor stenosis is considered mostly for the left colon and rectum and burdened with significant risks of perforation and stent migration. Stent impact on oncological outcome is controversial because of possible tumor cell mobilization and increased postoperative cancer recurrence rates. Surgery, as primary intervention, achieves its objective in most cases. Decompression effect by endoscopic suctioning of gas and intestinal fluid is usually transient so that it is combined with transrectal decompression tubes insertion. This paper reviews the advantages and flaws of various decompression procedures in different clinical settings.

Schlüsselwörter

kolorektales Karzinom - Colitis ulcerosa - Ileus - Dekompression - akute kolonische Pseudoobstruktion - Ogilvie

Key words

carcinoma, colorectal - ulcerative colitis - ileus - decompression - acute colonic pseudoobstruction - Ogilivie's Syndrome

^* Collaborators: Mitglieder der DGVS-Kommission im Anhang (members of the DGVS committee in the appendix).

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