[Surgical Indications for Diverticulitis in Germany: Are All Operations Justified?]. / Operationsindikation der Sigmadivertikulitis in Deutschland: Sind alle Operationen gerechtfertigt?

INTRODUCTION: Pathological changes of preexisting sigma diverticulosis into a state of sigma diverticulitis are possible. Treatment of sigma diverticulitis accounts for a significant proportion of emergency treatments in clinics. The number of patients treated for sigma diverticulitis has risen steadily in recent years. Although it can be observed that operated cases making 7 % compared with 14 % to all stationary admissions, there is a less marked increase. Nevertheless, the question should be clarified as to how high the proportion of complicated surgical cases is in relation to non-complicated cases. It is important to clarify, in this context, if each operation is justified or whether in some cases there is over-treatment. MATERIAL AND METHODS: All data relating to Germany, were prospectively collected by the treating hospitals using the DRG and evaluated by the Federal Statistical Office. The treatment numbers from Erlangen were prospectively collected from the encrypted DRG and analysed retrospectively by the coding officer. The investigated period lasted from 2005 to 2010. To demonstrate some treatment options, the following possible forms of therapy were examined with reference to the Hansen/Stock classification. RESULTS: In Germany, about 40 % of stationary patients with sigma diverticulitis are treated surgically. It is striking that in about two thirds of all operated patients uncomplicated forms of diverticulitis were present. The remainder consisted of covered or free perforations. For these complicated forms, various treatment approaches have been established. Ultimately, in dependence of timing these are always surgically treated. In the milder forms the general indication for surgery has come into discussion as the recommendation for a surgical approach after the second relapse in the symptom-free interval is being questioned by several groups based on the age of the studies on which the recommendations are based. CONCLUSION: A significant increase in hospital admissions and surgically treated patients is demonstrated. Striking was that a closer analysis of data revealed that mainly non-complicated cases were surgically treated. This should be seen as a clear indication for an over-treatment. Therefore, possibly not all surgeries performed are justified. In the case of complicated forms, in consideration of various treatment paths, surgery is inevitable in most cases.

[Rational diagnostics of acute abdomen]. / Rationelle Diagnostik des "akuten Abdomens"

BACKGROUND: In view of the threat that comes with an acute abdomen, it is of major importance that diagnostics are executed quickly and efficiently. In the course of this two tendencies can be differentiated: 1) general use of complex examination (e.g. CT, MRT) of all potential patients and 2) step-by-step-diagnostics with advanced diagnostics as and when required. MATERIAL AND METHODS: A total of 444 patients with an acute abdomen as admission diagnosis were investigated. All data were evaluated prospectively and analyzed retrospectively. All patients had the same basic diagnostics consisting of aclinical history, clinical examination, laboratory examination, abdominal sonography and x-ray overview images. These examinations were supplemented when required by advanced measures, such as CT, colon enema with contrast fluid, endoscopic examination and diagnostic laparotomy. RESULTS: Three different disease groups of unequal diagnostic need could be identified. The first group, presented in the form of an appendicitis showed that in 80% of all patients a basic diagnosis was sufficient. Advanced examination such as CT affected 14%. The negative appendectomy rate amounted to 8%. Other diseases belonging to the first group were ileus, acute biliary diseases, perforation etc. In the second group presented in the form of a diverticulitis, an advanced radiological examination was required in 84% of all cases. Similar results are also expected in cases of pancreatitis. In the third group presented in the form of coprostasis, inflammatory etiology was found in 39% of all secondary diseases. However the symptoms became clinically apparent after treatment of the coprostasis. In this group a basic diagnosis was satisfactory in 84% of cases, however, a diagnostic laparotomy was inevitable for 3% of these patients. CONCLUSION: Generally step-by-step diagnostic approach has proven itself to be efficient. For 80% of all patients it makes advanced diagnostic measures unnecessary. The exceptions are diseases in which it is necessary to know not only the diagnosis but also the disease stage. In these cases (e.g. pancreatitis, diverticulitis etc.) advanced diagnostics should be pursued from the onset. The necessity of a diagnostic laparotomy has lost importance for 1% of all patients.