Palliativtherapie im Grenzgebiet zwischen Gastroenterologie und (Viszeral-)Chirurgie

Zusammenfassung

Hintergrund: In der Behandlung gastrointestinaler Tumoren wächst die Bedeutung der palliativen Therapie zusehends. Wie auch bei kurativem Ansatz in der Therapie ist eine interdisziplinäre Zusammenarbeit zwischen Gastroenterologen und Chirurgen in der Palliativmedizin anzustreben. Ziel: Anhand häufig auftretender Krankheitsbilder der Palliativmedizin soll das diagnostische und therapeutische Management dieser Erkrankungen erläutert werden. Methode: Komplementäre Kurzübersicht von klinischer Erfahrung und einschlägig recherchierten Referenzen aus dem aktuell-selektiven Schrifttum. Ergebnisse: Der Symptomenkomplex ist heterogen und bedarf genauer differenzialdiagnostischer Vorgehensweisen. Das palliativ-gastroenterologische Vorgehen wird wesentlich vom kompetenten Management des Aszites, der „malignen intestinalen Obstruktion und Obstipation“ (MIO) sowie Nutrition und Schmerz bestimmt. Chirurgisch stehen nach sequenzieller Ausschöpfung von medikamentösen, interventionell-endoskopischen, (teils radiologischen) Maßnahmen die peritoneovenöse Shuntanlage (Aszites), Bypassverfahren (gastroenteral, biliodigestiv, enteroenteral) sowie im Ausnahmefall die Resektion neben der i. v.-Portimplantation oder Korrektur der PEG- / Stentkomplikation im Vordergrund, wobei nach wie vor eine absolute Indikation bei unstillbarer Blutung und Perforation besteht. Diskussion: Mangelnde Studienlage, fehlende Studienergebnisse einschließlich die schwierige Initiierung palliativ-medizinisch ausgerichteter Studien erschweren ein kompetentes evidenzbasiertes Vorgehen, weshalb dieses erheblich von klinischer Erfahrung geprägt ist. Schlussfolgerung: Die effiziente Palliativbetreuung des viszeralmedizinischen Symptomenkomplexes erfordert einschlägige fachspezifische Expertise und interdisziplinäres Handeln aufgrund der nicht seltenen klinischen Fallkonstellationen im Grenzbereich zwischen Gastroenterologie und Chirurgie.

Abstract

Background: In the management of gastrointestinal tumour lesions, palliative treatment has attained an increasing role. As also in curative treatment, an interdisciplinary cooperation between gastroenterologists and surgeons has to be aimed for. Aim: The aim of this study is to illustrate the diagnostic and therapeutic management of frequently occurring diseases in palliative medicine from a gastroenterological point of view. Methods: Complementary short overviews on clinical experience and selectively searched references from the current scientific literature were evaluated. Results: The symptomatic complex is very heterogeneous and requires an adequate approach taking into account the differential diagnosis. The palliative gastroenterological approach is characterised by the competent care on ascites, management of “malignant intestinal obstruction and obstipation” (MIO) as well as appropriate nutrition and analgetic therapy. The surgical approach is indicated after sequential exhaustion of medical, interventional endoscopic and (eventually) image-guided radiological measures; it comprises creation of a peritoneovenous shunt (ascites), bypass procedures (gastroenteral, biliodigestive, enteroenteral) as well as, in extraordinary cases, resection in addition to the implantation of an i. v. port-a-cath or surgical revision of a PEG / stent complication; in particular, in case of recurrent and massive haemorrhage and perforation (absolute indication), surgery becomes necessary. Discussion: A lack of appropriate studies, absence of adequate study results including the difficult initiation of medical studies with palliative intention aggravate a competent evidence-based approach. Therefore, the management is considerably affected by clinical experience. Conclusion: Efficacious care in palliative visceral medicine requires relevant clinical expertise and interdisciplinary action because of the occurrence of clinical cases in gastroenterology at the border to surgery.

Schlüsselwörter

palliative Gastroenterologie - Lebensqualität - Aszites - maligne intestinale Obstruktion und Obstipation (MIO) - Nutrition - gastrointestinales (GI-)Karzinom

Key words

palliative gastroenterology - quality of life - ascites - malignant intestinal obstruction and obstipation (MIO) - nutrition - gastrointestinal (GI) cancer

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gleichberechtigte Erstautoren

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