Chirurgische Therapie bei CED

Zusammenfassung

Der Morbus Crohn ist eine weder internistisch noch chirurgisch heilbare Erkrankung. Operationspflichtige Rezidive sind daher vorprogrammiert. Daher sind eine strenge Indikationsstellung auf der einen Seite und darmsparende Operationsstrategien auf der anderen Seite unabdingbar. Indikationen zur Operation sind: 1. eine theapierefraktäre Entzündung; 2. hochgradige Stenosen, Strikturen mit entsprechender Symptomatik; 3. blind endende abdominelle Fisteln; 4. enterovesikale Fisteln; 5. perianale Fisteln. Nur relative Operationsindikationen stellen hingegen 1. enterokutane Fisteln; 2. interenterische Fisteln; 3. enterogenitale Fisteln dar. Bei allen Crohn-Resektionen darf nur das makroskopisch befallene Segment entfernt werden, da eine Resektion im mikroskopisch gesunden keine Erniedrigung der Rezidivrate bewirkt und so der Darmverlust minimal gehalten werden kann. 

Die Colitis ulcerosa ist hingegen hinsichtlich ihrer Manifestation im Kolon durch die Koloproktomukosektomie heilbar geworden. Relativiert wird dieser Heilungserfolg lediglich durch das mögliche Auftreten einer Pouchitis in 20 − 30 %, die in der Regel jedoch gut durch eine kurzfristige Therapie mit Metronidazole therapierbar ist. Operationsindikationen sind: 1. Das Karzinom; 2. niedrigradige (fakultativ) und hochgradige (obligat) intraepitheliale Neoplasien; 3. der Therapierefraktäre Verlauf; 4. schwere Medikamentennebenwirkungen; 5. der Notfall (Perforation, Blutung, toxisches Megakolon / Verlauf). Die chirurgische Standardtherapie ist die Koloproktomukosektomie mit ileoanaler J-Pouchanlage. Wenn auch die perioperative Komplikationsrate 30 % beträgt, so lassen sich 95 % der Patienten erfolgreich und mit einer guten Lebensqualität behandeln.

Abstract

Crohn’s disease is a neither medically nor surgically to cure disease. The reoparation is often unevitable. Hence the indication must be set sorrowfully and bowel sparing surgical strategies have to be created. Indications for surgery are: 1. therapy refractory inflammation; 2. severe stenosis and stricture together with the corresponding symptoms; 3. blind ending intraabdominal fistulas; 4. enterovesical fistulas; 5. perianal fistulas. Relative indications for surgery are: 1. enterocutaneous fistulas; 2. interenteric fistulas; 3. enterogenital fistulas. In all Crohn-resections it is just allowed to resect the macroscopically affected bowel segment since a resection within also microscopically disease free areas does not reduce the recurrence rate. Additionally the lost of bowel can be minimised.

Ulcerative colitis is concerning the affection of the colon surgically curable. Relativated is this just by the occurrence of pouchitis in 20 − 30 % of the cases, which can be successfully treated by a short course of metranidazole in most of the patients. Indications for surgery are: 1. a colitis related carcinoma; 2. low grade (facultative) and high grade (obligatory) intraepithelial neoplasias; 3. therapy refractory course; 4. serious medical side effects; 5. emergency (bleeding, perforation, toxic megacolon / course). The standard surgical option is the coloproctomucosectomy with creation of an ileoanal J-pouch. Although there is a perioperative complication rate of 30 %, 95 % of the patients regain a good quality of life.

Schlüsselwörter

Morbus Crohn - Colitis ulcerosa - konservative Chirurgie - ileoanaler Pouch

Key words

Crohn’s disease - ulcerative colitis - conservative surgery - ileoanal pouch

• Literatur

• 1 Borley NR, Mortensen NJ, Jewell DP. Preventing postoperative recurrence of Crohn’s disease. Br J Surg 1997; 84: 1493-1502
• 2 Schulzke JD, Fromm M, Bentzel CJ et al. Adaptation of the jejunal mucosa in the experimental blind loop syndrome: changes in paracellular conductance and tight junction structure. Gut 1987; 28 Suppl: 159-164
• 3 Mekjihan HS, Switz DM, Watts HD et al. National cooperative Crohns disease study: Factors determnining recurrence of Crohn’s diesease after surgery. Gastroenterology 1979; 77: 907-913
• 4 Schulzke JD, Fromm M, Hegel U. Epithelial and subepithelial resistance of rat large intestine: segmental differences, effect of stripping, time course, and action of aldosterone. Pflugers Arch 1986; 407: 632-637
• 5 Ewe K, Malchow H, Herfarth C. [Radical operation and recurrence prevention with azulfidine in Crohn disease: a prospective multicenter study – initial results]. Langenbecks Arch Chir 1984; 364: 427-430
• 6 Fazio VW, Marchetti F, Church M et al. Effect of resection margins on the recurrence of Crohn’s disease in the small bowel. A randomized controlled trial. Ann Surg 1996; 224: 563-571
• 7 Kotanagi H, Kramer K, Fazio VW et al. Do microscopic abnormalities at resection margins correlate with increased anastomotic recurrence in Crohn’s disease? Retrospective analysis of 100 cases. Dis Colon Rectum 1991; 34: 909-916
• 8 Wolff BG. Factors determining recurrence following surgery for Crohn’s disease 2. World J Surg 1998; 22: 364-369
• 9 Lee EC, Papaioannou N. Minimal surgery for chronic obstruction in patients with extensive or universal Crohn’s disease. Ann R Coll Surg Engl 1982; 64: 229-233
• 10 Wagtmans MJ, van Hogezand RA, Griffioen G et al. Crohn’s disease of the upper gastrointestinal tract. Neth J Med 1997; 50: S2-S7
• 11 Makowiec F, Jehle EC, Becker HD et al. Clinical course after transanal advancement flap repair of perianal fistula in patients with Crohn’s disease. Br J Surg 1995; 82: 603-606
• 12 Ozuner G, Hull TL, Cartmill J et al. Long-term analysis of the use of transanal rectal advancement flaps for complicated anorectal / vaginal fistulas. Dis Colon Rectum 1996; 39: 10-14
• 13 Scott NA, Nair A, Hughes LE. Anovaginal and rectovaginal fistula in patients with Crohn’s disease. Br J Surg 1992; 79: 1379-1380
• 14 Williamson PR, Hellinger MD, Larach SW et al. Twenty-year review of the surgical management of perianal Crohn’s disease. Dis Colon Rectum 1995; 38: 389-392
• 15 Herfarth C, Bindewald H. [Perianal involvement in Crohn disease]. Chirurg 1986; 57: 304-308
• 16 Fazio VW, Tjandra JJ, Lavery IC et al. Long-term follow-up of strictureplasty in Crohn’s disease. Dis Colon Rectum 1993; 36: 355-361
• 17 Poggioli G, Stocchi L, Laureti S et al. Conservative surgical management of terminal ileitis: side-to-side enterocolic anastomosis. Dis Colon Rectum 1997; 40: 234-237
• 18 Marchetti F, Fazio VW, Ozuner G. Adenocarcinoma arising from a strictureplasty site in Crohn’s disease. Report of a case. Dis Colon Rectum 1996; 39: 1315-1321
• 19 Ribeiro MB, Greenstein AJ, Heimann TM et al. Adenocarcinoma of the small intestine in Crohn’s disease. Surg Gynecol Obstet 1991; 173: 343-349
• 20 Wolff BG, Beahrs OH. Preservation of the anorectum. Adv Surg 1984; 18: 1-35
• 21 Wolff BG, Culp CE, Beart Jr RW et al. Anorectal Crohn’s disease. A long-term perspective. Dis Colon Rectum 1985; 28: 709-711
• 22 Ky A, Sohn N, Weinstein MA et al. Carcinoma arising in anorectal fistulas of Crohn’s disease [see comments]. Dis Colon Rectum 1998; 41: 992-996
• 23 Michelassi F, Melis M, Rubin M et al. Surgical treatment of anorectal complications in Crohn’s disease. Surgery 2000; 128: 597-603
• 24 Penna C, Daude F, Parc R et al. Previous subtotal colectomy with ileostomy and sigmoidostomy improves the morbidity and early functional results after ileal pouch-anal anastomosis in ulcerative colitis. Dis Colon Rectum 1993; 36: 343-348
• 25 Bohm B, Milsom JW, Fazio VW. [Laparoscopic ileocecal resection in Crohn disease]. Zentralbl Chir 1994; 119: 420-426
• 26 Schlemminger R, Neufang T, Leister I et al. [Laparoscopic stoma technique]. Chirurg 1999; 70: 656-661
• 27 Hildebrandt U, Schiedeck T, Kreissler-Haag D et al. [Laparoscopically assisted surgery in Crohn disease]. Zentralbl Chir 1998; 123: 357-361
• 28 Ludwig KA, Milsom JW, Church JM et al. Preliminary experience with laparoscopic intestinal surgery for Crohn’s disease. Am J Surg 1996; 171: 52-55
• 29 Canin-Endres J, Salky B, Gattorno F et al. Laparoscopically assisted intestinal resection in 88 patients with Crohn’s disease. Surg Endosc 1999; 13: 595-599
• 30 Wu JS, Birnbaum EH, Kodner IJ et al. Laparoscopic-assisted ileocolic resections in patients with Crohn’s disease: are abscesses, phlegmons, or recurrent disease contraindications?. Surgery 1997; 122: 682-688
• 31 Alabaz O, Iroatulam AJ, Nessim A et al. Comparison of laparoscopically assisted and conventional ileocolic resection for Crohn’s disease. Eur J Surg 2000; 166: 213-217
• 32 Bauer JJ, Harris MT, Grumbach NM et al. Laparoscopic-assisted intestinal resection for Crohn’s disease. Dis Colon Rectum 1995; 38: 712-715
• 33 Hildebrandt U, Ecker KW, Feifel G. [Minimally invasive surgery and Crohn disease]. Chirurg 1998; 69: 915-921
• 34 Jess P, Moller EH, Ladefoged K et al. Laparoscopic-assisted ileocecal resection for Crohn’s disease: a preliminary study. Scand J Gastroenterol 1996; 31: 302-304
• 35 Reissman P, Salky BA, Pfeifer J et al. Laparoscopic surgery in the management of inflammatory bowel disease. Am J Surg 1996; 171: 47-50
• 36 Reissman P, Agachan F, Wexner SD. Outcome of laparoscopic colorectal surgery in older patients. Am Surg 1996; 62: 1060-1063
• 37 Lochs H, Mayer M, Fleig WE et al. Prophylaxis of postoperative relapse in Crohn’s disease with mesalamine: European Cooperative Crohn’s Disease Study VI. Gastroenterology 2000; 118: 264-273
• 38 Sutherland L, Roth D, Beck P, May G, Makiyama K. Oral 5-aminosalicylic acid for maintaining remission in ulcerative colitis. Cochrane Database Syst Rev; 2000 CD000544
• 39 Fraser AG, Orchard TR, Jewell DP. The efficacy of azathioprine for the treatment of inflammatory bowel disease: a 30 year review. Gut 2002; 50: 485-489
• 40 Lamers CB, Griffioen G, van Hogezand RA et al. Azathioprine: an update on clinical efficacy and safety in inflammatory bowel disease. Scand J Gastroenterol Suppl 1999; 230: 111-115
• 41 Steinhart H. Maintenance therapy in Crohn’s disease. Can J Gastroenterol Suppl 2000; 14: 23C-28C
• 42 Fazio VW, Ziv Y, Church JM et al. Ileal pouch-anal anastomoses complications and function in 1005 patients. Ann Surg 1995; 222: 120-127
• 43 Heuschen UA, Autschbach F, Allemeyer EH et al. Long-term follow-up after ileoanal pouch procedure: algorithm for diagnosis, classification, and management of pouchitis. Dis Colon Rectum 2001; 44: 487-499
• 44 Heuschen UA, Hinz U, Allemeyer EH et al. One- or Two-stage Procedure for Restorative Proctocolectomy: Rationale for a Surgical Strategy in Ulcerative Colitis. Ann Surg 2001; 234: 788-794
• 45 Heuschen UA, Hinz U, Allemeyer EH et al. Risk factors for ileoanal J pouch-related septic complications in ulcerative colitis and familial adenomatous polyposis. Ann Surg 2002; 235: 207-216
• 46 Buhr HJ, Heuschen UA, Stern J et al. [Continence preserving operation after proctocolectomy. Indications, technique and results]. Chirurg 1993; 64: 601-613
• 47 Buhr HJ, Heuschen UA, Stern J et al. [Technique and results of the ileoanal pouch after proctocolectomy]. Zentralbl Chir 1994; 119: 867-877
• 48 Fazio VW, O’Riordain MG, Lavery IC et al. Long-term functional outcome and quality of life after stapled restorative proctocolectomy. Ann Surg 1999; 230: 575-584
• 49 Hurst RD, Finco C, Rubin M et al. Prospective analysis of perioperative morbidity in one hundred consecutive colectomies for ulcerative colitis. Surgery 1995; 118: 748-754
• 50 Mikkola K, Luukkonen P, Jarvinen HJ. Long-term results of restorative proctocolectomy for ulcerative colitis. Int J Colorectal Dis 1995; 10: 10-14
• 51 Porschen R. [Guidelines of the DGVS. Prevention of carcinoma. German Society of Digestive and Metabolic Diseases]. Z Gastroenterol 2001; 39: 51-54
• 52 Stange EF. [Guidelines of the DGVS. Fulminant process. German Society of Digestive and Metabolic Diseases]. Z Gastroenterol 2001; 39: 39-42
• 53 Choen S, Tsunoda A, Nicholls RJ. Prospective randomized trial comparing anal function after hand sewn ileoanal anastomosis with mucosectomy versus stapled ileoanal anastomosis without mucosectomy in restorative proctocolectomy. Br J Surg 1991; 78: 430-434
• 54 Tsunoda A, Talbot IC, Nicholls RJ. Incidence of dysplasia in the anorectal mucosa in patients having restorative proctocolectomy. Br J Surg 1990; 77: 506-508
• 55 Lavery IC, Sirimarco MT, Ziv Y et al. Anal canal inflammation after ileal pouch-anal anastomosis. The need for treatment. Dis Colon Rectum 1995; 38: 803-806
• 56 Tjandra JJ, Fazio VW, Milsom JW et al. Omission of temporary diversion in restorative proctocolectomy – is it safe?. Dis Colon Rectum 1993; 36: 1007-1014
• 57 Dozois RR, Nelson H, Metcalf AM. [Sexual function after ileo-anal anastomosis]. Ann Chir 1993; 47: 1009-1013
• 58 Akovbiantz A, Kock N. [The continent ileostomy]. Helv Chir Acta 1972; 39: 259-262
• 59 Schaudig A, Kock N, von Bary S et al. [Kock’s continent ileostomy]. Munch Med Wochenschr 1973; 115: 290-295
• 60 Kroesen AJ, Stern J, Buhr HJ et al. [Incontinence after ileo-anal pouch anastomosis – diagnostic criteria and therapeutic sequelae]. Chirurg 1995; 66: 385-391
• 61 Metcalf AM, Dozois RR, Kelly KA. Sexual function in women after proctocolectomy. Ann Surg 1986; 204: 624-627
• 62 Keighley MR. [“Pouchitis”; histology]. Ann Chir 1993; 47: 1029-1033
• 63 Luukkonen P, Jarvinen H, Tanskanen M et al. Pouchitis – recurrence of the inflammatory bowel disease?. Gut 1994; 35: 243-246
• 64 Kmiot WA, Youngs D, Tudor R et al. Mucosal morphology, cell proliferation and faecal bacteriology in acute pouchitis. Br J Surg 1993; 80: 1445-1449
• 65 Luukkonen P, Valtonen V, Sivonen A et al. Fecal bacteriology and reservoir ileitis in patients operated on for ulcerative colitis. Dis Colon Rectum 1988; 31: 864-867
• 66 Ruseler-van EmbdenJG, Schouten WR, van Lieshout LM. Pouchitis: result of microbial imbalance?. Gut 1994; 35: 658-664
• 67 Sandborn WJ, Tremaine WJ, Batts KP et al. Fecal bile acids, short-chain fatty acids, and bacteria after ileal pouch-anal anastomosis do not differ in patients with pouchitis. Dig Dis Sci 1995; 40: 1474-1483
• 68 Santavirta J, Mattila J, Kokki M et al. Mucosal morphology and faecal bacteriology after ileoanal anastomosis. Int J Colorectal Dis 1991; 6: 38-41
• 69 Heppell J, Kelly K. Pouchitis. Current Opinion in Gastroenterology 1998; 14: 322-326
• 70 Keighley MR. Review article: the management of pouchitis. Aliment Pharmacol Ther 1996; 10: 449-457
• 71 Keranen U, Luukkonen P, Jarvinen H. Functional results after restorative proctocolectomy complicated by pouchitis. Dis Colon Rectum 1997; 40: 764-769
• 72 Kmiot WA, Williams MR, Keighley MR. Pouchitis following colectomy and ileal reservoir construction for familial adenomatous polyposis. Br J Surg 1990; 77: 1283
• 73 Kuhbacher T, Schreiber S, Runkel N. Pouchitis: pathophysiology and treatment. Int J Colorectal Dis 1998; 13: 196-207
• 74 Sandborn WJ, Tremaine WJ, Batts KP et al. Pouchitis after ileal pouch-anal anastomosis: a Pouchitis Disease Activity Index. Mayo Clin Proc 1994; 69: 409-415
• 75 Sandborn WJ. Pouchitis following ileal pouch-anal anastomosis: definition, pathogenesis, and treatment [see comments]. Gastroenterology 1994; 107: 1856-1860
• 76 Heuschen UA, Heuschen G, Autschbach F et al. Adenocarcinoma in the ileal pouch: late risk of cancer after restorative proctocolectomy. Int J Colorectal Dis 2001; 16: 126-130
• 77 Stern H, Walfisch S, Mullen B et al. Cancer in an ileoanal reservoir: a new late complication?. Gut 1990; 31: 473-475
• 78 Cox CL, Butts DR, Roberts MP et al. Development of invasive adenocarcinoma in a long-standing Kock continent ileostomy: report of a case. Dis Colon Rectum 1997; 40: 500-503
• 79 Veress B, Reinholt FP, Lindquist K et al. Long-term histomorphological surveillance of the pelvic ileal pouch: dysplasia develops in a subgroup of patients. Gastroenterology 1995; 109: 1090-1097
• 80 Ferguson A, Glen M, Ghosh S. Crohn’s disease: nutrition and nutritional therapy. Baillieres Clin Gastroenterol 1998; 12: 93-114
• 81 Besnard M, Jaby O, Mougenot JF et al. Postoperative outcome of Crohn’s disease in 30 children. Gut 1998; 43: 634-638
• 82 Higgens CS, Allan RN. Crohn’s disease of the distal ileum. Gut 1980; 21: 933-940
• 83 Hellberg R, Hulten L, Rosengren C et al. The recurrence rate after primary excisional surgery for Crohn’s disease. Acta Chir Scand 1980; 146: 435-443
• 84 Schulzke JD, Fromm M, Bentzel CJ et al. et al. Ion transport in the experimental short bowel syndrome of the rat. Gastroenterology 1992; 102: 497-504
• 85 Heen LO, Nygaard K, Bergan A. Crohn’s disease. Results of excisional surgery in 133 patients. Scand J Gastroenterol 1984; 19: 747-754
• 86 Whelan G, Farmer RG, Fazio VW et al. Recurrence after surgery in Crohn’s disease. Relationship to location of disease (clinical pattern) and surgical indication. Gastroenterology 1985; 88: 1826-1833
• 87 Sayfan J, Wilson DA, Allan A et al. Recurrence after strictureplasty or resection for Crohn’s disease. Br J Surg 1989; 76: 335-338
• 88 Wettergren A, Christiansen J. Risk of recurrence and reoperation after resection for ileocolic Crohn’s disease. Scand J Gastroenterol 1991; 26: 1319-1322
• 89 Nordgren SR, Fasth SB, Oresland TO et al. Long-term follow-up in Crohn’s disease. Mortality, morbidity, and functional status. Scand J Gastroenterol 1994; 29: 1122-1128
• 90 Kendall GP, Hawley PR, Nicholls RJ et al. Strictureplasty. A good operation for small bowel Crohn’s disease?. Dis Colon Rectum 1986; 29: 312-316
• 91 Silverman RE, McLeod RS, Cohen Z. Strictureplasty in Crohn’s disease. Can J Surg 1989; 32: 19-22
• 92 Pritchard TJ, Schoetz Jr DJ, Caushaj FP et al. Strictureplasty of the small bowel in patients with Crohn’s disease. An effective surgical option. Arch Surg 1990; 125: 715-717
• 93 Dehn TC, Kettlewell MG, Mortensen NJ et al. Ten-year experience of strictureplasty for obstructive Crohn’s disease. Br J Surg 1989; 76: 339-341
• 94 Betzler M, Post S, Herfarth C. [Surgical therapy of Crohn disease – definition of Crohn-specific surgery]. Internist (Berl) 1991; 32: 524-529
• 95 Reissman P, Salky BA, Edye M et al. Laparoscopic surgery in Crohn’s disease. Indications and results. Surg Endosc 1996; 10: 1201-1203
• 96 Milsom JW, Casillas S. Current status in laparoscopic colorectal surgery. Rev Gastroenterol Mex 1996; 61: 113-118
• 97 Meijerink WJ, Eijsbouts QA, Cuesta MA et al. Laparoscopically assisted bowel surgery for inflammatory bowel disease. The combined experiences of two academic centers. Surg Endosc 1999; 13: 882-886
• 98 Hendriksen C, Kreiner S, Binder V. Long term prognosis in ulcerative colitis – based on results from a regional patient group from the county of Copenhagen. Gut 1985; 26: 158-163
• 99 Mir-Madjlessi SH, Farmer RG, Easley KA et al. Colorectal and extracolonic malignancy in ulcerative colitis. Cancer 1986; 58: 1569-1574
• 100 Gyde SN, Prior P, Allan RN et al. Colorectal cancer in ulcerative colitis: a cohort study of primary referrals from three centres. Gut 1988; 29: 206-217
• 101 Gilat T, Fireman Z, Grossman A et al. Colorectal cancer in patients with ulcerative colitis. A population study in central Israel. Gastroenterology 1988; 94: 870-877
• 102 Lennard-Jones JE, Melville DM, Morson BC et al. Precancer and cancer in extensive ulcerative colitis: findings among 401 patients over 22 years. Gut 1990; 31: 800-806