Chirurgische Therapie bei CED

A. J. Kroesen

doi:10.1055/s-0031-1283875

Endoskopie heute, Inhaltsverzeichnis

Endoskopie heute 2011; 24(4): 229-239
DOI: 10.1055/s-0031-1283875

Originalarbeit

Chirurgische Therapie bei CED

Aktuelle TherapiekonzepteSurgical Therapy of Inflammatory Bowel DiseasesActual Concepts

A. J. Kroesen

Abteilung für Allgemein-, Viszeral- und Unfallchirurgie, Krankenhaus Porz am Rhein, Köln

› Institutsangaben

Abstract

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

Volltext

Referenzen

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