Skip to main content
SpringerLink
Log in

Chirurgische Behandlung der Colitis ulcerosa

Surgical management of ulcerative colitis

  • Standorte
  • Published:
coloproctology Aims and scope

Zusammenfassung

Fragestellung und Hintergrund

Eine Operation ist die einzige kurative Option bei der Behandlung einer Colitis ulcerosa. Trotz Fortschritten in der konservativen Behandlung ist bei etwa einem Drittel der Patienten eine Operation erforderlich.

Chirurgische Behandlung

Im akuten Fall ist eine Operation indiziert wenn die konservative Behandlung bei einer akuten schweren Kolitiserkrankung nicht anschlägt. Die Methode der Wahl ist zunächst eine stufenweise Kolektomie mit Endileostomie und Erhaltung des Rektums. Indikationen für elektive Eingriffe sind Versagen einer konservativen Therapie sowie maligne Transformation. Die chirurgischen Optionen umfassen eine konventionelle Proktektomie mit Ileostomie oder eine kontinente Ileostomie nach Kock und eine Kolektomie mit ileorektaler Anastomose. Aktueller Goldstandard ist eine restaurative Proktokolektomie mit ileumpouchanaler Anastomose. Meist schließt diese Methode einen J-Pouch mit einer Stapler-Anastomose und temporärem Stoma mit einer Loop-Ileostomie ein. Die laparoskopische Pouchoperation stellt eine durchführbare und sichere Option mit einem exzellenten kosmetischen Ergebnis dar.

Schlussfolgerung

Obwohl die Morbidität nach dem Eingriff signifikant bleibt, ist die Lebensqualität gut und hat ein zufriedenstellendes funktionelles Langzeitergebnis.

Abstract

Purpose

Surgery is the only curative option in the treatment of ulcerative colitis. Despite advances in the medical management surgery is required in about a third of patients.

Surgical management

In the acute setting surgery is indicated when medical treatment fails to improve an episode of acute severe colitis. The intervention of choice is a staged colectomy with end ileostomy and preservation of the rectal stump in the first instance. Indications for elective surgery are failure of medical therapy and malignant transformation. The surgical options include conventional proctectomy with ileostomy or a Kock’s continent ileostomy and colectomy with an ileorectal anastomosis. The current gold standard is restorative proctocolectomy with ileal pouch-anal anastomosis. Most frequently the technique includes a J pouch with a stapled anastomosis and temporary faecal diversion with a loop ileostomy. Laparoscopic pouch surgery is a feasible and safe option with an excellent cosmetic result.

Conclusions

Although the morbidity remains significant after surgery, the quality of life is good with a satisfactory long-term functional outcome.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Literatur

  1. Grainge MJ, West J, Card TR (2010) Venous thrombembolism during active disease and remission in inflammatory bowel disease: a cohort study. Lancet 375:657–663

    Article  PubMed  Google Scholar 

  2. Truelove SC, Witts LJ (1955) Cortisone in ulcerative colitis; final report on a therapeutic trial. Br Med J 2:1041–1048

    Article  PubMed  CAS  Google Scholar 

  3. Lichtiger S, Present S, Kornbluth A et al (1994) Cyclosporine in severe ulcerative colitis refractory to steroid therapy. N Engl J Med 330:1841–1845

    Article  PubMed  CAS  Google Scholar 

  4. Shibolet O, Regushevskaya E, Brezis M, Soares-Weiser K (2005) Cyclosporine A for induction of remission in severe ulcerative colitis. Cochrane Database Syst Rev (1). Art. No.: CD004277. doi:10.1002/14651858.CD004277.pub2

  5. Jarnerot G, Hertervig E, Friis-Liby I et al (2005) Infliximab as rescue therapy in severe to moderately severe ulcerative colitis: a randomized, placebo-controlled study. Gastroenterology 40:476–481

    Google Scholar 

  6. Travis SP, Farrant JM, Ricketts C et al (1996) Predicting outcome in severe ulcerative colitis. Gut 38:905–910

    Article  PubMed  CAS  Google Scholar 

  7. Travis SP, Stange EF, Lemann M et al (2008) European evidencebased consensus on the management of ulcerative colitis: current management. J Crohns Colitis 2:24–62

    Article  PubMed  Google Scholar 

  8. Alves A, Panis Y, Bouhnik Y et al (2003) Subtotal colectomy for severe acute colitis: a 20-year experience of a tertiary care center with an aggressive and early surgical policy. J Am Coll Surg 197:379–385

    Article  PubMed  Google Scholar 

  9. Hyman NH, Cataldo P, Osler T (2004) Urgent subtotal colectomy for severe inflammatory bowel disease. Dis Colon Rectum 48:70–73

    Article  Google Scholar 

  10. Dunker MS, Bemelman WA, Slors JF et al (2000) Laparoscopic-assisted vs open colectomy for severe acute colitis in patients with inflammatory bowel disease (IOBD): a retrospective study in 42 patients. Surg Endosc 14(10):911–914

    Article  PubMed  CAS  Google Scholar 

  11. Marceau C, Alves A, Ouaissi M et al (2007) Laparoscopic subtotal colectomy for acute or severe colitis complicating inflammatory bowel disease: a case-matched study in 88 patients. Surgery 141(5):640–644

    Article  PubMed  Google Scholar 

  12. Telem DA, Vine AJ, Swain G (2010) Laparoscopic subtotal colectomy for medically refractory ulcerative colitis: the time has come. Surg Endosc 24:1616–1620

    Article  PubMed  Google Scholar 

  13. Cahill RA, Lindsey I, Jones O et al (2010) Single-port laparoscopic total colectomy for medically uncontrolled colitis. Dis Colon Rectum 53:1143–1147

    Article  PubMed  Google Scholar 

  14. Eaden JA, Abrams KR, Mayberry JF (2001) The risk of colorectal cancer in ulcerative colitis: a meta-analysis. Gut 48:526–535

    Article  PubMed  CAS  Google Scholar 

  15. Biancone L, Michetti P, Travis S et al (2008) European evidencebased consensus on the management of ulcerative colitis: special situations. J Crohns Colitis 2:63–92

    Article  PubMed  Google Scholar 

  16. Jayaram H, Satsangi J, Chapman RWG (2001) Increased colorectal neoplasia in chronic ulcerative colitis complicated by primary sclerosing cholangitis: fact or fiction? Gut 48:430–434

    Article  PubMed  CAS  Google Scholar 

  17. Farraye FA, Odze RO, Eaden J (2010) AGA medical position statement on the diagnosis and management of colorectal neoplasia in inflammatory bowel disease. Gastroenterology 138:738–745

    Article  PubMed  Google Scholar 

  18. Castillo E, Thomassie LM, Whitlow CB (2005) Continent ileostomy: current experience. Dis Colon Rectum 48:1263–1268

    Article  PubMed  Google Scholar 

  19. Da Luz A, Kiran RP, Lavery I (2010) Clinical outcome of ileorectal anastomosis for ulcerative colitis. Br J Surg 97:65–69

    Google Scholar 

  20. Gorfine SR, Harris MT, Bub DS, Bauer J (2004) Restorative proctocolectomy for ulcerative colitis complicated by colorectal cancer. Dis Colon Rectum 47:1377–1385

    Article  PubMed  Google Scholar 

  21. Hahnloser D, Pemberton JH, Wolff BG (2004) The effect of ageing on function and quality of life in ileal pouch patients. Ann Surg 240(4):615–623

    PubMed  Google Scholar 

  22. Wibmer AG, Kroesen AJ, Groene J (2010) Predictors of permanent ileostomy after restorative proctocolectomy. Br J Surg 97:1561–1566

    Article  PubMed  CAS  Google Scholar 

  23. Burns EM, Bottle A, Aylin P (2011) Volume analysis of outcome following restorative proctocolectomy. Br J Surg 98:408–417

    Article  PubMed  CAS  Google Scholar 

  24. Lovegrove RE, Constantinides VA, Heriot AG et al (2006) A comparison of hand-sewn versus stapled ileal pouch anal anastomosis (IPAA) following proctocolectomy. Ann Surg 244:18–26

    Article  PubMed  Google Scholar 

  25. Weston-Petrides G, Lovegrove RE, Tilney HS (2008) Comparison of outcomes after restorative proctocolectomy with or without defunctioning ileostomy. Arch Surg 143(4):406–412

    Article  PubMed  Google Scholar 

  26. Tilney HS, Lovegrove RF, Heriot AG et al (2007) Comparison of short-term outcomes of laparoscopic vs open approaches to ileal pouch surgery. Int J Colorectal Dis 22:531–542

    Article  PubMed  Google Scholar 

  27. Ahmed Ali U, Keus F, Heikens JT et al (2009) Open versus laparoscopic (assisted) ileo pouch anal anastomosis for ulcerative colitis and familial polyposis (review). Cochrane Database Syst Rev (1):CD006267. doi:10.1002/14651858.CD006267. pub2

    Google Scholar 

  28. El-Gazzaz GS, Kiran RP, Remzi FH et al (2009) Outcomes for case-matched laparoscopically assisted versus open restorative proctocolectomy. Br J Surg 96:522–526

    Article  PubMed  CAS  Google Scholar 

  29. Lefevre JH, Bretagnol F, Ouaissi M et al (2009) Total laparoscopoic ileal pouch-anal anastomosis: prospective series of 82 patients. Surg Endosc 23:166–173

    Article  PubMed  Google Scholar 

  30. Indar AA, Efron JE, Young-Fadok T (2009) Laparoscopic ileal pouch-anal anastomosis reduces abdominal and pelvic adhesions. Surg Endosc 23:174–177

    Article  PubMed  Google Scholar 

  31. Heuschen UA, Hinz U, Allemeyer EH et al (2002) Risk factors for ileoanal J pouch-related septic complications in ulcerative colitis and familial adenomatous polyposis. Ann Surg 235(2):207–216

    Article  PubMed  Google Scholar 

  32. Meagher AP, Farouk R, Dozois RR et al (1998) J ileal pouch-anal anastomosis for chronic ulcerative colitis: complications and long-term outcome in 1310 patients. Br J Surg 85:800–803

    Article  PubMed  CAS  Google Scholar 

  33. Gionchetti P, Rizzello F, Helwig U et al (2003) Prophylaxis of pouchitis onset with probiotic therapy: a doubleblind placebo-controlled trial. Gastroenterology 124:1202–1209

    Article  PubMed  Google Scholar 

  34. Mimura T, Rizzello F, Helwig U et al (2004) Once daily high dose therapy (VSL3) for maintaining remission in recurrent or refractory pouchitis. Gut 53:108–114

    Article  PubMed  CAS  Google Scholar 

  35. Olsen KO, Joelsson M, Laurberg S, Oresland T (1999) Fertility after ileal pouch-anal anastomosis in women with ulcerative colitis. Br J Surg 86:493–495

    Article  PubMed  CAS  Google Scholar 

  36. Ording Olsen KO, Juul S, Berndtsson I et al (2002) Ulcerative colitis: female fecundity before diagnosis, during disease, and after surgery compared with a population sample. Gastroenterology 122:15–19

    Article  Google Scholar 

  37. Waljee A, Waljee J, Morris AM (2006) Three-fold increased risk of infertility: a meta-analysis of infertility after ileal pouch anal anastomosis in ulcerative colitis. Gut 55:1575–1580

    Article  PubMed  CAS  Google Scholar 

  38. Lepistoe A, Sarna S, Tiitinen A, Jaervinen HJ (2007) Female fertility and childbirth after ileal pouch-anal anastomosis for ulcerative colitis. Br J Surg 94:478–482

    Article  Google Scholar 

  39. Hahnloser D, Pemberton JH, Wolff BG (2007) Results at up to 20 years after ileal pouch-anal anastomosis for chronic ulcerative colitis. Br J Surg 94:333–340

    Article  PubMed  CAS  Google Scholar 

  40. Scarpa M, van Koperen PJ, Ubbink DT (2007) Systematic review of dysplasia after restorative proctocolectomy for ulcerative colitis. Br J Surg 94:534–545

    Article  PubMed  CAS  Google Scholar 

  41. Tulchinsky H, Hawley PR, Nicholls J (2003) Long-term failure after restorative proctocolectomy for ulcerative colitis. Ann Surg 238:229–234

    PubMed  Google Scholar 

  42. Prudhomme M, Dehni N, Dozois RR et al (2006) Causes and outcomes of pouch excision after restorative proctocolectomy. Br J Surg 93:82–86

    Article  PubMed  CAS  Google Scholar 

  43. Karoui M, Cohen R, Nicholls J (2004) Results of surgical removal of the pouch after failed restorative proctocolectomy. Dis Colon Rectum 47:869–875

    Article  PubMed  Google Scholar 

  44. Dehni N, Remacle G, Dozois RR et al (2005) Salvage reoperation for complications after ileal pouch-anal anastomosis. Br J Surg 92:748–753

    Article  PubMed  CAS  Google Scholar 

Download references

Interessenskonflikt

Ein Interessenkonflikt liegt nicht vor.

Author information

Authors and Affiliations

  1. Department of Digestive Surgery, Hôpital Saint-Antoine AP-HP, University Paris VI (Pierre et Marie Curie), 184 rue du Faubourg Saint-Antoine, 75571 , Paris Cedex 12, Frankreich

    M. Bennis & E. Tiret

Authors
  1. M. Bennis
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. E. Tiret
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to E. Tiret.

Rights and permissions

Reprints and permissions

About this article

Cite this article

Bennis, M., Tiret, E. Chirurgische Behandlung der Colitis ulcerosa. coloproctology 34, 273–279 (2012). https://doi.org/10.1007/s00053-012-0275-7

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00053-012-0275-7

Schlüsselwörter

Keywords

Search

Navigation