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Coloproctology

, Volume 19, Issue 6, pp 221–227 | Cite as

Colitis ulcerosa: Operationsindikationen und-verfahren

Limitierte Resektion versus Kolektomie
  • A. J. Kroesen
  • H. J. Buhr
Article
  • 126 Downloads

Zusammenfassung

Die Koloproktomukosektomie mit ileoanaler Pouchanlage gilt als der gegenwärtige „Goldstandard” für die chirurgische Therapie der Colitis ulcerosa. Eine limitierte Resektion gilt als obsolet. Als limitierte Resektion ist bei der chirurgischen Therapie der Colitis ulcerosa lediglich die subtotale Kolektomie vertretbar. Eine limitierte Resektion im Sinne einer linksseitigen Hemikolektomie ist auch bei einer geringgradigen distalen Kolitis wegen der Kolitisexazerbationsgefahr und dem persistierenden Karzinomrisiko obsolet. Die subtotale Kolektomie mit Ileorektostomie stellt ein funktionell zufriedenstellendes Verfahren mit nur geringer Komplikationsrate dar. Wegen des fortdauernden Proktitis- und Rektumkarzinomrisikos (in den angeführten Studien 2,5%) ist diese Operation jedoch nur einer Ausnahmeindikation vorbehalten. Wegen der Impotenzgefahr der ileoanalen Pouchoperation (1,8% Impotenz, 5,8% retrograde Ejakulation) kann die ileorektale Anastomose jungen Männern als Alternative angeboten werden. Die subtotale Kolektomie mit Ileostoma und Sigmaschleimfistel ist fester Bestandteil der dreizeitigen ileoanalen Pouchanlage bei Notfällen, schlechtem Allgemeinzustand und hoher präoperativer Kortisonmedikation. Wegen der fehlenden Gefahr einer Rektumstumpfinsuffizienz (0% bei Sigmaschleimfistel versus 35% bei Rektumblindverschluß) und besseren topischen Behandelbarkeit des verbleibenden Rektums ist die subtotale Kolektomie mit Ileostoma und Sigmaschleimfistel dem Rektumblindverschluß vorzuziehen.

Schlüselwörter

Ulzerative Kolitis Kolektomie Limitierte Resektion Ileoanaler Pouch Ileorektale Anastomose 

Ulcerative colitis: Indications and procedures. Limited resection versus colectomy

Summary

The procedure of choice for the treatment of ulcerative colitis is coloproctomucosectomy with ileal pouch-anal anastomosis. Limited resections are considered to be obsolete. Only subtotal colectomy is a possible variation of the therapy of surgical procedures. Left sided colectomies or sigmoid resections for cancer should not be allowed, since there is still a remaining risk of exacerbation of the inflammation respectively a risk of carcinoma. Subtotal colectomy with ileorectal anastomosis is a reliable procedure with a good functional result and a low complication rate. But since there always remains the risk of proctitis and of rectal carcinoma (2.5% in the reviewed literature) also this procedure should only be performed in special cases. Because of the sexual disturbances after ileoanal anastomosis (1.8% impotence, 5.8% retrograde ejaculation) in men ileorectal anastomosis can be an alternative for this subgroup. Subtotal colectomy with ileostomy and sigmoid mucus fistula is the procedure of choice for the treatment in emergencies. Apart of the emergency indication it should be performed if there is a very bad general condition of the patient or a high dosage of corticoids or immunosuppressant drugs. Subtotal colectomy with mucus fistula should be performed in preference to a simple closure of the rectal stump, since the rectal stump closure has an insufficiency rate of 35%.

Key Words

Ulcerative colitis Colectomy Limited resection Ileoanal pouch Ileorectal anastomosis 

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Literatur

  1. 1.
    Baker WN, Glass RE, Ritchie JK, Aylett SO. Cancer of the rectum following ileorectal anastomosis for ulcerative colitis. Br Med J 1978;65.Google Scholar
  2. 2.
    Bolton PR. Colitis treated by valvular colostomy and irrigation. Ann Surg 1901;99:753.Google Scholar
  3. 3.
    Brown JY. The Lane operation: the indications for and the limitations of the procedure with a discussion of the principles underlying it. Trans South Surg Gynecol Assoc 1911;137.Google Scholar
  4. 4.
    Buhr HJ, Heuschen UA, Stern J, Herfarth C. Continence-preserving operation after proctocolectomy. Indications, technique and results. Chirurg 1993;64:601–13.PubMedGoogle Scholar
  5. 5.
    Carter FM, McLeod RS, Cohen Z. Subtotal colectomy for ulcerative colitis: complications related to the rectal remnant. Dis Colon Rectum 1991;34:1005–9.PubMedCrossRefGoogle Scholar
  6. 6.
    Damgaard B, Wettergren A, Kirkrgaard P. Social and sexual function following ileal pouch-anal anastomosis. Dis Colon Rectum 1995;38:286–9.PubMedCrossRefGoogle Scholar
  7. 7.
    Dozois RR, Nelson H, Metcalf AM. Sexual function after ileoanal anastomosis. Ann Chir 1993;47:1009–13.PubMedGoogle Scholar
  8. 8.
    Farnell MB, Van Heerden JA, Beart RW Jr, Weiland LH. Rectal preservation in nonspecific inflammatory disease of the colon. Ann Surg 1980;192:249–53.PubMedCrossRefGoogle Scholar
  9. 9.
    Fazio VW, Ziv Y, Church JM, Oakley JR, Lavery IC, Milsom JW, Schroeder TK. Ileal pouch-anal anastomoses complications and function in 1005 patients. Ann Surg 1995;222:120–7.PubMedCrossRefGoogle Scholar
  10. 10.
    Johnson WR, Hughes ES, McDermott FT, Pihl EA, Katrivessis H. The outcome of patients with ulcerative colitis managed by subtotal colectomy. Surg Gynecol Obstet 1986;162:421–5.PubMedGoogle Scholar
  11. 11.
    Keith S. The treatment of membranous colitis. Lancet 1895;I:639.CrossRefGoogle Scholar
  12. 12.
    Kroesen AJ, Stern J, Herfarth C. Kontinenzerhaltende Colon-und Ileumreservoire im funktionellen Vergleich. Chirurgisches Forum '94: Langenbecks Arch Chir 1994; Suppl: 177–180.Google Scholar
  13. 13.
    Lane A. Côtectomie totale: indication, technique, accidents, résultats. Presse Med 1921;29:613.Google Scholar
  14. 14.
    MacGuire DP. Aseptic total colectomy. NY State J Med 1940;40:1515.Google Scholar
  15. 15.
    Michelassi F, Stella M, Block GE. Prospective assessment of functional results after ileal J pouch-anal restorative proctocolectomy. Arch Surg 1993;128:889–94; discussion 894–5.PubMedGoogle Scholar
  16. 16.
    Mikkola K, Luukkonen P, Jarvinen HJ. Long-term results of restorative proctocolectomy for ulcerative colitis. Int J Colorectal Dis 1995;10:10–4.PubMedCrossRefGoogle Scholar
  17. 17.
    Parc R, Legrand M, Frileux P, Tiret E, Ratelle R. Comparative clinical results of ileal-pouch anal anastomosis and ileorectal anastomosis in ulcerative colitis. Hepatogastroenterology 1989;36:235–9.PubMedGoogle Scholar
  18. 18.
    Penna C, Daude F, Parc R, Tiret E, Prileux P, Hannoun L, Nordlinger B, Leva E. 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;36:343–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Oakley JR, Jagelman DG, Fazio VW. Complications and quality of life after ileorectal anastomosis for ulcerative colitis. Am J Surg 1985;149:23–8.PubMedCrossRefGoogle Scholar
  20. 20.
    Ravitch MM, Handelsman JC. One stage resection of the entire colon and rectum for ulcerative colitis and adenomatosis. Bull Johns Hopkins Hosp 1951;88:59.PubMedGoogle Scholar
  21. 21.
    Ravitch MM, Sabiston DC. Anal ileostomy with preservation of the sphincter. A proposed operation in patients requiring total colectomy for benign lesions. Surg Gynecol Obstet 1947;84: 1095–9.Google Scholar
  22. 22.
    Robson I, Mayo I. Case of colitis treated by inguinal colectomy and local treatment of the ulcerated surface with subsequent closure of the artificial anus. Trans Clin Soc London 1893;26:213.Google Scholar
  23. 23.
    Schwartz RJ, Pezim ME. Failure of right-sided ileoanal anastomosis for treatment of left-sided ulcerative colitis. Report of a case. Dis Colon Rectum 1991;34:618–21.CrossRefGoogle Scholar
  24. 24.
    Weir RF. A new use for the useless appendix in the surgical treatment of obstipate colitis. Med Records 1902;62:201.Google Scholar
  25. 25.
    Wilks S, Moxon W. Lectures on pathological anatomy. London: Churchill, 1875.Google Scholar

Copyright information

© Urban & Vogel 1997

Authors and Affiliations

  • A. J. Kroesen
    • 1
  • H. J. Buhr
    • 1
  1. 1.Allgemein-, Gefäß- und Thoraxchirurgie, Chirurgische Klinik IUniversitätsklinikum Benjamin Franklin FU BerlinBerlin

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