Z Gastroenterol 2012; 50(5): 468-474
DOI: 10.1055/s-0031-1299467
Übersicht
© Georg Thieme Verlag KG Stuttgart · New York

Aspects in the Interdisciplinary Decision-Making for Surgical Intervention in Ulcerative Colitis and its Complications

Aspekte in der interdisziplinären Entscheidungsfindung zum operativen Eingriff bei Colitis ulcerosa und ihren Komplikationen
J. Brown
1   Division of Digestive Diseases, Emory University School of Medicine, Atlanta, USA
,
F. Meyer
2   Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum A.ö.R., Magdeburg, Deutschland
,
J.-M. Klapproth
2   Klinik für Allgemein-, Viszeral- und Gefäßchirurgie, Universitätsklinikum A.ö.R., Magdeburg, Deutschland
› Author Affiliations
Further Information

Publication History

20 November 2011

13 March 2012

Publication Date:
11 May 2012 (online)

Abstract

Ulcerative colitis (UC) is a chronic inflammation of the large bowel, predominantly affecting young adults of 20 to 30 years of age. Even though the majority of patients with limited and extensive UC can be managed medically, 20 to 30 % will require surgical intervention at some point in their life to gain control of the inflammatory process. The most common reason for urgent and emergency surgery is a lack of response to maximal medical inpatient therapy after five to ten days. Other indications include hemorrhage, free perforation, sepsis, and toxic megacolon. Procedure of choice for the majority of surgeons is open or laparoscopic subtotal colectomy and end ileostomy, with or without exteriorization of the rectal stump. The laparoscopic approach requires more time, but allows for faster return of bowel function and discharge from the hospital. Creation of a definite restoration in form of a J pouch should be delayed for at least three months. Indications for elective surgical intervention include cancer, dysplasia associated lesion or mass, and stricture. Preferably, the J pouch and Brooke ileostomy are performed in two stages, with a takedown of the ileostomy several months later. A single-stage operation is associated with increased anastomotic dehiscence, sepsis, and long-term pouch failure. The laparoscopic creation of a J pouch is largely dependent on the surgeon’s experience, but results in a number of advantages, including faster return of bowel function, tolerance of diet, and discharge. Regardless of emergency, urgent, or elective surgical intervention, early involvement of a team of gastroenterologist, surgeon, nutritionist, and stoma nurse is essential in the management of severe UC to maximize a satisfactory patient outcome.

Zusammenfassung

Die Colitis ulcerosa ist eine chronische Inflammation des Kolons vorwiegend jüngerer Erwachsener zwischen dem 20. und 30. Lebensjahr. Die Mehrheit der Patienten mit eher begrenzter als auch ausgedehnter Colitis ulcerosa kann medikamentös geführt und beherrscht werden, 20 − 30 % erfordern jedoch eine Operation in ihrem Leben, um den Entzündungsprozess nicht außer Kontrolle geraten zu lassen. Der häufigste Grund einer dringlichen oder Notfalloperation ist das ausbleibende Anschlagen einer initiierten, stationär geführten medikamentösen Behandlung betroffener Patienten von 5 − 10 Tagen. Andere Indikationen beinhalten Hämorrhagie, die freie Perforation, Sepsis und das toxische Megakolon. Die Methode der Wahl ist mehrheitlich die offene oder laparoskopische (sub-)totale Kolektomie und die endständige Ileostomie einschließlich als auch ohne Rektumstumpfexstirpation. Das laparoskopische Vorgehen ist zeitaufwendiger, gewährleistet jedoch in der Regel eine frühere Normalisierung der Darmfunktion als auch eine zügigere Rekonvaleszenz und damit verbundene kürzere Krankenhausverweildauer. Eine definitive Restauration in Form eines meist verwendeten J-Pouches (falls möglich) sollte um wenigstens 3 Monate aufgeschoben werden. Indikationen für eine elektive Operation beinhalten Malignität, Dysplasie und Striktur. Bevorzugt kommen J-Pouch und Brooke-Ileostomie zur Anwendung in 2 Sitzungen mit einer Ileostomarückverlagerung einige Wochen später, meist nach ca. 3 Monaten. Ein einzeitiges Vorgehen ist mit einer erhöhten Rate von Anastomoseninsuffizienzen, Sepsis und Pouch-Dysfunktion im Langzeitverlauf assoziiert. Die laparoskopische Anlage eines J-Pouches ist nicht unerheblich von der Erfahrung des Operateurs abhängig, weist jedoch eine Reihe von Vorteilen auf: zügigere Normalisierung der Darmfunktion, Wiederaufnahme der Kost und Entlassung. Unabhängig vom dringlichen, Notfall- oder Elektivvorgehen hinsichtlich der Operationsplanung im Management der schweren Colitis ulcerosa ist die kompetente interdisziplinäre Absprache eines Teams von Gastroenterologe, Chirurg, Ernährungsmediziner und Stomaschwester essenziell für die Gewährleistung einer maximalen Patientenzufriedenheit.

 
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