Download PDF
Viszeralchirurgie 2000; 35(1): 36-42
DOI: 10.1055/s-2000-11228
ORIGINALARBEIT
© Georg Thieme Verlag Stuttgart · New York

Differenzierte chirurgische Strategie bei anorektalemMorbus-Crohn-Befall

D. Lorenz, P. Palma, S. Post
  • Universitätsklinikum Mannheim
Further Information

Publication History

Publication Date:
31 December 2000 (online)

    Permissions and Reprints

Zusammenfassung.

In den letzten Jahren hat sich in koloproktologisch aktiven Zentren der Therapieansatz bei komplizierten anorektalen Crohn-Fisteln von einem konservativ abwartenden zu einem selektiv-operativen Vorgehen geändert. Die früher häufig als definitive Therapie verwendete Fadendrainage ist dabei Teil eines Therapiekonzeptes, das letztlich den operativen Verschluss der Fistel durch endoanale Verschiebelappen-Techniken zum Ziel hat. In geübten Händen lassen sich so Raten der kontinenten Langzeit-Heilung von bis zu 85% erreichen - gelegentlich auch unter Anlage einer vorübergehenden Deviationsileostomie. Bei Patienten mit langjährigem anorektalen Crohn-Befall scheint ein gesteigertes Risiko für die Entwicklung eines Karzinoms vorzuliegen, in Fisteln findet sich dabei gehäuft ein Plattenepithelkarzinom. Die Therapieempfehlung unterliegt dabei den gleichen onkologischen Grundsätzen wie bei nicht Crohn-assoziierten Karzinomen.

Schlüsselwörter:

Anorektaler Morbus Crohn - Fadendrainage - Verschiebelappen - Crohn-assoziiertes Karzinom

Surgical strategies for anorectal crohn's disease.

In recent years, surgeons treating complicated cases of anorectal Crohn's disease have shifted from a cautious conservative to a selective surgical approach. The former concept of seton drainage as the main treatment has now been intregrated with the aim of surgical closure of the fistula by endoanal advancement flap. In experienced hands rates of longterm continence up to 85% can be reached - occasionally including the temporary deviation ileostomy. Patients with a long history of anorectal Crohn's disease seem at higher risk for developing squamous cell carcinoma in the fistula region. Treatment recommendations are based on the same oncological principles as for carcinomas not associated with Crohn's disease.

Key words:

Anorectal crohn's disease - Seton-drainage - Advancement-flap - Crohn associated carcinoma

Literatur

  • 1 Gabriel W B. Results of an experimental and historical investigation into seventy-fife cases of rectal fistulae.  J R Soc Med. 1921;  14 156-161
    PubMedGoogle Scholar
  • 2 Penner A, Crohn B B. Perianal fistulae as a complication of regional ileitis.  Ann Surg. 1938;  108 867-873
    CrossrefPubMedGoogle Scholar
  • 3 Farmer R G, Whelan G, Fazio V W. Long-term follow-up of patients with Crohn's disease.  Gastroenterology. 1985;  88 1818-1825
    PubMedGoogle Scholar
  • 4 Wolf B G, Culp C E, Beart R W, Ilstrup D M, Ready R L. Anorectal Crohn's disease. A long-term perspective.  Dis Colon Rectum. 1985;  28 709-711
    PubMedGoogle Scholar
  • 5 Sangwan Y P, Schoetz D J, Murray J J, Roberts P L, Coller J A. Perianal Crohn's disease. Results of local surgical treatment.  Dis Colon Rectum. 1996;  39 529-535
    CrossrefPubMedGoogle Scholar
  • 6 Williams N S, Macfie J, Celestin L R. Anorectal Crohn's disease.  Br J Surg. 1979;  66 743-748
    PubMedGoogle Scholar
  • 7 Makowiec F, Schmidtke C, Paczulla D, Lamberts R, Becker H D, Starlinger M. Progression and prognosis of Crohn's disease.  Z Gastroenterol. 1997;  35 7-14
    PubMedGoogle Scholar
  • 8 Post S, Herfarth C, Böhm E, Timmermanns G, Schumacher H, Schürmann G, Golling M. The impact of disease pattern, surgical management, and individual surgeons on the risk for relaparotomy for recurrent Crohn's disease.  Ann Surg. 1996;  223 253-260
    CrossrefPubMedGoogle Scholar
  • 9 Allan A, Keighley M R. Management of perianal Crohn's disease.  World J Surg. 1988;  12 198-202
    CrossrefPubMedGoogle Scholar
  • 10 Williams J G, Rothenberger D A, Nemer F D, Goldberg S M. Fistula-in-ano in Crohn's disease: results of aggressive surgical treatment.  Dis Colon Rectum. 1991;  34 378-384
    CrossrefPubMedGoogle Scholar
  • 11 Fuhrman F M, Larach S W. Experience with perirectal fistulas in patients with Crohn's disease.  Dis Colon Rectum. 1989;  32 847-848
    PubMedGoogle Scholar
  • 12 Sohn N, Korelitz B I, Weinstein M A. Anorectal Crohn's disease: definitive surgery for fistulas and recurrent abscesses.  Am J Surg. 1980;  139 394-397
    CrossrefPubMedGoogle Scholar
  • 13 Editorial. Br Med J 1976 2: 1341
    Google Scholar
  • 14 Post S, Kunhardt M, Herfarth C. Subjektive Einschätzung von Lebensqualität, Schmerzen und Operationserfolg nach Laparotomien wegen Morbus Crohn.  Chirurg. 1995;  66 800-806
    PubMedGoogle Scholar
  • 15 Winkler R. Chirurgische Aufgaben bei anorektalen Komplikationen des Morbus Crohn.  Zentralbl Chir. 1998;  123 362-367
    PubMedGoogle Scholar
  • 16 Lockhart-Mummery H E. Crohn's disease: anal lesions.  Dis Colon Rectum. 1975;  18 200-202
    PubMedGoogle Scholar
  • 17 Pritchard T J, Schoetz D J, Roberts P L, Murray J J, Coller J A, Veidenheimer M C. Perirectal abscess in Crohn's diesease. Drainage and outcome.  Dis Colon Rectum. 1990;  33 933-937
    CrossrefPubMedGoogle Scholar
  • 18 Makowiec F, Jehle E C, Becker H D, Starlinger M. Perianal Abscess in Crohn's disease.  Dis Colon Rectum. 1997;  40 443-450
    PubMedGoogle Scholar
  • 19 Rankin G B, Watts H D, Melnyk C S, Kelley M L. National Cooperative Crohn's Disease Study: extraintestinal manifestations and perianal complications.  Gastroenterology. 1979;  77 914-920
    PubMedGoogle Scholar
  • 20 Buchmann P, Keighley M RB, Allan R N, Thompson H, Alexander-Williams J. Natural history of perianal Crohn's disease. Ten-year follow up: A plea for conservation.  Am J Surg. 1980;  190 642-644
    PubMedGoogle Scholar
  • 21 Fleshner P R, Schoetz D J, Roberts P L, Murray J J, Coller J A, Veidenheimer M C. Anal fissure in Crohn's disease: a plea for aggressive management.  Dis Colon Rectum. 1995;  38 1137-1143
    CrossrefPubMedGoogle Scholar
  • 22 Brisinda G, Maria G, Bentivoglio A R, Cassetta E, Gui D, Albanese A. A Comparison of Injections of Botulinum Toxin and Topical Nitroglycerin Ointment for the Treatment of Chronic Anal Fissure.  NEJM. 1999;  341 65-69
    CrossrefPubMedGoogle Scholar
  • 23 Stelzner F. Die anorektalen Fisteln. 3 Aufl. Springer, Berlin, HD, NY 1976
    Google Scholar
  • 24 Parks A G, Hardcastle J D, Gordon P H. A classification of fistula-in-ano.  Br J Surg. 1976;  63 1-12
    CrossrefPubMedGoogle Scholar
  • 25 Hughes L E. Clinical classification of perianal Crohn's disease.  Dis Colon Rectum. 1992;  35 928-932
    PubMedGoogle Scholar
  • 26 Orsoni P, Barthet M, Portier F, Panuel M, Desjeux A, Grimaud J C. Prospective comparison of endosonography, magnetic resonance imaging and surgical findings in anorectal fistula and abscess complicating Crohn's disease.  Br J Surg. 1999;  86 360-364
    CrossrefPubMedGoogle Scholar
  • 27 Alexander-Williams J, Buchmann P. Perianal Crohn's disease.  World J Surg. 1980;  4 203-208
    PubMedGoogle Scholar
  • 28 McCourtney J S, Finley I G. Setons in the surgical management of fistula in ano.  Br J Surg. 1995;  82 448-452
    PubMedGoogle Scholar
  • 29 Faucheron J L, Saint-Marc O, Guibert L, Parc R. Long-term Seton Drainage for High Anal Fistulas in Crohn's disease - A Sphincter-Saving Operation?.  Dis Colon Rectum. 1996;  39 208-211
    CrossrefPubMedGoogle Scholar
  • 30 Humphrey J S, Northover J MA. Evaluation of Surgery for perianal Crohn's Fistulas.  Dis Colon Rectum. 1996;  39 1039-1043
    PubMedGoogle Scholar
  • 31 García Aguilar J, Belmonte C, Wong D W, Goldberg S M, Madoff R D. Cutting seton versus two-stage seton fistulotomy in the surgical management of high anal fistula.  Br J Surg. 1998;  85 243-245
    CrossrefPubMedGoogle Scholar
  • 32 Aguilar P S, Plasencia G, Hardy T G, Hartmann R F, Stewart W RC. Mucosal advancement in the treatment of anal fistula.  Dis Colon Rectum. 1995;  28 469-501
    PubMedGoogle Scholar
  • 33 Ozuner Gokhan, Hull T L, Cartmill J, Fazio V W. Long-term analysis of the use of transanal rectal advancement flaps for complicated anorectal/vaginal fistulas.  Dis Colon Rectum. 1996;  39 10-14
    PubMedGoogle Scholar
  • 34 Szone J M, Goldberg S M. The endorectal advancement flap procedure.  Int J Colorect Dis. 1990;  5 232-235
    CrossrefPubMedGoogle Scholar
  • 35 Marchesa P, Hull T L, Fazio V W. Advancement sleeve flaps for treatment of servere perianal Crohn's disease.  Br J Surg. 1998;  85 1695-1698
    CrossrefPubMedGoogle Scholar
  • 36 Athanasiadis S, Köhler A, Ommer A. Management der perianalen Crohn-Fistel.  Dt. Ärzteblatt. 1998;  48 2373-2375
    PubMedGoogle Scholar
  • 37 Athanasiadis S, Köhler A, Weyand G, Nafe M, Kuprian A, Oladeinde I. Endoanale und transperineale kontinenzschonende Verschlußtechniken bei der chirurgischen Behandlung der Crohn-Fisteln.  Chirurg. 1996;  67 59-71
    PubMedGoogle Scholar
  • 38 Brough W A, Schofield P F. The value of the Rectus Abdominis Myocutaneous Flap in the Treatment of Complex Perineal Fistula.  Dis Colon Rectum. 1991;  34 149-150
    PubMedGoogle Scholar
  • 39 Grant D R, Cohen Z, McLeod R S. Loop ileostomy for anorectal Crohn's disease.  Can J Surg. 1986;  29 32-35
    PubMedGoogle Scholar
  • 40 Post S, Herfarth C, Schumacher H, Golling H, Schürmann G, Timmermanns G. Experience with ileostomy and colostomy in Crohn's disease.  Br J Surg. 1995;  82 1629-1633
    PubMedGoogle Scholar
  • 41 Sher M E, Bauer J J, Grophine S, Gelernt I. Low Hartmann's procedure for severe anorectal Crohn's disease.  Dis Colon Rectum. 1992;  35 975-980
    PubMedGoogle Scholar
  • 42 Brandt L J, Bernstein L H, Boley S J, Frank M S. Metronidazole therapy for perineal Crohn's disease: a follow-up study.  Gastroenterology. 1982;  83 383-387
    PubMedGoogle Scholar
  • 43 Korelitz B I, Present D H. Favorable effect of 6-mercaptopurine on fistulae of Crohn's disease.  Dig Dis Sci. 1985;  30 58-64
    CrossrefPubMedGoogle Scholar
  • 44 Hinterleitner T A, Petritsch W, Aichbichler B, Fickert P, Ranner G, Krejs G J. Combination of cyclosporine, azathioprine and prednisolone for perianal fistulas in Crohn's disease.  Z Gastroenterol. 1997;  35 603-608
    PubMedGoogle Scholar
  • 45 Sandborn W J, Strong R M, Forland S C. The pharmacokinetics and colonic tissue concentrations of cyclosporine after iv, oral and enema administration.  J Clin Pharmacol. 1991;  31 76-80
    PubMedGoogle Scholar
  • 46 Reimund J M, Wittersheim C, Dumont S. Mucosal inflammatory cytocine production by intestinal biopsies in patients with ulcerative colitis and Crohn's disease.  J Clin Immunol. 1996;  16 144-150
    CrossrefPubMedGoogle Scholar
  • 47 Breese E J, Michie C A, Nicholls S W. Tumor necrosis factor -α producing cells in the intestinal mucosa of children with inflammatory bowel disease.  Gastroenterology. 1994;  106 1455-1466
    PubMedGoogle Scholar
  • 48 Present D H, Rutgeerts P, Targan S. Infliximab for the treatment of Fistulas in Patients with Crohn's disease.  NEJM. 1999;  340 1398-1405
    CrossrefPubMedGoogle Scholar
  • 49 Connell W R, Sheffield J P, Kamm M A, Ritchie J K, Hawley P R, Lennard-Jones J E. Lower gastrointestinal malignancy in Crohn's disease.  Gut. 1994;  35 347-352
    CrossrefPubMedGoogle Scholar
  • 50 Nikias G, Eisner T, Katz S, Levin L, Eskries D, Urmacher C, McKinley M. Crohn's disease and colorectal carcinoma: rectal cancer complicating longstanding active perianal disease.  AJG. 1995;  90 216-219
    PubMedGoogle Scholar
  • 51 Kulaylat M H, Gallina G, Bem J, Zeid M. Carcinoma arising in anorectal fistulas of Crohn's disease.  Dis Colon Rectum. 1999;  42 826-827
    PubMedGoogle Scholar
  • 52 Ky A, Sohn N, Weinstein M A, Korelitz B I. Carcinoma arising in anorectal fistulas of Crohn's disease.  Dis Colon Rectum. 1998;  41 992-996
    CrossrefPubMedGoogle Scholar

Prof. Dr. med. Stefan Post

Direktor der Chirurgischen Klinik Universitätsklinikum Mannheim

68135 Mannheim

URL: http://E-mail: stefan.post@chir.ma.uni-heidelberg.de

      >