Zusammenfassung
Fragestellung und Hintergrund
Die restaurative Proktokolektomie ist zur Standardtherapie bei Patienten mit familiärer adenomatöser Polyposis coli (FAP) geworden. Die Verwendung von Staplergeräten löste eine kontroverse Diskussion über die ileo-pouch-anale Rekonstruktion aus. Dabei propagieren einige Autoren die Handnaht-Anastomose nach transanaler Mukosektomie. Eine Klammernahtanastomose führt zwar zu besseren funktionellen Ergebnissen, scheint aber mit einem erhöhten Risiko an verbleibender Restrektumschleimhaut mit Dysplasie und Adenomen einherzugehen. Die vorliegende Studie untersucht systematisch die Rate der Restrektumschleimhaut nach restaurativer Proktokolektomie und Handnaht- vs. Stapler-Anastomose.
Patienten und Methodik
Einhundert FAP-Patienten nach restaurativer Proktokolektomie, die sich regelmäßigen Nachuntersuchungen in unserer Ambulanz unterzogen, wurden in die Studie aufgenommen. Es erfolgte eine Proktoskopie mit standardisierten Biopsien.
Ergebnisse
Von den 100 Patienten hatten 50 eine Stapler- und 50 eine Handnaht-Anastomose erhalten. Die mediane Nachbeobachtungszeit betrug 146,1 Monate (Handnaht) vs. 44,8 Monate (Staplernaht) (p < 0,0001). Bei 87 Patienten wurde eine Proktoskopie mit standardisierten Biopsien durchgeführt. Bei 13 Patienten war zuvor der Verbleib von Restrektumschleimhaut festgestellt worden. Bei insgesamt 63 Patienten (63 %) wurde verbliebene Rektumschleimhaut nachgewiesen (42 [66,6 %] nach Staplernaht, 21 [33,3 %] nach Handnaht, p < 0,0001). Patienten nach Anlage einer Stapler-Anastomose wiesen vermehrt Rektumschleimhaut in Form eines zirkulären Saums auf, wohingegen kleine Schleimhautinseln in der Gruppe mit Handnaht vorherrschten. Die Rektumadenomrate lag in der Staplergruppe signifikant höher (21 vs. 10, p = 0,02).
Schlussfolgerung
Restrektumschleimhaut, insbesondere ein breiter Schleimhautsaum, und Rektumadenome fanden sich signifikant häufiger nach Stapler- als nach Handnaht-Anastomose. Angesichts des signifikant kürzeren Nachuntersuchungsintervalls in der Staplergruppe wird die Bedeutung dieser Ergebnisse möglicherweise unterschätzt.
Abstract
Introduction
Restorative proctocolectomy has become the standard surgical procedure for familial adenomatous polyposis (FAP) patients. The use of stapler devices has initiated a controversial discussion concerning the ileal pouch-anal reconstruction. Some authors advocate a handsewn anastomosis after transanal mucosectomy. A double-stapled anastomosis leads to better functional results but seems to bear a higher risk of residual rectal mucosa with dysplasia and adenomas. The present study systematically analyses the rate of residual rectal mucosa after restorative proctocolectomy and handsewn vs. stapled anastomosis.
Patients and methods
One hundred FAP patients after restorative proctocolectomy undergoing regular follow-up at our outpatient clinic were included in the study. Proctoscopy with standardised biopsy sampling was performed.
Results
Of the 100 patients, 50 had undergone a stapled and 50 a handsewn anastomosis. Median follow-up was 146.1 months (handsewn) vs. 44.8 months (stapled) (P < 0.0001). Eighty-seven patients received a proctoscopy with standardised biopsy sampling. Thirteen patients had been diagnosed with residual rectal mucosa before. Sixty-three patients (63 %) showed remaining rectal mucosa (42 (66.6 %) stapler, 21 (33.3 %) handsewn, P < 0.0001). Patients after stapled anastomosis had higher rates of circular rectal mucosa seams, while small mucosa islets predominated in the handsewn group. The rate of rectal adenomas was significantly higher in the stapler group (21 vs. 10, P = 0.02).
Conclusion
Rectal mucosa, especially wide mucosa seams, as well as rectal adenomas are found significantly more often after a stapled than after a handsewn anastomosis. As the follow-up interval in the stapler group was significantly shorter, the impact of these findings may still be underestimated.
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P. Ganschow, I. Treiber, U. Hinz, C. Leowardi, M. W. Büchler und M. Kadmon geben an, dass kein Interessenkonflikt besteht.
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Petra Ganschow und Irmgard Treiber waren zu gleichen Teilen an der Erstellung dieses Manuskripts beteiligt.
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Ganschow P, Treiber I, Hinz U et al (2015) Residual rectal mucosa after stapled vs. handsewn ileal J-pouch-anal anastomosis in patients with familial adenomatous polyposis coli (FAP) – a critical issue. Langenbecks Arch Surg (2015) 400:213–219
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Ganschow, P., Treiber, I., Hinz, U. et al. Restrektumschleimhaut an der ileo-J-Pouch-analen Anastomose nach Stapler- vs. Handnaht bei Patienten mit familiärer adenomatöser Polyposis coli (FAP) – eine Problemzone. coloproctology 37, 365–372 (2015). https://doi.org/10.1007/s00053-015-0055-2
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DOI: https://doi.org/10.1007/s00053-015-0055-2