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Therapierefraktäre chronisch entzündliche Darmerkrankungen

Eine chirurgische Herausforderung

Refractory inflammatory bowel disease

Surgical challenges

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Zusammenfassung

Operieren unter Immunsuppression ist ein hochaktuelles Thema in der Chirurgie chronisch entzündlicher Darmerkrankungen. Durch den Wandel der Therapieregime kommt kaum noch ein Patient ohne Immunsuppression zur Operation. Die Datenlage, inwiefern diese Substanzen im Falle einer Operation tatsächlich einen Risikofaktor darstellen, ist allerdings sehr uneinheitlich. Beim M. Crohn scheint eine Monotherapie mit Immunmodulatoren und Biologika keinen negativen Einfluss zu haben. Allerdings potenzieren sich die einzelnen Substanzen in ihrer Wirkung. Bei der Colitis ulcerosa überwiegen die Arbeiten, die ein erhöhtes Risiko für infektiöse Komplikationen nach Biologika und Immunsuppression aufzeigen. Zur Herabsetzung des Risikos müssen alle Risikofaktoren reduziert werden. Beim M. Crohn sind das in erster Linie eine Optimierung des Ernährungsstatus, eine Reduktion der Kortikoidtherapie, Pausierung der Biologika und Immunsuppression, Splitstoma/protektives Stoma. Bei der Colitis ulcerosa sollte zusätzlich beim Hochrisikopatienten eine dreizeitige statt eine ein-/zweizeitige restaurative Proktokolektomie vorgenommen werden.

Abstract

Surgery for inflammatory bowel disease under immunosuppressant drugs is a widely discussed topic. Because therapeutic concepts have significantly changed, almost no patient is currently without an immunosuppressant or biologic agent prior to surgery. However, the data whether biological agents and immunosuppressant are a risk factor are very inconsistent. Concerning Crohn’s disease, monotherapy with immunosuppressants or biological agents seems to have no negative influence on the postoperative results. In contrast, however, for ulcerative colitis more publications recognise biologic agents and immunosuppressants as a single therapy as a risk factor for infections. To reduce the general risk, all risk factors have to be reduced. In Crohn’s disease, nutritional status must be optimised, corticoids should be reduced, biological agents and immunosuppressant drugs should be stopped, protection of an eventual anastomosis by a stoma. For ulcerative colitis in high-risk patients, a three-stage restaurative proctocolectomy is favoured to a one- or two-staged proctocolectomy.

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Einhaltung ethischer Richtlinien

Interessenkonflikt. H.J. Buhr und A.J. Kroesen geben an, dass kein Interessenkonflikt besteht. Dieser Beitrag beinhaltet keine Studien an Menschen oder Tieren.

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Authors and Affiliations

  1. Deutsche Gesellschaft für Allgemein- und Viszeralchirurgie e.V., Haus der Bundespressekonferenz, Schiffbauerdamm 40, 10117, Berlin, Deutschland

    H.J. Buhr

  2. Allgemein, Viszeral- und Unfallchirurgie, Krankenhaus Porz, Köln, Deutschland

    A.J. Kroesen

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Correspondence to H.J. Buhr.

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Buhr, H., Kroesen, A. Therapierefraktäre chronisch entzündliche Darmerkrankungen. Chirurg 84, 945–950 (2013). https://doi.org/10.1007/s00104-013-2516-x

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