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Die Proktokolektomie bei Colitis ulcerosa

Ist ein mehrzeitiges Vorgehen bei Immunsuppression sinnvoll?

Proctocolectomy in ulcerative colitis

Is a multistep procedure in cases of immunosuppression advisable?

  • Klinische Studien
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Zusammenfassung

Einleitung

Die Koloproktomukosektomie (CPM) gilt als Verfahren der Wahl für die chirurgische Therapie der Colitis ulcerosa (CU). Bei ausgeprägter Immunsuppression (IS) wird dabei häufig ein dreizeitiges (3Z) Vorgehen gewählt, bei dem eine subtotale Kolektomie der ileoanalen Pouchanlage (IPAA) und abschließenden Ileostomarückverlagerung vorangestellt wird. Im Vergleich zum zweizeitigen (2Z) Vorgehen wird dadurch eine Reduktion der perioperativen Komplikationen erwartet, allerdings ist ein zusätzlicher stationärer Aufenthalt und operativer Eingriff erforderlich. Ziel der hier vorliegenden Studie war es, die beiden Vorgehensweisen im Hinblick auf das klinische Outcome nach IPAA zu vergleichen, um die tatsächliche Effektivität dieser beiden Konzepte überprüfen zu können.

Patienten und Methoden

Zwischen 1997 und 2010 wurden insgesamt 225 Patienten mit IPAA operiert und einem 2Z oder 3Z Verfahren unterzogen. Zur Erfassung des klinischen Outcomes wurde der operative Schritt der Pouchanlage und IPAA gewertet. Die Datenerhebung erfolgte im Rahmen einer prospektiven Studiendokumentation.

Ergebnisse

Von 225 Patienten mit CPM mussten 66 aufgrund einer anderen Diagnose als CU (FAP, Colitis indeterminata, Morbus Crohn) sowie Patienten mit definitiver ILS-Anlage ohne Möglichkeit oder Wunsch einer IPAA (n = 54) ausgeschlossen werden. Untersucht wurden 71 Patienten mit einem 2Z (w = 30, m = 41) und 34 Patienten mit einem 3Z Vorgehen (w = 21, m = 13). Das 3Z Vorgehen wies im Vergleich zum 2Z eine kürzere Operationszeit (246 vs. 296 min; p < 0,05), kürzere Liegedauer (15,5 vs. 24,6 Tage; p < 0,05), kürzeren Intensivaufenthalt (3,3 vs. 7,2 Tage; p < 0,05) und weniger Majorkomplikationen auf (5,9 % vs. 22,5 %; p = 0,035). Patienten mit 3Z Vorgehen zeigten einen höheren BMI (26,2 vs. 23,1 kg/m2; p < 0,05) und nahmen weniger IS ein (10 % vs. 62 %; p < 0,05).

Schlussfolgerung

Die Entscheidung zu einem 3Z Vorgehen bei CU und ausgeprägter IS ist sinnvoll und gerechtfertigt. Durch dieses Vorgehen werden die Immunsuppression sowie deren Einfluss auf die perioperative Morbidität reduziert. Somit kann die IPAA mit kürzerer Operationsdauer, kürzerer Liegedauer und weniger Majorkomplikationen durchgeführt werden.

Abstract

Background

The coloproctomucosectomy (CPM) is the procedure of the choice for the surgical treatment of ulcerative colitis (UC). In cases with pronounced immunosuppression (IS), a 3-step (3S) procedure [i.e., subtotal colectomy and ileal pouch-anal anastomosis (IPAA) and finally ileostomy reconstruction] is often selected. Fewer perioperative complications can be expected compared to the 2-step (2S) procedure; however, an additional in-hospital stay and surgical intervention are necessary. The aim of the present study was to compare both approaches using the clinical outcome of our patients undergoing IPAA to determine efficacy of these two concepts.

Patients and methods

From 1997–2010, a total of 225 patients were operated using a 2S or 3S IPAA procedure. Clinical outcomes were evaluated based on the number of surgical steps for the ileoanal pouch procedure and IPAA. The survey was performed within the scope of prospective study.

Results

Of the 225 patients with CPM, 66 were excluded due to a diagnosis other than UC (familial adenomatous polyposis, indeterminate colitis, Crohn’s disease) and patients with permanent ILS procedures without the possibility or wish for an IPAA (n =  54). Included were 71 patients with 2S (w = 30, m = 41) and 34 patients with 3S procedures (w = 21, m = 13). Compared to the 2S procedure, the 3S procedure was shown to have shorter operation times (246 versus 296 min; p  = 0.05), shorter hospital stays (15.5 versus 24.6 days; p = 0.05), shorter intensive care unit stays (3.3 versus 7.2 days; p = 0.05), and fewer major complications (5.9 % versus 22.5 %; p = 0.035). Patients with 3S procedures had a higher BMI (26.2 versus 23.1 kg/m²; p = 0.05) and fewer required IS (10 % vs. 62 %; p < 0.05).

Conclusion

The decision for a 3S procedure in UC and pronounced IS is advisable and justified. Using a 3S procedure, immunosuppression and its influence on perioperative morbidity are thus reduced. The IPAA can be performed with shorter operation times, shorter hospital stays and fewer major complications.

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Authors and Affiliations

  1. Chirurgische Klinik I, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Hindenburgdamm 30, 12200, Berlin, Deutschland

    C. Seifarth, J. Gröne, N. Slavova & H.J. Buhr

  2. Medizinische Klinik I, Charité – Universitätsmedizin Berlin, Campus Benjamin Franklin, Berlin, Deutschland

    B. Siegmund

  3. Klinik für Allgemein- und Viszeralchirurgie, Helios Kliniken, Schwerin, Deutschland

    J.-P. Ritz

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  1. C. Seifarth
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  2. J. Gröne
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Correspondence to C. Seifarth.

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Seifarth, C., Gröne, J., Slavova, N. et al. Die Proktokolektomie bei Colitis ulcerosa. Chirurg 84, 802–808 (2013). https://doi.org/10.1007/s00104-013-2552-6

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