Skip to main content
SpringerLink
Log in

Herausforderungen bei der chirurgischen Therapie der Crohn-Krankheit des Dünndarms

Challenges in the surgical treatment of Crohn’s disease of the small bowel

  • Leitthema
  • Published:
coloproctology Aims and scope

Zusammenfassung

Die chirurgische Behandlung des Morbus Crohn kann bei Befall des Dünndarms herausfordernd sein. Beim häufigen Fall des isolierten, distalen Ileumbefalls ist eine frühzeitige Operation eine gute Option. Die Indikation zur Operation bei Fisteln, Abszessen und Stenosen hängt von der Klinik, der Lage des Befunds und auch davon ab, ob die konservative Therapie erfolgreich ist. Bei Warnzeichen (prästenotische Dilatation, Gewichtsabnahme, Änderung der Essgewohnheiten) sollte in der Regel operiert werden. Bei multisegmentalem Befall werden darmschonende Techniken (kurzstreckige Resektion, Strikturoplastiken) eingesetzt. Inwiefern geänderte Operationstechniken (radikale Mesenteriumresektion, Kono-S-Anastomose) einen Vorteil bringen, werden laufende Studien zeigen müssen. Eine interdisziplinäre Absprache ist essenziell, um zeitgerecht die Operationsindikation zu finden und den Patienten präoperativ adäquat hinsichtlich der bekannten Risikofaktoren vorzubereiten.

Abstract

The surgery of Crohn’s disease with involvement of the small bowel can be challenging. In the frequent case of isolated involvement of the distal ileum early surgery is a good option. The indications for surgery of fistulas, abscesses and stenoses depend on the clinical presentation, the location of the findings and also whether conservative treatment is successful. In the case of red flags (prestenotic dilatation, loss of weight, change of eating habits) surgery should normally be performed. In cases of multisegmental involvement bowel-preserving techniques are used (short segment resection, strictureplasty). Whether modified surgical techniques (radical mesenterial resection, Kono‑S anastomosis) will improve outcomes must be shown in ongoing studies. Interdisciplinary cooperation is essential to guarantee timely indications for surgery and to adequately preoperatively prepare patients with respect to the known risk factors.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Abb. 1
Abb. 2
Abb. 3
Abb. 4
Abb. 5
Abb. 6
Abb. 7
Abb. 8
Abb. 9
Abb. 10

Literatur

  1. Tsai L, Ma C, Dulai PS et al (2021) Contemporary risk of surgery in patients with ulcerative colitis and Crohn’s disease: a meta-analysis of population-based cohorts. Clin Gastroenterol Hepatol 19:2031–2045.e11

    Article  PubMed  Google Scholar 

  2. Vadstrup K, Alulis S, Borsi A et al (2020) Intestinal surgery rates in ulcerative colitis and Crohn’s disease in the era of biologics: a Danish nationwide register study from 2003 to 2016. J Crohns Colitis 14:S116–S117

    Article  Google Scholar 

  3. Stöss C, Berlet M, Reischl S et al (2021) Crohn’s disease: a population-based study of surgery in the age of biological therapy. Int J Colorectal Dis 36:2419–2426

    Article  PubMed  PubMed Central  Google Scholar 

  4. Sturm A, Atreya R, Bettenworth D et al (2022) Aktualisierte S3-Leitlinie „Diagnostik und Therapie des Morbus Crohn “der Deutschen Gesellschaft für Gastroenterologie, Verdauungs-und Stoffwechselkrankheiten (DGVS)–August 2021–AWMF-Registernummer: 021-004. Z Gastroenterol 60:332–418

    Article  PubMed  Google Scholar 

  5. Bemelman WA, Warusavitarne J, Sampietro GM et al (2017) ECCO-ESCP consensus on surgery for Crohn’s disease. J Crohns Colitis 12:1–16

    Google Scholar 

  6. Eshuis EJ, Bemelman WA, Van Bodegraven AA et al (2008) Laparoscopic ileocolic resection versus infliximab treatment of distal ileitis in Crohn’s disease: a randomized multicenter trial (LIR! C‑trial). BMC Surg 8:1–8

    Article  Google Scholar 

  7. Stevens TW, Haasnoot ML, D’haens GR et al (2020) Laparoscopic ileocaecal resection versus infliximab for terminal ileitis in Crohn’s disease: retrospective long-term follow-up of the LIR!C trial. Lancet Gastroenterol Hepatol 5:900–907

    Article  PubMed  Google Scholar 

  8. Nakase H, Esaki M, Hirai F et al (2023) Treatment escalation and de-escalation decisions in Crohn’s disease: Delphi consensus recommendations from Japan, 2021. J Gastroenterol 58:313–345

    Article  PubMed  PubMed Central  Google Scholar 

  9. Bettenworth D, Bokemeyer A, Baker M et al (2019) Assessment of Crohn’s disease-associated small bowel strictures and fibrosis on cross-sectional imaging: a systematic review. Gut 68:1115–1126

    Article  CAS  PubMed  Google Scholar 

  10. Aksan A, Farrag K, Blumenstein I et al (2021) Chronic intestinal failure and short bowel syndrome in Crohn’s disease. World J Gastroenterol 27:3440

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  11. Iesalnieks I, Kilger A, Glaß H et al (2010) Perforating Crohn’s ileitis: delay of surgery is associated with inferior postoperative outcome. Inflamm Bowel Dis 16:2125–2130

    Article  PubMed  Google Scholar 

  12. Garcia JC, Persky SE, Bonis PA et al (2001) Abscesses in Crohn’s disease: outcome of medical versus surgical treatment. J Clin Gastroenterol 32:409–412

    Article  CAS  PubMed  Google Scholar 

  13. Pineton De Chambrun G, Pariente B, Seksik P et al (2019) Adalimumab for patients with Crohn’s disease complicated by intra-abdominal abscess: a multicentre, prospective, observational cohort study. J Crohns Colitis 13:S616

    Article  CAS  PubMed  Google Scholar 

  14. Ewe K, Herfarth C, Malchow H et al (1989) Postoperative recurrence of Crohn’s disease in relation to radicality of operation and sulfasalazine prophylaxis: a multicenter trial. Digestion 42:224–232

    Article  CAS  PubMed  Google Scholar 

  15. Coffey CJ, Kiernan MG, Sahebally SM et al (2018) Inclusion of the mesentery in ileocolic resection for Crohn’s disease is associated with reduced surgical recurrence. J Crohns Colitis 12:1139–1150

    Article  PubMed  PubMed Central  Google Scholar 

  16. Van Der Does De Willebois E, Cj SSGBWB (2022) Mesenteric SParIng versus extensive mesentereCtomY in primary ileocolic resection for ileocaecal Crohn’s disease (SPICY): study protocol for randomized controlled trial. BJS Open 6:zrab136

    Article  Google Scholar 

  17. Yzet C, Riault C, Brazier F et al (2023) Positive margins and plexitis increase the risk of recurrence after ileocecal resection: a systematic review and meta-analysis. Dig Liver Dis. https://doi.org/10.1016/j.dld.2022.12.021

    Article  PubMed  Google Scholar 

  18. Bislenghi G, Fieuws S, Wolthuis A et al (2021) Positioning strictureplasty in the treatment of extensive Crohn’s disease ileitis: a comparative study with ileocecal resection. Int J Colorectal Dis 36:791–799

    Article  PubMed  Google Scholar 

  19. Dragoni G, Allocca M, Myrelid P et al (2023) Results of the Eighth Scientific Workshop of ECCO: diagnosing postoperative recurrence of Crohn’s disease after an ileocolonic resection with ileocolonic anastomosis. J Crohns Colitis. https://doi.org/10.1093/ecco-jcc/jjad055

    Article  Google Scholar 

  20. Kono T, Ashida T, Ebisawa Y et al (2011) A new antimesenteric functional end-to-end handsewn anastomosis: surgical prevention of anastomotic recurrence in Crohn’s disease. Dis Colon Rectum 54:586–592

    Article  PubMed  Google Scholar 

  21. Luglio G, Rispo A, Imperatore N et al (2020) Surgical prevention of anastomotic recurrence by excluding mesentery in Crohn’s disease: the SuPREMe-CD study‑a randomized clinical trial. Ann Surg 272:210–217

    Article  PubMed  Google Scholar 

  22. Kienle P (2020) The SuPREMe-CD study: a randomized clinical trial to evaluate anastomotic recurrence by excluding mesentery in Crohn’s disease. coloproctology 42:421–422

    Article  Google Scholar 

  23. Alibert L, Betton L, Falcoz A et al (2023) Does KONO‑S anastomosis reduce recurrence in Crohn’s disease compared to conventional ileocolonic anastomosis? A nationwide propensity score-matched study from GETAID Chirurgie Group (KoCoRICCO study). J Crohns Colitis 17:i155–i155

    Article  Google Scholar 

  24. Clinicaltrials.Gov Study of the Kono‑S anastomosis versus the side-to-side functional end anastomosis (NCT03256240). https://clinicaltrials.gov/ct2/show/NCT03256240?recrs=ab&cond=Crohn+Disease&cntry=US&state=US%3ANY&draw=4&rank=25#contacts. Zugegriffen: 15. März 2023

  25. Butt WT, Ryan ÉJ, Boland MR et al (2020) Strictureplasty versus bowel resection for the surgical management of fibrostenotic Crohn’s disease: a systematic review and meta-analysis. Int J Colorectal Dis 35:705–717

    Article  PubMed  Google Scholar 

  26. Iesalnieks I (2020) Strikturoplastik versus Darmresektion bei Crohn-Stenosen. coloproctology 42:353–354

    Article  Google Scholar 

  27. Cohen BL, Fleshner P, Kane SV et al (2022) Prospective cohort study to investigate the safety of preoperative tumor necrosis factor inhibitor exposure in patients with inflammatory bowel disease undergoing intra-abdominal surgery. Gastroenterology 163:204–221

    Article  CAS  PubMed  Google Scholar 

  28. Shim HH, Ma C, Kotze PG et al (2018) Preoperative ustekinumab treatment is not associated with increased postoperative complications in Crohn’s disease: a Canadian multi-centre observational cohort study. J Can Assoc Gastroenterol 1:115–123

    Article  PubMed  PubMed Central  Google Scholar 

  29. Cira K, Weber M‑C, Wilhelm D et al (2022) The effect of anti-tumor necrosis factor-Alpha therapy within 12 weeks prior to surgery on postoperative complications in inflammatory bowel disease: a systematic review and meta-analysis. J Clin Med 11:6884

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  30. Reber E, Gomes F, Vasiloglou MF et al (2019) Nutritional risk screening and assessment. J Clin Med 8:1065

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  31. Galata C, Weiss C, Hardt J et al (2018) Risk factors for early postoperative complications and length of hospital stay in ileocecal resection and right hemicolectomy for Crohn’s disease: a single-center experience. Int J Colorectal Dis 33:937–945

    Article  PubMed  Google Scholar 

  32. Huang W, Tang Y, Nong L et al (2015) Risk factors for postoperative intra-abdominal septic complications after surgery in Crohn’s disease: a meta-analysis of observational studies. J Crohns Colitis 9:293–301

    Article  PubMed  Google Scholar 

  33. Grass F, Pache B, Martin D et al (2017) Preoperative nutritional conditioning of Crohn’s patients—Systematic review of current evidence and practice. Nutrients 9:562

    Article  PubMed  PubMed Central  Google Scholar 

  34. Reindl W, Thomann AK, Galata C et al (2019) Reducing perioperative risks of surgery in Crohn’s disease. Visc Med 35:348–354

    Article  PubMed  PubMed Central  Google Scholar 

  35. Reinshagen M (2020) Klinik des Morbus Crohn. Chronisch-entzündliche Darmerkrankungen. In: Klinik und Praxis, S 73–85

    Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Allgemein- und Viszeralchirurgie, Theresienkrankenhaus, Bassermannstraße 1, 68165, Mannheim, Deutschland

    Gerrit Arlt &  Peter Kienle

Authors
  1. Gerrit Arlt
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Peter Kienle
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Peter Kienle.

Ethics declarations

Interessenkonflikt

G. Arlt und P. Kienle geben an, dass kein Interessenkonflikt besteht.

Für diesen Beitrag wurden von den Autor/-innen keine Studien an Menschen oder Tieren durchgeführt. Für die aufgeführten Studien gelten die jeweils dort angegebenen ethischen Richtlinien.

Additional information

figure qr

QR-Code scannen & Beitrag online lesen

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Arlt, G., Kienle, P. Herausforderungen bei der chirurgischen Therapie der Crohn-Krankheit des Dünndarms. coloproctology 45, 277–284 (2023). https://doi.org/10.1007/s00053-023-00730-4

Download citation

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00053-023-00730-4

Schlüsselwörter

Keywords

Search

Navigation