Das inoperable Pankreaskarzinom – palliative interventionelle und chirurgische Therapie

Zusammenfassung

Das Pankreaskarzinom ist bei Diagnosestellung in der Mehrzahl der Fälle bereits nicht mehr kurativ resektabel, sodass palliative Therapiekonzepte bei diesen Patienten im Vordergrund stehen. Patienten ohne Fernmetastasen – aber mit grenzwertig resektablen bzw. lokal nicht resektablen Tumoren – sollten allerdings nicht primär palliativ therapiert, sondern in neoadjuvante Radiochemotherapie-Protokolle eingeschlossen werden. Nach abgeschlossener Therapie und Reevaluation ist eine potenziell kurative Resektion bei etwa einem Drittel dieser Patienten möglich. Im Rahmen bestmöglicher Palliation stellt auch die Metastasenresektion plus Primärtumorresektion in ausgewählten Fällen eine optionale Therapiemaßnahme dar. Bei definitiv lokal irresektablem oder fernmetastasiertem, fortgeschrittenem Pankreaskarzinom ist ein wesentlicher Bestandteil der Palliation die Therapie einer Gallengangs- und / oder Duodenalobstruktion. Sowohl endoskopische / perkutane Stentverfahren als auch operative Bypassanlagen sind sichere und mit hoher Erfolgsrate durchführbare Optionen. Bei operativer Anlage einer Gallengangsableitung wird die prophylaktische Anlage eines Magenbypasses (Doppelbypass) favorisiert. Die Entscheidung für ein operatives versus endoskopisches Verfahren zur Palliation hängt wesentlich vom Tumorbefund und der Prognoseabschätzung ab und muss interdisziplinär und individuell entschieden werden.

Abstract

In most cases pancreatic cancer appears in a non-curatively resectable stage at time the diagnosis is made. Thus, palliative treatment concepts come to the fore in these patients. Patients without metastases, but presenting with marginally resectable or locally non-resectable tumours should not be treated in a palliative therapeutic scheme. These patients should be enrolled in neoadjuvant radiochemotherapy trials. After finishing treatment and restaging, a potentially curative resection can be achieved in approximately one-third of these patients. Within the scope of the best possible palliative care, excision of metastases together with resection of the primary cancer represents a therapeutic option to be contemplated in selected cases. For distinct locally unresectable or metastasised advanced pancreatic cancer, treatment of bile duct or duodenal obstruction is an essential part of the comprehensive palliative therapy. However, both endoscopic / percutaneous stenting procedures and surgical bypass makeshifts constitute safe and highly effective therapeutic alternatives in this context. In the case of operative drainage of the biliary tract the prophylactic creation of a gastro-intestinal bypass (double bypass) is recommended. The decision on a surgical versus an endoscopic procedure for palliation depends considerably on the tumour stage and the estimated prognosis and has to be determined interdisciplinary and individually in each case.

Schlüsselwörter

Ikterus - neoadjuvante Chemotherapie - Pankreaskarzinom - palliative Pankreaschirurgie - Duodenalobstruktion - prophylaktische Gastroenterostomie

Key words

jaundice - neoadjuvant chemotherapy - pancreatic carcinoma - palliative pancreatic surgery - duodenal obstruction - prophylactic gastroenterostomy

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