Diagnostik und Therapie von Gallenwegerkrankungen: ERCP und MRCP – Update

Kernaussagen

Sphinkter-Oddi-Dysfunktion

• Der Begriff der Sphinkter-Oddi-Dysfunktion (SOD) sollte zugunsten des Terminus „Funktionelle biliäre Sphinkter-Oddi-Erkrankung“ (ehemals SOD Typ II) verlassen werden. Ein kausaler Zusammenhang der Typen SOD I und III mit einer Dysfunktion des Sphinkter Oddi im eigentlichen Sinne scheint unwahrscheinlich. Die Indikation zur diagnostischen (Manometrie) und therapeutischen (Sphinkterotomie) ERCP sollte bei den verbleibenden Patienten wegen hoher Komplikations- und fragwürdiger Ansprechraten sehr streng gestellt werden. Die MRCP hat dabei nur eine untergeordnete diagnostische Bedeutung.

ERCP und MRCP

• Der Nutzen der aktuell üblichen Praxis einer universellen Post-ERCP-Pankreatitis-Prophylaxe mit NSAR (meist Indometacin supp.) muss zumindest in einem Niedrig-Risiko-Kollektiv infrage gestellt werden. Andere, zumindest ebenso gut validierte Maßnahmen zur Risikoreduktion sollten bedacht werden, insbesondere eine gewissenhafte Patientenselektion.

• Die MRCP hat als nicht invasives und hochsensitives Verfahren insbesondere bei Patienten mit intermediärem Risiko einer Choledocholithiasis einen hohen Stellenwert im Rahmen der Risikostratifizierung. Bei negativem Steinnachweis kann in der Regel auf eine ERCP verzichtet werden.

• Mittels ERC und verschiedener endoskopischer Techniken (Sphinkterotomie, Ballondilatation, Lithotripsie etc.) gelingt auch bei großen und/oder impaktierten Konkrementen in nahezu 100 % der Fälle die Steinextraktion.

• Bei benignen Läsionen der Gallenwege ist die MRCP diagnostisches Mittel der Wahl. Insbesondere bei der PSC und bei Gallengangleckagen liefert sie wichtige Informationen, die für die Planung einer Intervention entscheidend sein können.

Therapie benigner Strikturen und Leckagen

• Bei der primär sklerosierenden Cholangitis (PSC) sprechen dominante Strikturen gut auf die wiederholte Ballondilatation an. Eine Verbesserung der Prognose konnte bisher jedoch nur in theoretischen Modellen gezeigt werden. Fast alle cholangiozellulären Karzinome entstehen dabei bei Patienten mit dominanten Strikturen, weshalb diese Gruppe engmaschig überwacht werden sollte.

• Die Langzeitprognose postoperativer Gallengangstrikturen ist unter der endoskopischen Therapie mit wiederholter Ballondilatation und Implantation multipler Plastikstents über 12 Monate exzellent. Auch postoperative Gangleckagen des Ductus choledochus oder Ductus cysticus lassen sich durch das kurzfristige Stenting oder den Einsatz von gecoverten Metallstents gut behandeln.

• Bei distalen Gallengangstenosen im Rahmen einer chronischen Pankreatitis ist die endoskopische Therapie mit vollgecoverten Metallstents der Behandlung mit multiplen Plastikstents wegen geringerer Interventionsraten sowie schnellerer und effektiverer Stenosenauflösung überlegen. Eine Reduktion der Rezidivrate konnte bisher nicht nachgewiesen werden.

Therapie maligner Strikturen

• Das präoperative Stenting von Patienten mit Pankreaskopfkarzinom wirkt sich negativ auf das Outcome aus und sollte daher möglichst unterlassen werden. In der Palliation bleiben dagegen ungecoverte Metallstents Therapie der Wahl. Vollgecoverte Modelle bieten hier keine Vorteile.

• Bei hilären Strikturen sollte das optimale Vorgehen wegen der oft schwierigen und komplikationsreichen endoskopischen Therapie mittels MRCP geplant werden. Meist ist die multisegmentale Drainage mittels ungecoverter Metallstents notwendig.

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