Kernaussagen
Diagnostik: ERCP vs. MRCP
Bei der Sphinkter-Oddi-Dysfunktion wird die ERCP wegen häufiger Post-ERCP-Pankreatitiden als alleinige diagnostische Methode kontrovers diskutiert. Der Wert der nichtinvasiven MRCP mit Sekretin zur Selektion der Patienten für eine mögliche Manometrie ist viel versprechend, muss aber noch in größeren Studien belegt werden.
Die MRCP hat in der Diagnostik von Gallengangsteinen eine hohe Übereinstimmung mit der ERCP mit Sensitivitäten und Spezifitäten > 90 %. Abhängig von der Steingröße ist sie jedoch weniger zuverlässig als die ERCP.
Zur reinen Diagnostik von Gallengangstrikturen und iatrogenen Verletzungen ist der nichtinvasiven MRC der Vorzug zu geben, da somit bei hoher diagnostischer Genauigkeit der MRC die bekannten Risiken nach ERC minimiert werden.
Therapie
Bei Choledocholithiasis ist die endoskopische Sphinkterotomie und Steinextraktion in mehr als 90 % erfolgreich. Das Risiko der Post-ERCP-Pankreatitis ist nach Ballondilatation wesentlich höher als nach Sphinkterotomie.
Die Langzeitergebnisse der endoskopischen Therapie bei postoperativen Stenosen sind exzellent bei geringen Komplikationen. Gallengangleckagen am Ductus cysticus oder im Ductus choledochus lassen sich gut durch Sphinkterotomie und/oder Stentimplantation für 4 - 6 Wochen mit Erfolgsraten von 80 - 100 % therapieren.
Die Langzeiterfolge nach endoskopischem Stenting benigner distaler Gallengangstenosen bei Patienten mit chronischer Pankreatitis sind mit Re-Stenoseraten von bis zu 70 % schlecht.
Dominante Strikturen bei der PSC sprechen gut auf eine endoskopische Therapie mittels Ballondilatation und/oder kurzfristiger Stentimplantation an, wobei sich hierdurch der Zeitpunkt einer Lebertransplantation jedoch nicht verzögern lässt.
Bei malignen hilären Stenosen sollte das Vorgehen mittels MRCP festgelegt werden. Sind mehrere Segmente betroffen, sollten so viele wie möglich mittels nicht gecoverter Metallstents drainiert werden.
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Dr. med. Brigitte Schumacher
EVK Evangelisches Krankenhaus Düsseldorf
Kirchfeldstr. 40 · 40127 Düsseldorf
eMail: BrgSchumacher@aol.com
