Endosonografisch gestützteTherapie der Cholangiolithiasis bei chirurgisch veränderter Anatomie – eine monozentrische Fallstudie

Zusammenfassung

Ziel Untersuchung von Machbarkeit und Outcome EUS-gestützter Steinextraktionstechniken über einen transhepatischen Zugang bei Patienten mit postoperativ modifizierter Anatomie.

Material/Methoden Alle konsekutiven Patienten (Pat.) mit Cholangiolithiasis und operativ veränderter Anatomie nach ggf. frustranem ERC-Versuch wurden in diese monozentrische Fallstudie eingeschlossen und bzgl. des technischen/klinischen Erfolgs charakterisiert.

Ergebnisse Von 2004 bis 03/2020 wurden bei 449 Pat. EUS-gestützte Gallenwegdrainagen durchgeführt (n = 37 Pat. mit Cholangiolithiasis). Bei 8 der 37 Pat. erfolgte die Steinextraktion in EUS-ERCP-Rendezvoustechnik (kein Bestandteil der Studie, da keine operativ veränderte Anatomie vorlag). Bei 13 der verbleibenden 29 Pat. (45 %) wurden im Vorfeld frustrane Versuche der ballonenteroskopischen ERCP bei fehlender Erreichbarkeit der Papilla Vateri bzw. der biliodigestiven Anastomose unternommen. Der EUS-gestützte Zugang zu den Gallenwegen gelang bei allen 29 Pat. Die Steinextraktion erfolgte bei 26 Pat. (90 %) in antegrader Push-Technik nach vorheriger Ballondilatation der Papilla Vateri beziehungsweise der biliodigestiven Anastomose. Bei 11 Pat. (42 %) erfolgte nachfolgend zur Schienung der Papilla Vateri/biliodigestiven Anastomose die Einlage einer Doppelpigtailprothese („Ringdrainage“), die in der Regel nach 3 Monaten nach vorheriger sonografischer und laborchemischer Kontrolle mittels Gastroskopie wieder entfernt wurde. Bei 2 Pat. (7 %) erfolgte die Steinextraktion retrograd über den transhepatischen Zugang, bei 1 Pat. (3 %) wurde die Steinextraktion kombiniert in antegrader und retrograder Technik vorgenommen. Bei 2 Pat. (7 %) kam eine Cholangioskopie mit elektrohydraulischer Lithotripsie zum Einsatz.

Die technische und klinische Erfolgsrate der Steinextraktion lag bei 100 % (29 von 29 Pat.). Re-Interventionen erfolgten bei 6 Pat. (21 %), Komplikationen traten bei 6 Pat. (21 %) auf.

Schlussfolgerung Die EUS-gestützte Steinextraktion in antegrader oder retrograder Technik bei Patienten mit operativ veränderter Anatomie ist eine sichere, wenn auch technisch anspruchsvolle Methode der interventionellen Endoskopie/EUS. Sie hat eine hohe technische und klinische Erfolgsrate und eine niedrige Komplikationsrate. Sie hat das Potenzial, die zeitaufwendige ERCP mit Ballon-Enteroskopen und v. a. auch die PTCD und somit sekundäre und tertiäre Therapiealternativen zu ersetzen.

Abstract

Aim To investigate feasibility and outcome the novel and favorable option of an endoscopic ultrasonography(EUS)-guided antegrade or even retrograde gall stone extraction via a transhepatic route in patients (pats.) with no option for the usual gold standard, ERCP.

Material/methods All consecutive pats. with cholangiolithiasis and surgically altered anatomy of the upper GI tract with and without previous attempts of an ERCP were enrolled in this unicenter case study and were characterized with regard to the technical and clinical success of this approach.

Results From 2004 to 03/2020, overall 449 pats. underwent EUS-guided cholangiodrainage (n = 37 pats. with cholangiolithiasis). In 8 of these 37 pats., gall stone extraction was achieved using EUS-ERCP rendezvous technique (not included in the study since there was no surgically altered anatomy of the upper GI tract). In 13 of the remaining 29 subjects (45 %), there was a failure of previous attempts to reach the papilla of Vater or biliodigestive anastomosis using balloon-enteroscopy-guided ERCP. EUS-guided access to the biliary system was achieved in all 29 pats. Stone extraction was performed in 26 individuals (90 %) by means of antegrade push-technique after balloon dilatation of the papilla of Vater and biliodigestive anastomosis, respectively, before. In 11/29 cases (42 %), double pigtail prostheses were subsequently placed to track papilla of Vater/biliodigestive anastomosis (“ring drainage”), which were removed with gastroscopy three months later after previous ultrasound- and lab parameter-based follow-up control. In two pats. (7 %), gall stones were extracted via a retrograde route using a transhepatic access site; in one patient (3 %), stones were removed by means of a combined ante-/retrograde technique. In two subjects (7 %), cholangioscopy with electrohydraulic lithotripsy was used.

Technical as well as clinical success rate was 100 % (29 of 29 pats.). Re-interventions became necessary in 6/29 cases (21 %), complications occurred in 6 individuals (21 %).

Conclusion EUS-guided stone extraction in antegrade or retrograde technique for pats. with surgically altered anatomy of the upper GI tract can be considered a favorable and safe but challenging approach of interventional endoscopy/EUS. It can provide high technical and clinical success and low complication rates; it has the potential to substitute the time-consuming balloon-enteroscopy-guided ERCP as well as, in particular, PTCD and, thus, secundary and tertiary therapeutic alternatives.

Schlüsselwörter

Cholangiolithiasis - EUS-geführte Gallensteinextraktion/Cholangiodrainage - unizentrische Studie - technischer/klinischer Erfolg - postinterventionelles Outcome

Key words

Cholangiolithiasis - EUS-guided gall stone extraction/cholangiodrainage - unicenter study - technical/clinical success - postinterventional outcome

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