Zusammenfassung
Fundamentale Veränderungen am Papillotom und an der Inzisionstechnik haben seit der
Einführung der Methode im Jahr 1973 nicht stattgefunden. Die Einführung eines Führungsdrahtes
hat jedoch die Anwendung des Papillotoms signifikant verbessert. Auch wurde der selektive
Zugang zum Gallengang und zum Pankreasgang durch eine Modifikation der Schneidetechnik
erleichtert. Wenn der selektive Zugang zum gestauten Gallengang zunächst nicht möglich
erscheint, der Pankreasgang jedoch sondiert werden kann, dann kann eine Inzision vom
Ductus Wirsungianus durch das Gewebe der Papille bis in den Gallengang durchgeführt
werden, ohne dass die Komplikationsrate bei diesem Vorgehen ansteigt. Das Nadelmesser
ist hilfreich, wenn eine enge Öffnung die selektive Einführung des Erlanger Papillotoms
in einen der Gänge nicht gestattet. Dies gelingt besonders leicht und risikoarm, wenn
die Papille vergrößert ist. Für eine Vielzahl von Erkrankungen von Papilla major et
minor, für Veränderungen des Gallen- und des Pankreasgangssystems stellt die endoskopische
Papillotomie eine maßgeschneiderte und minimalinvasive Therapie dar. Einige Fragen
sind zum gegenwärtigen Zeitpunkt nicht definitiv und für alle Patienten zu beantworten,
nämlich die Rolle der EPT bei akuter biliärer Pankreatitis und bei Sphinkter Oddi
Dyskinesie des Pankreassphinkters. Die Einführung eines dünnkalibrigen Stents in den
Pankreasgang nach EPT bei Risikopatienten verhindert die am meisten gefürchtete Komplikation,
nä mlich die akute biliäre Pankreatitis bei vielen, aber nicht bei allen Patienten.
Für diese und andere offene Fragestellungen werden weitere klinische Studien benötigt.
Abstract
Following the introduction of endoscopic papillotomy (EPT) in 1973 there have not
been any substantial modifications neither of the papillotome itself nor of the cutting
technique. Using the papillotome over a guidewire has greatly facilitated the procedure.
The guidewire also enables better selective cannulation of the common bile duct; should
this fail and the pancreatic duct be intubated, papillotomy in an upwards direction
via the pancreatic orifice until the biliary duct is reached has been shown to be
successful without an increase in complication rate. In case of failure of even pancreatic
duct cannulation, the needle knife is used to gain access to the pancreatobiliary
system, a successful and easy way especially in enlarged papillas. Endoscopic papillotomy
has established itself as a tailored and minimal-invasive treatment modality for a
variety of diseases of both papillae, as well as of the biliary tract and the pancreatic
duct. Still, some questions remain unanswered even at present, e. g. the role of sphincterotomy
in acute biliary pancreatitis and spincter Oddi dyskinesia of the pancreatic sphincter.
Placement of a small-caliber stent into the pancreatic duct after papillotomy in patients
at high risk of pancreatitis - the most feared complication of ERCP and papillotomy
- has been shown to reduce this complication. Further studies are needed to clarify
this and other open question.
Schlüsselwörter
Endoskopische Papillotomie - Sphinkterotomie - Pankreopathien, Erkrankungen des biliären
Systems
Key words
Endoscopic papillotomy - Sphincterectomy - pancreatic/hiliary disorders
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Prof. Dr. Drs. h. c. M. Classen
II. Medizinische Klinik und Poliklinik · Klinikum r. d. Isar · Technische Universität
München
Ismaninger Str. 22
81675 München
Phone: 0 89/41 40-22 57
Fax: 0 89/41 40-67 05
Email: meinhard.classen@lrz.tum.de
