Zusammenfassung
Die Entwicklung endoskopisch-interventioneller Verfahren hat in der Vergangenheit
die Therapie von Gallengangsstenosen unterschiedlicher Ätiologie maßgeblich beeinflusst.
Benigne Stenosen der Gallenwege entstehen vorwiegend nach operativen Eingriffen an
der Gallenblase oder Leber bzw. bei entzündlichen Erkrankungen. Bei 60 - 90 % der
Patienten führt die endoskopische Therapie mit Endoprothesen oder die Ballondilatation
zu einem klinisch befriedigenden Ergebnis mit adäquater Aufweitung der Engstelle.
Lediglich bei Strikturen infolge chronischer Pankreatitis ist es bisher nicht gelungen,
durch die endoskopische Therapie langfristig die Lokalsituation zu bessern. Bei malignem
Verschlussikterus ist die endoskopische Endoprotheseneinlage ein Grundpfeiler der
Therapie und bessert nachweislich nicht nur den Ikterus, sondern auch die Lebensqualität.
Mehrere Studien belegen die länger anhaltende Offenheit von Metallstents (SEMS) im
Vergleich zu konventionellen Endoprothesen. Unter wirtschaftlichen Aspekten ist ein
differenzierter Einsatz von SEMS notwendig, zumal viele Patienten mit malignem Verschlussikterus
aufgrund der limitierten Lebenserwartung versterben, bevor die erste Plastikprothese
okkludiert. Bei hilären Gallengangskarzinomen führt die Kombination aus photodynamischer
Therapie und Endoprotheseneinlage wahrscheinlich zu einem Überlebensvorteil. Mit antiproliferativen
Substanzen beschichtete oder bioresorbierbare Stents könnten in naher Zukunft zur
Optimierung der endoskopischen Behandlungsergebnisse führen.
Abstract
During the past years several endoscopic and interventional techniques have been developed
for the treatment of bile duct strictures and have had a strong impact on therapeutic
regimens. Benign stenoses of the bile duct are mainly caused by cholecystectomy or
liver resection or by inflammatory diseases. Insertion of an endoprosthesis insertion
or balloon dilation is clinically successful in 60 to 90 % of these patients and will
result in adequate opening of the stricture. To date, only bile duct stenosis in chronic
pancreatitis are not improved satisfactorily by endoscopy. The insertion of an endoprosthesis
is a cornerstone in the treatment of malignant obstructive jaundice in patients with
cancer. Several comparative studies have demonstrated the advantages of self-expanding
metal stents (SEMS) over plastic prostheses in terms of patency. A selective use of
SEMS is mandatory, as the costs for SEMS are high and many patients with malignant
jaundice will die with their first plastic prosthesis in situ without stent occlusion.
In patients with hilar cholangiocarcinoma, the combination of photodynamic therapy
and endoprosthesis insertion might result in a survival advantage. The use of bioabsorbable
stent materials or coating of the stent with antiproliferative drugs will improve
the treatment results in the future.
Schlüsselwörter
ERCP - PTCD - Stenose - Gallengang - Ballondilatation - photodynamische Therapie
Key words
ERCP - PTCD - stenosis - bile duct - balloon dilation - photodynamic therapy
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Priv.-Doz. Dr. med. Ralf Jakobs
Med. Klinik C, Klinikum der Stadt Ludwigshafen
Bremserstraße 79
67063 Ludwigshafen
Phone: 06 21/5 03-41 80
Fax: 06 21/5 03 41 12
Email: jakobsr@klilu.de