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.

• Literatur

• 1 Cotton PB, Durkalski V, Romagnuolo J et al. Effect of endoscopic sphincterotomy for suspected sphincter of Oddi dysfunction on pain-related disability following cholecystectomy: the EPISOD randomized clinical trial. Jama 2014; 311: 2101-2109
• 2 Cotton PB, Elta GH, Carter CR et al. Rome IV. Gallbladder and sphincter of Oddi disorders. Gastroenterology 2016; Feb 19 pii: S0016-5085(16)00224-9. DOI: 10.1053/j.gastro.2016.02.033. [Epub ahead of print]
• 3 Rehman A, Affronti J, Rao S. Sphincter of Oddi dysfunction: an evidence-based review. Expert Rev Gastroenterol Hepatol 2013; 7: 713-722
• 4 Suarez AL, Pauls Q, Durkalski-Mauldin V et al. Sphincter of Oddi manometry: reproducibility of measurements and effect of sphincterotomy in the EPISOD study. J Neurogastroenterol Motil 2016; 22: 477-482
• 5 Yaghoobi M, Pauls Q, Durkalski V et al. Incidence and predictors of post-ERCP pancreatitis in patients with suspected sphincter of Oddi dysfunction undergoing biliary or dual sphincterotomy: results from the EPISOD prospective multicenter randomized sham-controlled study. Endoscopy 2015; 47: 884-890
• 6 Pereira SP, Gillams A, Sgouros SN et al. Prospective comparison of secretin-stimulated magnetic resonance cholangiopancreatography with manometry in the diagnosis of sphincter of Oddi dysfunction types II and III. Gut 2007; 56: 809-813
• 7 Gurusamy KS, Giljaca V, Takwoingi Y et al. Endoscopic retrograde cholangiopancreatography versus intraoperative cholangiography for diagnosis of common bile duct stones. Cochrane Database Syst Rev 2015; 2: CD010339
• 8 Giljaca V, Gurusamy KS, Takwoingi Y et al. Endoscopic ultrasound versus magnetic resonance cholangiopancreatography for common bile duct stones. Cochrane Database Syst Rev 2015; 2: CD011549
• 9 Polistina FA, Frego M, Bisello M et al. Accuracy of magnetic resonance cholangiography compared to operative endoscopy in detecting biliary stones, a single center experience and review of literature. World J Radiol 2015; 7: 70-78
• 10 Dumonceau JM, Andriulli A, Elmunzer BJ et al. Prophylaxis of post-ERCP pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) Guideline – updated June 2014. Endoscopy 2014; 46: 799-815
• 11 Levenick JM, Gordon SR, Fadden LL et al. Rectal indomethacin does not prevent post-ERCP pancreatitis in consecutive patients. Gastroenterology 2016; 150: 911-917
• 12 Elmunzer BJ, Serrano J, Chak A et al. Rectal indomethacin alone versus indomethacin and prophylactic pancreatic stent placement for preventing pancreatitis after ERCP: study protocol for a randomized controlled trial. Trials 2016; 17: 120
• 13 Möller M, Gustafsson U, Rasmussen F et al. Natural course vs interventions to clear common bile duct stones: data from the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks). JAMA Surg 2014; 149: 1008-1013
• 14 Reinders JS, Goud A, Timmer R et al. Early laparoscopic cholecystectomy improves outcomes after endoscopic sphincterotomy for choledochocystolithiasis. Gastroenterology 2010; 138: 2315-2320
• 15 Iranmanesh P, Frossard JL, Mugnier-Konrad B et al. Initial cholecystectomy vs sequential common duct endoscopic assessment and subsequent cholecystectomy for suspected gallstone migration: a randomized clinical trial. Jama 2014; 312: 137-144
• 16 Lammert F et al. DGVS S3-Leitlinie Diagnostik und Therapie von Gallensteinen. (Veröffentlichung noch ausstehend) 2016
• 17 Chathadi KV, Chandrasekhara V, Acosta RD et al. for the ASGE Standards of Practice Committee. The role of ERCP in benign diseases of the biliary tract. . Gastrointest Endosc 2015; 81: 795-803
• 18 Ishiwatari H, Kawakami H, Hisai H et al. Balloon catheter versus basket catheter for endoscopic bile duct stone extraction: a multicenter randomized trial. Endoscopy 2016; 48: 350-357
• 19 Jin PP, Cheng JF, Liu D et al. Endoscopic papillary large balloon dilation vs endoscopic sphincterotomy for retrieval of common bile duct stones: a meta-analysis. World J Gastroenterol 2014; 20: 5548-5556
• 20 Yang XM, Hu B. Endoscopic sphincterotomy plus large-balloon dilation vs endoscopic sphincterotomy for choledocholithiasis: a meta-analysis. World J Gastroenterol 2013; 19: 9453-9460
• 21 Lai KH, Chan HH, Tsai TJ et al. Reappraisal of endoscopic papillary balloon dilation for the management of common bile duct stones. World J Gastrointest Endosc 2015; 7: 77-86
• 22 Bhandari S, Bathini R, Sharma A et al. Usefulness of single-operator cholangioscopy-guided laser lithotripsy in patients with Mirizzi syndrome and cystic duct stones: experience at a tertiary care center. Gastrointest Endosc 2016; 84: 56-61
• 23 Suthar M, Purohit S, Bhargav V et al. Role of MRCP in differentiation of benign and malignant causes of biliary obstruction. J Clin Diagn Res 2015; 9: TC08-12
• 24 Parashari UC, Khanduri S, Bhadury S et al. Diagnostic role of magnetic resonance cholangiopancreatography in evaluation of obstructive biliopathies and correlating it with final diagnosis and clinical profile of patients. J Nat Sci Biol Med 2015; 6: 131-138
• 25 Bilgin M, Toprak H, Burgazli M et al. Diagnostic value of dynamic contrast-enhanced magnetic resonance imaging in the evaluation of the biliary obstruction. Scientific World Journal 2012; 2012: 731089
• 26 Khan SA, Davidson BR, Goldin RD et al. Guidelines for the diagnosis and treatment of cholangiocarcinoma: an update. Gut 2012; 61: 1657-1669
• 27 Navaneethan U, Njei B, Lourdusamy V et al. Comparative effectiveness of biliary brush cytology and intraductal biopsy for detection of malignant biliary strictures: a systematic review and meta-analysis. Gastrointest Endosc 2015; 81: 168-176
• 28 Boberg KM, Lind GE. Primary sclerosing cholangitis and malignancy. Best Pract Res Clin Gastroenterol 2011; 25: 753-764
• 29 Navaneethan U, Hasan MK, Lourdusamy V et al. Single-operator cholangioscopy and targeted biopsies in the diagnosis of indeterminate biliary strictures: a systematic review. Gastrointest Endosc 2015; 82: 608-614 e2
• 30 Dave M, Elmunzer BJ, Dwamena BA et al. Primary sclerosing cholangitis: meta-analysis of diagnostic performance of MR cholangiopancreatography. Radiology 2010; 256: 387-396
• 31 Rudolph G, Gotthardt D, Klöters-Plachky P et al. Influence of dominant bile duct stenoses and biliary infections on outcome in primary sclerosing cholangitis. J Hepatol 2009; 51: 149-155
• 32 Chapman MH, Webster GJ, Bannoo S et al. Cholangiocarcinoma and dominant strictures in patients with primary sclerosing cholangitis: a 25-year single-centre experience. Eur J Gastroenterol Hepatol 2012; 24: 1051-1058
• 33 Gotthardt DN, Rudolph G, Klöters-Plachky P et al. Endoscopic dilation of dominant stenoses in primary sclerosing cholangitis: outcome after long-term treatment. Gastrointest Endosc 2010; 71: 527-534
• 34 Kaya M, Petersen BT, Angulo P et al. Balloon dilation compared to stenting of dominant strictures in primary sclerosing cholangitis. Am J Gastroenterol 2001; 96: 1059-1066
• 35 Chang JH, Lee I, Choi MG et al. Current diagnosis and treatment of benign biliary strictures after living donor liver transplantation. World J Gastroenterol 2016; 22: 1593-1606
• 36 Xu YB, Min ZG, Jiang HX et al. Diagnostic value of magnetic resonance cholangiopancreatography for biliary complications in orthotopic liver transplantation: a meta-analysis. Transplant Proc 2013; 45: 2341-2346
• 37 Kulaksiz H, Weiss KH, Gotthardt D et al. Is stenting necessary after balloon dilation of post-transplantation biliary strictures? Results of a prospective comparative study. Endoscopy 2008; 40: 746-751
• 38 Dumonceau JM, Tringali A, Blero D et al. Biliary stenting: indications, choice of stents and results: European Society of Gastrointestinal Endoscopy (ESGE) clinical guideline. Endoscopy 2012; 44: 277-298
• 39 Hsieh TH, Mekeel KL, Crowell MD et al. Endoscopic treatment of anastomotic biliary strictures after living donor liver transplantation: outcomes after maximal stent therapy. Gastrointest Endosc 2013; 77: 47-54
• 40 Verdonk RC, Buis CI, Porte RJ et al. Anastomotic biliary strictures after liver transplantation: causes and consequences. Liver Transpl 2006; 12: 726-735
• 41 Pasha SF, Harrison ME, Das A et al. Endoscopic treatment of anastomotic biliary strictures after deceased donor liver transplantation: outcomes after maximal stent therapy. Gastrointest Endosc 2007; 66: 44-51
• 42 Kao D, Zepeda-Gomez S, Tandon P et al. Managing the post-liver transplantation anastomotic biliary stricture: multiple plastic versus metal stents: a systematic review. Gastrointest Endosc 2013; 77: 679-691
• 43 Kaffes A, Griffin S, Vaughan R et al. A randomized trial of a fully covered self-expandable metallic stent versus plastic stents in anastomotic biliary strictures after liver transplantation. Therap Adv Gastroenterol 2014; 7: 64-71
• 44 Sauer P, Chahoud F, Gotthardt D et al. Temporary placement of fully covered self-expandable metal stents in biliary complications after liver transplantation. Endoscopy 2012; 44: 536-538
• 45 Rystedt J, Lindell G, Montgomery A. Bile duct injuries associated with 55,134 cholecystectomies: treatment and outcome from a national perspective. World J Surg 2016; 40: 73-80
• 46 Costamagna G, Tringali A, Mutignani M et al. Endotherapy of postoperative biliary strictures with multiple stents: results after more than 10 years of follow-up. Gastrointest Endosc 2010; 72: 551-557
• 47 Pozsar J, Sahin P, László F et al. Medium-term results of endoscopic treatment of common bile duct strictures in chronic calcifying pancreatitis with increasing numbers of stents. J Clin Gastroenterol 2004; 38: 118-123
• 48 Devière J, Nageshwar Reddy D, Püspök A et al. Successful management of benign biliary strictures with fully covered self-expanding metal stents. Gastroenterology 2014; 147: 385-95 ; quiz e15
• 49 Haapamäki C, Kylänpää L, Udd M et al. Randomized multicenter study of multiple plastic stents vs. covered self-expandable metallic stent in the treatment of biliary stricture in chronic pancreatitis. Endoscopy 2015; 47: 605-610
• 50 Coté GA, Slivka A, Tarnasky P et al. Effect of covered metallic stents compared with plastic stents on benign biliary stricture resolution: a randomized clinical trial. Jama 2016; 315: 1250-1257
• 51 Cieszanowski A, Stadnik A, Lezak A et al. Detection of active bile leak with Gd-EOB-DTPA enhanced MR cholangiography: comparison of 20–25 min delayed and 60–180 min delayed images. Eur J Radiol 2013; 82: 2176-2182
• 52 Dechêne A, Jochum C, Fingas C et al. Endoscopic management is the treatment of choice for bile leaks after liver resection. Gastrointest Endosc 2014; 80: 626-633 e1
• 53 Canena J, Liberato M, Meireles L et al. A non-randomized study in consecutive patients with postcholecystectomy refractory biliary leaks who were managed endoscopically with the use of multiple plastic stents or fully covered self-expandable metal stents (with videos). Gastrointest Endosc 2015; 82: 70-78
• 54 van der Gaag NA, Rauws EA, van Eijck CH et al. Preoperative biliary drainage for cancer of the head of the pancreas. N Engl J Med 2010; 362: 129-137
• 55 Fang Y, Gurusamy KS, Wang Q et al. Pre-operative biliary drainage for obstructive jaundice. Cochrane Database Syst Rev 2012; 9: CD005444
• 56 Tol JA, van Hooft JE, Timmer R et al. Metal or plastic stents for preoperative biliary drainage in resectable pancreatic cancer. Gut 2015; Aug 25 pii: gutjnl-2014-308762 [Epub ahead of print] DOI: 10.1136/gutjnl-2014-308762.
• 57 Wilcox VT, Huang AY, Tariq N et al. Endoscopic suture fixation of self-expanding metallic stents with and without submucosal injection. Surg Endosc 2015; 29: 24-29
• 58 Zorrón PuL, de Moura EG, Bernardo WM et al. Endoscopic stenting for inoperable malignant biliary obstruction: a systematic review and meta-analysis. World J Gastroenterol 2015; 21: 13374-13385
• 59 Kullman E, Frozanpor F, Söderlund C et al. Covered versus uncovered self-expandable nitinol stents in the palliative treatment of malignant distal biliary obstruction: results from a randomized, multicenter study. Gastrointest Endosc 2010; 72: 915-923
• 60 Li J, Li T, Sun P et al. Covered versus uncovered self-expandable metal stents for managing malignant distal biliary obstruction: a meta-analysis. PLoS One 2016; 11: e0149066
• 61 Soderlund C, Linder S, Bergenzaun PE et al. Nitinol versus steel partially covered self-expandable metal stent for malignant distal biliary obstruction: a randomized trial. Endoscopy 2014; 46: 941-948
• 62 Lee BS, Ryu JK, Jang DK et al. Reintervention for occluded metal stent in malignant bile duct obstruction: a prospective randomized trial comparing covered and uncovered metal stent. J Gastroenterol Hepatol 2016; [Epub ahead of print] DOI: 10.1111/jgh.13392.
• 63 Sawas T, Al Halabi S, Parsi MA et al. Self-expandable metal stents versus plastic stents for malignant biliary obstruction: a meta-analysis. Gastrointest Endosc 2015; 82: 256-267 e7
• 64 Inoue T, Naitoh I, Okumura F et al. Reintervention for stent occlusion after bilateral self-expandable metallic stent placement for malignant hilar biliary obstruction. Dig Endosc 2016; [Epub ahead of print] DOI: 10.1111/den.12657.
• 65 Walter T, Ho CS, Horgan AM et al. Endoscopic or percutaneous biliary drainage for Klatskin tumors?. J Vasc Interv Radiol 2013; 24: 113-121
• 66 Wiggers JK, Coelen RJ, Rauws EA et al. Preoperative endoscopic versus percutaneous transhepatic biliary drainage in potentially resectable perihilar cholangiocarcinoma (DRAINAGE trial): design and rationale of a randomized controlled trial. BMC Gastroenterol 2015; 15: 20
• 67 Inamdar S, Slattery E, Bhalla R et al. Comparison of adverse events for endoscopic vs percutaneous biliary drainage in the treatment of malignant biliary tract obstruction in an inpatient national cohort. JAMA Oncol 2016; 2: 112-117
• 68 Vienne A, Hobeika E, Gouya H et al. Prediction of drainage effectiveness during endoscopic stenting of malignant hilar strictures: the role of liver volume assessment. Gastrointest Endoscopy 2010; 72: 728-735
• 69 Li M, Wu W, Yin Z et al. [Unilateral versus bilateral biliary drainage for malignant hilar obstruction: a systematic review and meta-analysis]. Zhonghua Gan Zang Bing Za Zhi 2015; 23: 118-123