Interventionelle Endoskopie bei benignen und malignen Gallengangsstenosen

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

Literatur

• 1 Weickert U, Jakobs R, Riemann J F. Diagnostik des Gallenwegskarzinoms.  Internist. 2004;  45 42-48
• 2 Classen M, Demling L. Endoskopische Sphinkterotomie der Papilla Vateri und Steinextraktion aus dem Ductus Choledochus.  Dtsch Med Wschr. 1974;  99 496-497
• 3 Soehendra N, Reynders-Frederix V. Palliative Gallengangsdrainage, eine neue Methode zur endoskopischen Einführung eines inneren Drains.  Dtsch Med Wschr. 1979;  104 206-207
• 4 Dezirel D J, Milikan K W, Econoumou S G. et al . Complications of laparoscopic cholecystectomy: a national survey of 4292 hospitals and an analysis of 77,604 cases.  Am J Surg. 1993;  165 9-14
• 5 Hasegawa K, Yazumi S, Egawa H. et al . Endosopic management of postoperative biliary compliactions in donors for living donor transplantation.  Clin Gastroenterol Hepatol. 2003;  1 183-188
• 6 Jakobs R, Riemann J F. The role of endoscopy in acute recurrent and chronic pancreatitis and pancreatic cancer.  Gastroenterology Clinics of North America. 1999;  28 783-800
• 7 Hintze R E, Abou-Rebyeh H, Adler A. et al . Endoscopic therapy of ischemia-type biliary lesions in patients following liver transplantation.  Z Gastroenterol. 1999;  37 13-20
• 8 Johnson G K, Geenen J E, Venu R P. et al . Endoscopic treatment of biliary strictures in sclerosing cholangitis: a larger series and recommendations for treatment.  Gastrointest Endosc. 1991;  37 38-43
• 9 Escare J J, Shea J a, Chen W. et al . Outcomes of open cholecystectomy in the elderly: A longitudinal analysis of 21 000 cases in the prelaparoscopic era.  Surgery. 1995;  117 156-164
• 10 Chapman W C, Halevy A, Blumgart L H. et al . Postcholecystectomy bile duct strictures. Management and outcome in 130 patients.  Arch Surg. 1995;  130 597-602
• 11 Bergman J J, Burgemeister L, Bruno M J. et al . Long-term follow-up after biliary stent placement for postoperative bile duct stenosis.  Gastrointest Endosc. 2001;  54 154-161
• 12 Costamagna C, Pandolfi M, Mutignani M. et al . Long-term results of endoscopic management of postoperative bile duct strictures with increasing number of stents.  Gastrointest Endosc. 2001;  54 162-168
• 13 De Palma G D, Galloro G, Romano G. et al . Long-term follow-up after endoscopic biliary stent placement for bile duct strictures from laparoscopic cholecystectomy.  Hepatogastroenterology. 2003;  50 1229-1231
• 14 Maier M, Schilling D, Kohler B. et al . Endoskopische Therapie benigner Gallengangsstenosen: eigene Erfahrungen bei 24 Patienten.  Chir Gastroenterol. 1993;  9 142-148
• 15 Draganov P, Hoffman B, Marsh W. et al . Long-term outcome in patients with benign biliary strictures treated endoscopically with multiple stents.  Gastrointest Endosc. 2002;  55 680-686
• 16 Misra S, Melton G B, Geschwind J F. et al . Percutaneous management of bile duct strictures and injuries associated with laparoscopic cholecystectomy: a decade of experience.  J Am Coll Surg. 2004;  198 218-226
• 17 Schumacher B, Othman T, Jansen M. et al . Long-term follow-up of percutaneous transhepatic therapy (PTT) in patients with definite benign anastomotic strictures after hepaticojejunostomy.  Endoscopy. 2001;  33 409-415
• 18 Born P, Rösch T, Brühl K. et al . Long-term results of endoscopic and percutaneous transhepatic treatment of benign biliary strictures.  Endoscopy. 1999;  31 725-731
• 19 Davids H, Tanka A K, Rau E A. et al . Benign biliary strictures - surgery or endoscopy.  Ann Surg. 1993;  217 237-243
• 20 Kiehne K, Fölsch U R, Nitsche R. High complication rate of bile duct stents in patients with chronic alcoholic pancreatitis due to noncompliance.  Endoscopy. 2000;  32 377-380
• 21 Barthet M, Bernard J P, Duval J L. et al . Biliary stenting in benign biliary stenosis complicationg chronic calcifying pancreatitis.  Endoscopy. 1994;  26 569-572
• 22 Smits M E, Rauws E AJ, van Gulik T M. et al . Long-term results of endoscopic stenting and surgical drainage for biliary stricture due to chronic pancreatitis.  Br J Surg. 1996;  83 764-768
• 23 Farnbacher M J, Rabenstein T, Ell C. et al . Is endoscopic drainage of common bile duct stenoses in chronic pancreatitis up-to-date?.  Am J Gastroenterol. 2000;  95 1466-1471
• 24 Eickhoff A, Jakobs R, Leonhardt A. et al . Endoscopic stenting for common bile duct stenoses in chronic pancreatitis: results and impact on long-term outcome.  Eur J Gastroenterol Hepatol. 2001;  13 1161-1167
• 25 Kahl S, Zimmermann S, Genz I. et al . Risk factors for failure of endoscopic stenting of biliary strictures in chronic pancreatitis: a prospective follow-up study.  Am J Gastroenterol. 2003;  98 2448-2453
• 26 Pozsar J, Sahin P, Laszlo 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
• 27 Deviere J, Cremer M, Baize M. et al . Management of common bile duct stricture caused by chronic pancreatitis with metal mesh self expandable stents.  Gut. 1994;  35 122-126
• 28 Kahl S, Zimmermann S, Glasbrenner B. et al . Treatment of benign biliary strictures in chronic pancreatitis by self-expandable metal stents.  Dig Dis. 2002;  20 199-203
• 29 van Berkel A M, Cahen D L, van Westerloo D J. et al . Self-expanding metal stents in benign biliary strictures due to chronic pancreatitis.  Endoscopy. 2004;  36 381-384
• 30 Eickhoff A, Jakobs R, Leonhardt A. et al . Self-expandable metal mesh stents for common bile duct stenosis: retrospective evaluation of long-term follow-up and clinical outcome of a pilot study.  Z Gastroenterol. 2003;  41 649-654
• 31 Wadhwa R P, Kozarek R A, France R E. et al . Use of self-expandable metallic stents in benign GI diseases.  Gastrointest Endosc. 2003;  58 207-212
• 32 Baluyut A R, Sherman S, Lehman G A. et al . Impact of endoscopic therapy on the survival of patients with primary sclerosing cholangitis.  Gastrointest Endosc. 2001;  53 308-312
• 33 Stiehl A, Rudolph G, Sauer P. et al . Efficacy of ursodeoxycholic acid treatment and endoscopic dilation of major duct stenoses in primary sclerosing cholangitis.  J Hepatol. 1997;  26 560-566
• 34 Ahrendt S A, Pitt H A, Kaloo A N. et al . Primary sclerosing cholangitis: Resect, dilate, or transplant?.  Ann Surg. 1998;  227 412-423
• 35 Ponsioen C Y, Lam K, de van Milligen Wit A WN. et al . Four years experience with short term stenting in primary sclerosing cholangitis.  Am J Gastroenterol. 1999;  94 2403-2407
• 36 van den Hazel S J, Wolfhagen E H, van Buuren H R. et al . Prospective risk assessment of endoscopic retrograde cholangiography in patients with primary sclerosing cholangitis. Dutch PSC Study Group.  Endoscopy. 2000;  32 779-782
• 37 de van Milligen Wit A WM, van Bracht J, Rauws E AJ. et al . Endoscopic stent therapy for dominant extrahepatic bile duct strictures in primary sclerosing cholangitis.  Gastrointest Endosc. 1996;  44 293-296
• 38 Kaya M, Petersen B T, Angulo P. et al . Balloon dilation compared to stenting of dominant strictures in primary sclerosing cholangitis.  Am J Gastroenterol. 2001;  96 1059-1066
• 39 Abraham N S, Barkun J S, Barkun A N. Palliation of malignant biliary obstruction: a prospective trial examining impact on quality of life.  Gastrointest Endosc. 2002;  56 835-841
• 40 Pereira-Lima J C, Jakobs R, Maier M. et al . Endoscopic stenting in obstructive jaundice due to liver metastases: Does it have a benefit for the patient?.  Hepato-Gastroenterol. 1996;  43 944-948
• 41 Saleh M M, Norregaard P, Jorgensen H L. et al . Preoperative endoscopic stent placement before pancreaticoduodenectomy: a meta-analysis of the effect on morbidity and mortality.  Gastrointest Endosc. 2002;  56 529-534
• 42 Smith A C, Dowsett J F, Russell R CG. et al . Randomized trial of surgery versus endoscopic stenting in malignant low bile duct obstruction.  Lancet. 1994;  344 1655-1660
• 43 Pereira-Lima J C, Jakobs R, Maier M. et al . Endoscopic biliary stenting for the palliation of pancreatic carcinoma: results, survival predictive factors and comparison of 10-French with 11,5-French gauge stents.  Am J Gastroenterol. 1996;  91 1-6
• 44 Wenderoth D F, Ferslev B, Macarri G. et al . Leitbakteria of microbial biofilm communities causing occlusion of biliary stents.  Environ Microbiol. 2003;  5 859-866
• 45 Zhang H, Tsang T K, Jack C A. et al . Role of bile mucin in bacterial adherence to biliary stents.  J Lab Clin Med. 2002;  139 28-34
• 46 Weickert U, Venzke T, Konig J. et al . Why do bilioduodenal plastic stents become occluded? A clinical and pathological investigation on 100 consecutive patients.  Endoscopy. 2001;  33 786-790
• 47 van Berkel A M, Huibregtse I L, Bergman J J. et al . A prospective randomized trial of Tannenbaum-type Teflon-coated stents versus polyethylene stents for distal malignant biliary obstruction.  Eur J Gastroenterol Hepatol. 2004;  16 213-217
• 48 England R E, Martin D F, Morris J. et al . A prospective randomised multicentre trial comparing 10 Fr Teflon Tannenbaum stents with 10 Fr polyethylene Cotton-Leung stents in patients with malignant common duct strictures.  Gut. 2000;  46 395-400
• 49 Catalano M F, Geenen J E, Lehman G A. et al . „Tannenbaum” Teflon stents versus traditional polyethylene stents for treatment of malignant biliary stricture.  Gastrointest Endosc. 2002;  55 354-358
• 50 Tringali A, Mutignani M, Perri V. et al . A prospective, randomized multicenter trial comparing DoubleLayer and polyethylene stents for malignant distal common bile duct strictures.  Endoscopy. 2003;  35 992-997
• 51 Schilling D, Rink G, Arnold J C. et al . Prospective, randomized, single-center trial comparing 3 different 10F plastic stents in malignant mid and distal bile duct strictures.  Gastrointest Endosc. 2003;  58 54-58
• 52 Seo D W. A prospective randomized trial of Teflon versus polyethylene stents for distal malignant biliary obstruction.  Gastrointest Endosc. 2000;  51 633-635
• 53 Galandi D, Schwarzer G, Bassler D. et al . Ursodeoxycholic acid and/or antibiotics for prevention of biliary stent occlusion.  Cochrane Database Syst Rev. 2002;  3 CD003043
• 54 Knyrim K, Wagner H L, Pausch J. et al . A prospective, randomized, controlled trial of metal stents for distal malignant obstruction.  Endoscopy. 1993;  25 207-212
• 55 Lammer J, Hausegger K A, Fluckiger F. et al . Common bile duct obstruction due to malignancy: treatment with plastic versus metal stents.  Radiology. 1996;  201 167-172
• 56 Davids P HP, Groen A K, Rauws E AJ. et al . Randomized trial of self-expanding metal stents versus polyethylene stents for distal malignant biliary obstruction.  Lancet. 1992;  340 1488-1492
• 57 McDougall N I, Edmunds S E. An audit of metal stent palliation for malignant biliary obstruction.  J Gastroenterol Hepatol. 2001;  16 1051-1054
• 58 Prat F, Chapat O, Ducot B. et al . A randomized trial of endoscopic drainage methods for inoperable malignant strictures of the common bile duct.  Gastrointest Endosc. 1998;  47 1-7
• 59 Kaassis M, Boyer J, Dumas R. et al . Plastic or metal stents for malignant stricture of the common bile duct? Results of a randomized prospective study.  Gastrointest Endosc. 2003;  57 178-182
• 60 Menon K, Romagnuolo J, Barkun A N. Expandable metal biliary stenting in patients with recurrent premature polyethylene stent occlusion.  Am J Gastroenterol. 2001;  96 1435-1440
• 61 Matsushita M, Takakuwa H, Nishio A. et al . Open-biopsy-forceps technique for endoscopic removal of distally migrated and impacted biliary metallic stents.  Gastrointest Endosc. 2003;  58 924-927
• 62 Bueno J T, Gerdes H, Kurtz R C. Endoscopic management of occluded biliary Wallstents: a cancer center experience.  Gastrointest Endosc. 2003;  58 879-884
• 63 Isayama H, Komatsu Y, Tsujino T. et al . A prospective randomised study of „covered” versus „uncovered” diamond stents for the management of distal malignant biliary obstruction.  Gut. 2004;  53 729-734
• 64 Bezzi M, Zolovkins A, Cantisani V. et al . New ePTFE/FEP-covered stent in the palliative treatment of malignant biliary obstruction.  J Vasc Interv Radiol. 2002;  13 581-589
• 65 Otto G, Romaneehsen B, Bittinger F. et al . Preoperative imaging of hilar cholangiocarcinoma: surgical evaluation of standard practises.  Z Gastroenterol. 2004;  42 9-14
• 66 Hirai I, Kimura W, Fuse A. et al . Management of unresectable hilar bile duct cancer-preoperative diagnosis, treatment selection, and clinical outcome.  Hepatogastroenterology. 2003;  50 614-620
• 67 Inal M, Akgul E, Aksungur E. et al . Percutaneous placement of biliary metallic stents in patients with malignant hilar obstruction: unilobar versus bilobar drainage.  J Vasc Interv Radiol. 2003;  14 1409-1416
• 68 Cheng J L, Bruno M J, Bergman J J. et al . Endoscopic palliation of patients with biliary obstruction caused by nonresectable hilar cholangiocarcinoma: efficacy of self-expandable metallic Wallstents.  Gastrointest Endosc. 2002;  56 33-39
• 69 Chang W H, Kortan P, Haber G B. Outcome in patients with bifurcation tumors who undergo unilateral versus bilateral hepatic duct drainage.  Gastrointest Endosc. 1998;  47 354-362
• 70 Lopera J E, Soto J A, Munera F. Malignant hilar and perihilar biliary obstruction: use of MR cholangiography to define the extent of biliary ductal involvement and plan percutaneous interventions.  Radiology. 2001;  220 90-96
• 71 Freeman M L, Overby C. Selective MRCP and CT-targeted drainage of malignant hilar biliary obstruction with self-expanding metallic stents.  Gastrointest Endosc. 2003;  58 41-49
• 72 Hintze R E, Abou-Rebyeh H, Adler A. et al . Magnetic resonance cholangiopancreaticography-guided unilateral endoscopic stent placement for Klatskin tumors.  Gastrointest Endosc. 2001;  53 40-46
• 73 De Palma G D, Galloro G, Siciliano S. et al . Unilateral versus bilateral endoscopic hepatic duct drainage in patients with malignant hilar biliary obstruction: results of a prospective, randomized, and controlled study.  Gastrointest Endosc. 2001;  53 547-553
• 74 Harewood G C, Baron T H. Cost analysis of magnetic resonance cholangiography in the management of inoperable hilar biliary obstruction.  Am J Gastroenterol. 2002;  97 1152-1158
• 75 Zoepf T, Jakobs R, Arnold J C. et al . Photodynamic therapy for palliation of nonresectable bile duct cancer - preliminary results with a new diode laser system.  Am J Gastroenterol. 2001;  96 2093-2097
• 76 Dumoulin F L, Gerhardt T, Fuchs S. et al . Phase II study of photodynamic therapy and metal stent as palliative treatment for nonresectable hilar cholangiocarcinoma.  Gastrointest Endosc. 2003;  57 860-867
• 77 Ortner M E, Caca K, Berr F. et al . Successful photodynamic therapy for nonresectable cholangiocarcinoma: a randomized prospective study.  Gastroenterology. 2003;  125 1355-1363
• 78 Ginsberg G, Cope C, Shah J. et al . In vivo evaluation of a new bioabsorbable self-expanding biliary stent.  Gastrointest Endosc. 2003;  58 777-784
• 79 Kalinowski M, Alfke H, Kleb B. et al . Paclitaxel inhibits proliferation of cell lines responsible for metal stent obstruction: possible topical application in malignant bile duct obstructions.  Invest Radiol. 2002;  37 399-404