Endosonografisch gestützte Dränagen – Indikationen und Technik

Zusammenfassung

Die unmittelbare Nähe des Pankreas und der Gallenwege zum Intestinum eröffnet für die therapeutische EUS völlig neue Indikationsgebiete. Eine transmurale Dränage von Pseudozysten oder Abszessen des Pankreas mit der Endosonografie ist ein sicheres und komplikationsarmes Verfahren mit einer im Vergleich zur endoskopischen Dränage höheren technischen Erfolgsrate. Ein kombiniertes Vorgehen der internen EUS-Dränage mit einer perkutanen Dränage kann die Anzahl der endoskopischen Interventionen zur Sanierung von infizierten Nekrosehöhlen minimieren und den Langzeiterfolg verbessern. Die interne EUS-geführte Dränage (EUCD) von gestauten Gallenwegen bei nicht sondierbaren oder nicht erreichbaren Papillen nach Operation oder aufgrund maligner Obturation ist ein interessanter therapeutischer Ansatz zur Vermeidung einer temporären oder dauerhaften PTCD. Für symptomatische Patienten mit erweitertem Pankreasgang nach Operation oder nach Nekrosektomie (abgehängter Pankreasgang, DPTS) bzw. mit persistierenden Pankreasfisteln gibt es bisher keine endoskopische Möglichkeit der Gangentlastung. Mithilfe der EUS gelingt es den gestauten Pan­kreasgang in den Magen oder das Duodenum ­abzuleiten (EUPD) und dem Patienten damit eine erneute Operation zu ersparen. Im Beitrag werden Therapiestandards von pankreatischen Pseudozysten, Abszessen und Nekrosen sowie neue Techniken in der EUS-geführten internen Gallengangsdränage und Pankreasgangdränage besprochen und ihre Relevanz im klinischen Alltag unter Einbeziehung aktueller Literaturdaten gewürdigt. 

Abstract

The neighborhood of the anatomical structures gastrointestinal tract, pancreatic and bile duct ­allows to consider novel approaches using EUS guidance, in particular, with therapeutic intend. Over the years, the EUS-guided transmural drain­age of pancreatic pseudocysts or abscesses of the pancreas has been established as a safe and suitable procedure with a low periinterventional complication rate including a substantially higher technical success rate compared with the endoscopic drainage. The combination of the internal EUS-guided drainage with a percutaneous drain­age can minimize the number of endoscopic ­interventions aiming for clearance of infected ­necrosis and improval of long-term outcome. The internal EUS-guided cholangiodrainage (EUCD) for cholestasis can be considered an interesting approach to avoid temporary or permanent PTCD if the papilla of Vater can not be reached or through which a catheter can not be introduced due to postsurgical changes in the anatomy of the upper GI tract and malignant tumor growth, respectively. For symptomatic patients with a ­dilated pancreatic duct after former surgical inter­vention or necrosectomy (disconnected pancreatic tail syndrome [DPTS]) or patients with a persisting pancreaticocutaneous fistula, there are no further reasonable endoscopic treatment op­tions of ductal drainage. Using EUS guidance, ­dilated and retained pancreatic duct can be drained to the intragastric or -duodenal lumen (EUPD), which allows to circumvent further surgical intervention. taking into account all these aspects, this overview reflects the therapeutic standards for pancreatic pseudocysts, abscesses and necrosis as well as novel techniques in the EUS-guided internal drainage of the bile and pancreatic duct based on their relevance and impact in daily clinical practice as ell as experiences reported in the literature. 

Schlüsselwörter

EUS-Intervention - Dränage von Pseudozysten - Cholangiodränage - Pankreasgangdränage

Key words

EUS-intervention - drainage of pseudocysts - cholangiodrainage - pancreatic duct drainage

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