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
Literatur
-
1
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
-
2
Akashi R, Kiyozumi T, Tanaka T, Sakurai K, Oda Y, Sagara K.
Mechanism of pancreatitis caused by ERCP.
Gastrointest Endosc.
2002;
55
50-54
-
3
Andriulli A, Clemente R, Solmi L, Terruzzi V, Suriani R, Sigillito A, Leandro G, Leo P, De Maio G, Perri F.
Gabexate or somatostatin administration before ERCP in patients at high rsik for post-ERCP pancreatitis: a multicenter, placebo-controlled, randomized clinical trial.
Gastrointest Endosc.
2002;
56
488-495
-
4
Battaille L, Deprez P.
A new application for therapeutic EUS: main pancreatic duct drainage with a “pancreatic rendezvous technique”.
Gastrointest Endosc.
2002;
55
740-743
-
5
Bergmann J J, Rauws E A, Fockens P, van Berkel A M, Bossuyt P M, Tijssen J G. et al .
Randomized trial of endoscopic balloon dilatation versus endoscopic sphincterotomy for removal of bile duct stones.
Lancet.
1997;
349
1124-1129
-
6
Born P, Sandschin W, Rösch T.
Percutaneous Antegrade Sphincterotomy under Endoscopic Retrograde Control: Report of Two Cases.
Endoscopy.
2002;
34
512-513
-
7
Brodsky J A, Marks J M, Malm J A, Bower A, Ponsky J L.
Sphincter of Oddi injection with botulinum toxin is as effective as endobiliary stent in resolving cystic duct leaks in a canine model.
Gastrointest Endosc.
2002;
56
849-851
-
8
Burmeister E, Niehaus J, Leineweber T, Huetteroth T.
EUS- cholangio-drainage of the bile duct: report of 4 cases.
Gastrointest Endosc.
2003;
57
246-251
-
9
Buscarini E, Tansini P, Vallisa D, Zambelli A, Buscarini L.
EUS for suspected choledocholithiasis: Do benefits outweigh costs? A prospective, controlled study.
Gastrointest Endosc.
2003;
57
510-518
-
10
Catalano M F, Geenen J E, Lehman G A, Siegel J H, Jacob L, Mc Kinley M J, Raijman I, Meier P, Jacobson I, Kozarek R, Al-Kawas F H, Lo S K, Dua K S, Baille J, Ginsberg G G, Parsons W, Meyerson S M, Cohen S, Nelson D B, Mc Hattie J D, Carr-Locke D L.
“Tannenbaum” Teflon stents versus traditional polyethylene stents for treatment of malignant biliary stricture.
Gastrointest Endosc.
2002;
55
354-358
-
11
Cheng J LS, Bruno M J, Bergmann J J, Rauws E A, Tytgat G N, Huibregtse K.
Endoscopic palliation of patients with biliary obstruction caused by nonresectable hilar cholangiocarcinoma: efficacy of self-expandable metallic Wallstents.
Gastrointest Endosc.
2002;
56
33-39
-
12
Classen M, Demling L.
Endoskopische Sphinkterotomie der Papilla Vateri und Steinextraktion aus dem Ductus choledochus.
Dtsch med Wschr.
1974;
99
496-497
-
13
Costamagna G, Mutignani M, Gabrielli A. et al .
Diagnostic and therapeutic ERCP in patients with Billroth II gastrectomy.
Acta Gastroenterol Belg.
1994;
57
155
-
14
Costamagna G, Tringali A, Shah S K, Mutignani M, Zuccala G, Perri V.
Long- Term Follow-Up of Patients After Endoscopic Sphincterotomy for Choledocholithiasis, and Risk Factors for Recurrence.
Endoscopy.
2002;
34
273-279
-
15
De Palma G D, Pezzullo A, Rega M, Persico M, Patrone F, Mastantuono L, Persico G.
Unilateral placement of metallic stents for malignant hilar obstruction: a prospective study.
Gastrointest Endosc.
2003;
58
50-53
-
16
DiSario J A.
Endoscopic balloon dilatation for extraction of bile duct stones: the devil is in the details.
Gastrointest Endosc.
2003;
57
282-285
-
17
Eickhoff A, Jakobs R, Leonhardt A, Eickhoff J C, Riemann J F.
Self-expandable Metal Mesh Stents for Common Bile Duct Stenosis in Chronic Pancreatitis: Retrospective Evaluation of Long-term Follow-up and Clinical Outcome of a Pilot Study.
Z Gastroenterol.
2003;
41
649-654
-
18
Ersoz G, Tekesin O, Ozutemiz A O, Gunsar F.
Biliary sphincterotomy plus dilation with a large balloon for bile duct stones that are difficult to extract.
Gastrointest Endosc.
2003;
57
156-159
-
19
Fazel A, Quadri A, Catalano M F, Meyerson S M, Geenen J E.
Does a pancreatic duct stent prevent post-ERCP pancreatitis? A prospective randomized study.
Gastrointest Endosc.
2003;
57
291-294
-
20
Freeman M L, Nelson D B, Sherman S, Haber G, Herman M E, Dorsher P J, Moore J P, Fennerty B, Ryan M E, Shaw M J, Lande J D, Pheley A M.
Complications of endoscopic biliary sphincterotomy.
N Engl J Med.
1996;
335
909-918
-
21
Fujita N, Maguchi H, Komatsu Y, Yasuda I, Hasebe O, Igarashi Y, Murakami A, Mukai H, Fujii T, Yamao K, Maeshiro K. for the JESED Study Group .
Endoscopic sphincterotomy and endoscopic papillary balloon dilatation for bile duct stones: a prospective randomized controlled multicenter trial.
Gastrointest Endosc.
2003;
57
151-155
-
22
Fulcher A S.
MRCP and ERCP in the diagnosis of common bile duct stones.
Gastrointest Endosc.
2002;
56 (Suppl)
S 178-S 182
-
23
Guidelines of the European Society of Gastrointestinal Endoscopy (E.S.G.E.) Antibiotic Prophylaxis for Gastrointestinal Endoscopy.
Endoscopy.
1998;
30
318-324
-
24
Holm M, Matzen P.
Stenting and Extracorporeal Shock Wave Lithotripsy in Chronic Pancreatitis.
Scand J Gastroenterol.
2003;
38
328-331
-
25
Kaassis M, Boyer J, Dumas R, Ponchon T, Coumaros D, Delcenserie R, Canard J M, Fritsch J, Rey J F, Burtin P.
Plastic or metal stents for malignant stricture of the common bile duct? Results of a randomized prospective study.
Gastrointest Endosc.
2003;
57
178-182
-
26
Kaw M, Al Antably Y, Kaw P.
Management of gallstone pancreatitis: cholecystectomy or ERCP and endoscopic sphincterotomy.
Gastrointest Endosc.
2002;
56
61-65
-
27
Kawai K, Akasaka Y, Murakami K, Tada M, Kohli Y, Nakajima M.
Endoscopic sphincterotomy of the ampulla of Vater.
Gastrointest Endosc.
1974;
20
148-151
-
28
Keeling S P, Freeman M L.
Placement of self- expanding metallic stents in the pancreatic duct for treatment of obstructive complications of pancreatic cancer.
Gastrointest Endosc.
2003;
57
756-759
-
29
Kim M H, Lee S K, Lee M H, Myung S J, Yoo B M, Seo D W, Min Y I.
Endoscopic retrogarde cholangiopancreatography and needle-knife sphincterotomy in patients with Billroth II gastrectomy: A comparative study of the forward-viewing endoscope and the side-viewing duodenoscope.
Endoscopy.
1997;
29
82-85
-
30
Kin H, Mochizuki T, Matsumura K, Watanabe K, Fukuzawa H, Hamamura K, Miyoshi H, Shirane N, Kondou M, Kojima K.
Needle-Knife Papillotomy With Pancreatic Stent: A Prospective Evaluation Of Efficacy And Complications.
Gastrointest Endosc.
2003;
57
AB 192
-
31
Kozarek R.
Role of ERCP in acute pancreatitis.
Gastrointest Endosc.
2002;
56 (Suppl)
S 231-S 236
-
32
Lee D WH, Chan A CW, Lam Y, Ng E KW, Lau J YW, Law B KB, Lai C, Sung J JY, Chung S CS.
Biliary decompression by nasobiliary catheter or biliary stent in acute suppurative cholangitis: a prospective randomized trial.
Gastrointest Endosc.
2002;
56
361-365
-
33
Lehman G A.
Role of ERCP and other endoscopic modalities in chronic pancreatitis.
Gastrointest Endosc.
2002;
56 (Suppl)
S 237-S 240
-
34
Manolakopoulos S, Avgerinos A, Vlachogiannakos J, Armonis A, Viazis N, Papadimitriou N, Mathou N, Stefanidis G, Rekoumis G, Vienna E, Tzourmakliotis D, Raptis A.
Octreotide versus hydrocortisone versus placebo in the prevention of post-ERCP pancreatitis: a multicenter randomized controlled trial.
Gastrointest Endosc.
2002;
55
470-475
-
35
Mark D H, Lefevre F, Flamm C R, Aronson N.
Evidence- based assessment of ERCP in the treatment of pancreatitis.
Gastrointest Endosc.
2002;
56 (Suppl)
S 249-S 254
-
36
Mcintosh D, Love J, Abraham N.
Endoscopic Sphincterotomy Using Pure-Cut Current Does Not Reduce The Risk Of Post-ERCP Pancreatitis: A Prospective Randomized Trial.
Gastrointest Endosc.
2003;
57
AB 189
-
37
Minami A, Fujita R.
A new technique for removal of bile duct stones with an expandable metallic stent.
Gastrointest Endosc.
2003;
57
945-948
-
38
Mönckemüller K E, Linder J D, Fry L C.
Modified Rendezvous Technique for Biliary Cannulation.
Endoscopy.
2002;
34
936
-
39
Mora J, Aguilera V, Sala T, Martinez F, Bastida G, Palau A, Arguello I, Pons V, Pertejo V, Berenguer J, Alapont J M.
Endoscopic treatment combined with extracorporeal shock wave lithotripsy of difficult bile duct stones.
Gastroenterol Hepatol.
2002;
25
585-588
-
40
Moreto M, Zaballa M, Casado I, Merino O, Rueda M, Ramirez K, Urcelay R, Baranda A.
Transdermal glyceryl trinitrate for prevention of post-ERCP pancreatitis: a randomized double-blind trial.
Gastrointest Endosc.
2003;
57
1-7
-
41
Murray B, Carter R, Imrie C, Evans S, O'Suillebhain C.
Diclofenac Reduces the Incidence of Acute Pancreatitis After Endoscopic Retrograde Cholangiopancreatography.
Gastroenterology.
2003;
124
1786-1791
-
42
Neuhaus H.
Endoscopic and Percutaneous Treatment of Difficult Bile Duct Stones.
Endoscopy.
2003;
35 (Suppl 1)
S 31-S 34
-
43
Oviedo J A, Barrison A, Lichtenstein D R.
Endoscopic argon plasma coagulation for refractory postsphincterotomy bleeding: report of two cases.
Gastrointest Endosc.
2003;
58
148-151
-
44
Park J J, Kim S S, Kim Y K, Jung M K, Park H C, Kim J H, Kim J S, Hyun J H.
Biliary drainage by endoscopic choledochoduodenal fistulotomy in patients with papillary carcinoma.
Gastrointest Endosc.
2002;
55
730-735
-
45
Park S H, Watkins J L, Fogel E L, Sherman S, Lazzell L, Bucksot L, Lehman G A.
Long-term outcome of endoscopic dual pancreatobiliry sphincterotomy in patients with manometry-documented sphincter of Oddi dysfunction and normal pancreatogram.
Gastrointest Endosc.
2003;
57
483-491
-
46
Prat F, Amaris J, Ducot B, Bocquentin M, Fritsch J, Choury A D, Pelletier G, Buffet C.
Nifedipin for prevention of post-ERCP pancreatitis: a prospective, double-blind randomized study.
Gastrointest Endosc.
2002;
56
202-208
-
47
Rabenstein T, Fischer B, Wiesner V, Schmidt H, Radespiel-Tröger M, Hochberger J, Mühldorfer S, Nusko G, Messmann H, Schölmerich J, Schulz H J, Schönekäs H, Hahn E G, Schneider H T.
Low-Molecular-Weight Heparin Does Not Prevent Acute Post-ERCP Pancreatitis.
Gastrointest Endosc.
2003;
57
AB 189
-
48
Rabenstein T, Roggenbruck S, Framke B, Martus P, Fischer B, Nusko G, Muehldorfer S, Hochberger J, Ell C, Hahn E G, Schneider T.
Complications of endoscopic sphincterotomy: can heparin prevent acute pancreatitis after ERCP?.
Gastrointest Endosc.
2002;
55
476-483
-
49
Saleh M MA, Norregaard P, Jorgensen H L, Andersen P K, Matzen P.
Preoperative endoscopic stent placement before pancreaticoduodenectomy: a meta-analysis of the effect on morbiditiy and mortality.
Gastrointest Endosc.
2002;
56
529-534
-
50
Schilling D, Rink G, Arnold J C, Benz C, Adamek H E, Jakobs R, Riemann J F.
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
-
51
Shah R J, Antillon M R, Springer E W, Penberthy J A, Chen Y K.
A New Rotatable Papillotome (RP) In Complex Therapeutic ERCP: Indications For Use And Results.
Gastrointest Endosc.
2003;
57
AB 206
-
52
Sherman S, Blaut U, Watkins J L, Barnett J, Freeman M, Geenen J, Ryan M, Parker H, Frakes J T, Fogel E L, Silverman W B, Dua K S, Aliperti G, Yakshe P, Uzer M, Jones W, Goff J, Earle D, Temkit M, Lehman G A.
Does prophylactic administration of corticosteroid reduce the risk and severity of post-ERCP pancreatitis: a randomized, prospective, multicenter study.
Gastrointest Endosc.
2003;
58
23-29
-
53
Sherman S, Earle D, Bucksot L, Rusche M, Lehman G.
Does leaving a main pancreatic duct stent in place reduce the incidence of precut biliary sphincterotomy (ES)-induced pancreatitis? A final analysis of a prospective study.
Gastrointest Endosc.
1996;
43
413 A
-
54
Singh P, Sivak M V, Agarwal D, Wong R, Isenberg G, Das A, Mughal T B, Singh R, Cnak A.
Prophylactic Pancreatic Stenting For Prevention Of Post-ERCP Acute Pancreatitis: A Meta-Analysis Of Controlled Studies.
Gastointest Endosc.
2003;
57
AB 89
-
55
Sivak M V.
EUS for bile duct stones: How does it compare with ERCP?.
Gastrointest Endosc.
2003;
56 (Suppl)
S 175-S 177
-
56
Smithline A, Silverman W, Rogers D, Nisi R, Wiersema M, Jamidar P, Hawes R, Lehman G.
Effect of prophylactic main pancreatic duct stenting on the incidence of biliary endoscopic sphincterotomy-induced pancreatitis in high-risk patients.
Gastrointest Endosc.
1993;
39
652-657
-
57
Sriram P VJ, Rao G V, Nageshwar Reddy D.
The Precut - When, Where and How? A Review.
Endoscopy.
2003;
35 (Suppl 1)
S 24-S 30
-
58
Stefanidis G, Karamanolis G, Viazis N, Sgouros S, Papadopoulou E, Ntatsakis K, Mantides A, Nastos H.
A comparative study of postendoscopic sphincterotomy complications with various types of electrosurgical current in patients with choledocholithiasis.
Gastrointest Endosc.
2003;
57
192-197
-
59
Sugiyama M, Izumisato Y, Abe N, Masaki T, Mori T, Atomi Y.
Predictive factors for acute pancreatitis and hyperamylasemia after endoscopic papillary balloon dilatation.
Gastrointest Endosc.
2003;
57
531-535
-
60
Tarnasky P, Cunningham J, Cotton P, Hoffman B, Palesch Y, Freeman J, Curry N, Hawes R.
Pancreatic sphincter hypertension increases the risk of post-ERCP pancreatitis.
Endoscopy.
1997;
29
252-257
-
61
Telford J J, Farrell J J, Saltzman J R, Shields SJ, Banks P A, Lichtenstein D R, Johannes R S, Kelsey P B, Carr-Locke D L.
Pancreatic stent placement for duct disruption.
Gastrointest Endosc.
2002;
56
18-24
-
62
Ueno N, Ozawa Y, Aizawa T.
Prognostic factors for recurrence of bile duct stones after endoscopic treatment by sphincter dilation.
Gastrointest Endosc.
2003;
58
336-340
-
63
Van Berkel A -M, Van Westerloo D, Cahen D, Bergman J, Rauws E, Huibregtse K, Bruno M.
Efficacy of Wallstents in Benign Biliary Strictures Due to Chronic Pancreatitis.
Gastrointest Endosc.
2003;
57
AB 198
-
64
Van Lent A UG, Bartelsman J FWM, Tytgat G NJ, Speelman P, Prins J M.
Duration of antibiotic therapy for cholangitis after successful endoscopic drainage of the biliary tract.
Gastrointest Endosc.
2002;
55
518-522
-
65
Varadarajulu S, Noone T, Hawes R H, Cotton P B.
Pancreatic duct stent insertion for functional smoldering pancreatitis.
Gastrointest Endosc.
2003;
58
438-441
-
66
Wright B E, Cass O W, Freeman M L.
ERCP in patients with long-limb Roux-en-Y gastrojejunostomy and intact papilla.
Gastrointest Endosc.
2002;
56
225-232
Prof. Dr. Drs. h. c. M. Classen
II. Medizinische Klinik und Poliklinik · Klinikum r. d. Isar · Technische Universität München
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