Endoskopische Therapie der chronischen Pankreatitis

Zusammenfassung

Die chronische Pankreatitis ist eine häufige abdominelle Erkrankung, die bei vielen der Betroffenen zu klinischen Problemen führt. Die endoskopische Therapie hat sich in den letzten 20 Jahren zu einer effektiven Alternative zu den bis dahin etablierten chirurgischen Maßnahmen entwickelt. Schmerzen bei Pankreasgangsteinen und -stenosen können bei einer Subgruppe von Patienten effektiv und mit hoher Erfolgsrate mittels ESWL, Steinextraktion und Pankreasgangdrainagen behandelt werden. Die prognostischen Kriterien, nach denen geeignete Patienten mit hoher Therapieeffektivität selektiert werden, sind nicht klar definiert. Einschränkend muss angemerkt werden, dass bei 2 vergleichenden Studien zwischen Endoskopie und Chirurgie Vorteile für die operative Therapie resultierten. Nachdem eine endoskopische Therapie – die nach der europäischen Leitlinie Therapie der ersten Wahl ist – nicht zum Erfolg führt, sollte daher frühzeitig interdisziplinär über Behandlungsalternativen nachgedacht werden. Die Endoprothesentherapie zur Ableitung bei Gallengangstenosen mit Cholangitis ist weltweit Standard; der Langzeiteffekt zur Stenosenbeseitigung ist allerdings bei Verwendung einer Prothese ernüchternd. Neuere Optionen, wie das Multistenting oder die Verwendung voll-gecoverter biliärer Metallstents, erreichen in Studien eine Erfolgsrate von über 80 % und sind daher wieder zu einer Konkurrenz für die laparoskopischen biliodigestiven Anastomose geworden. Die endoskopische Pseudozystendrainage ist insbesondere unter Einschluss der Endosonografie eine äußerst erfolgreiche Behandlung und hat außerhalb von Studien weltweit Akzeptanz gefunden.

Abstract

Chronic pancreatitis (CP) is a common gastrointestinal disease affecting the well-being of most of the patients. Endoscopic treatment has developed as an effective alternative to the surgical therapy through the last two decades. Pain in patients with CP and pancreatic duct stones and strictures can be managed successfully in a subgroup of patients by ESWL, stone extraction and pancreatic duct stenting. The selection of patients or those endoscopic options are not very well defined. Two small randomized studies comparing endoscopic and surgical treatment have shown advantages for the operated group. When the endoscopic treatment attempted is not reducing pain effectively a new interdisciplinary discussion about choosing the proper therapy, e. g. surgical resection of the pancreatic head, should start. Endoscopic stenting of patients with biliary stenosis and cholangitis is the procedure of choice. The long-term results for biliary duct stenosis if only a single plastic stent is used are disappointing. New endoscopic options like multistenting or the use of fully-covered metal stents (fc-SEMS) are promising with success rates close to 80 %. Pseudocyst drainage using endosonography or ERCP can be offered with a high success rate and low complication rates even in standard care circumstances.

Schlüsselwörter

endoskopische Drainage - chronische Pankreatitis - Pseudozyste

Key words

pseudocyst - endoscopic drainage - chronic pancreatitis

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