Zusammenfassung
GRUNDLAGEN: Gallengangssteine stellen ein häufiges diagnostisches und therapeutisches Problem im Rahmen der Cholelithiasis dar. Seit Einführung der endoskopischen retrograden Cholangio-Pankreatikographie (ERCP) und Papillotomie (EPT) hat sich das so genannte therapeutische Splitting vor allem nach Etablierung der laparoskopischen Cholezystektomie (LC) als Verfahren der Wahl durchgesetzt. Als alternative Therapieoption wird die einzeitige laparoskopische Choledochusrevision anhand der Literatur und eigener Daten diskutiert. METHODIK: Bei präoperativ oder während der routinemäßig durchgeführten intraoperativen Cholangiographie diagnostizierter Choledocholithiasis wird primär eine transzystische Steinentfernung angestrebt. Gelingt dies nicht, wird der Hauptgallengang über eine Choledochotomie saniert. Ausschlusskriterien für dieses einzeitige Vorgehen sind eine schwere Pankreatitis und/oder Cholangitis, der Verdacht auf Malignität, beziehungsweise Narkoseuntauglichkeit. ERGEBNISSE: Zwischen November 1991 und September 2005 wurde bei 260 Patienten eine laparoskopische Choledochusrevision durchgeführt. Die transzystische Sanierung gelang bei 166 Patienten (64 %), bei 94 (36 %) wurde choledochotomiert. Definitive Steinfreiheit wurde in 93 % der Fälle einzeitig erreicht, viermal (1,5 %) musste konvertiert werden. Die Komplikationsrate betrug 6,6 %, die Mortalität 1,1 %. SCHLUSSFOLGERUNGEN: Die einzeitige laparoskopische Choledochusrevision stellt bezüglich Sicherheit und Erfolgsraten eine ebenbürtige Alternative zum Therapeutischen Splitting dar. Beim Therapeutischen Splitting addieren sich die Morbiditäts- und Mortalitätsraten der LC und der EPT. Im Vergleich hierzu erzielt insbesondere die Subgruppe der transzystisch sanierten Patienten deutlich bessere Ergebnisse. Durch das einzeitig laparoskopische Vorgehen können über 90 % der sonst notwendigen diagnostischen und therapeutischen ERCPs mit den damit verbundenen Komplikationen und Spätfolgen vermieden und die Unversehrtheit der Papilla Vateri erhalten werden.
Summary
BACKGROUND: Debate and controversy remain concerning detection and management of common bile duct (CBD) stones in the era of laparoscopic cholecystectomy (LC). Since ERCP was introduced in the 1970s, therapeutic splitting with endoscopic sphincterotomy (ES) as a two-step procedure has become the most accepted strategy to remove CBD stones. This paper evaluates the one-step laparoscopic management of CBD stones during LC. METHODS: After economic clarification (anamnesis, clinical examination, laboratory tests, ultrasound) LC was performed even when CBD stones were suspected. During LC a cholangiography via the cystic duct was routinely performed. If bile duct stones were detected during cholangiography, retrieval via the cystic duct or via choledochotomy was intended using Dormia basket or Fogarty catheter. Exclusion criteria against laparoscopic CBD exploration were suspicion of malignancy, severe pancreatitis and/or cholangitis or unfitness for general anesthesia. RESULTS: From November 1991 to September 2005, 260 patients underwent laparoscopic therapy for bile duct stones. Retrieval was performed transcystically in 166 patients (64 %) and via choledochotomy in 94 patients (36 %). Laparoscopic CBD exploration was successful in 93 %. Conversion rate, complication rate and mortality were 1.5 % (n = 4), 6.6 % (n = 17), and 1.1 % (n = 3), respectively. CONCLUSIONS: Laparoscopic common bile duct exploration (LCBDE) as a one-step procedure is a safe alternative to therapeutic splitting, with comparable success rate. Regarding morbidity and mortality, the laparoscopic transcystic approach has clear advantages over therapeutic splitting. In more than 90 per cent of patients with CBD stones, LCBDE avoids diagnostic and therapeutic ERCP and preserves the papilla Vateri.
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Ebner, S., Müller, W., Beller, S. et al. Laparoscopic common bile duct exploration. Eur Surg 38, 171–175 (2006). https://doi.org/10.1007/s10353-006-0243-y
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DOI: https://doi.org/10.1007/s10353-006-0243-y