Summary
Modern cross sectional imaging methods like CT and MRCP have replaced more invasive methods for the diagnosis of cholangiolithiasis as well as benign and malignant biliary strictures. Only if a histologic or cytologic confirmation of the diagnosis is necessary, is a direct access to the biliary tract either with ERC or PTC justified as a diagnostic procedure. Due to technical advancements in laparoscopic surgery intraoperative bile duct revision has become a standard procedure for patients with choledocholithiasis discovered during cholecystectomy. It has been shown to be equally effective to ERC. In this setting ERC therefore has lost its unique claim for the treatment of bile duct stones, while it remains the treatment of choice in patients with prior cholecystectomy. In contrast ERC, sometimes in combination with PTC, has become the mainstay in the treatment of biliary lesions like leakage and benign strictures. The same is true for the palliation of malignant biliary strictures. Surgery should be reserved for patients in whom minimal invasive methods fail and for the curative treatment of malignant lesions.
Zusammenfassung
Moderne Schnittbildverfahren haben invasivere Methoden, wie die ERC und PTC in der Diagnostik der Choledocholithiasis, sowie von benignen und malignen Strikturen weitgehend abgelöst. Der direkte Zugang zum Gallengang aus diagnostischen Gründen ist lediglich noch für die Gewinnung von Material zur histologischen oder zytologischen Diagnostik notwendig. Seit Einführung der routinemäßigen intraoperativen Cholangiographie bzw. Choledochusrevision im Rahmen der laparoskopischen Cholezystektomie ist neuerlich ein Wechsel in der Behandlungsstrategie der Choledocholithiasis erfolgt. Die ERC hat hier ihren singulären Anspruch als wenig invasives Verfahren zur Therapie der Choledocholithiasis verloren, sofern gleichzeitig die Indikation zur Cholezystektomie besteht; sie ist lediglich für Patienten mit St.p. Cholezystektomie das Therapieverfahren der ersten Wahl geblieben. In der Therapie von Gallengangsläsionen, seien es Leckagen, benigne oder maligne Stenosen, haben sich wenig invasive Verfahren, allen voran die Endoskopie als Therapie der ersten Wahl durchgesetzt. Der Stellenwert der Chirurgie liegt hier in der Behandlung von Therapieversagern sowie in der kurativen Tumorchirurgie.
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Püspök, A. Gallengangsprobleme – durch technische Entwicklungen zu verändertem Patientenmanagement. Wien Med Wochenschr 156, 386–390 (2006). https://doi.org/10.1007/s10354-006-0313-6
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DOI: https://doi.org/10.1007/s10354-006-0313-6