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Choledocholithiasis

Diagnostische und therapeutische Strategien

Common bile duct stones

Diagnostic and therapeutic management

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Zusammenfassung

Die besten prädiktiven Parameter für das Vorliegen von Gallengangssteinen sind Cholangitis, Ikterus sowie der direkte sonographische Steinnachweis. Bei hochgradigem Verdacht auf das Vorliegen einer Choledocholithiasis ist die Durchführung einer ERC (endoskopische retrograde Cholangiographie) indiziert, da bei Bestätigung der Verdachtsdiagnose in gleicher Sitzung die interventionelle Steinextraktion durchgeführt werden kann. Ist mit mittlerer Wahrscheinlichkeit von Gallengangssteinen auszugehen, sollte im 1. Schritt die Endosonographie oder Magnetresonanzcholangiographie erfolgen. Bei Patienten mit simultaner Cholezysto-/Choledocholithiasis wird allgemein das präoperative therapeutisches Splitting empfohlen. Die zum Standard gewordene laparoskopische Cholezystektomie erfolgt zeitversetzt (>24 h bis <6 Wochen) zur ERC/EPT (endoskopischen Papillotomie), um mögliche periinterventionelle Komplikationen abzuwarten. Bei primär offenem Vorgehen zeigt sich die offene Choledochusrevision der ERC mit EPT überlegen und stellt aus diesem Grunde auch die erste Behandlungsoption dar. Nur in ausgewählten Zentren mit entsprechender laparoskopischer Expertise stellt die laparoskopische Choledochusrevision eine Alternative zum therapeutischen Splitting dar.

Abstract

The best predictors for the presence of common bile duct stones (CBDS) are cholangitis, jaundice, and direct visualization of stones with ultrasound. In the setting of high suspicion of choledocholithiasis, endoscopic retrograde cholangiography (ERC) is indicated because when CBDS are identified, it allows immediate therapy in the same sitting. If there is a moderate probability of choledocholithiasis, endosonography or magnetic resonance cholangiopancreatography are the first-line options. In patients with gallbladder stones and CBDS, preoperative ERC with or without endoscopic sphincterotomy (ES) is widely recommended as a standard approach. The interval between that and laparoscopic cholecystectomy (LC) should be at least 24 h (<6 weeks) to exclude possible complications due to the ERC/ES. In the setting of open cholecystectomy, open bile duct surgery is significantly superior to ERC with sphincterotomy in achieving common bile duct clearance and is the method of choice. Only in centres with advanced laparoscopic expertise is the laparoscopic removal of CBDS an equivalent treatment option.

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  1. Abteilung für Allgemeine, Gefäß-, Thorax- und Transplantationschirurgie, Klinik und Poliklinik für Chirurgie Universität Rostock, Schillingallee 35, 18057, Rostock, Deutschland

    S. Förster & E. Klar

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  2. E. Klar
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Correspondence to S. Förster.

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Förster, S., Klar, E. Choledocholithiasis. Chirurg 79, 881–892 (2008). https://doi.org/10.1007/s00104-008-1588-5

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