Endosonografie (EUS)-gestützte transluminale Cholangiodränage (EUCD) – eine neue Option der interventionellen Endoskopie im interdisziplinären Management des obstruktiven Ikterus

 

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Zusammenfassung

Hintergrund: ERCP und PTCD gelten als der Goldstandard für die interventionelle Behandlung der biliären Obstruktion, insbesondere unter palliativer Intention. Unter bestimmten Bedingungen sind eine ERCP als auch PTCD nicht möglich. In diesen Fällen können alternative Entlastungsverfahren wie beispielsweise eine endosonografisch gestützte Cholangiodränage zum Einsatz kommen.

Ziel / Methode: Anhand einer kompakten Kurzübersicht sollen Indikation, Technik, Varianten des Herangehens, Behandlungszahlen verschiedener Autoren, Erfolgsrate, Komplikationsspektrum und -management als auch Nachsorgeempfehlungen zur EUS-geführten Cholangiodränage (EUCD) auf der Basis eigener klinischer Erfahrungen als auch im Vergleich zu publizierten Daten umrissen werden.

Ergebnisse: Die EUCD ist ein interventionell-endoskopisches / endosonografisches Verfahren, das bei veränderter Oberbauchanatomie nach Vor-OP (BII-Magenresektion, PPPHR, Whipple-OP, [sub-]totale Gastrektomie, Roux-en-Y-Rekonstruktion) und damit Nicht-Erreichbarkeit bzw. -Sondierbarkeit der Papilla Vateri (Papille) sowie bei PTCD-Ablehnung beim rezidivierenden, fortgeschrittenen oder metastasierten malignen Tumorgeschehen mit assoziierter Gallenwegsobstruktion und Ikterus Anwendung findet. Vom Prinzip her wird mittels EUS-geführter transluminaler Punktion vom oberen GI-Trakt aus in verschiedene extra- / intrahepatische Gallenwegssegmente die Tumorstenose mittels Stent rekanalisiert oder unter Tumorumgehung der stentbasierte Galleabfluss retrograd oder antegrad herbeigeführt. Daraus leiten sich Zugänge und Vorgehen ab: 1. Rendezvous-Technik, 2. transhepatisch mit retrograder (permanente Hepatico-Enterostomie) oder 3. transtumoröse antegrade interne Dränage, 4. extrahepatisch mit antegrader Galleableitung (permanente Choledocho-Enterostomie), die je nach Obstruktion zu favorisieren sind. Im Komplikationsspektrum (Rate_Lit.: 0 – 25 %) sind Blutung, Perforation, Stentdislokation / -migration / -okklusion sowie moderater postinterventioneller Schmerz zu nennen. Derzeit sind mehr als 200 Fälle in der Welt publiziert, wobei sich der eigene Erfahrungswert auf > 70 Interventionen stützt.

Diskussion: Im derzeitigen Verbreitungsgrad der EUCD ist noch nicht von einem Standardverfahren auszugehen. Als Vorteile sind das meist geringe Gewebstrauma, die primäre interne Dränage und die endoskopisch mögliche Reintervention bei Komplikationen zu nennen. Nachteilig fällt der hohe technische Anspruch für eine breitere Anwendung ins Gewicht. Bei ausweisbarer Erfolgsaussicht im Rahmen offen gelegter EUCD-Behandlungsergebnisse kann die EUCD bereits durchaus als kompetitives Verfahren zu ERCP und PTCD betrachtet werden.

Schlussfolgerung: Die EUCD ist eine sich etablierende, allerdings noch immer experimentelle, interventionell-endoskopische / -endosonografische Prozedur, die eine hohe Expertise des Interventionalisten im interdisziplinären Verbund eines viszeralmedizinischen Zentrums voraussetzt. Sie stellt eine elegante, in erfahrener Hand sichere Vorgehensweise dar, die jedoch noch immer ein systematisches Follow-up sowie eine multizentrische Evaluierung bis hin zur möglichen Leitlinienrelevanz erfordert.

Abstract

Background: ERCP and PTCD are considered the gold standard in the interventional treatment of biliary obstruction, in particular, with palliative intention. If ERCP and PTCD are not possible, an alternative drainage procedure such as the EUS-guided cholangiodrainage (EUCD) can be used.

Aim / Method: By the mean of a compact review, indication, technique, variants of approach, number of treated patients and therapeutic procedures reported by various authors, success rate, spectrum and management of complications as well as recommendations for an appropriate follow-up-investigation protocol for EUCD based on our own clinical experiences and compared to published data are described.

Results: EUCD is an interventionally endoscopic / -sonografic procedure, which is used in case of postoperatively changed anatomy of the upper GI tract (BII gastric resection, PPPHR, Whipple procedure, [sub-]total gastrectomy, Roux-en-Y reconstruction) and, thus, if papilla of Vater (papilla) can not be reached or catheterized or if the patient denies PTCD in subjects with recurrent, advanced or metastasized tumor lesion(s) of the upper abdomen, hepatobiliary system as well as pancreas and associated obstruction of the biliary tree − / + jaundice. Principle: EUS-guided transluminal puncture from the upper GI tract into various extra- / intrahepatic segments of the biliary system, recanalization of the tumor stenosis with stent insertion through the access site or bypassing the tumor (stent-based retro- or antegrade drainage of the biliary tree). Derived from this, there are various approaches and procedures – EUCD i) combined with rendesvouz technique, ii / iii) transhepatically with retro- (permanent hepaticoenterostomy) / antegrade internal drainage, iv) extrahepatically with antegrade drainage (permanent choledocho-enterostomy), which are distinguished according to tumor site, possible direction of translumenal puncture, insertion of a guide wire and final stent placement. Within the spectrum of complications (rate_Lit.: 0 – 25 %), bleeding, perforation, stent dislocation / -migration/-occlusion and slight postinterventional pain are relevant. Currently, approximately 200 cases have been published worldwide; the clinical experience of the reporting institution is based on more than > 70 interventions.

Discussion: With regard to the limited diffusion process, EUCD cannot be considered a standard procedure yet. The advantages comprise low tissue trauma, primary internal drainage and the possible endoscopic re-intervention in case of complications. The high technical challenge in performing EUCD is a disfavourable aspect for broader use in clinical practice. However, the disclosed treatment results demonstrating an acceptable complication rate show that EUCD can be competitively considered to ERCP und PTCD with a great chance for primary success.

Conclusion: EUCD is an elegant, not yet fully established, but rather still experimental procedure of interventional endoscopy / EUS, which needs great expertise of the endoscopist in an interdisciplinary centre of visceral medicine as one of the main predictions. In experienced hands, a safe procedure can be provided, for which a systematic follow-up and a multicentre evaluation of periinterventional management are still needed in order to achieve a final assessment of EUCD for guideline approval.

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