Gegenwärtiger Stellenwert der perkutanen
transhepatischen Cholangiodrainage

 

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Zusammenfassung

Die perkutane transhepatische Cholangiodrainage (PTCD) ist ein etabliertes Verfahren zur Behandlung von Gallengangsobstruktionen und wird mittlerweile seit drei Jahrzehnten in der klinischen Routine eingesetzt. Das Indikationsspektrum umfasst vorwiegend maligne Erkrankungen, bei denen entweder vorübergehend präoperativ oder dauerhaft unter palliativen Gesichtspunkten eine Entlastung erzielt werden soll. Die präoperative Ableitung hat in den letzten Jahren offensichtlich an Bedeutung verloren. Eigene Erfahrungen während eines Zeitraumes von über 15 Jahren spiegeln diese Verschiebung der Indikationen zugunsten der dauerhaften, palliativen PTCD-Anlage wider. Die speziellen diagnostischen Möglichkeiten, die den für die PTCD gewählten Zugangsweg eröffnen (intravasaler Ultraschall, Cholangioskopie, Biopsie), werden heutzutage nur in seltenen Fällen genutzt. Grundsätzlich lag in den letzten Jahren das Bestreben vor, eine Gallengangsentlastung primär auf endoskopischem Weg zu erzielen, da die perkutane Vorgehensweise als belastender und risikoreicher gilt. Die eigenen Ergebnisse von über 1000 Eingriffen während eines Zeitraumes von 16 Jahren zeigen jedoch, dass der Prozentsatz schwerer Komplikationen (3,4 - 5,0 %) bei der PTCD dem endoskopischen Verfahren entspricht und nicht übertrifft.

Abstract

Percutaneous transhepatic biliary drainage (PTBD) is a well established method in the treatment of obstructive jaundice. Major indications are malignant diseases. PTBD may be necessary preoperatively in cases with severe jaundice or cholangitis or as part of palliative treatment concepts. In the past, it has been proposed that a period of preoperative PTBD may improve the morbidity rates of surgery. Various studies could not prove this theory. The significance of preoperative PTBD has changed, as observed during a 15 years period in our own institution, the indications for preoperative PTBD have decreased by half. At present, the majority of treatments with PTBD are palliative (almost 70 % of all procedures). The diagnostic opportunities of the transhepatic approach (intraductal sonography, cholangioscopy, biopsy) are exploited only in few selected cases. Since the radiological approach ist considered to be invasive and related to serious complications most patients are being referred to endoscopic drainage first. Radiologists are consulted in complicated cases of jaundice and when endoscopic approaches have failed. The retrospective evaluation of more than 1000 procedures over a period of 16 years demonstrates good results with a low rate of serious complications. During the two observed periods of nine and seven years, respectively, there occurred complications like sepsis in 1.9 %/0.5 %, peritonitis in 0.5 %/0.7 %, severe bleeding in 0.5 %/1.5 %, procedure-related death in 0.8 %/0.7 %. The overall rate of serious complications was 5 %/3.4 %. These results are comparable to those of the endoscopic approach with a complication rate of 3.6 - 14 % and a mortalitiy rate of 0.5 %.

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Dr. Katja Oberholzer

Klinik für Radiologie, Universitätskliniken der Johannes-Gutenberg-Universität


Langenbeckstraße 1

55131 Mainz

Phone: + 49-6131-172019

Fax: + 49-6131-176633

Email: oberholz@radiologie.klinik.uni-mainz.de