Viszeralmedizin最新文献

Physiological digestion and absorption of nutrients within the gastrointestinal tract requires a complex interaction between motor, secretory, digestive, and absorptive functions that is vulnerable to a multitude of potential disturbances which may lead to global or specific malabsorption syndromes. Potential pathomechanisms that are illustrated in this article include insufficient mechanical breakdown of harder food components due to chewing problems and/or decreased antral contractility, critical reduction of time for absorption in patients with markedly enhanced upper gastrointestinal transit (e.g. dumping syndrome), impaired digestion and absorption of nutrient components caused by reduced gastric acid secretion, pancreatic exocrine insufficiency or reduced biliary secretion, defects of the enteral mucosa with enzyme deficiencies (e.g. disaccharidases) or lack of specific carrier mechanisms (e.g. hexose or aminoacid transporters), and critical quantitative loss of intestinal mucosa in patients with short bowel syndrome.

Background: The pancreas has a central function in digestion and glucose homeostasis. With regard to the exocrine function, which is responsible for the digestion and absorption of nutrients and vitamins, the most important disturbances of these physiological processes are based on deficiencies in enzyme production and secretion, either due to impaired excretion caused by obstruction of the pancreatic duct or due to loss of pancreatic tissue. Both conditions result in maldigestion, malabsorption, and malnutrition.

Methods: Systematic literature review.

Results: Symptoms associated with pancreatic exocrine failure are gastrointestinal discomfort, steatorrhea, and weight loss. Pancreatic exocrine insufficiency caused by ductal obstruction occurs in chronic pancreatitis or with neoplasia of the pancreatic head. Loss of functional parenchyma can be caused either by chronic pancreatitis resulting in fibrotic replacement of the destroyed parenchyma or by a postoperative state of pancreatic resection.

Conclusion: In patients with chronic pancreatitis, a stage-adapted and timely therapy including conservative as well as surgical measures is essential to prevent functional deterioration and to preserve residual function. In the case of pancreatic resection for chronic pancreatitis, this can be achieved with modern organ-sparing surgery such as the duodenum-preserving pancreatic head resection. In patients requiring more extended pancreatic resections and even total duodenopancreatectomy, regardless of the underlying indication, adequate enzyme replacement and monitoring of the nutritional status is critical to prevent impairment of quality of life as well as detrimental malnutrition in the long term.

Coeliac disease (CD) is one of the most common diseases worldwide, resulting from a combination of environmental (gluten) and genetic (human leucocyte antigen (HLA) and non-HLA genes) factors. Depending on the geographical location, the prevalence of CD has been estimated to approximate 0.5-1%. The only treatment currently available for CD is a gluten-free diet (GFD) excluding gluten-containing cereals such as wheat, rye, and barley, and other foodstuffs with natural or added gluten. However, adherence rates and patient acceptance are often poor. Moreover, even in fully adherent patients, the diet may fail to induce clinical or histological improvement. Hence, it is unsurprising that studies show CD patients to be highly interested in non-dietary alternatives. The following review focuses on current pathophysiological concepts of CD, spotlighting those pathways which may serve as new possible, non-dietary therapeutic targets in the treatment of CD.

Background: Whipple's disease (WD) is rarely the cause of a malabsorption syndrome. The disease is a chronic infection of the intestinal mucosa with the bacterium Tropheryma whipplei, which leads to a lymphostasis with an impaired absorption of the nutrition. Due to its low incidence (1:1,000,000) and the non-specific early symptoms, the disease is often diagnosed only after many years.

Methods: Based on a selective literature review and the clinical experience of the authors, the current knowledge of WD regarding pathogenesis, clinical presentation, diagnosis, and therapy are presented in this paper.

Results: Recent studies suggest that a host-specific dysfunction of the intestinal macrophages is responsible for the chronic infection with T. whipplei. Prior to patients reporting symptoms of a malabsorption syndrome (chronic diarrhea/steatorhea, weight loss), they often suffer from non-specific symptoms (polyarthralgia, fever, fatigue) for many years. Misdiagnoses such as seronegative polyarthritis are frequent. Furthermore, neurological, cardiac, ocular, or dermatological symptoms may occur. The standard method concerning diagnosis is the detection of PAS(periodic acid-Schiff)-positive macrophages in the affected tissues. Immunohistochemical staining and PCR(polymerase chain reaction)-based genetic analysis increase the sensitivity and specificity of conventional detection methods. Endoscopically, the intestinal mucosa appears edematous with lymphangiectasias, enlarged villi, and white-yellowish ring-like structures. The German treatment recommendations include a two-week intravenous induction therapy with ceftriaxone, which is followed by a three-month oral maintenance therapy with trimethoprim/sulfamethoxazole.

Conclusion: WD is rarely responsible for a malabsorption syndrome. However, if WD is not recognized, the disease can be lethal. New diagnostic methods and prospectively approved therapeutic concepts allow an adequate treatment of the patient. Due to the host-specific susceptibility to T. whipplei, a lifelong follow-up is necessary.

Background: Short bowel syndrome (SBS) is a state of malabsorption resulting from massive small bowel resection leading to parenteral nutrition (PN) dependency. Considerable advances have been achieved in the medical and surgical management of SBS over the last few decades.

Methods: This review discusses in detail the surgical approach to SBS.

Results: Widespread use of PN enables long-term survival in patients with intestinal failure but at the cost of PN-associated life-threatening complications including catheter-associated blood stream infection, venous thrombosis, and liver disease. The goal of management of intestinal failure due to SBS is to enable enteral autonomy and wean PN by means of a multi-disciplinary approach. Availability of modified enteral feeding formulas have simplified nutrition supplementation in SBS patients. Similarly, advances in the medical field have made medications like growth hormone and glucagon-like peptide (GLP2) available to improve water and nutrient absorption as well as to enable achieving enteral autonomy. Autologous gastrointestinal reconstruction (AGIR) includes various techniques which manipulate the bowel surgically to facilitate the bowel adaptation process and restoration of enteral nutrition. Ultimately, intestinal transplantation can serve as the last option for the cure of intestinal failure when selectively applied.

Conclusion: SBS continues to be a challenging medical problem. Best patient outcomes can be achieved through an individualized plan, using various AGIR techniques to complement each other, and intestinal transplantation as a last resort for cure. Maximum benefit and improved outcomes can be achieved by caring for SBS patients at highly specialized intestinal rehabilitation centers.

Background: The short bowel syndrome (SBS) is a condition caused by extensive intestinal resection for a variety of conditions. The etiology varies by age group. Necrotizing enterocolitis is the leading cause in infants. In older children, trauma and malignancies are most common. Postoperative SBS has become most common in adults, followed by mesenteric vascular disease and cancer/irradiation.

Methods: Systematic literature review.

Results: Prevention of SBS should be given high priority. Each of the etiologies has been evaluated and strategies to prevent extensive resection have been developed. These include a thoughtful approach to reoperation, early identification of complications, e.g. intestinal ischemia, reducing radiation enteritis, and bowel-conserving therapies in diseases such as Crohn's disease.

Conclusion: Several operative strategies to prevent SBS are useful. Timing and extent of reoperation need careful consideration. Minimizing intestinal resection, bowel-conserving techniques for complications such as fistula or strictures, and remodeling procedures are important.

Background: The purpose of this study was to describe as well as compare our surgical treatment experiences of solid pseudopapillary neoplasms (SPN) of the pancreas and to provide a review of the literature.

Methods: A retrospective analysis of data from Vilnius University Hospital Santariskiu Klinikos (VUH SK) and of the literature, which was researched using Karger Publishers, Springer Science, BioMed Central, and disserCat databases, was conducted.

Results: From 2001 to 2012, seven cases were identified with pathologically confirmed SPN diagnosis. A precise preoperative diagnosis was made by computertomography and magnetic resonance imaging. The median diameter of the tumors was 6.36 cm (range 1.5-12 cm). Surgical treatment was undertaken for all patients. Results of the immunohistochemical analysis confirmed a nuclear accumulation of β-catenin. The Ki-67 level was 1-2% in all of the cases. According to our collected data, all types of histological analysis revealed decent prognostic behavior with low mitotic activity (1-2 mitoses per 50 high power fields). Besides, angioinvasion, perineural invasion, and outside capsule invasion were not detected.

Conclusions: There was no correlation between more aggressive types of SPN and tumor size, localization, age, and gender.

Background: Since the beginning of the new millennium gender medicine has become more and more relevant. The goal has been to unveil differences in presentation, treatment response, and prognosis of men and women with regard to various diseases.

Methods: This study encompassed 1,061 patients who underwent surgery for rectal cancer at the Department of Surgery, University Medical Center Schleswig-Holstein Campus Lübeck, Germany, between January 1990 and December 2011. Prospectively documented demographic, clinical, pathological, and follow-up data were obtained. Analysis encompassed the comparison of clinical, histopathological, and oncological parameters with regard to the subcohorts of male and female patients.

Results: No statistically significant differences could be found for clinical and histopathological parameters, location of tumor, resection with or without anastomosis, palliative or curative treatment, conversion rates, duration of surgery, and long-term survival. For the entire cohort, gender-related statistically significant differences in complications encompassed anastomotic leakage, burst abdomen, pneumonia, and urinary tract complications all of which occurred more often in men.

Conclusion: Data obtained in this study suggest that there are no gender-related differences in the oncologic surgical treatment of patients with rectal carcinoma. However, male sex seems to be a risk factor for increased early postoperative morbidity.