Visceral Medicine最新文献

Background: Alveolar echinococcosis (AE) is a rare but potentially life-threatening parasitic disease caused by the larval stage of Echinococcus multilocularis, primarily affecting the liver with infiltrative, tumor-like growth. Sectional imaging plays a pivotal role in diagnosis, staging, and treatment planning. This study aimed to systematically evaluate the initial imaging findings in a cohort of patients with suspected AE, focusing on morphological and metabolic imaging features and their implications for staging and therapeutic decision-making.

Methods: We retrospectively analyzed all patients who presented with suspected AE at the University Hospital Ulm between January 2019 and December 2023 and had F-18-fluorodeoxyglucose positron emission tomography (F-18-FDG-PET/computed tomography [CT] or PET/ magnetic resonance imaging [MRI]) and/or MRI within 6 months of presentation. PET imaging was visually assessed for increased FDG uptake as a marker of metabolic activity. Lesions were classified according to the Kodama MRI classification. Imaging-based staging was performed using the PNM classification and compared with the clinical PNM stage.

Results: A total of 203 patients were included. PET imaging was performed in 198 cases (97.5%), while MRI was available in 94 patients (46.3%). Kodama types 2 (n = 30) and 3 (n = 55) were the most frequent lesion types. In the subgroup with both PET and MRI imaging (n = 89), PET activity was observed in 96.4% of Kodama type 2 and 90.6% of type 3 lesions, while no FDG uptake was noted in type 5 lesions. Imaging-based PNM classification disagreed with clinical staging in 56 cases (27.6%), likely due to standardized review by experienced radiologists and nuclear medicine specialists. PET/CT proved valuable for assessing extrahepatic and distant involvement, offering a whole-body evaluation that was more consistent than MRI, which often varied in protocol and anatomical coverage.

Conclusion: F-18-FDG-PET/CT is a cornerstone in the initial diagnostic workup and staging of AE, enabling both assessment of disease extent and evaluation of inflammatory activity in specialized centers. While MRI provides essential morphological details, its limited availability and heterogeneous acquisition protocols reduce its utility for comprehensive staging. Kodama lesion types correlate with metabolic activity, but further studies are needed to clarify their prognostic relevance. Our findings underscore the importance of standardized imaging protocols and the central role of PET/CT in managing newly diagnosed AE.

Background: Echinococcosis is a parasitic disease, caused by the larval stage of the genus Echinococcus. Echinococcus multilocularis and Echinococcus granulosus cause alveolar echinococcosis (AE) and cystic echinococcosis (CE) in humans. Pathologists may be confronted with the larval stage of both species. Diagnosis may be difficult due to the low incidence in daily routine. However, right diagnosis of the pathologist is still the gold standard and crucial for further treatment of the patient.

Summary: Macroscopically, specimens of AE show multiple small cysts and a bread-like appearance. Instead, CE manifests as solitary or multiple grape-like cysts. In this review, we give a short algorithm for the differential diagnosis on histological grounds. Hematoxylin and eosin staining is supported by an additional periodic acid-Schiff (PAS) staining, highlighting the laminated layer (LL) as key microscopic structure. Lymphocytes and fibrosis are present at the interface with the adjoining liver tissue. The main difference lies in the morphology of the LL. In the PAS staining, this deeply violet structure is fragmented and thin in AE, while in CE, it is broad and striated. Further important characteristics are the size of the cysts and the pericystic fibrosis. The different types of CT lesions correspond to different histological features. Treatment with benzimidazoles may influence morphology. Immunohistochemistry (IHC) with the monoclonal antibodies (mAbs) EmG3 and Em2G11 shows differences in staining patterns regarding AE and CE. IHC is decisive to settle the diagnosis in unclear situations and when only small particles of E. multilocularis (SPEMS) or E. granulosus (SPEGS) are present, e.g., in lymph nodes.

Key messages: The PAS-positive LL is the microscopic hallmark for the differential diagnosis of AE/CE. For further support in unclear situations, IHC with mAb EmG3 and mAb Em2G11 is advised.

Introduction: Hirschsprung's disease is a congenital anomaly affecting intestinal motility. Its main characteristic is the absence of ganglion cells in the distal colon, which results in chronic constipation. To date, confirmatory biopsies in the pediatric population have been obtained through suction biopsies or open surgical procedures. Therapeutic endoscopic full-thickness resection (EFTR) has been successfully used in adult endoscopy to treat various diseases of the lower gastrointestinal tract. This procedure has been shown to be safe and effective.

Methods: A single-center retrospective case series study from May 2024 to September 2025, including 13 pediatric patients aged 3.5-14.4 years (median 9.5 years) with therapy-refractory constipation, who underwent an EFTR biopsy using Ovesco diagnostic FTRD® as part of the diagnostic workup for Hirschsprung's disease. EFTR was performed in the distal rectum, 2 cm above the linea dentata, to exclude an ultrashort variant of Hirschsprung's disease.

Results: All EFTR procedures were successful, and only 1 patient had non-hemodynamically relevant rectal bleeding during the 1-year follow-up. All biopsies fulfilled the requirements to validate or exclude Hirschsprung's disease, showing an excellent success rate of full-thickness resection (100%).

Conclusions: This is the first case series of EFTR using the Ovesco diagnostic FTRD® technique in pediatric patients for the diagnosis of Hirschsprung's disease. EFTR is a safe, time-saving, and successful method that can be used to diagnose Hirschsprung's disease in pediatric patients starting from 3 years of age.

Background: Pancreatic cancer remains the fourth leading cause of cancer-related deaths in the USA despite its lower incidence, primarily due to late-stage diagnosis. While early detection could double survival rates, screening the general population is not cost-effective due to low disease prevalence and technical limitations.

Summary: This review examines the relationship between diabetes and pancreatic cancer, highlighting how diabetes types differently impact cancer risk. New-onset diabetes triples pancreatic cancer risk compared to the general population, while long-standing diabetes doubles it. Several prediction models have been developed to identify high-risk individuals among new-onset diabetes patients, with recent models achieving AUCs up to 0.91. Current biomarkers like CA 19-9 show improved utility when combined with other clinical parameters, though they remain inadequate for general population screening. Cost-effectiveness analysis suggests that screening becomes viable when 3-year cancer incidence exceeds 2% and 25% of cases are detected at a localized stage.

Key messages: (1) New-onset diabetes presents a stronger risk factor for pancreatic cancer than long-standing diabetes. (2) Multiple prediction models show promise but face challenges with missing data and cross-population validation. (3) Integrated approaches combining clinical parameters, biomarkers, and machine learning offer the most promising path forward for early detection. (4) Current detection rates fall below cost-effectiveness thresholds, highlighting the need for improved screening strategies.

Background: Although they are evaluated in the same disease spectrum, the physiopathologies, diagnoses, treatment management strategies, and prognoses of AE and CE differ completely. Management of both diseases requires a multidisciplinary approach involving many branches such as surgery, interventional radiology, gastroenterology, anesthesia, and infectious diseases. The technical success of any AE or CE treatment depends largely on the technical skills and experience of the surgeon, gastroenterologist, or interventional radiologist, but the clinical success of the treatment depends on multidisciplinary collaboration to prevent and manage complications.

Summary: For liver CE, successful treatment results is achieved through three established percutaneous techniques The evaluation of percutaneous treatment outcomes should be based on the types of liver CE cysts, categorized into two groups according to the World Health Organization Informal Working Group on Echinococcosis (WHO-IWGE) classification: the first group includes CE1 and CE3a, while the second group encompasses CE2 and CE3b. Liver CE1 and CE3a cysts are treated using either Puncture, Aspiration, Injection, Reaspiration (PAIR) or catheterization techniques, with success rates reaching as high as 96% and recurrence rates as low as 4%. Modified catheterization (Mo-CAT) technique is a highly effective, safe, and successful option for treating CE2 and CE3b liver cysts. Although percutaneous interventional radiologic techniques have largely taken the place of surgery in treating patients with liver CE, radical surgery is the only cure option for AE. Partial hepatectomy or liver transplantation constitutes the primary therapeutic approach. Nevertheless, owing to the insidious nature of disease progression, diagnosis frequently occurs at an unresectable stage. In such instances, involvement of the biliary ducts and vascular structures, along with central necrosis of the lesion, may give rise to severe complications, including cholangitis, hepatic abscesses, portal hypertension, Budd-Chiari syndrome, biliary cirrhosis, and secondary infections, all of which can adversely affect both morbidity and mortality. Interventional radiologist is responsible for diagnosing the disease using radiological imaging methods (such as ultrasound, BT, and MRI), performing imaging-guided biopsy for definitive diagnosis, evaluating the resectability, managing both pre and postoperative biliary/vascular complications, and finally monitoring the disease progress.

Key messages: Liver CE management: percutaneous techniques such as PAIR or standard catheterization are preferred as first choice for treating CE1 and CE3a cysts. CE2 and CE3b (Gharbi type III) cysts can be treated with Mo-CAT technique as an alternative to surgery. Liver AE management: radical surgery is curative, but interventional radiology provides critical palliative care and enhances the

Background: Anastomotic leaks and fistulas are a feared and challenging postoperative complication in colorectal surgery. Traditionally managed with protective ileostomy and revisional surgery, less-invasive endoscopic approaches are increasingly being utilized.

Summary: This article provides a comprehensive overview of current endoscopic treatment principles for managing anastomotic leaks after colorectal surgery. These approaches can be categorized into three main strategies: endoscopic negative pressure therapy - using negative pressure via polyurethane foam drains to promote wound healing and drain secretions; direct closure techniques - including endoscopic suturing systems (e.g., OverStitch) and clipping devices (e.g., over-the-scope clip) to approximate tissue and close defects; and vacuum stenting - a hybrid approach that combines negative pressure therapy with defect coverage using a covered self-expanding metal mesh stent (VAC-stent). Each method offers unique advantages depending on the leak characteristics and timing of detection. Early diagnosis and individualized treatment selection are critical to successful outcomes.

Key messages: Endoscopic treatment of anastomotic insufficiencies represents a minimally invasive, effective and safe alternative to traditional surgical interventions, particularly in clinically stable patients.

Background: Proctological diseases are highly prevalent during pregnancy, with reported incidence rates ranging from 45% to 68%. The true prevalence is likely higher due to underreporting. These conditions frequently persist into the postpartum period, causing significant discomfort and emotional distress. Physiological changes in the maternal body - including hormonal, metabolic, immunological, and cardiovascular alterations - play a central role in the development of these disorders. The enlargement of the uterus, increased blood volume, and elevated pressure in the pelvic veins contribute to venous stasis in the hemorrhoidal plexus, thereby predisposing pregnant individuals to symptomatic hemorrhoids and perianal thromboses.

Summary: The most frequently reported symptoms are anal pain and constipation. Anal pain, which is often intense, is commonly associated with constipation and is due to the high density of sensory nerve endings in the anal canal. Constipation affects more than 60% of pregnant women, primarily as a result of hormonal changes, decreased physical activity, and iron supplementation. Straining during defecation further aggravates proctological conditions, facilitating the development of hemorrhoids, anal fissures, and perianal thrombosis. Diagnosis should include a thorough medical history, physical examination, and proctoscopy. In selected cases, additional imaging may be warranted. Conservative treatment is the mainstay of management, with a focus on symptom control and regulation of bowel habits. Hemorrhoidal disease is particularly common during pregnancy. Conservative treatment includes increased fluid intake, the use of stool softeners, and local cooling measures. Surgical interventions should be reserved for refractory cases and only considered when absolutely necessary. Anal fissures, the second most prevalent condition after hemorrhoids, are primarily caused by constipation. First-line treatment involves stool regulation, analgesic therapy, and the application of topical ointments. While chronic fissures may occasionally require surgical intervention, noninvasive approaches are strongly preferred to minimize risks. Perianal thrombosis, often misdiagnosed as thrombosed external hemorrhoids, typically occurs in the third trimester or shortly after delivery. Conservative therapy is generally effective, focusing on pain control. In selected cases, surgical excision of thrombosed nodules may be indicated.

Key messages: In summary, proctological conditions during pregnancy are common but usually manageable through accurate diagnosis, conservative treatment, and empathetic patient support. Prioritizing symptom relief and avoiding unnecessary surgical interventions are essential to achieving favorable outcomes.