Visceral Medicine最新文献

Background: Achalasia is a motility disorder of the esophagus and depending on its type, esophageal tubular hypo- or hypermotility can cause typical symptoms, such as dysphagia, chest pain, weight loss, or regurgitation. Clinical symptoms during initial diagnosis as well as over the course of therapy can be measured by the Eckardt score. Diagnostics include high-resolution manometry (HR manometry), (timed barium) esophagogram, upper gastrointestinal endoscopy, multiple rapid swallow response, and Endo-FLIP measurement. In this work, we provide a review of the recent literature on surgical treatment of achalasia.

Summary: Besides pharmacological and endoscopic interventions, surgical procedures of laparoscopic/robotic Heller myotomy (LHM/RHM) and 180° anterior Dor's semifundoplication versus 270° dorsal Toupet's fundoplication are primary therapeutic options, especially for type I and II achalasia. Both surgical procedures display little morbidity and mortality. Postsurgical results are comparable between LHM and RHM. RHM allows better angulation during myotomy, lower rates of intraoperative mucosal laceration, and better visualization of the muscles in the lower esophageal sphincter area. Surgery can also be performed safely after failed endoscopic treatments.

Key messages: Surgery in achalasia is especially indicated in patients ≤40 years and also recommended after repeated unsuccessful or complicated endoscopic interventions. In selected patients with end-stage achalasia and sigmoid-shaped megaesophagus, esophagectomy is a reasonable option in order to improve quality of life.

Background: Disorders of the gut-brain axis are public diseases ("Volkskrankheiten") and are among the most frequent reasons to visit a doctor. Despite their great medical and socio-economic importance, patients suffering from these disorders are often not taken seriously and, therefore, do not receive sufficient diagnostic evaluation, or a diagnosis, in conformity with the relevant guidelines. In addition, the inadequate compensation of services makes handling of neurogastroenterological disorders increasingly unattractive. As a result, neurogastroenterology is under-represented in medical curricula, with a decreasing number of scientists in academia who are familiar with this field in Germany.

Summary: The prevalence of neurogastroenterological diseases, which is associated with the need for medical care, should create corresponding care as a "bottom-up" development. However, this is not possible in the German healthcare system, due to the inadequate reimbursement structures. Therefore, a "top-down" strategy must be developed through health policy directives, directing the establishment of neurogastroenterology units based on quality parameters and need. These centers must form comprehensive network structures and share essential information on neurogastroenterological diseases with general practitioners, clinicians, and patients. Appropriate apps that also focus on interdisciplinary care with the involvement of various specialist disciplines (e.g., gastroenterology, neurology, gynecology, urology, psychology, psychosomatics, nutritional medicine) would be helpful for this purpose.

Key messages: Neurogastroenterology units are important and should be interdisciplinary and located in tertiary centers. Due to the lack of incentives in the German healthcare system, they must be instituted through health policy directives from the top down.

Background: The prevalence of neurogastroenterological diseases, i.e., disorders of gut brain interaction, has increased over the last decades. Altered gastrointestinal (GI) motility is a key feature of this group of diseases and is affecting all anatomical segments of the GI tract, ranging from swallowing disorders to fecal incontinence. Considering the ongoing demographic transformation in developed countries worldwide, it is highly relevant to understand the age-dependency of motility disorders per se and its pathophysiological mechanisms with a special focus on neurodegeneration. This review summarizes the most relevant findings and open research questions in the field of age-dependent changes in GI motility with a strong focus on studies performed on humans or with biological material obtained from humans.

Summary: While the basic function of the GI tract including motility in most of its segments is largely unaltered by aging per se, there is clear evidence supporting an age-dependent increase in the prevalence of constipation and fecal incontinence, the latter mainly affecting women. When, however, the large percentage of elderly patients suffering from frequent chronic diseases such as diabetes, Parkinson's disease, or cerebrovascular disease are included, a clear increase in "secondary" motility disorders also affecting the esophagus or the stomach is evident. Studies regarding the pathophysiology of geriatric dysmotility are often limited by the heterogenous clinical history of the studied patients and by coincident impairments of interoceptive sensory function. However, a loss in the number of cholinergic neurons together with changes in the number of interstitial cells of Cajal, certain subtypes of enteric glia, changes in immune cell function, and changes in the endocrine signaling throughout the GI tract have been reported.

Key messages: The overall prevalence of swallowing disorders, impaired gastric emptying, constipation and fecal incontinence is high among elderly patients. The pathophysiology most likely includes a variety of factors ranging from degeneration of enteric neurons and the non-neuronal cell populations involved in GI motility up to age-dependent metabolic and neuroendocrine changes and dietary factors. Deciphering the effects of "healthy aging" but also of the numerous typical chronic diseases of the elderly on GI motility is an ongoing challenge and prerequisite for improving patients' medical care and quality of life.

Background: Gastroesophageal reflux disease (GERD) is common. Management of reflux symptoms includes medical and nonmedical interventions. Proton pump inhibitors (PPIs) continue to be considered first-line agents. Standard investigations to diagnose GERD include upper endoscopy, impedance-pH measurement or capsule-based pH measurements and high-resolution manometry. However, diagnosis can sometimes be difficult in individual cases when measurements yield borderline results. Combination of the three mentioned techniques is considered the diagnostic gold standard now.

Summary: Aside from the current measures considered gold standard, new measurement parameters, mostly focusing on impedance of the esophageal mucosa will help better diagnose GERD. Another promising new modality is the combination of wireless pH measurements and evaluation of esophageal motility and structural abnormalities using the endoscopic functional lumen imaging probe (FLIP). Artificial intelligence may play an increasingly supportive role.

Key messages: GERD needs to be better diagnosed to avoid unnecessary or potentially harmful long-term acid suppression therapy or reflux surgery. A number of tools is under investigation. However, as of now they only have supportive value.

Background: Gastro-oesophageal reflux disease (GORD) is extremely common, with at least 1 in 10 people in the general population reporting heartburn and acid regurgitation on a weekly basis. GORD can also be associated with a variety of atypical symptoms, including chest pain, chronic cough, and laryngopharyngeal symptoms. The causes of GORD are multifactorial, and the severity of symptoms is influenced by peripheral and central factors, including psychosocial stress and anxiety. Therefore, for a variety of reasons, no single investigation provides a definitive diagnosis, and standard treatment with acid suppressants is not always effective.

Summary: This review introduces the Lyon Consensus, now in its second iteration, a classification system that provides a "conclusive" positive or negative diagnosis of GORD by integrating the results of endoscopy, ambulatory reflux monitoring, and high-resolution manometry. Different algorithms are applied to patients with high and low pre-test probability of a causal relationship between reflux episodes and patient symptoms. The results of these studies identify patients with "actionable" results that require escalation, revision, or discontinuation of GORD treatment. Guidance is provided on the range of conservative treatments available for GORD, including dietary and lifestyle advice, antacids and alginates, and drugs that suppress acid secretion.

Key messages: GORD is a common disorder; however, the causes of reflux and symptoms can be complex. As a result, the diagnosis can be missed, and management is sometimes challenging, especially for patients with atypical symptoms. The Lyon classification establishes a conclusive diagnosis of GORD, based on results of endoscopic and physiological investigation. Typical symptoms usually respond to empiric use of alginate-antacid preparations and acid suppression; however, the management of treatment refractory symptoms is tailored to the individual.

Background: Fecal incontinence (FI) is a frequent, often underestimated, health issue in adults. Its treatment is primarily nonsurgical. Only if conservative options fail to result in adequate symptom reduction should surgery be considered. We present an overview of historical and current surgical treatment options.

Summary: Well-known sphincter replacement techniques such as dynamic graciloplasty and the artificial bowel sphincter are no longer used because of their invasiveness and relevant comorbidity. Today, sphincteroplasty and sacral neuromodulation (SNM) are the most common procedures recommended in current guidelines. The therapeutic choice is based on diagnostic findings. Sphincteroplasty is an option only in patients with an anal sphincter lesion and has only moderate long-term success. SNM has become the established first choice in multiple pathophysiological conditions resulting in FI, as it has proved highly successful with minimal invasiveness. Over time, the spectrum of indications has evolved and the technique is now successful in morphological sphincter defects as well.

Key messages: The spectrum of surgical options to treat FI is limited. Owing to its efficacy and low comorbidity, SNM is now considered the gold standard in multiple pathophysiological and morphological conditions, whereas sphincteroplasty remains an option in patients with FI from a defined sphincter lesion.

Background: Fecal incontinence is a common problem especially in the elderly resulting in a reduced quality of life.

Summary: The etiology of fecal incontinence is often multifactorial with little options for a causal therapy. The mechanisms causing incontinence can be detected by sophisticated methods in most of the patients. Using therapeutic algorithms, incontinence can be improved or even continence restored in many patients.

Key messages: Diagnostic work-up starts with history, digital investigation, and anoproctoscopy. The specialist will further investigate with anorectal manometry, anal endosonography, and electromyography of the external anal sphincter muscle. Nonoperative therapy comprises hygienic methods, medical therapy, intraanal electrostimulation, and training methods like pelvic floor exercises or biofeedback. Second-line conservative therapies are tibial nerve stimulation, transanal irrigation, or anal inserts.

Introduction: As natural calcium (Ca) antagonist, magnesium (Mg) seems to counteract Ca-signaling pathways involved in the intracellular protease activation leading to acute pancreatitis. We systematically reviewed the current literature to investigate the role of Mg in the pathogenesis of acute pancreatitis and its possible use in detecting, predicting, and preventing acute pancreatitis.

Methods: A systematic search was performed in PubMed/Scopus/Web of Science to identify in vivo and in vitro studies reporting data on Mg in acute pancreatitis.

Results: Twelve studies were included. Due to their heterogeneity, we conducted a review without the intent of inference. Mg deficiency in pancreatic acinar cells seems to be frequently associated with serum hypocalcemia and acute pancreatitis. Mg seems to contrast intracellular Ca accumulation which induces premature enzyme activation and acute pancreatitis. Several in vivo and in vitro experiments showed beneficial effects of Mg supplementation in counteracting Ca-signaling pathways and subsequent pathological events. Moreover, a recent randomized trial demonstrated the efficacy of Mg supplementation in reducing the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in high-risk patients.

Conclusion: Mg is a natural antagonist of Ca-signaling pathways and, when deficient, predisposes to acute pancreatitis. Mg supplementation may be useful to prevent acute pancreatitis in many contexts, such as post-ERCP or after pancreatic surgery. The heterogeneity of the included studies represents an important limitation that may hinder robust conclusions.