Visceral Medicine最新文献

Background: The prevalence of nonalcoholic fatty liver disease (NAFLD) is increasing and strongly associated with the metabolic syndrome, especially with obesity. A subtype, nonalcoholic steatohepatitis (NASH), might progress to advanced fibrosis and cirrhosis. NASH patients have an increased all-cause mortality. First and foremost are malignancies, followed by cardiovascular diseases.

Summary: The NAFLD fibrosis score and noninvasive liver stiffness measurement (transient hepatic elastography) are essential components for the diagnostic risk assessment of NAFLD patients. Other steatoses (alcohol, genetic disorders, drugs, toxins, malnutrition, etc.) must be considered in the differential diagnosis. So far, there is no approved liver-specific drug therapy with a proven effect on NAFLD for patients without diabetes mellitus. Obeticholic acid (FXR agonist), cenicriviroc (a dual inhibitor of the chemokine receptors (CCR), CCR2 and CCR5), acetyl-CoA carboxylase inhibitors, and several thyroid hormone analogs are the most advanced substances in clinical development in ongoing phase 2 and 3 studies.

Key messages: Weight loss, physical training, and the screening and treatment of risk factors represent the cornerstones of NAFLD therapy. Treatment with glucagon-like peptide 1 analogs (e.g., liraglutide, semaglutide) and sodium-dependent glucose transporter 2 inhibitors can be recommended in patients with diabetes and NASH.

Background: Gastric cancer (GC) is associated with a poor prognosis mostly due to peritoneal metastasis, which will develop in time during the patient's disease history. To prevent and treat peritoneal metastasis, different kinds of treatment regimens have been described.

Summary: In this review, we addressed two main topics - prophylaxis and treatment of peritoneal metastasis in GC. Prevention should be directed towards diminishing cancer cell spillage and reducing adherence of cancer cells to the abdominal cavity. Postoperative washing of the abdomen with or without chemotherapy and additional heat are herein discussed.

Key messages: Treatment of existing peritoneal metastasis is effective in patients with limited disease and tumour spread. Cytoreductive surgery including resection of peritoneal metastasis followed directly with hyperthermic intraperitoneal chemotherapy can increase overall survival and progression-free survival in selected patients. Drugs, duration and time schedules of intraperitoneal chemotherapy are reviewed and presented. Intraperitoneal chemotherapy seems to improve the prognosis of patients with GC and peritoneal metastasis after complete resection of both primary and metastatic tumours.

Background: Recurrence after resection of pancreatic cancer occurs in up to 80% of patients in the first 2 years after complete resection. While most patients are not eligible for surgical treatment due to disseminated disease, a certain group of patients can be evaluated for re-resection of local recurrence. This review summarizes the current literature on surgical treatment of recurrent pancreatic cancer and potential prognostic factors.

Summary: Re-resection of recurrent pancreatic cancer provides a significant survival benefit to selected patients with acceptable procedure-related mortality. Median overall survival after re-resection of recurrent pancreatic cancer is up to 28 months. The most relevant clinical parameters associated with a prognostic benefit are young patient age (<65 years), time to initial resection (>10 months), and preoperative chemotherapy before re-resection. Molecular markers are currently under investigation and might help to improve patient selection in the future.

Key message: Re-resection of recurrent pancreatic cancer is safe and feasible in experienced hands. Selected patients benefit from surgical treatment, but future studies are needed to identify reliable prognostic markers predicting survival.

Background: Obesity and metabolic disorders as type 2 diabetes (T2D), nonalcoholic fatty liver disease (NAFLD) or better called metabolic dysfunction fatty liver disease (MAFLD), arterial hypertension (AHT), and obstructive sleep apnea syndrome (OSAS) show a rising prevalence. The increased cardiovascular risk is one of the main causes for death of obese, metabolic ill patients. Sustainable and efficient therapeutic options are needed.

Summary: Metabolic surgery not only permits a substantial and lasting weight loss but also ameliorates metabolic co-morbidities and reduces cardiovascular risk and mortality of obese patients. Most existing data focused on T2D, but evidence for other metabolic co-morbidities such as NAFLD, AHT, and OSAS increase constantly. After metabolic surgery, glycemic control of diabetic patients is superior compared to conservative treatment. Also, diabetes related micro- and macrovascular complications are reduced after surgery, and the median life expectancy is over 9 years longer. In patients with MAFLD, metabolic surgery leads to reduction of steatosis and fibrosis while the risk to develop a hepatocellular carcinoma is reduced significantly. Patients with OSAS have an improved lung function and continuous pressure airway treatment during the night is unnecessary in many patients. Patients with AHT need significantly less or even no antihypertensive medication after surgery and the hazard ratio of death is reduced by 49.2%. Therefore, the focus in treating obese and metabolic ill patients is no longer on pure weight loss but on improvement of co-morbidities and reduction of mortality. This is reflected by the updated S3-guidelines of 2018 that provide nationally established consistent guidelines with clear indications for metabolic surgery no longer focusing on body mass index (BMI) only. This article aims to give an overview over the existing literature concerning surgical treatment options for metabolic syndrome.

Key messages: Metabolic co-morbidities impact life-quality and life expectancy of obese patients. Metabolic surgery offers the chance to treat those metabolic co-morbidities independently of the preoperative BMI and should be considered early as a treatment option for obese patients.

Background: The advent of next-generation sequencing technologies has enabled the identification of molecular subtypes of pancreatic ductal adenocarcinoma (PDAC) with different biological traits and clinically targetable features.

Summary: Although current chemotherapy trials are currently exploiting this knowledge, these molecular subtypes have not yet sufficiently caught the attention of surgeons. In fact, integration of these molecular subtypes into the timing of surgery can in theory improve patient outcome. Here, we present the molecular subtypes of PDAC from the surgeon's perspective and a clinically applicable algorithm that integrates the molecular subtyping of PDAC preoperatively into the decision of primary surgery versus neoadjuvant therapy. Furthermore, we point out the potential of "tailored" (in addition to conventional) neoadjuvant treatment for exploiting the molecular subtypes of PDAC.

Key messages: We believe that for surgeons, the preoperative knowledge on the subtype of PDAC can properly guide in deciding between upfront surgery versus neoadjuvant treatment for improving patient outcome.