Visceral Medicine最新文献

Background: Thoracic epidural analgesia (TEA) is a key component of Enhanced Recovery After Surgery protocols for major abdominal and thoracic procedures. Despite its benefits for pain management, TEA has been associated with an increased risk of postoperative urinary retention (POUR). Consequently, it is common practice to maintain a urinary catheter (UC) for the duration of TEA. This study aimed to evaluate the impact of early UC removal in patients receiving TEA through a randomized controlled trial.

Methods: In this randomized controlled trial approved by the Rostock University Medical Center Ethics Board (AZ A2018-0220), patients scheduled for elective major abdominal or thoracic surgery with anticipated TEA within 1 year were enrolled. Participants were randomized into two groups: the early removal group (ERG), where the UC was removed within 48 h post-surgery, and the standard group (SG), where the UC was retained until TEA discontinuation. POUR was defined as a residual urine volume of ≥400 mL measured by ultrasound, and catheter-associated urinary tract infections (CAUTIs) were assessed.

Results: Of the 99 patients initially enrolled, 81 patients were available for analysis. In the ERG (n = 43), the UC was removed within 48 h, whereas in the SG (n = 38), the UC was maintained until TEA cessation. The incidence of POUR was similar between the groups, with 1 patient in each group (2.3% in ERG vs. 2.6% in SG, p = 1) requiring recatheterization. CAUTI developed in 4 patients (4.9%), all of whom were in the SG (10.5%), indicating a statistically significant association between the timing of UC removal and CAUTI incidence (p = 0.044).

Conclusion: Our results suggest that early UC removal under TEA is safe and does not significantly increase the risk of POUR while reducing the incidence of CAUTIs. These findings support the feasibility of early UC removal in this patient population and may inform future guidelines on perioperative UC management in the context of TEA.

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.

Introduction: The prediction of occurrence and form of a postoperative pancreatic fistula (POPF) could decrease the risk after pancreatic resections. We developed a score based on histomorphological criteria to predict POPF earlier on. In this study, we test the scoring system to differentiate between patients developing grades B and C POPF.

Methods: We analysed 92 patients who underwent pancreatic head resection and developed a grade B or C POPF postoperatively. There were no exclusion criteria. Pancreatic resection margins were analysed histologically and pancreatic duct size, fibrosis, fat content, and signs of inflammation were transformed into a scoring system.

Results: Patients with a grade B fistula (n = 48) were compared to patients with grade C fistula (n = 44). The grade C group was characterized by higher mortality (0 vs. 22, p < 0.001), postpancreatectomy haemorrhage (3 vs. 24, p < 0.001), longer stays in intensive care unit (2.6 vs. 21.1, p < 0.001) and in hospital (29.8 vs. 44.6, p < 0.001). The scoring system was unable to predict grade C fistula. We calculated receiver operator characteristics for all assessed characteristics, which revealed an area under the curve of 0.561. The strongest predictors of POPF grade C were pancreatic fat and soft pancreatic tissue. A combination of only these two items led to a statistically significant difference (p < 0.001) and an AUC of 0.771.

Conclusion: Establishing a score to differentiate between grade B and grade C POPF is a difficult task. Pancreatic fat seems to be the most relevant histomorphological feature to be used in any scoring system, and it should be combined with other clinical features to enhance its precision and validity.

Background: The functional lumen imaging probe (EndoFLIP), which utilizes impedance planimetry, has emerged as a valuable tool for a more comprehensive evaluation of esophageal physiology and pathophysiology beyond traditional high-resolution manometry.

Summary: EndoFLIP, including its variations EndoFLIP and EsoFLIP, measures intraluminal distensibility and compliance by assessing diameter and distension pressure using balloon catheters.

Key messages: This technology is applicable to various organs such as the esophagus, stomach, and anorectal region, and serves in both diagnostic and therapeutic contexts, especially in ambiguous clinical cases.

Background: Gastrointestinal leaks and fistulae are serious conditions with the potential to be life-threatening, and they are of significant relevance for both endoscopists and surgeons. These conditions may present in a wide variety of ways in clinical settings. These defects may arise from malignant or inflammatory conditions, or may be iatrogenic, occurring after surgery, endoscopic, or radiation therapy. The therapeutic approach to these conditions is often complex and is associated with a high incidence of morbidity. Consequently, in recent years, advances in interventional endoscopic techniques have earned a pivotal role in the management of gastrointestinal defects, both as a first-line treatment and as a rescue therapy. The advent of clips and luminal stents marked the advent of gastrointestinal defect therapy. However, the advent of innovative endoscopic closure devices and techniques, such as endoscopic internal drainage, suturing systems, and vacuum therapy, has broadened the indications of endoscopy for the management of gastrointestinal wall defects. This is because surgical therapy still tends to be complex and is plagued by high rates of morbidity.

Summary: A successful endoscopic management of gastrointestinal leaks and fistulae necessitates a tailored and multidisciplinary approach, based on the aforementioned factors, in addition to local expertise and the availability of devices. Moreover, a standardized evidence-based algorithm for the management of GI defects is still not available. Endotherapy represents a minimally invasive, effective approach with lower morbidity and mortality compared to surgical techniques.

Background: Behaviorally conspicuous "odd" patients have a considerable potential to complicate selection for anti-reflux surgery. This is mainly due to a certain overlap of diseases, like GERD, disorders of gut-brain Interaction, like rumination syndrome, and somatization representing an individually increased perception of bodily complaints. Therefore, some basic insight is required to address these patients properly. Somatization and somatoform disorders are found in patients who report an unusually high number of bodily complaints. They complain about (much) more symptoms than expected from patients with "simple" reflux disease. These patients can be identified by specific instruments, lists of symptoms or also quality-of-life indices. When identified properly, these patients can also benefit from anti-reflux surgery. Other patients suffer from disorders, recently termed as disorders of the gut-brain interaction like belching disorders or rumination syndrome. In the few patients with rumination syndrome, a relevant overlap of at least 10% with gastroesophageal reflux disease exists and must be diagnosed. Apart from reflux disease, rumination syndrome, and supragastric belching are behavioral entities which have recently become amenable to cognitive based mental training. In addition, awareness techniques are advisable (awareness-based cognitive mental stress reduction techniques also exist as digital applications for mobile phones, i.e., for breathing modification techniques).

Key messages: Somatization and rare disorders like belching and rumination syndrome, which are part of the disorders of brain gut interaction, should be recognized and considered in patient selection for anti-reflux surgery.

Background: Pancreatic cancer continues to retain the highest mortality rate among all major organ cancers. New strategies for early detection are being proposed to increase long-term survival. A plethora of molecular markers are discovered yearly, but so far none have demonstrated screening utility.

Summary: Promising discovery technologies include affinity-based proteomics and ddPCR. In the validation phase, researchers must decide on key benchmark criteria, what type of pancreatic lesions are desirable to find early through molecular screening, and when to terminate the biomarker study and return to the discovery phase. If the biomarkers meet set benchmarks, retrospective analysis should be conducted in relevant cohorts based on intended use, followed by prospective real-world evaluation. Lastly, regulatory approval, incorporation into clinical practice guidelines, and thorough health economic evaluations must be completed before the screening markers can be fully implemented.

Key messages: In this review, important strategies and phases for molecular biomarker development in pancreatic cancer have been outlined.