Visceral Medicine最新文献

Background: Alveolar echinococcosis (AE) is a rare, potentially fatal zoonosis. In recent years, imaging diagnostics have become increasingly important compared to serologic diagnostics in AE. We will provide an overview of the importance of ultrasound diagnostics in AE in the detection of the disease and its significance in follow-up, as well as the typical sonographic presentation patterns and pitfalls.

Summary: The use of the ultrasound classification developed by us and the use of contrast-enhanced ultrasound (CEUS) helps make the diagnosis faster and better. Without CEUS, the hemangioma-like pattern and the metastasis-like pattern in particular cannot be diagnosed with certainty. The limitations of ultrasound diagnostics on the patient side, in terms of examiner experience and equipment, remain.

Key messages: Ultrasound is an important procedure in the detection and follow-up of AE. Contrast-enhanced sonography is indispensable. Fundamental limitations of ultrasound diagnostics such as examiner experience remain.

Background: Pancreatic ductal adenocarcinoma (PDAC) is characterized by a poor prognosis, with a high mortality rate often attributed to its late-stage diagnosis. Early detection remains paramount in improving survival outcomes for affected individuals.

Summary: The prognosis of PDAC can be significantly improved if the cancer is diagnosed at an early stage, specifically when it remains localized to the ductal epithelium. This early stage is commonly referred to as high-grade pancreatic intraepithelial neoplasia (HG-PanIN) or carcinoma in situ (CIS, stage 0). At this stage, metastasis has not yet occurred, offering the potential for more effective therapeutic interventions. Focal pancreatic parenchymal atrophy (FPPA) has emerged as a crucial radiological and pathological feature suggestive of HG-PanIN/CIS.

Key message: Accurate identification of FPPA is critical for diagnosing HG-PanIN and CIS, both of which represent preinvasive stages of PDAC. Given the implications of early detection, serial pancreatic juice cytologic examination is recommended for patients exhibiting FPPA to facilitate timely diagnosis and intervention.

Background: The shift in surgery is taking place in two directions. On the one hand, it is shifting from open surgery to minimally invasive surgery which will ultimately morph into robot-assisted surgery. On the other hand, the therapeutic possibilities of flexible endoscopy have developed enormously in recent years. Various procedures, such as the debridement of pancreatic necrosis, the resection of early neoplasms, the treatment of achalasia, or the resection of numerous submucosal tumors, have passed into the hands of the interventional endoscopist. Endoscopic procedures have also become established in the management of complications of major intestinal procedures. Despite the fact that endoscopic therapy requires time to heal, for example, in VAC therapy, it being less invasive reduces patient morbidity.

Summary: The most common complications in modern pancreatic surgery are pancreatogenic fistulas and fluid collections, as well as insufficiencies of pancreatointestinal or biliodigestive anastomoses. Such complications can be treated endoscopically using methods such as stent placement in the pancreatic or bile duct, endosonographically guided drainage of fluid collections, and even VAC therapy.

Key messages: Endoscopic intervention is the first procedure of choice offered in the treatment of complications in pancreatic surgery. It primarily reduces morbidity in the recovery phase of patients.

Background: Biliary leakages are notable complications that can occur following hepatobiliary surgery, traumatic injury, or iatrogenic causes related to medical interventions. The management of biliary leaks is critical as untreated leaks can result in severe complications such as biliary peritonitis, abscess formation, and sepsis.

Summary: Treatment approaches for biliary leaks are highly variable and depend on the severity and anatomical location of the leak. Options range from conservative management and endoscopic interventions to surgical repair in more severe cases. A clear understanding of the classification of biliary leaks - whether anatomical, etiological, or severity-based - is essential to guide appropriate treatment strategies and improve clinical outcomes. Notably, several endoscopic techniques are now available and have significantly enhanced patient outcomes, even in complex surgical anatomies.

Key messages: The management of biliary duct leaks requires a comprehensive approach that includes endoscopic, percutaneous, and surgical interventions. The choice of treatment is determined by the severity of the leak, the patient's overall condition, and the specific context of the injury. Endoscopic retrograde cholangiopancreatography in combination with sphincterotomy and stent placement is widely regarded as the first-line treatment when the papilla is conventionally accessible.

Introduction: During pregnancy, acute appendicitis is responsible for about two-thirds of nontraumatic surgical emergencies. The aim of this study was to investigate whether the group of pregnant patients differs from the group of the normal population in perioperative features and whether surgery during pregnancy affects its further course.

Methods: We retrospectively analyzed a cohort of 1,054 patients who underwent surgery for signs of acute appendicitis. The cohort included 16 pregnant patients (1.5%), 6 patients (37.5%) in the first trimester, 10 patients (62.5%) in the second. Perioperative features of the groups were compared, and postoperative course of pregnancy was followed.

Results: We discovered that pregnant patients had a higher ratio of negative appendectomies (25% vs. 5.3%, p = 0.010) and shorter operating time (40 min vs. 51 min, p = 0.013).

Conclusion: Based on our data, acute appendectomy in pregnancy is associated with a higher rate of negative appendectomy and shorter operating time. Due to the small number of pregnant patients in the group and the occurrence of only one first trimester miscarriage of unknown etiology, it is not possible to clearly draw conclusion about the impact of acute appendectomy on the further course of pregnancy and further investigation is needed.

Background: Robot-assisted surgery aims to combine the advantages of open surgery with those of minimally invasive surgery to overcome the previous limitations of laparoscopy. Compared to conventional laparoscopic methods, robot-assisted techniques offer significant advantages, which are currently increasingly employed despite mostly longer operating times and higher costs. The aim of this review was to describe the current role of robotics in the treatment spectrum of colorectal surgery.

Summary: A comprehensive literature review was conducted using PubMed, Medline, and Embase to identify studies, systematic reviews, and meta-analyses on robotic surgery for colorectal benign and malignant disease, focusing on studies and meta-analyses comparing the laparoscopic with the robotic approach; articles published between 2004 and 2024 were screened: results of studies on surgical techniques must always be interpreted with caution, taking into account the technical skills and preferences of the participating surgeons. Compared to conventional laparoscopic methods and independent of the indication, robot-assisted techniques offer obvious technical and ergonomic advantages. Most colorectal procedures can safely be conducted via robotic-assisted surgery. Throughout the various indications described in this manuscript, the most evident advantage of robotic surgery remains a lower conversion rate, followed by less blood loss and a shorter hospital stay at the price of a longer operating time. For malignant disease, robotic surgery seems to be additionally associated with a higher lymph node yield in the majority of the studies. In acute or chronic inflammatory colorectal diseases, robotic-assisted surgery may facilitate interventions through improved visibility and a potentially more precise dissection of the correct plane; furthermore, robotic-assisted surgery offers advantages for performing complex intracorporal anastomoses. Last but not least, the surgeon's well-being and preferences make a relevant impact on the utilization of the system in colorectal surgery.

Key messages: The use of robot-assisted procedures has increased significantly in the last decade across the various surgical specialties, with the largest increase in colorectal surgery. Next to the surgeons' preferences, capacity and costs will define the future role of robotic surgery in colorectal disease. As robotic surgery is becoming a mainstream surgical approach, there is a crying need for implementable training concepts of robotic techniques in colorectal surgery.

Introduction: Clinically relevant postoperative pancreatic fistula (CR-POPF) is a severe complication following pancreatic surgery, leading to increased mortality, morbidity, and healthcare burden. This review focuses on the role of drain amylase and lipase as biomarkers for predicting and diagnosing CR-POPF and explores perspectives considering novel markers and their clinical applicability.

Methods: A comprehensive literature review was conducted using Medline via PubMed, Scopus via Elsevier, and Web of Science via Clarivate, selecting studies from 2019 to 2024. Search terms included pancreatic fistula, drainage, amylase, lipase, biomarkers, and corresponding MeSH terms. Studies were screened and selected for their assessment of biomarker accuracy, sensitivity, specificity, and postoperative timing of drain fluid collection.

Results: A total of 13 studies met the inclusion criteria, analyzing amylase, lipase, or other biomarkers in drain fluid for CR-POPF prediction. Both amylase and lipase consistently showed high diagnostic accuracy, with AUC values above 0.8. However, variability in optimal cut-off values across studies complicated standardization. Other drain biomarkers such as CRP or drain fluid culture positivity as well as amylase/lipase ratio and the temporal drain amylase-level progression were found to be promising predictors of CR-POPF.

Conclusion: Drain fluid amylase and lipase remain valuable diagnostic tools for CR-POPF, though variabilities and inconsistencies still pose challenges. Combining these with dynamic biomarker progression analysis and emerging markers as well as standardizing protocols could advance prediction and management. Further research is needed to verify the usefulness of supplementary novel biomarkers and to establish their clinical application in order to improve postoperative outcomes.

Background: Alveolar echinococcosis (AE) is a significant health concern worldwide, primarily affecting the liver. The standard treatment of surgical removal faces significant challenges due to the complex nature of AE. Despite advancements in pharmacological treatments, surgery complemented by at least 2 years of adjuvant medical treatment post-surgery remains the primary curative approach for AE.

Summary: The introduction of minimally invasive techniques, such as laparoscopic and robot-assisted surgery, has expanded surgical options, offering reduced recovery times and minimized surgical trauma while maintaining efficacy and safety comparable to traditional open surgery. Robotic surgery, known for its enhanced precision and visualization, emerges as a preferable method for complex resections in AE treatment, despite challenges such as high costs and the need for specialized training.

Key messages: The decision on the surgical approach is influenced by several factors, including parasite size, patient health, and technology availability. However, there is a clear preference for robotic procedures for their potential to offer better outcomes, though long-term data on outcomes and recurrence rates are needed. The treatment of AE, therefore, underscores the importance of an interdisciplinary approach and the advantages of minimally invasive surgery, advocating for its application in high-volume centers to optimize patient outcomes.

Background: In the last 3 decades, we have witnessed a significant shift from traditional surgical approaches to minimally invasive and robotic surgery for treating gastrointestinal (GI) conditions minimalizing the associated morbidity and mortality. Meanwhile, endoscopy has continually evolved, reshaping the landscape of both diagnostic and therapeutic procedures. The implementation of postsurgical endoscopy as a critical diagnostic tool is primarily due to its capabilities in early complication detection and providing a prompt therapy possibility, assessment of healing, management of symptoms, and surveillance for recurrence in malignancy cases.

Summary: This review will first delve into the history of endoscopic developments, explore the various available postoperative diagnostic tools, focusing particularly on endoscopy and showing some real-life examples.

Key messages: As an essential diagnostic tool, postsurgical endoscopy plays a crucial role in the management of patients undergoing upper and lower GI surgeries. It is indispensable for ensuring an optimal postoperative result. The continuous advancements in endoscopic technology and techniques have significantly enhanced the diagnostic and therapeutic capabilities of this modality, solidifying its role in modern GI surgery. Integrating postsurgical endoscopy into routine clinical practice and learning curriculum for surgical residents is vital and essential for optimizing the postoperative care to ensure the best possible outcome for patients.