Visceral Medicine最新文献

Background: Gastrointestinal cancers account for approximately one-fourth of all cancer cases and one-third of all tumor-related deaths worldwide. For the most frequent gastrointestinal tumor entities including colorectal, gastric, esophageal, and liver cancer, the incidence is expected to increase by more than 50% until 2040. While most gastrointestinal cancers are diagnosed beyond the age of fertility and predominantly in men, the increasing incidence of gastrointestinal malignancies in patients below the age of fifty suggests a growing importance in women of childbearing age. While localized cancers in pregnant women can either be monitored or treated surgically, more advanced stages might require radio- or chemotherapy to control tumor growth until delivery. Under these circumstances, critical decisions have to be made to preserve maternal health on the one side and minimize harm to the infant on the other side.

Summary: Here we summarize data from case reports, meta-analyses, and registries of women undergoing radio- or chemotherapy during pregnancy and provide guidance for therapeutic decision-making in pregnant women suffering from gastrointestinal cancers.

Key message: After the first trimester, most chemotherapeutic regimens can be safely administered to pregnant patients with gastrointestinal cancers. With appropriate safety measures, both radiotherapy and radiochemotherapy can be applied to pregnant patients with rectal cancers.

Background: Malignant (and benign) tumors of the upper gastrointestinal tract are very rare in pregnancy and can be difficult to diagnose because their symptoms are often misinterpreted as "typical" symptoms of pregnant women like vomiting, nausea, and reflux. Alterations of the female hormones may affect central aspects, such as modulation of immune response and prognosis.

Summary: Prolonged "pregnancy-associated" symptoms need further diagnostics in all cases. Once diagnosed, treatment of upper gastrointestinal tumors during pregnancy is based on multimodal treatment approaches depending on the gestational age of the pregnancy and the stage of the tumor and may include chemotherapy and radical surgical resection.

Key message: Only little data exist analyzing the treatment modalities of upper gastrointestinal tumors during pregnancy. Nevertheless, this data demonstrates that curative therapeutic options and guideline-related oncologic concepts can safely be performed in pregnant women. In particular, radical oncologic surgical resection is practicable in different stages of pregnancy and should not be delayed. In any case, decisions in regard to therapy have to be made by a group of specialists taking into account the specific circumstances of the individual patient especially gestational age and tumor stage.

Introduction: Appendectomy for acute appendicitis is the most common surgical procedure performed during pregnancy. The primary treatment for acute appendicitis is emergency surgery, which can be particularly challenging due to altered anatomical conditions. Preoperative and postoperative care may require certain examinations due to pregnancy that are not standard within surgical practice or may be overlooked by the attending gynecologist.

Case presentation: A patient at 31 weeks of gestation presented to the obstetric clinic with an acute onset of acute appendicitis. After completing all necessary examinations and a thorough multidisciplinary evaluation, a successful laparoscopic appendectomy was performed. The subsequent hospitalization was complicated by the onset of uterine contractions, for which tocolysis was administered in combination with corticosteroid therapy to induce fetal lung maturity.

Conclusion: In the presented case report, we demonstrate an example of the appropriate multidisciplinary approach with an analysis of the specific steps that should be taken to maximize the benefit for both the fetus and the mother, as well as the surgical team. In the discussion, we outline the steps that should be followed for patient benefit and forensic reasons.

Background: Colorectal cancer (CRC) during pregnancy can be a challenging situation due to the spatial confinement of the tumor with the growing uterus carrying the fetus. It is one of the more common tumor entities occurring in pregnant women, and therefore, it has to be taken into account if "patients describe suspicious" symptoms.

Summary: Diagnosis and treatment are complex and require a specialized multidisciplinary team of visceral oncologists with expertise in colorectal surgery, gastrointestinal oncologists, gynecologists, obstetricians, and neonatologists to coordinate the optimal treatment plan with the patient. Multimodal treatment options depend on gestational age and tumor stage. Radical surgical oncologic therapy at the latest possible stage of pregnancy is often the only feasible, potentially curative treatment option. Chemotherapy and radiotherapy should be postponed to the postpartum period, if possible. Neonatological aspects, including the high risk of serious complications for the infant during and after anesthesia for oncologic surgery, such as cerebral hemorrhage, pulmonary hypoplasia, and necrotizing enterocolitis, must always be in the focus when considering the optimal timing of surgery, as well as the prognosis of the mother concerning her tumor.

Key message: Treatment of CRC during pregnancy is based on highly individualized therapeutic decisions rather than on standardized guideline recommendations. Surgical resection via partial colectomy, anterior rectal resections, and abdominoperineal extirpations are feasible. However, it has always to be considered if surgery has to be performed in elective situations or damage control procedures due to emergencies, such as mechanical ileus or perforations with intra-abdominal sepsis.

Introduction: Treating biliary obstruction remains a common clinical problem. Endoscopic retrograde cholangiopancreatography (ERCP) with stent insertion remains the gold standard. If ERCP fails, percutaneous transhepatic biliary drainage (PTBD) is one treatment option. Despite a high success rate, early- and late-onset complications occur frequently, ranging from 20 to 70%. With this study, we aimed to provide further insights on possible risk factors for PTBD-related complications.

Methods: All cases with PTBD placement at our institution over the past 13 years were retrospectively analyzed and median premature exchange rate as well as procedural-associated complications were determined.

Results: A total of 976 PTBDs were inserted in 194 patients. In 853 cases (87%), only one PTBD was inserted. Most patients had a benign disease as an indication for the PTBD insertion (n = 558 cases, 56.9%). A premature PTBD exchange occurred in 246 cases (26%). The most common reason for a premature PTBD exchange or extraction was dislocation (n = 98/39.5%), followed by cholangitis in 70 cases (28.6%). A malignant indication (multivariate p = 0.001 OR = 1.69 95% CI = 1.23-2.30), female sex (multivariate p < 0.001 OR = 2.21 95% CI = 1.56-3.12), and a PTBD ≥14Fr (multivariate p < 0.03 1.50 (1.04-2.11) were associated with a premature stent exchange in the mixed multivariate regression analysis.

Conclusion: Premature exchanges occur frequently in patients treated with PTBD. Especially in patients with malignancy, other interventional bile drainage interventions should be discussed. In case PTBD is chosen, earlier exchange rates than 12 weeks should be considered.

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.