Visceral Medicine最新文献

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.

Introduction: Infectious complications, such as anastomotic leakage (AL) and surgical site infections (SSIs), remain a significant challenge in colorectal surgery. Consequently, there is growing interest in oral antibiotic bowel decontamination with nonabsorbable antibiotics (selective digestive decontamination or SDD), which can reduce perioperative complications while also minimizing antibiotic use. This study aimed to determine whether a 3-day SDD regimen is as effective as a 7-day regimen in preventing postoperative complications in laparoscopic diverticular surgery.

Methods: A bicenter data analysis of prospectively and retrospectively collected patient data was performed. A 3-day versus 7-day perioperative use of an SDD-based regimen (polymyxin B, gentamicin, vancomycin, and amphotericin B) in patients undergoing minimally invasive surgery for diverticular disease was compared using noninferiority analysis.

Results: A total of 469 patients were included in the analysis: 101 patients received a 3-day perioperative SDD regimen, while 368 patients received a 7-day regimen. Due to the use of routine clinical data, no control cohort is available. The overall complication rate was 16.5% in both groups. AL and SSI occurred in 2.0% and 6.0% of the 3-day group, and in 1.4% and 6.3% of the 7-day group, respectively, with no significant differences between the groups. However, for wound infections and overall infectious complications, the 3-day regimen can be considered noninferior to the 7-day regimen. Our data did not confirm the noninferiority of the SDD3 regimen compared to the SDD7 regimen for AL.

Discussion: We report low rates of AL and other surgical and nonsurgical complications in minimally invasive diverticular disease surgery. The low complication rates demonstrate noninferiority regarding SSI. Our findings are consistent with recent evidence, highlighting the positive impact of perioperative SDD treatment on SSI and infectious complications.

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.

Background: Anastomotic leakage (AL) in the upper gastrointestinal tract (uGIT) is a critical condition associated with high mortality and significant morbidity. Effective management requires prompt and specialized diagnostic and therapeutic interventions through an interdisciplinary approach. In current practice, surgical intervention is infrequent and typically reserved for cases of extensive damage. Close collaboration between radiology, endoscopy, and surgery is essential for optimal care. Endoscopic therapy is the primary modality for managing AI in the upper GIT. This review offers an overview of the most common endoscopic treatment strategies for AL in this region.

Summary: Significant advancements have been made in the endoscopic management of AL in the uGIT in recent years. Endoscopic sutures and clips remain appropriate for smaller defects, but for larger leakages, endoscopic vacuum therapy (EVT) is gaining prominence over stent placement. Innovative approaches, such as vacuum stents and small diameter filmed drainage (FD), offer promising new therapeutic options for treating AL in the uGIT.

Key messages: (1) Endoscopy plays a pivotal role in the management of AL in the upper GIT. (2) A growing body of evidence supports EVT as superior to other modalities such as sutures, tissue sealants, or clips. Notably, EVT has a lower complication rate and higher healing success compared to stent therapy in AL treatment. (3) New endoscopic techniques, including the vacuum stent and FD, represent promising advancements in the treatment of AL.

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.

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.