Visceral Medicine最新文献

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: 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.

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.