Visceral Medicine最新文献

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.

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.

Introduction: Long-term sequelae following acute SARS-CoV-2 infection appear to be common in patients with inflammatory bowel diseases (IBDs).

Methods: We examined the frequency and characteristics of post-COVID-symptoms in patients with IBD (IBD-COVID), comparing them to two control cohorts: infected household members of the IBD-COVID patients without IBD (CONT-COVID) and IBD patients without SARS-COV-2 infection (IBD-no-COVID). A questionnaire for the retrospective documentation of possible post-COVID-19 symptoms was distributed to patients and controls from eight referral centers.

Results: The 319 IBD-COVID, 108 CONT-COVID, and the 221 IBD-no-COVID patients were similar in terms of sex, age, and comorbidities. The occurrence and duration of fatigue in the IBD-COVID cohort correlated with IBD activity. Other complaints such as reduced cognitive performance (p < 0.05) and sleeping disorders (p < 0.05) were even more common in IBD-COVID patients. Persistent hematochezia (p < 0.001), abdominal pain (p < 0.005), diarrhea (p < 0.0001), and anal problems (p < 0.01) were more often in the IBD-COVID patients than in the CONT-COVID cohort. Furthermore, typical IBD-associated symptoms persist for a longer period after an infection. Frequency of post-COVID complaints is higher in IBD patients compared to controls. After infection, the number of outpatient consultations increased in IBD-COVID patients (7.8% vs. 10.9%, p = 0.008).

Conclusion: Fatigue, cognitive impairment, and sleep disturbances are more prevalent among IBD-COVID than CONT-COVID patients. Furthermore, typical IBD-associated symptoms persist for a longer period after an infection. Frequency of post-COVID complaints is higher in IBD patients compared to controls. Tight control of IBD activity could be a suitable tool to avoid post-COVID problems.

Introduction: The development of an intestinal stricture in patients with Crohn's disease represents an important and frequent complication, reflecting the progressive nature of the disease. Depending on the inflammatory and fibrotic composition of the stricture, intensified medical therapy, interventional endoscopy, or surgical intervention is required. However, currently available diagnostic approaches can only assess the level of inflammation, but not the degree of fibrosis, limiting rational therapeutic management of Crohn's disease patients. Recently, prolyl endopeptidase fibroblast activating protein (FAP) has been functionally implicated in fibrotic tissue remodelling, indicating it as a promising target for detection of sites of fibrotic tissue remodelling. Thus, intestinal fibrosis might be visualized using Gallium-68 labelled inhibitors of FAP (FAPI). While F-18-fluorodeoxyglucose (FDG)-positron emission tomography (PET)/CT is a standard diagnostic tool for visualizing inflammatory processes, we combined Ga-68-FAPI-46-PET/CT and F-18-FDG-PET/CT to differentiate predominantly fibrotic or inflammatory areas in Crohn's disease patients with ileo-colonic strictures.

Methods: In our study, we analysed three Crohn's disease patients with anastomotic ileo-colonic strictures who underwent both dynamic Ga-68-FAPI-46-PET/CT and static F-18-FDG-PET/CT imaging to assess the level of visualized fibrotic areas within the stricture and differentiate it from inflammatory ones. PET images were analysed both visually and quantitatively. Furthermore, conventional MR enterography and endoscopy were performed in parallel to correlate observed findings. Two of the included patients underwent surgery and the histological specimen were analysed for the level of inflammation and fibrosis, which results were similarly compared to the findings of the PET imaging procedures.

Results: Different uptake patterns of Ga-68-FAPI-46 could be observed in the anastomotic ileo-colonic strictures of the examined Crohn's disease patients, respectively. Immunohistochemical analyses demonstrated that there was a correlation between the level of Ga-68-FAPI-46 uptake and severity of fibrosis, while FDG uptake correlated with the inflammatory activity in the analysed strictures.

Discussion: The combination with F-18-FDG-PET/CT represents a promising imaging modality to distinguish inflammation from fibrosis and guide subsequent therapy in stricturing Crohn's disease patients, warranting further studies.

Introduction: Inflammatory bowel disease (IBD), encompassing Crohn's disease (CD) and ulcerative colitis (UC), exhibits a multifactorial pathogenesis influenced by genetic and environmental factors. Antibiotic usage has been implicated in modifying the gut microbiome, potentially leading to dysbiosis and contributing to IBD risk. Despite existing literature, the relationship remains inconclusive. This meta-analysis aimed to evaluate the association between prior antibiotic use and the onset of IBD.

Methods: A systematic literature search in PubMed was conducted to identify studies exploring the link between antibiotic use and subsequent IBD diagnosis. Studies reporting CD, UC, or both as primary outcomes were included. The meta-analysis, performed according to PRISMA guidelines, summarized risk estimates, represented as odds ratios (ORs), and corresponding confidence intervals (CIs). Subgroup analyses involved the categorization of antibiotics and the determination of the minimum number of antibiotic therapy courses administered.

Results: Out of 722 publications, 31 studies comprising 102,103 individuals met eligibility criteria. The pooled OR for IBD in those with prior antibiotic exposure was 1.40 (95% CI: 1.25-1.56). Antibiotic use was associated with an increased risk of IBD (OR: 1.52, 95% CI: 1.19-1.94). Notably, this association was confined to CD (OR: 1.50, 95% CI: 1.27-1.77), while no significant association was observed with UC (OR: 1.21, 95% CI: 1.00-1.47). Risk augmentation for IBD correlated positively with the number of antibiotic courses (OR: 1.08, 95% CI: 1.05-1.12).

Conclusion: Previous antibiotic use is associated with the later development of CD. A positive dose-response effect was also observed. Against this background, antibiotics should be used rationally.

Introduction: Ambulatory surgeries are on the rise in recent years and can offer benefits to patients as well as healthcare providers. Laparoscopic cholecystectomy is one of the procedures commonly done in an ambulatory setting, in some European countries. This study aims to gather patients' perceptions towards ambulatory cholecystectomy after undergoing laparoscopic cholecystectomy in an inpatient setting.

Methods: A total of 300 patients from two different hospitals in Germany received a postoperative questionnaire aimed at evaluating their willingness to undergo an ambulatory surgery. Surgeries were performed between January 1, 2017, and July 11, 2018. Operation setting (acute vs. elective), ASA classification, length of hospital stay, age, sex, living situation and location (city vs. rural), as well as status of employment were documented.

Results: Overall, 23% of patients reported considering ambulatory laparoscopic cholecystectomy (ALC), while 77% rejected an ALC. Objections included fear of complications (69%), anticipated pain (65%), concerns about their living situation/home care (21%), other reasons (8%), nausea and vomiting (3.4%). Baseline characteristics of the participants provided no statistical significance on willingness to undergo ALC: acute versus elective (p = 0.22), ASA classification (p = 0.77), age ≥65 years versus <65 years (p = 0.60), gender (p = 0.07), living situation (p = 0.49), location (p = 0.15).

Conclusion: There is a willingness for ALC, albeit still limited. Chosen criteria did not show a significant association for positive perception of ALC.

Background: Achalasia is a motility disorder of the esophagus and depending on its type, esophageal tubular hypo- or hypermotility can cause typical symptoms, such as dysphagia, chest pain, weight loss, or regurgitation. Clinical symptoms during initial diagnosis as well as over the course of therapy can be measured by the Eckardt score. Diagnostics include high-resolution manometry (HR manometry), (timed barium) esophagogram, upper gastrointestinal endoscopy, multiple rapid swallow response, and Endo-FLIP measurement. In this work, we provide a review of the recent literature on surgical treatment of achalasia.

Summary: Besides pharmacological and endoscopic interventions, surgical procedures of laparoscopic/robotic Heller myotomy (LHM/RHM) and 180° anterior Dor's semifundoplication versus 270° dorsal Toupet's fundoplication are primary therapeutic options, especially for type I and II achalasia. Both surgical procedures display little morbidity and mortality. Postsurgical results are comparable between LHM and RHM. RHM allows better angulation during myotomy, lower rates of intraoperative mucosal laceration, and better visualization of the muscles in the lower esophageal sphincter area. Surgery can also be performed safely after failed endoscopic treatments.

Key messages: Surgery in achalasia is especially indicated in patients ≤40 years and also recommended after repeated unsuccessful or complicated endoscopic interventions. In selected patients with end-stage achalasia and sigmoid-shaped megaesophagus, esophagectomy is a reasonable option in order to improve quality of life.