Visceral Medicine最新文献

Introduction: Acute mesenteric ischemia (AMI), either arterial or venous, is still a devastating disease with poor prognosis. It is unknown, whether AMI is associated with impaired quality of life (QoL) in long-term survivors.

Material and methods: This retrospective analysis includes 64 patients with occlusive arterial or venous mesenteric ischemia treated operatively between 2008 and 2016 at the University Medical Center Rostock. Short-term outcome with focus on comorbidities was measured by the Charlson comorbidity index (CCI) an instrument that operationally measures comorbidity based on 17 clinical parameters including age. Operative outcome in view of enterostomy placement and long-term outcome measured as QoL by the EQ-5D in the long-term survivors were evaluated. The EQ-5D is a standardized, self-reported five-dimension QoL questionnaire built to provide a simple and generic measure of health.

Results: Thirty-day mortality was 60.9%, and in-hospital mortality was 70.3% (n = 45). No patient was discharged with a stoma. Patients with a primary anastomosis after the initial operation for AMI had a high leak rate of 27% (4/15 patients) compared to no dehiscence in the group of patients who had secondary anastomosis during second or third laparotomy. The long-term survivors had significantly lower CCI compared to the 45 nonsurvivors (median 4 [3, 4, 5, 6] vs. 6 [4, 5, 6, 7]). All long-term survivors had QoL assessment. QoL score was significantly impaired compared to an age- and sex-matched reference population. This impairment was not due to disease-specific sequelae such as presence of stool deviation or intestinal failure but due to preexisting risk factors as shown by an inverse relation between the CCI and QoL score.

Conclusion: Herein, we show for the first time that long-term QoL in patients with AMI is impaired but this impairment is not due to disease-specific aspects but rather general risk factors underlying the presence of a higher level of comorbidities at the time of AMI.

Introduction: The use of technetium 99m diethylenetriaminepentaacetic acid-galactosyl human serum albumin (^99mTc-GSA) scintigraphy parameters, HH15 and LHL15, in assessing the future liver remnant function is not expedient because of their nonlinear behaviour against liver volume. Uptake rate constant for the binding of ^99mTc-GSA to asialoglycoprotein receptors is probably more favourable, but the reported calculation methods are complex. We devised a simple method to calculate the uptake rate constant, KrGSA.

Methods: Radioactivity counts for the entire liver and heart regions were extracted at 10, 20, and 30 min. Using whole liver and heart volumes measured from single-photon emission computed tomography images, free radioactivity corresponding to the liver blood pool was subtracted. The time activity curve was fitted to the equation L(t) = L(∞) × [1 - Exp (-kt)] using Microsoft Office Excel (add-in free programme Solver)®, where L(∞) is the count at plateau level and k denotes KrGSA.

Results: KrGSA values accurately identified liver cirrhosis and were similar to the KICG. The areas under the curve for KrGSA and KICG in the receiver operating characteristic analysis were 0.808 and 0.795, respectively, and a good correlation was seen between KrGSA and KICG.

Discussion/conclusion: KrGSA can be utilized as an alternative to KICG in assessing the future liver remnant function.

Objectives: Mirizzi syndrome (MS) is a condition when an impacted stone in the cystic duct or the Hartmann's pouch due to its extrinsic compression and concomitant inflammation causes an obstruction of the common bile duct. Laparotomy was the preferred surgical technique to treat this syndrome. However, with advances in technologies, an increasing number of surgeons are starting to choose minimally invasive surgery. The objective of this study is to review existing literature relating to minimally invasive surgery treatment of MS.

Methods: PubMed and ClinicalKey were used to search and identify relevant articles since January 2000 to December 2020. The following keywords were applied: Mirizzi syndrome, laparoscopy, minimally invasive. The criteria for exclusion were applied: case reports with less than 2 patients, nonsurgical treatments, and reviews were excluded from this study.

Results: Thirty-two articles were identified for analysis, 17 (540 patients in total) of these articles fulfilled the inclusion criteria: 8 retrospective studies, 4 case series, and 5 prospective studies. In the analyzed cohort, 295 patients were treated laparoscopically. Out of 17 articles included in the manuscript, 14 articles provided the information on minimally invasive surgery approach. There were 221 minimally invasive surgeries, out of which 143 (64.7%) were successful, thus according to the type of MS: MS I-175 (79.2%), successful 105 (60%); MS II-40 (18%), successful 32 (80%); MS III-6 (2.7%), successful 6 (100%). The mean conversion rate from laparoscopic to open surgery was 26.2% (range 0-67%), and the median complication rate in seventeen studies was 18.1% (range 0-40%), respectively. The female/male ratio was 1.2:1, and the median age in fifteen studies providing overall data on age was 57.4 years (range 40.1-70.1 years).

Conclusions: Current evidence presents that open surgery remains the main treatment for MS. Minimally invasive approaches are feasible, safe, and are associated with short-term recovery, significant differences in the operation time and blood loss during operation. However, minimally invasive approaches are mainly restricted to selected patients with type I MS.

Introduction: The present study aimed to examine the clinical implications of postoperative hyperamylasemia (POH) after partial pancreaticoduodenectomy (PD).

Methods: Data from all consecutive patients undergoing PD were obtained from a prospectively maintained database and reviewed. POH was defined as an elevation of serum pancreatic amylase above the upper limit of normal (53 U/L) on postoperative days 0-2. Clinically relevant POH (cr-POH) was defined as POH in patients with clinically relevant (Clavien-Dindo ≥ III) postoperative complications.

Results: POH occurred in 61 of 170 (35.9%) and cr-POH in 24 of 170 (14.1%) patients. Patients with POH had higher rates of clinically relevant postoperative pancreatic fistula (cr-POPF) (44.3 vs. 3.7%, p < 0.001) and clinically relevant postoperative complications than those without POH (39.3 vs. 21.1%, p = 0.001). Patients with cr-POH had higher C-reactive protein (CRP, milligrams per liter) levels on third (257.7 vs. 187.85 mg/L, p = 0.016) and fourth (222.5 vs. 151, p = 0.002) postoperative day (POD) than those with POH alone. Serum procalcitonin (PCT, micrograms per liter) levels on POD 2 (1.2 vs. 0.4 μg/L, p = 0.028) and POD 3 (0.85 vs. 0.4 μg/L, p = 0.001) were also higher in patients with cr-POH. Rates of cr-POPF in patients with cr-POH were higher than in those with POH alone (70.8 vs. 27%, p = 0.001). POH (OR 0.011, 95% CI: 0.001-0.097, p < 0.001) was an independent predictor of cr-POPF in the multivariable analysis. A high-risk pathology, defined as nonadenocarcinoma/nonchronic pancreatitis pathology (OR 0.277, 95% CI: 0.106-0.727, p = 0.009), and a small duct diameter (OR 0.333, 95% CI: 0.139-0.796, p = 0.013) were independent predictors of POH in the multivariable analysis.

Conclusion: POH is a frequent, but not always clinically relevant, finding after partial PD. Serum CRP and PCT levels in the early postoperative period can be used to identify patients with cr-POH. POH is an independent risk factor for increased postoperative morbidity, including cr-POPF, after partial PD.

Background: Surgical site infections are among the most common healthcare-associated infections, especially in patients undergoing cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC). The aim of this retrospective study was to examine postoperative infectious complications according to preoperative screening findings of nasal and rectal swabs.

Methods: Two hundred four consecutive patients received nasal and rectal swab examination for multidrug-resistant (MDR) bacteria within 30 days before the operation in patients where CRS and HIPEC were planned. Inclusion criteria were as follows: confirmed peritoneal metastases (histologically and/or cytologically); age under 85 years; adequate renal, liver, and bone marrow function; no sign of infection preoperatively; resectable disease; and CRS and HIPEC procedure. If surgical site infection occurred, the microbial spectrum of the site was assessed. One hundred twenty-one patients (63 female [52.1%] and 58 male [47.9%]) met the criteria and were further analyzed retrospectively. Statistical correlations between postoperative complications and risk factors were investigated by univariate and multivariate analysis.

Results: Postoperative complications in total were observed in 57 patients (47.1%) with major complications (Clavien-Dindo grades 3-4) in 15 patients (12.4%) and infectious complications in 37 (30.6%) patients. The overall prevalence of nasal MRSA carriage was 3.28%, and the overall prevalence of rectal MDR bacteria carriage was 10.7%. In propensity score analysis, colonized patients compared to noncolonized patients showed increased total complications (CD1-5, p = 0.025), infectious complications (p = 0.028), surgical site infections (p = 0.022) as well as pneumonia (p = 0.016). Multivariate analysis showed that in addition to preoperative rectal colonization, American Society of Anesthesiologists score was a risk factor for postoperative complications.

Conclusions: Preoperative 3-MRGN and vancomycin-resistant enterococcus colonization were associated with increased complications and surgical site infections. Special antimicrobial treatment pathways are necessary for these patients to reduce postoperative complications due to colonization.

Background: Alterations in the anatomy of the upper gastrointestinal tract may pose a challenge to the endoscopist, especially if interventions to the biliary system are indicated in patients with altered continuity of the gastrointestinal tract, impeding to reach the papilla with conventional ERC techniques. The success of any endoscopic intervention in this setting depends on optimal knowledge on the postoperative anatomy in each individual patient.

Summary: If conventional endoscopic retrograde cholangiopancreaticography is impossible, biliary tree access can be achieved by applying novel techniques including endosonography-directed approaches, overtube-assisted approaches or spiral enteroscopy to reach the papilla or biliodigestive anastomosis in case of long limbs, percutaneous or even hybrid approaches. This review gives an overview of the most common techniques.

Key message: The choice of endoscopic approach should be individual in each patient, taking indication and urgency, type of anatomic alteration, local expertise, patients' characteristics and preferences as well as prognosis into account. Early interdisciplinary discussion is essential to choose the procedure with the optimal risk-benefit ratio in the individual patient.

Background: Enhanced recovery after surgery (ERAS®) is increasingly finding its way into clinical practice. ERAS® protocols have not been universally adopted, and they have often been criticized for being difficult to implement. So, the question for more tailor-made approaches arises.

Methods: We conducted a literature search on March 16, 2022, using the following search string, which was modified to fit the input of each of the queried databases: ("ERAS®" or "enhanced recovery after surgery" or "fast recovery" or "fast track") and ("tailored" or "individual").

Results: Despite the massive increase in general hits on the subject, stratification according to phenotypic characteristics such as age or a classification according to disease patterns in the sense of specific guidelines is still fundamentally apparent. Evidence suggests that generic protocols can be followed by almost all patients. Prehabilitation, in particular, can be used as an adaptive tool.

Conclusion: ERAS® works only in the totality of its tools and can be followed by almost all patients. Prehabilitation is more adaptive and can also increase adherence to ERAS® protocols. A tailored program outside of disease-specific pathways does not seem to be useful.