Visceral Medicine最新文献

Background: The prevalence of neurogastroenterological diseases, i.e., disorders of gut brain interaction, has increased over the last decades. Altered gastrointestinal (GI) motility is a key feature of this group of diseases and is affecting all anatomical segments of the GI tract, ranging from swallowing disorders to fecal incontinence. Considering the ongoing demographic transformation in developed countries worldwide, it is highly relevant to understand the age-dependency of motility disorders per se and its pathophysiological mechanisms with a special focus on neurodegeneration. This review summarizes the most relevant findings and open research questions in the field of age-dependent changes in GI motility with a strong focus on studies performed on humans or with biological material obtained from humans.

Summary: While the basic function of the GI tract including motility in most of its segments is largely unaltered by aging per se, there is clear evidence supporting an age-dependent increase in the prevalence of constipation and fecal incontinence, the latter mainly affecting women. When, however, the large percentage of elderly patients suffering from frequent chronic diseases such as diabetes, Parkinson's disease, or cerebrovascular disease are included, a clear increase in "secondary" motility disorders also affecting the esophagus or the stomach is evident. Studies regarding the pathophysiology of geriatric dysmotility are often limited by the heterogenous clinical history of the studied patients and by coincident impairments of interoceptive sensory function. However, a loss in the number of cholinergic neurons together with changes in the number of interstitial cells of Cajal, certain subtypes of enteric glia, changes in immune cell function, and changes in the endocrine signaling throughout the GI tract have been reported.

Key messages: The overall prevalence of swallowing disorders, impaired gastric emptying, constipation and fecal incontinence is high among elderly patients. The pathophysiology most likely includes a variety of factors ranging from degeneration of enteric neurons and the non-neuronal cell populations involved in GI motility up to age-dependent metabolic and neuroendocrine changes and dietary factors. Deciphering the effects of "healthy aging" but also of the numerous typical chronic diseases of the elderly on GI motility is an ongoing challenge and prerequisite for improving patients' medical care and quality of life.

Background: Fecal incontinence (FI) is a frequent, often underestimated, health issue in adults. Its treatment is primarily nonsurgical. Only if conservative options fail to result in adequate symptom reduction should surgery be considered. We present an overview of historical and current surgical treatment options.

Summary: Well-known sphincter replacement techniques such as dynamic graciloplasty and the artificial bowel sphincter are no longer used because of their invasiveness and relevant comorbidity. Today, sphincteroplasty and sacral neuromodulation (SNM) are the most common procedures recommended in current guidelines. The therapeutic choice is based on diagnostic findings. Sphincteroplasty is an option only in patients with an anal sphincter lesion and has only moderate long-term success. SNM has become the established first choice in multiple pathophysiological conditions resulting in FI, as it has proved highly successful with minimal invasiveness. Over time, the spectrum of indications has evolved and the technique is now successful in morphological sphincter defects as well.

Key messages: The spectrum of surgical options to treat FI is limited. Owing to its efficacy and low comorbidity, SNM is now considered the gold standard in multiple pathophysiological and morphological conditions, whereas sphincteroplasty remains an option in patients with FI from a defined sphincter lesion.

Background: Fecal incontinence is a common problem especially in the elderly resulting in a reduced quality of life.

Summary: The etiology of fecal incontinence is often multifactorial with little options for a causal therapy. The mechanisms causing incontinence can be detected by sophisticated methods in most of the patients. Using therapeutic algorithms, incontinence can be improved or even continence restored in many patients.

Key messages: Diagnostic work-up starts with history, digital investigation, and anoproctoscopy. The specialist will further investigate with anorectal manometry, anal endosonography, and electromyography of the external anal sphincter muscle. Nonoperative therapy comprises hygienic methods, medical therapy, intraanal electrostimulation, and training methods like pelvic floor exercises or biofeedback. Second-line conservative therapies are tibial nerve stimulation, transanal irrigation, or anal inserts.

Introduction: As natural calcium (Ca) antagonist, magnesium (Mg) seems to counteract Ca-signaling pathways involved in the intracellular protease activation leading to acute pancreatitis. We systematically reviewed the current literature to investigate the role of Mg in the pathogenesis of acute pancreatitis and its possible use in detecting, predicting, and preventing acute pancreatitis.

Methods: A systematic search was performed in PubMed/Scopus/Web of Science to identify in vivo and in vitro studies reporting data on Mg in acute pancreatitis.

Results: Twelve studies were included. Due to their heterogeneity, we conducted a review without the intent of inference. Mg deficiency in pancreatic acinar cells seems to be frequently associated with serum hypocalcemia and acute pancreatitis. Mg seems to contrast intracellular Ca accumulation which induces premature enzyme activation and acute pancreatitis. Several in vivo and in vitro experiments showed beneficial effects of Mg supplementation in counteracting Ca-signaling pathways and subsequent pathological events. Moreover, a recent randomized trial demonstrated the efficacy of Mg supplementation in reducing the incidence of post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis in high-risk patients.

Conclusion: Mg is a natural antagonist of Ca-signaling pathways and, when deficient, predisposes to acute pancreatitis. Mg supplementation may be useful to prevent acute pancreatitis in many contexts, such as post-ERCP or after pancreatic surgery. The heterogeneity of the included studies represents an important limitation that may hinder robust conclusions.

Background: Postoperative continuous thoracic epidural analgesia (TEA) is an integral aspect of pain management after major abdominal and thoracic surgery. Under TEA, postoperative urinary retention (POUR) is frequently noted, prompting a common practice of maintaining the transurethral catheter (UC) until the cessation of TEA to avoid the necessity for reinsertion of the UC. This study analyzes the effect of an early bladder catheter removal during TEA on POUR incidence.

Methods: The retrospective study was conducted on 71 patients undergoing elective abdominal and thoracic operations with TEA for postoperative pain control. Patients were divided into two groups based on the UC removal time in relation to the epidural catheter removal. In the early removal group (ERG), the UC was removed within 3 days of surgery, while in the standard group (SG), it was removed after completion of TEA. All patients in the ERG were still receiving TEA at the time of the UC removal. The primary outcome assessed was the incidence of POUR, while secondary outcomes included urinary tract infections (UTI), hospital length of stay (LOS), and patient's comfort.

Results: The overall prevalence of POUR was 7%, with five POUR cases - two (4.9%) of 41 patients in SG and three (10%) of 30 in ERG (p = 0.644). No significant difference was found in POUR occurrence between ERG and SG (p = 0.644). Additionally, no UTIs were observed in the study. The postoperative pain scores (visual analog scale [VAS]) 72 h and 96 h and the LOS (SG: 16.74 [±8.39] days; ERG: 14.53 [±6.99] days; p = 0.3) were similar between both study groups.

Conclusion: Based on our results, it can be concluded that the removal of UC in the early postoperative period, even during TEA, can be performed safely without significantly increasing the risk of recatheterization.

Background: Colorectal cancer is a highly prevalent malignancy and a significant driver of cancer mortality and health-related expenditure worldwide. Polyp removal reduces the incidence and mortality of colorectal cancer. In 2024, endoscopists have an array of resection modalities at their disposal. Each technique requires a unique skillset and has individual advantages and limitations. Consequently, resection in the colorectum requires an evidence-based algorithm approach that considers these factors.

Summary: A literature review of endoscopic resection for colonic neoplasia was conducted. Best supporting scientific evidence was summarized for the endoscopic resection of diminutive polyps, large ≥20 mm lesions and polyps containing invasive cancer. Factors including resection modality, complications and lesion selection were explored to inform an algorithm approach to colorectal resection.

Key messages: Endoscopic resection in the colorectum is not a one-size-fits-all approach. Detailed understanding of polyp size, location, morphology and predicted histology are critical factors that inform appropriate endoscopic resection practice.

Background: Liver surgery is an essential component of hepatocellular carcinoma (HCC) treatment. Advances in surgical techniques and perioperative care have improved outcomes and have helped to expand surgical indications. However, liver fibrosis and cirrhosis still remain major problems for liver surgery due to the relevant impact on liver regeneration of the future liver remnant (FLR) after surgery. Especially in patients with clinically significant portal hypertension due to liver cirrhosis, surgery is limited. Despite recent efforts in developing predictive models, estimating the postoperative hepatic function remains difficult.

Summary: In this review, we focus on the role of surgery in the treatment of HCC in structurally altered livers. The importance of assessing FLR with techniques such as contrast-enhanced CT, e.g., with the help of artificial intelligence is highlighted. Moreover, strategies for increasing the FLR with approaches like portal vein embolization and liver vein deprivation prior to surgery are discussed. Patient selection, minimally invasive liver surgery including robotic techniques, and perioperative concepts like the Enhanced Recovery After Surgery (ERAS) guidelines are identified as crucial parts of avoiding posthepatectomy liver failure.

Key message: The need for ongoing research to optimize patient selection criteria and perioperative care and to develop innovative biomarkers for outcome prediction is emphasized.