Akute Gefäßerkrankungen in der Gastroenterologie

Zusammenfassung: Vaskulär-gastroenterologische Notfälle zählen zu den häufigen Krankheitsbildern auf internistischen und chirurgischen Notfallstationen. Die klinischen Konsequenzen reichen von trivialen bis zu lebensbedrohlichen Situationen. Nur eine frühzeitige Erkennung der Symptomenkomplexe und die Anwendung der adäquaten diagnostischen Mittel führen zur korrekten Diagnosestellung mit nachfolgend - möglicherweise lebensrettender - Therapie. Um die hohen Mortalitätsraten der akuten Mesenterialischämien (50%), aortoenterischen Fisteln (30-40%), Aneurysmen viszeraler Arterien (10-100%) sowie des Budd-Chiari-Syndroms weiter senken zu können, gewinnen neue Strategien mit endovaskulärem Therapieansatz zunehmend an Bedeutung und ersetzen teilweise über viele Jahrzehnte etablierte Diagnose- und Therapiealgorithmen. Diese Übersichtsarbeit soll einen Überblick über aktuelle Diagnostik- und Therapiekonzepte häufiger vaskulär-gastroenterologischer Notfälle verschaffe

Complementary feeding practices and associated factors of dietary diversity among uncomplicated severe acute malnourished children aged 6-23 months in Burkina Faso

Nutritional treatment of children with uncomplicated severe acute malnutrition (SAM) is based on ready-to-use therapeutic foods (RUTF). With treatment provided at community level, children could have access to other foods, and a reduction in the dose of RUTF could further increase dietary diversity during treatment. We assessed the dietary diversity score (DDS), the minimum dietary diversity (MDD), the minimum meal frequency (MMF) and the minimum acceptable diet (MAD) of 459 infants and young children aged 6-23 months being treated for SAM with different doses of RUTF. We also investigated the factors associated with DDS. Dietary intake was estimated using a single 24-h multipass dietary recall, 1 month after starting treatment, from December 2016 to August 2018. The DDS was calculated on the basis of eight food groups. Differences between children receiving the reduced RUTF and the standard RUTF dose and factors associated with DDS were assessed by Poisson and logistic regression models. RUTF dose was not associated with DDS (4.07 +/- 1.25 for reduced RUTF and 4.01 +/- 1.26 for standard RUTF; P = 0.77). Food groups most consumed by children were grains, roots or tubers (96%) and legumes and nuts (72%). Eggs consumption was low (3%). DDS was positively associated with child's age, mother's education, household wealth index, urban residence and rainy season. The present findings show that children with SAM consumed a variety of foods during treatment in addition to the RUTF ration prescribed to them. Reducing the dose of RUTF during SAM treatment did not impact DDS

The Gore Hybrid Vascular Graft in renovisceral debranching for complex aortic aneurysm repair

Objective This study reports our initial experience with the Gore Hybrid Vascular Graft (GHVG; W. L. Gore & Associates, Flagstaff, Ariz) for staged hybrid open renovisceral debranching and endovascular aneurysm repair in patients affected by thoracoabdominal aortic aneurysms and pararenal abdominal aortic aneurysms (PAAAs). Methods Between December 2012 and December 2013, we analyzed outcomes of 13 patients who underwent open surgical debranching of renovisceral vessels for thoracoabdominal aortic aneurysm and PAAAs. All patients were considered at high risk for conventional surgery. Inclusion criterion was treatment by open surgical debranching of at least one visceral artery (renal artery, superior mesenteric artery [SMA], or celiac trunk [CT]) using the GHVG. In a second step, the aortic stent graft was implanted to exclude the aneurysm. If required, parallel grafts to the remaining visceral arteries were deployed in the same procedure. One patient had a symptomatic descending thoracic aortic aneurysm and another had a ruptured PAAA. Perioperative measured outcomes were immediate technical success rate, mortality, and morbidity. Median follow-up was 24.8 months (range, 0-15; mean, 8.2; standard deviation, 4 months). Results All open surgical debranching of renovisceral vessels were completed as intended. GHVG was used to revascularize 20 visceral vessels in 13 patients with a mean of 1.54 vessels per patient. Six renal arteries (30%; 2 right and 4 left), 9 SMAs (45%), and 5 CTs (25%) were debranched. In nine of 13 (66%) patients, other renovisceral arteries were addressed with chimney/periscope, Viabahn Open Revascularization Technique, and end-to-side anastomosis. Two of 13 patients (15%) died of bowel ischemia. Neither patient had GHVG revascularization to the SMA or CT. Perioperative complications occurred in three patients (23%; 1 renal hematoma, 1 respiratory insufficiency, and 1 small-bowel ischemia related to a SMA GHVG thrombosis). At 24 months, estimated survival was 85%, and estimated primary and secondary patency were 94% and 100%, respectively. Conclusions This limited series extracted from a more consistent hybrid procedure experience showed a mortality rate similar to most recent reports. Technical feasibility and the short-term patency rate of the GHVG for renovisceral debranching during staged hybrid open and endovascular procedures were satisfactory. Use of GHVGs may represent a useful revascularization adjunct to minimize visceral ischemia in these challenging patients

Collected world experience about the performance of the snorkel/chimney endovascular technique in the treatment of complex aortic pathologies: The PERICLES registry

Objectives: We sought to analyze the collected worldwide experience with use of snorkel/chimney endovascular aneurysm repair (EVAR) for complex abdominal aneurysm treatment. Background: EVAR has largely replaced open surgery worldwide for anatomically suitable aortic aneurysms. Lack of availability of fenestrated and branched devices has encouraged an alternative strategy utilizing parallel or snorkel/chimney grafts (ch-EVAR). Methods: Clinical and radiographic information was retrospectively reviewed and analyzed on 517 patients treated by ch-EVAR from 2008 from 2014 by prearranged defined and documented protocols. Results: A total of 119 patients in US centers and 398 in European centers were treated during the study period. US centers preferentially used Zenith stent-grafts (54.2%) and European centers Endurant stent-grafts (62.2%) for the main body component. Overall 898 chimney grafts (49.2% balloon expandable, 39.6% self-expanding covered stents, and 11.2% balloon expandable bare metal stents) were placed in 692 renal arteries, 156 superior mesenteric arteries (SMA), and 50 celiac arteries. At a mean follow-up of 17.1 months (range: 1-70 months), primary patency was 94%, with secondary patency of 95.3%. Overall survival of patients in this high-risk cohort for open repair at latest follow-up was 79%. Conclusions: This global experience represents the largest series in the ch-EVAR literature and demonstrates comparable outcomes to those in published reports of branched/fenestrated devices, suggesting the appropriateness of broader applicability and the need for continued careful surveillance. These results support ch-EVAR as a valid off-the-shelf and immediately available alternative in the treatment of complex abdominal EVAR and provide impetus for the standardization of these techniques in the future

Periskop-, Kamin- und Sandwichtechnik sowie VORTEC zur Vereinfachung der Behandlung von Aneurysmen der Aorta abdominalis und thoracoabdominalis

Zusammenfassung: VORTEC (Viabahn Open Revascularisation TEChnique) und die Kaminprothesentechnik sind Verfahren zur Erhaltung oder Wiederherstellung des Blutflusses von Aortenästen, die geplant oder als Notlösung bei offener Operation oder endovaskulärem Vorgehen eingesetzt werden können. VORTEC ist eine stentbasierte vaskuläre Verbindungstechnik zur Herstellung einer End-zu-End-Anastomose, die insbesondere geeignet ist, wenn die herkömmliche Nahttechnik schwierig ist (sein könnte). Es handelt sich um ein schnelles Verfahren, das praktisch ohne Blutflussunterbrechung und ohne Anastomosenblutung ist, die Durchgängigkeitsraten sind ähnlich gut wie bei Nahtanastomosen. Die Kamin-Periskop-Sandwich-Prothesentechnik ("chimney/periscope and sandwich graft technique”, CHIMPES) ist ein endovaskuläres Verfahren, bei dem parallele Endoprothesen zur Erhaltung oder Wiederherstellung des Blutflusses von Aortenästen verwendet werden, während ein herkömmlicher Aortenstent oberhalb ihres Ursprungs platziert wird. Es ist ein relativ schnelles Verfahren mit der Möglichkeit, selbst in Notfällen handelsübliche Produkte zu verwenden. Bei der Sandwichtechnik verlaufen parallele Prothesen zwischen 2Aortenstents. Publizierten Erfahrungen zufolge scheinen diese beiden Techniken besonders für die Behandlung von Aneurysmen der Aortenäste und der Aorta thoracoabdominalis geeignet zu sein, vor allem in Hochrisiko- oder Akutfällen. Die englische Volltextversion dieses Beitrags ist über SpringerLink (unter "Supplemental") verfügba

RS12. Sustained Late Branch Patency and Low Incidence of Persistent Type Ia Endoleaks Following Snorkel/chimney EVAR Shown in the Updated PERICLES Registry

Not availabl

High field brain proton magnetic resonance spectroscopy and volumetry in children with chronic, compensated liver disease - A pilot study.

There is increasing evidence that children or young adults having acquired liver disease in childhood display neurocognitive impairment which may become more apparent as they grow older. The molecular, cellular and morphological underpinnings of this clinical problem are incompletely understood. Therefore, we used the advantages of highly-resolved proton magnetic resonance spectroscopy at ultra-high magnetic field to analyze the neurometabolic profile and brain morphometry of children with chronic, compensated liver disease, hypothesizing that with high field spectroscopy we would identify early evidence of rising brain glutamine and decreased myoinositol, such as has been described both in animals and humans with more significant liver disease. Patients (n = 5) and age-matched controls (n = 19) underwent 7T MR scans and short echo time <sup>1</sup> H MR spectra were acquired using the semi-adiabatic SPECIAL sequence in two voxels located in gray and white matter dominated prefrontal cortex, respectively. A 3D MP2RAGE sequence was also acquired for brain volumetry and T <sub>1</sub> mapping. Liver disease had to have developed at least 6 months before entering the study. Subjects underwent routine blood analysis and neurocognitive testing using validated methods within 3 months of MRI and MRS. Five children aged 8-16 years with liver disease acquired in childhood were included. Baseline biological characteristics were similar among patients. There were no statistically significant differences between subjects and controls in brain metabolite levels or brain volumetry. Finally, there were minor neurocognitive fluctuations including attention deficit in one child, but none fell in the statistically significant range. Children with chronic, compensated liver disease did not display an abnormal neurometabolic profile, neurocognitive abnormalities, or signal intensity changes in the globus pallidus. Despite the absence of neurometabolic changes, it is an opportunity to emphasize that it is only by developing the use of <sup>1</sup> H MRS at high field in the clinical arena that we will understand the significance and generalizability of these findings in children with CLD. Healthy children displayed neurometabolic regional differences as previously reported in adult subjects

Adequacy of nutrient intakes of severely and acutely malnourished children treated with different doses of ready-to-use therapeutic food in Burkina Faso

Background: Ready-to-use therapeutic foods (RUTF) are designed to cover the daily nutrient requirements of children with severe acute malnutrition (SAM). However, with the transfer of uncomplicated SAM care from the hospital environment to the community level, children will be able to consume complementary and family foods (CFF) in addition to RUTF, and this might decrease the quantity of RUTF needed for recovery. Objectives: Using an individually randomized clinical trial, we investigated the effects of a reduced RUTF dose on the daily energy and macronutrient intakes, the proportion of energy coming from CFF, and the mean probability of adequacy (MPA) of intake in 11 micronutrients of 516 children aged 6–59 mo who were treated for SAM in Burkina Faso. Methods: The data were collected using a single 24-h multipass dietary recall, 1 mo after starting treatment, from December 2016 to August 2018, repeated on a subsample of 66 children. Differences between children receiving the reduced RUTF (intervention arm) and those receiving standard RUTF (control arm) were assessed by linear mixed models. Results: Daily energy intake was lower (P < 0.01) in the intervention arm (mean ± SD 1321 ± 339 kcal) than in the control arm (1467 ± 319 kcal). CFF contributed to 40% of the daily energy intake in the intervention and 35% in the control arm. The MPA for 11 micronutrients was 0.89 ± 0.1 in the intervention arm and 0.95 ± 0.07 in the control arm (P = 0.06). Conclusions: Reducing the dose of RUTF during SAM treatment had a negative impact on daily energy intake of the children. Despite this, children covered their recommended energy intake. The energy intake coming from CFF was similar between arms, suggesting that children’s feeding practices did not change due to the reduction in RUTF in this context. This trial was registered at the IRSCTN registry as ISRCTN5003902