Intrathorakale Anastomosen-Insuffizienz - chirurgisches Problem, endoskopische Therapie

Einleitung: Eine postoperative, intrathorakale Anastomoseninsuffizienzen (ITAI) stellt die schwerwiegendste Komplikation nach Ösophagus- oder Magenresektionen dar. In den letzten Jahren hat sich das endoskopische Komplikationsmanagement bei ITAI gewandelt. Wurden zunächst ITAI mittels Stent-Implantation überbrückt, wird aktuell zunehmend die endoskopische Unterdrucktherapie eingesetzt. Methodik: Es erfolgte eine retrospektive Analyse aller Patienten mit Ösophagus- und proximalen Magenresektionen, der Klinik für Allgemein-, Viszeral- und Transplantationschirurgie der Universität Tübingen im Zeitraum 2005 bis 2016. ITAI wurden entsprechend der CAES-Klassifikation eingeteilt und je nach Häufigkeit, Art der Therapie und klinischem Verlauf ausgewertet. Anhand der Ergebnisse wurde eine SOP für das primäre diagnostische und endoskopisch-therapeutische Management entwickelt. Ergebnisse: Im gesamten Beobachtungszeitraum entwickelten 24/176 Patienten (13,64%) eine ITAI. In der CAES-Einteilung der Insuffizienzen hatten 3 Patienten eine Insuffizienz Typ I, 17 Patienten eine Insuffizienz Typ IIa, 2 Patienten eine Insuffizienz Typ IIb und je 1 Patient eine Insuffizienz Typ IV a und b. Eine primäre endoskopische Therapie erfolgte bei 83,33% der Patienten. 15 Patienten wurden primär mittels Stent und 4 Patienten mit endoskopischer Unterdrucktherapie (EVT) behandelt. Ein Drittel der Patienten hatten nach Stentimplantation ein Therapie-Versagen. Hiervon erhielten 3 Patienten eine weiterführende EVT. Die EVT erfolgte bei insgesamt 7 Patienten, wobei im weiteren Verlauf kein Therapiewechsel notwendig war. Die EVT führte bei 71,43% der Patienten zu einer Ausheilung der ITAI. Insgesamt verstarben 8/176 Patienten während des postoperativen Krankenhausaufenthaltes (4,54%), hiervon hatten 5 Patienten eine nachgewiesene ITAI. Diskussion: Eine frühe endoskopische Anastomosen-Beurteilung erscheint sinnvoll und kann direkt mit einer primären endoskopischen Therapie verbunden werden. Anhand der Literaturrecherche und der Auswertung der eigenen Daten wird die primäre EVT empfohlen

Bariatric Surgery—from the Non-surgical Approach to the Post-Surgery Individual Care: Role of Endoscopy in Bariatric Therapy

Obesity is the underlying constant for the development of the most common modern diseases such as insulin resistance, high blood pressure, lipid metabolism disorders, non-alcoholic steatohepatitis (fatty liver), joint problems and various malignancies. The role of endoscopic diagnostic and therapy in obese patients is highlighted in this chapter. In this chapter all devices and methods used in flexible endoscopy for diagnostic and treatment in obese patients are introduced. Role of endoscopy is presented in three parts: in preoperative setting, in post-operative complication management and instead of surgery as endoscopic bariatric therapy. If possible presentation of the effectiveness is compiled with study data. Finally, the interaction between endoscopy and surgery in the treatment of obesity is complex, essential and promising. Endoscopy is indispensable in preoperative preparation, as a primary therapeutic approach, and also in the detection and treatment of acute complications and long-term complications of obesity surgery

Identification of Novel Genetic Loci Associated with Thyroid Peroxidase Antibodies and Clinical Thyroid Disease

Peer reviewe

Is There a High Risk for GI Bleeding Complications in Patients Undergoing Abdominal Surgery?

Introduction: Gastrointestinal bleeding (GIB) can cause life-threatening situations. Here, endoscopy is the first-line diagnostic and therapeutic mode in patients with GIB among further therapeutic approaches such as embolization or medical treatment. Although GIB is considered the most common indication for emergency endoscopy in clinical practice, data on GIB in abdominal surgical patients are still scarce. Patients and methods: For the present study, all emergency endoscopies performed on hospitalized abdominal surgical patients over a 2-year period (1 July 2017–30 June2019) were retrospectively analyzed. Primary endpoint was 30-day mortality. Secondary endpoints were length of hospital stay, cause of bleeding, and therapeutic success of endoscopic intervention. Results: During the study period, bleeding events with an indication for emergency endoscopy occurred in 2.0% (129/6455) of all surgical inhouse patients, of whom 83.7% (n = 108) underwent a surgical procedure. In relation to the total number of respective surgical procedures during the study period, the bleeding incidence was 8.9% after hepatobiliary surgery, 7.7% after resections in the upper gastrointestinal tract, and 1.1% after colonic resections. Signs of active or past bleeding in the anastomosis area were detected in ten patients (6.9%). The overall 30-day mortality was 7.75%. Conclusions: The incidence of relevant gastrointestinal bleeding events in visceral surgical inpatients was overall rare. However, our data call for critical peri-operative vigilance for bleeding events and underscore the importance of interdisciplinary emergency algorithms

Classification und Treatment Algorithm of Small Bowel Perforations Based on a Ten-Year Retrospective Analysis

Background: Small bowel perforations are a rare diagnosis compared with esophageal, gastric, and colonic perforations. However, small bowel perforations can be fatal if left untreated. A classification of small bowel perforations or treatment recommendations do not exist to date. Methods: A retrospective, monocentric, code-related data analysis of patients with small bowel perforations was performed for the period of 2010 to 2019. Results: Over a 10-year period, 267 cases of small bowel perforation in 257 patients (50.2% male and 49.8% female; mean age of 60.28 years) were documented. Perforation’s localization was 5% duodenal, 38% jejunal, 39% ileal, and 18% undocumented. Eight etiologies were differentiated: iatrogenic (41.9%), ischemic (20.6%), malignant (18.9%), inflammatory (8.2%), diverticula-associated (4.5%), traumatic (4.5%), foreign-body-associated (1.9%), and cryptical (1.5%) perforations. Operative treatment combined with antibiotics was the most commonly used therapeutic approach (94.3%). The mortality rate was 14.23%, with highest rate for patients with ischemic perforations. Discussion: An algorithm for diagnostic and therapeutic steps was established. Furthermore, it was found that small bowel perforations are rare events with poor outcomes. Time to diagnosis and grade of underlying disease are the most essential parameters to predict perforation-associated complications