[Overview of relevant clinical recommendations from the new S3 guidelines on acute and chronic pancreatitis]. / Überblick über relevante klinische Empfehlungen aus der neuen S3-Leitlinie "Akute und chronische Pankreatitis".

Acute pancreatitis is a primary sterile inflammation of the pancreas, which is characterized by an unphysiological enzyme activation. This leads to an inflammatory reaction with edema, vascular damage and cell decay. The first German interdisciplinary S3 guidelines on chronic pancreatitis were published in 2012. Under the auspices of the German Society of Gastroenterology, Digestive and Metabolic Diseases (DGVS) and with the participation of various societies and patient representatives, the guidelines were recently revised and extended, Comprehensive S3 guidelines on acute and chronic pancreatitis were compiled and agreed by consensus. This article presents the important clinical aspects on acute pancreatitis from these guidelines in a compact form and the recommendations are justified.

[Treatment recommendations for early esophageal cancer : Endoscopic and surgical options]. / Therapieempfehlungen beim Frühkarzinom des Ösophagus : Endoskopische und chirurgische Optionen.

BACKGROUND: Esophageal cancer represents a complex tumor entity with an increasing proportion of adenocarcinomas. Early esophageal cancer is staged as m1-m3 depending on the depth of infiltration into the mucosa and as sm1-sm3 depending on invasion into the submucosa. The risk of lymph node metastasis is strongly correlated with the depth of invasion and increases by leaps and bounds with submucosal infiltration. MATERIAL AND METHODS: This review is based on publications retrieved by a selective database search (MEDLINE, PubMed, Cochrane Library, International Standard Randomised Controlled Trial Number, ISRCTN, registry) on the current management of early esophageal cancer. RESULTS: The endoscopic diagnostics and evaluation of the dignity of superficial esophageal cancer by traditional staining techniques have been expanded by virtual chromoendoscopy. Endoscopic resection is the diagnostic and therapeutic procedure of choice for mucosal low risk adenocarcinomas (grade 1 or 2, no blood or lymph vessel invasion). Under certain prerequisites adenocarcinomas of the upper submucosa (sm1) can also be endoscopically removed. All other stages necessitate surgical treatment. In squamous cell carcinoma without risk factors a surgical oncological esophageal resection is indicated after infiltration of the third mucosal layer (m3). Endoscopic submucosal dissection (ESD) shows high rates of en bloc and R0 (curative) resections even with large lesions. CONCLUSION: Borderline cases between endoscopic and surgical treatment of early esophageal cancer necessitate an interdisciplinary approach and individually adapted management, which in the locally advanced stage are always embedded in a multimodal concept.

[Endoscopic diagnosis, treatment, and follow-up of polyps of the lower gastrointestinal tract]. / Endoskopische Diagnostik, Therapie und Nachsorge von Polypen des unteren Gastrointestinaltrakts.

BACKGROUND: The endoscopic management of polyps of the lower gastrointestinal tract (l-GIT) has emerged in recent years as a result of numerous technological innovations. However, proven expertise and experience are essential. OBJECTIVES: Presentation of novel and standard techniques and best-practice recommendations for the characterization and resection of l­GIT polyps. METHODS: Recent specialist literature and current guidelines. RESULTS: High-definition endoscopy should be the standard when performing colonoscopy. The (virtual) chromoendoscopy can improve detection and characterization of polyps, but always requires special expertise and experience of the endoscopist in advanced endoscopic imaging. In this regard, computer-aided-diagnosis (CAD) systems have the potential to support endoscopists in the future. Pedunculated polyps should be removed with a hot snare. Small flat polyps can be resected by cold snare or large forceps. Large, non-pedunculated polyps should be treated in an interdisciplinary approach at a referral center with long-standing experience depending on its malignancy potential. After complete resection of small adenoma without high grade dysplasia, surveillance endoscopy is recommended after 5-10 years. Patients with large adenoma or high grade dysplasia should undergo endoscopy after 3 years and patients with multiple adenoma earlier than 3 years. After incomplete or piecemeal resection or insufficient bowel preparation, near-term endoscopy is recommended. CONCLUSIONS: Adequate characterization and treatment are essential for the appropriate management of l­GIT polyps.

[Interventional endoscopy in the gastrointestinal tract : Indications and limitations]. / Interventionelle Endoskopie im Gastrointestinaltrakt : Indikationen und Grenzen.

The spectrum of endoscopic techniques has been greatly enlarged in recent years. Lesions and also (iatrogenic) complications that required surgical procedures in the past can now often be treated endoscopically. Advances in endoscopic mucosal resection and submucosal dissection also enable the resection of large or laterally spreading polyps in the gastrointestinal tract. Full-thickness resection is also possible by means of specially designed clips. By the creation of a submucosal tunnel submucosal lesions can be completely excised and the muscle fibers of the lower esophageal sphincter can be endoscopically severed in achalasia patients. Endosonography-guided interventions have developed into the standard procedure for complicated pancreatitis and the use of cholangioscopy offers new therapeutic procedures for the bile and pancreatic ducts. In this continuing medical education article interventional endoscopic techniques are presented and critically evaluated.

[Surgical approach to benign bile duct alterations]. / Chirurgisches Vorgehen bei benignen Gallengangsveränderungen.

BACKGROUND: Benign biliary diseases comprise entities, which present with very similar pathognomonic symptoms despite fundamental etiological differences. Obstructions of intrahepatic and extrahepatic bile ducts due to stones, tumors or parasites as well as stenoses and cystic alterations belong to the group of benign biliary diseases. OBJECTIVE: This article provides a systematic overview of the indications and differential treatment of benign biliary diseases with special emphasis on the surgical treatment. MATERIAL AND METHODS: The presented recommendations are in accordance with national and international guidelines, current scientific papers and expert opinions. RESULTS: Essentially the surgical options for benign biliary diseases consist of revision, reconstruction through bilioenteric anastomosis, resection and complete organ replacement in the sense of liver transplantation. The location of the affected segment of the biliary tree, the symptoms, the progress of the disease and suspected malignancy essentially determine the level of escalation in the described treatment level scheme. CONCLUSION: The treatment of benign biliary diseases is complex and requires achievement of unimpaired, unobstructed bile drainage. It serves the purpose of resolving cholestasis and thereby avoiding recurrent cholangitis and long-term complications, such as biliary cirrhosis and malignant transformation; however, in some cases of premalignant lesions of the bile ducts the strategy resembles cancer surgery, including resection of the affected tissue.

Inspiratory threshold loading reduces lipoperoxidation in obese and normal-weight subjects.

Obesity is related to increased oxidative stress. Although low-intensity physical exercise reduces oxidative stress, obese subjects may show exercise intolerance. For these subjects, inspiratory threshold loading could be an alternative tool to reduce oxidative stress. We investigated the effects of inspiratory threshold loading on biomarkers of oxidative stress in obese and normal-weight subjects. Twenty obese (31.4 ± 6 years old, 10 men and 10 women, 37.5 ± 4.7 kg/m2) and 20 normal-weight (29.4 ± 8 years old, 10 men and 10 women, 23.2 ± 1.5 kg/m2) subjects matched for age and gender participated in the study. Maximal inspiratory pressure (MIP) was assessed by a pressure transducer. Blood sampling was performed before and after loading and control protocols to assess thiobarbituric acid reactive substances (TBARS), protein carbonylation, and reduced glutathione. Inspiratory threshold loading was performed at 60% MIP and maintained until task failure. The 30-min control protocol was performed at 0 cmH2O. Our results demonstrated that inspiratory threshold loading reduced TBARS across time in obese (6.21 ± 2.03 to 4.91 ± 2.14 nmol MDA/ml) and normal-weight subjects (5.60 ± 3.58 to 4.69 ± 2.80 nmol MDA/ml; p = 0.007), but no change was observed in protein carbonyls and glutathione in both groups. The control protocol showed no significant changes in TBARS and protein carbonyls. However, reduced glutathione was increased across time in both groups (obese: from 0.50 ± 0.37 to 0.56 ± 0.35 µmol GSH/ml; normal-weight: from 0.61 ± 0.11 to 0.81 ± 0.23 µmol GSH/ml; p = 0.002). These findings suggest that inspiratory threshold loading could be potentially used as an alternative tool to reduce oxidative stress in both normal-weight and obese individuals.

[Importance of functional diagnostics in gastroenterology]. / Stellenwert der Funktionsdiagnostik in der Gastroenterologie.

In this review article important and frequently used investigation methods for gastrointestinal functional diagnostics are presented. Some other rarely used special investigations are also explained. The hydrogen breath test is simple to carry out, ubiquitously available and enables the detection of lactose, fructose and sorbitol malabsorption. Furthermore, by the application of glucose, the test can be carried out when there is a suspicion of abnormal intestinal bacterial colonization and using lactulose for measuring small intestinal transit time. The 13C urea breath test is applied for non-invasive determination of Helicobacter pylori infections and assessment of gastrointestinal transit time, liver and exocrine pancreas functions. The secretin cholecystokinin test was the gold standard for the detection of exocrine pancreas insufficiency. However, measurement of pancreatic elastase in stool is less invasive but also less sensitive. Scintigraphy and capsule investigations with pH and temperature probes constitute important methods for determination of gastric emptying, intestinal and colon transit times. For evaluation of constipation panoramic abdominal images are taken after intake of radiologically opaque markers (Hinton test). For the diagnosis of functional esophageal diseases manometry is indispensable. In addition, manometry is only occasionally used for diagnosing a dysfunction of the sphincter of Oddi, due to the danger of inducing pancreatitis. A 24 h pH-metry is applied for the detection of non-erosive gastroesophageal reflux disease and, if necessary, with impedance measurements. Recent investigation procedures, e. g. specific MRI sequences, sonographic determination of gall bladder ejection fraction, analysis of gastric accomodation or real-time lumen imaging, require further evaluation prior to clinical application.

[Endoscopic treatment of obesity and complications following bariatric surgery]. / Endoskopische Therapie von Adipositas und von Komplikationen nach bariatrischer Chirurgie.

The prevalence of obesity in the population has been increasing for many years. Due to associated comorbidities the treatment of obesity is becoming more important. Conservative treatment alone is often unsuccessful, particularly in cases of severe obesity. In these cases, multimodal therapy in specialized treatment units is warranted. Between conservative treatment and bariatric surgery, interventional endoscopic treatment options also play an increasing role. Nowadays, implantation of gastric balloons and duodenojejunal bypass liners (EndoBarrier) are the most often used endoscopic options. A further typical application of endoscopy in the treatment of obesity is the management of complications after bariatric surgery, such as stenosis and insufficiency. This article gives an overview on the currently available endoscopic options associated with treatment of obesity.

English language version of the S3-consensus guidelines on chronic pancreatitis: Definition, aetiology, diagnostic examinations, medical, endoscopic and surgical management of chronic pancreatitis.

Chronic pancreatitis is a disease of the pancreas in which recurrent inflammatory episodes result in replacement of pancreatic parenchyma by fibrous connective tissue. This fibrotic reorganization of the pancreas leads to a progressive exocrine and endocrine pancreatic insufficiency. In addition, characteristic complications arise, such as pseudocysts, pancreatic duct obstructions, duodenal obstruction, vascular complications, obstruction of the bile ducts, malnutrition and pain syndrome. Pain presents as the main symptom of patients with chronic pancreatitis. Chronic pancreatitis is a risk factor for pancreatic carcinoma. Chronic pancreatitis significantly reduces the quality of life and the life expectancy of affected patients. These guidelines were researched and compiled by 74 representatives from 11 learned societies and their intention is to serve evidence-based professional training as well as continuing education. On this basis they shall improve the medical care of affected patients in both the inpatient and outpatient sector. Chronic pancreatitis requires an adequate diagnostic workup and systematic management, given its severity, frequency, chronicity, and negative impact on the quality of life and life expectancy.

[Neoadjuvant therapy for tumors of the upper gastrointestinal tract : Complication management]. / Neoadjuvante Therapie bei Tumoren des oberen Gastrointestinaltrakts : Komplikationsmanagement.

Recent studies could demonstrate that neoadjuvant chemotherapy and radiochemotherapy for esophageal and gastric cancer do not significantly increase the risk of postoperative morbidity and mortality as compared to surgery alone. With respect to patient safety and effectiveness of neoadjuvant concepts, quality assured performance of each treatment modality and close interdisciplinary cooperation play an important role. The majority of potential side effects and complications, which might occur during neoadjuvant therapy can be adequately controlled by correct prophylaxis and professional medical complication management. Complications before, during and after neoadjuvant therapy of upper gastrointestinal tract tumors can also be caused by the tumor itself or by medicinal therapy. These comprise bleeding, fistulas, perforations and stenoses. Modern endoscopic techniques are the therapy of choice in these situations. Preoperative conditioning during the period of neoadjuvant therapy opens the possibility of reduced postoperative complications to patients with tumors of the upper gastrointestinal tract.

S3 guideline for chronic pancreatitis - diagnosis, classification and therapy for the radiologist.

UNLABELLED: Chronic pancreatitis shows an increasing prevalence and incidence mainly in the Western Hemisphere. Early diagnosis and therapy are frequently delayed because of non-specific symptoms as well as non-specific blood values. The German Society of Digestive and Metabolic Diseases (DGVS) organized the preparation and publication of an interdisciplinary S3 level guideline with the support of the German Radiological Society (DRG) as 1 of 11 contributing societies. In this article we present and discuss the main topics of the guideline regarding the diagnosis, differential diagnosis and therapy of complications of this complex chronic disease with a focus on clinical and scientific radiologists. KEY POINTS: • Ultarsound represents the perfect first line imaging modality • For further diagnostic werk up MRI with MRCP are recommended for the differential diagnosis of pancreatic cancer • For clinical studies the modified (CT, MRI) Cambridge classification is recommended.

[Treatment of gastric cancer]. / Therapie des Magenkarzinoms.

From a global perspective, gastric cancer including adenocarcinoma of the esophagogastric junction is the fourth most common malignant tumor and the second most common cause of cancer-related death. Due to the lack of specific symptoms of early cancer, most gastric cancers are diagnosed in advanced stages. Staging should include high-resolution computed tomography of the thorax, abdomen, and pelvis and documented video-endoscopy and endoscopic ultrasound. In mucosal gastric cancer, endoscopic resection can replace surgical resection. In more advanced stages, perioperative chemotherapy has been established as a standard of care. In the metastatic setting, treatment goals are palliative. Chemotherapy can prolong survival, improve symptoms, and enhance the quality of life. Combination chemotherapy including a platinum salt plus fluoropyrimidine is the standard of care. About 16 % of gastric cancers exhibit overexpression of the growth factor receptor HER2. Trastuzumab has shown to prolong survival when combined with chemotherapy in HER2-positive gastric cancer.

[A quite usual pancreatitis?]. / Eine ganz normale Pankreatitis?

HISTORY AND CLINICAL FINDINGS: A 55-year-old man suffered from severe acute abdominal pain. 10 years previously he had been diagnosed with acute pancreatitis. On palpation, there was pronounced abdominal tenderness and guarding. INVESTIGATIONS: Emergency CT revealed signs of intra- and extrahepatic cholestasis and biliar sludge; serum-lipase was increased. TREATMENT AND COURSE: Acute biliary pancreatitis was diagnosed. After admission the patient's condition deteriorated; acute renal failure and respiratory insufficiency developed. After 4 weeks of intensive care he was discharged to a rehabilitation facility via normal ward. At that time pancreatic sonography showed a walled-off necrosis. 7 weeks later colicky abdominal pain occurred again. Altough there were no signs of infection, suction-irrigation drainage was administered. This led to a secondary infection of the necrotic cavity, and 20 sessions of endoscopic necrosectomy were performed for 3 month. Then the patient was discharged to follow-up treatment in a stable condition. CONCLUSION: Even in supposedly "usual" acute pancreatitis complications can lead to a prolonged course. Sterile necroses should be managed very cautiously.

Acute cerebrovascular incident as a complication of TIPS procedure.

The formation of a transjugular intrahepatic portosystemic shunt (TIPS) is a well-established procedure in the management of complications of severe portal hypertension. It is also performed if portal hypertension is a result of acute portal vein thrombosis. We report the case of an acute cerebrovascular incident after TIPS formation in a patient with partial portal vein thrombosis. Even when no patent foramen ovale (PFO) is detectable the presence of PFO and thus the risk of cerebrovascular incident cannot be excluded. We therefore propose to inform patients with preexisting portal vein thrombosis prior to undergoing this intervention that TIPS procedure may be associated with the risk of cerebral embolization.

[The role of endoscopy in the therapy for perforations and leakages of the gastrointestinal tract]. / Endoskopische Therapieoptionen für Perforationen und Insuffizienzen des Gastrointestinaltrakts.

Perforations and leakages of hollow organs of the gastrointestinal tract can occur spontaneously among other causes. They can also develop as complications of an endoscopic intervention or after surgical construction of an anastomosis. For the patient, these situations usually are serious and life-threatening. Standard therapy has always been - and most of the time still is - major surgery. These procedures usually are technically difficult and their mortality and morbidity are not satisfactory due to, among others, the occurrence of local infections. Thus, various endoscopic techniques as therapy for perforations and leakages have been developed over the last years. These include above all the endoscopic placement of clip systems and stents and the relatively new vacuum drainage systems. In case of perforations and leakages of the bile duct and the rectum especially, these minimal invasive techniques are widely used, also increasingly in lesions of the esophagus. However, these new, endoscopic procedures suffer from a lack of evidence. This paper highlights the possibilities and limitations of endoscopic options in therapy for perforations and leakages of organs of the gastrointestinal tract.

Risk factors for bleeding complications after endoscopic variceal ligation therapy.

BACKGROUND: Bleeding from esophageal varices is a severe complication of portal hypertension. Endoscopic band ligation (EBL) is the treatment of choice for acute variceal bleeding. It is also performed for primary and secondary prophylaxis of bleeding from esophageal varices. After EBL, patients are at risk of postinterventional bleeding; the risk factors for this complication are poorly evaluated. METHODS: We retrospectively analyzed data from patients who underwent EBL. We evaluated clinical data, laboratory and endoscopic findings. RESULTS: 255 patients with 387 ligation sessions were included in the analysis. Patients with bleeding complications had a significantly higher severity of liver disease as measured by a higher Child-Pugh score (10.5 vs. 8, p = 0.002), lower albumin (26.5 vs. 31.9 [g/L], p = 0.0001) and lower prothrombin activity (46.5 vs. 70 [%], p = 0.0001). The incidence of bacterial infection was significantly higher in patients with postinterventional bleeding. As well, the white blood cell count was significantly higher in the bleeding group (9.5 vs. 6.5 [× 10 (9) /L], p = 0.030). In patients with bleeding events we observed an elevated heart rate compared to those without this complication (80 vs. 72 [bpm], p = 0.017). Furthermore, we found a lower hemoglobin level (5.9 vs. 6.4 [mmol/L], p = 0.028) and a lower hematocrit (0.280 vs. 0.314, p = 0.031) in the bleeding group. Younger patients suffered more often from postinterventional bleeding (52.5 vs. 58 [years], p = 0.012). CONCLUSION: There are clinical data which can be ascertained easily in order to reflect the risk of bleeding complications after EBL.