The mortality of patients with COVID-19 varies substantially from region to region. In a German observational study of 10 021 patients, the death rate was 22% for hospitalized patients and 53% for ventilated patients (1). Lower mortality might be expected in the second wave due to increasing experience and improved treatment options. Because no detailed comparative data are available on patient characteristics and treatment in identical settings in Germany, we set out to compare the mortality and other clinical endpoints among firstand second-wave COVID-19 patients treated in hospitals in and around Rosenheim, regarded as a first-wave hotspot.

Routine blood parameters are altered in patients with COVID-19 with differences depending on the severity of the disease. Therefore, they may predict diagnosis as well as prognosis of patients with COVID-19 and may be helpful when resources are limited.All patients admitted to our hospital were analyzed for routine blood parameters and SARS-CoV-2 screening results on admission. Primary endpoint was the area under the curve (AUC) of the receiver operating characteristic (ROC) analysis of routine blood parameters with PCR as gold standard.A total of 115 patients were included in the study. Median age was 79 years and male/female ratio was 49%/51%. 77 (67%) patients had PCR confirmed COVID-19. The lactate dehydrogenase (LDH) to leukocyte (WBC) ratio was the best diagnostic predictor (AUC 0.82), markedly better than the single parameters LDH (AUC 0.72) and WBC (AUC 0.75). Optimum cut-off of LDH/WBC ratio was 24.7 nU (sensitivity 87%, specificity 76%). The best single parameter for predicting a severe course of COVID-19 patients were CRP (AUC 0.83) and absolute lymphocyte count (ALC, AUC 0.77). Their ratio CRP/ALC surpassed both with an AUC of 0.88. Optimum cut-off was 77 n*mg (sensitivity 83%, specificity 80%).Our study showed, that on admission the LDH/WBC ratio is a diagnostic predictor of COVID-19 in symptomatic patients. In patients with COVID-19 the CRP/ALC ratio predicts severe course and probability of survival. Both are simple and good tools and may be helpful during pandemic when resources are limited.

Background and objective Stroke volume variation (SVV) has high sensitivity and specificity in predicting fluid responsiveness. However, sinus rhythm (SR) and controlled mechanical ventilation (CV) are mandatory for their application. Several studies suggest a limited applicability of SVV in intensive care unit (ICU) patients. We hypothesized that the applicability of SVV might be different over time and within certain subgroups of ICU patients. Therefore, we analysed the prevalence of SR and CV in ICU patients during the first 24 h of PiCCO-monitoring (primary endpoint) and during the total ICU stay. We also investigated the applicability of SVV in the subgroups of patients with sepsis, cirrhosis, and acute pancreatitis. Methods The prevalence of SR and CV was documented immediately before 1241 thermodilution measurements in 88 patients. Results: In all measurements, SVV was applicable in about 24%. However, the applicability of SVV was time-dependent: the prevalence of both SR and CV was higher during the first 24 h compared to measurements thereafter (36.1% vs. 21.9%; P <0.001). Within different subgroups, the applicability during the first 24 h of monitoring ranged between 0% in acute pancreatitis, 25.5% in liver failure, and 48.9% in patients without pancreatitis, liver failure, pneumonia or sepsis. Conclusions The applicability of SVV in a predominantly medical ICU is only about 25%–35%. The prevalence of both mandatory criteria decreases over time during the ICU stay. Furthermore, the applicability is particularly low in patients with acute pancreatitis and liver failure.

Stroke volume variation (SVV) has high sensitivity and specificity in predicting fluid responsiveness. However, sinus rhythm (SR) and controlled mechanical ventilation (CV) are mandatory for their application. Several studies suggest a limited applicability of SVV in intensive care unit (ICU) patients. We hypothesized that the applicability of SVV might be different over time and within certain subgroups of ICU patients. Therefore, we analysed the prevalence of SR and CV in ICU patients during the first 24 h of PiCCO-monitoring (primary endpoint) and during the total ICU stay. We also investigated the applicability of SVV in the subgroups of patients with sepsis, cirrhosis, and acute pancreatitis.

Bisher wird zur kompletten Darstellung der Papille, als die Goldstandard-Methode, die Verwendung eines Duodenoskops mit Seitblickoptik empfohlen. Ziel der Studie sollte der diagnostische Nutzen der Kappen-assistierten ÖGD (KAE) im Vergleich zu einer konventionellen Seitblick-Duodenoskopie (SBD) zur Darstellung und Beurteilung der Papilla duodeni major evaluiert werden.

BACKGROUND : Use of a side-viewing endoscope is currently mandatory to examine the major duodenal papilla; however, previous studies have used cap-assisted endoscopy for complete examination of the papilla. The aim of this study was to compare cap-assisted endoscopy with side-viewing endoscopy for examination of the major duodenal papilla. METHODS : This was a prospective, randomized, blinded, controlled, noninferiority crossover study. Patients were randomized to undergo either side-viewing endoscopy followed by cap-assisted endoscopy or cap-assisted endoscopy followed by side-viewing endoscope. Photographs of the major duodenal papilla were digitally edited to mask the cap area before they were evaluated by three blinded external examiners. Our primary end point was complete visualization of the major duodenal papilla. Secondary end points were the ability to examine the mucosal pattern, the overview of the periampullary region, overall satisfaction, and time to locate the papilla. RESULTS : 62 patients completed the study. Complete visualization of the major duodenal papilla was achieved in 60 examinations by side-viewing endoscopy and in 59 by cap-assisted endoscopy (97 % vs. 95 %). The difference between the two examinations was 1.6 % with a two-sided 95 % confidence interval of -4.0 % to 7.3 %, which did not exceed the noninferiority margin of 8 %. Cap-assisted endoscopy achieved better scores regarding the examination of mucosal pattern and overall satisfaction, whereas side-viewing endoscopy had a better overview score (P < 0.001, P = 0.004, and P < 0.001, respectively). There was no relevant difference in the median times to locate the major duodenal papilla. CONCLUSION : Cap-assisted endoscopy and side-viewing endoscopy had similar success rates for complete visualization of the major duodenal papilla. Cap-assisted endoscopy is superior to side-viewing endoscopy regarding the mucosal pattern and overall satisfaction. Side-viewing endoscopy gives a better overview of the periampullary region.

Morphology-based imaging modalities have replaced classical conventional nuclear medicine modalities for detection of liver or pancreatic lesions. With positron emission tomography and the glucose analog F-18 fluorodeoxyglucose (FDG), a sensitive and specific modality for the detection of hepatic metastases and extrahepatic tumor deposits from hepatocellular or pancreatic cancer is available. F-18 FDG PET can increase the accuracy of staging primary tumors of the liver or the pancreas, and can be used for response monitoring. Radiopharmaceuticals such as Ga-68 DOTATOC and F-18 DOPA allow the specific detection of neuroendocrine pancreatic tumors and their metastatic deposits. Hybrid scanners such as PET-CT integrate morphologic and metabolic information, and allow to increase the sensitivity and specificity of noninvasive imaging in many tumor entities. The development of specific radiopharmaceuticals and technical innovations such as SPECT-CT has increased the reliability of conventional scintigraphic imaging. This chapter focuses on the use of PET-CT in hepatobiliary and pancreatic cancers.

Ziele: Die Detektion und das Staging des hepatozellulären Karzinoms (HCC) ist eine Domäne der Schnittbildgebung wie der CT und MRT. Mittels PET und dem Radiotracer FLT soll die Möglichkeit geprüft werden, ob die Detektion verbessert und eine Therapieverlaufskontrolle bzw. die Prädiktion eines Therapieansprechens evaluiert werden kann. Methode: In dieser prospektiven Studie wurde bei 8 Patienten mit einem histologisch gesicherten HCC eine FLT-PET durchgeführt. Die übrige Diagnostik umfasste eine Kontrastmittel-verstärkte Spiral-CT mit arterieller und portal-venöser Kontrastmittelphase, eine Ultraschall-Diagnostik, sowie eine Endosonographie. 45–60min nach der i.v.-Injektion von 350–425MBq FLT erfolgte die FLT-PET mit einem PET-Scanner. Die Aufnahme von FLT in der jeweiligen tumorösen Raumforderung und den übrigen parenchymatösen Organen wurde in Form des mittleren und max. Tracer-Uptakes (FLT-SUV) bestimmt. Die Ergebnisse wurden mit der Histopathologie und den CT-morphologischen Veränderungen korreliert. Ergebnis: 4 von 8 bösartigen Tumoren zeigten eine fokale FLT-Aufnahme, welche höher, als die des Leberparenchyms war. 2 bösartige Tumore zeigten ein inhomogenes Speicherverhalten. 2 Tumore blieben photopen ohne wesentliche fokale Speicherung. Der durchschnittliche SUV aller Läsionen lag bei 7.1 (Wertebereich:1.8–12.0) und der max. FLT-Uptake bei 8.8 (Wertebereich:2.1–13.2). Das umgebende Leberparenchym wies einen mittleren SUV von 5.1 (Wertebereich:3.5–6.8) und eine max. Aufnahme von 5.6 (Wertebereich:4.0–7.3) auf. Schlussfolgerung: Die ersten Daten dieser fortlaufenden prospektiven Studie der nicht invasiven Bestimmung der Proliferation von HCC-Tumoren zeigten ein insgesamt gemischtes Speicherverhalten. 4 von 8 Tumoren konnten in Korrelation zur CT als HCC-Knoten sicher detektiert werden. Die übrigen waren entweder photopen oder nicht eindeutig zu detektieren. Es gilt die diagnostische Relevanz eines hohen FLT-Uptake bei histologisch gesichertem HCC weiterhin zu prüfen.

We determined the ability of PET with the thymidine analog 3'-deoxy-3'-F-18-fluorothymidine (F-18-FLT) to detect hepatocellular carcinoma (HCC). Methods: In this pilot study, F-18-FLT PET was performed in 18 untreated patients with clinically suspected HCC. Routine diagnostic procedures included ultrasound, MRI, or contrast-enhanced spiral CT of the upper gastrointestinal tract in all patients. At 45-60 min after the intravenous injection of approximately 270-340 MBq of F-18-FLT, emission and transmission scanning was performed with a high-resolution PET scanner. Tracer uptake in the tumor and surrounding liver tissue was evaluated semiquantitatively by calculation of mean and maximum standardized uptake values (SUVs). Results were correlated with those of the conventional imaging methods. Results: A total of 13 of 18 tumors (sensitivity, 72%; 95% confidence interval [CI], 47% 290%) showed focal F-18-FLT uptake higher than surrounding liver activity and were detectable as hot lesions. Five tumors were characterized as photopenic lesions or contained a mixture of hot and cold lesions exhibiting a comparable or lower F-18-FLT uptake than the surrounding liver tissue. When all lesions were considered, the mean F-18-FLT SUV was 7.8 (range, 2.5-11.1), and the maximum F-18-FLT SUV was 9.3 (range, 2.9-14.3). Histology and clinical follow-up revealed HCC in 16 patients and cholangiocarcinoma in 2 patients. In the subgroup of HCC, the sensitivity for tumor detection was 69% (11/16; 95% CI, 41% 289%). Correlation analysis demonstrated a significant positive relationship between the proliferation marker MIB-1 and the mean SUV (r = 0.66, P = 0.02). Survival analysis (Cox proportional hazards regression) for initial F-18-FLT uptake (mean and maximum SUVs) revealed increased hazard ratios (mean SUV, 1.20; maximum SUV, 1.12), but because of the small number of events, these results were not statistically significant. Conclusion: In this pilot study, HCC tumors showed a mixed uptake pattern for the in vivo proliferation marker F-18-FLT. A total of 69% of the HCC lesions showed F-18-FLT uptake higher than that of the surrounding liver tissue, whereas the remaining lesions were photopenic or contained a mixture of hot and cold lesions. High initial F-18-FLT uptake seems lto be associated with reduced overall survival and could be an important prognostic factor if this tendency can be confirmed in a larger prospective trial.

Epidemiological and experimental data demonstrate, that inflammation contributes significantly to pancreatic carcinogenesis. IL1beta, a pleiotropic cytokine produced by inflammatory cells and tumor cells, promotes cancer progression. Single nucleotide polymorphisms (SNPs) of the IL1beta promoter were found to be associated with an increased risk for certain cancers. In this case-control study we determined IL1beta promoter SNPs in 73 patients with pancreatic cancer and 235 controls. We found that the IL1beta -511CT/-31TC genotype was significantly associated with an increased risk for pancreatic cancer (OR 1.42, p=0.0456). Among pancreatic cancer cases, patients with the -511CT/-31TC genotype had less frequently resectable disease than patients with other IL1beta -511/-31 genotypes (p=0.0323). Furthermore, the IL1beta -511CT/-31TC genotype was more frequent observed in UICC stage IV (p=0.039) and undifferentiated tumors (G3) (p=0.019). In addition, we found that the proinflammatory IL1beta -511CT/-31TC alleles define an IL1beta secretory phenotype in pancreatic cancer cell lines in vitro. These findings provide a first evidence for an association of the IL1beta gene promoter SNPs with risk for pancreatic cancer.

BACKGROUND & AIMS:Ablation of gastric inlet patches (GIP) in the cervical esophagus by argon plasma coagulation (APC) can alleviate chronic globus sensations in the throat. We investigated the efficacy of this therapy in a randomized, controlled multicenter trial.METHODS:Patients with chronic globus sensations and GIP were randomly assigned 1:1 to groups that were treated with APC or a sham procedure (controls). Patients and their referring physicians were blinded to therapy. All patients completed a standardized questionnaire about symptoms before and 3 months after the procedure. Thereafter, control patients were eligible for cross-over therapy. Long-term efficacy was assessed in all patients >or=6 months after APC.RESULTS:Improvement of symptoms was reported in 9 (82%) of 11 patients who received APC, compared with 0 (0%) of 10 patients in the control group (P = .002). Nine (90%) of 10 patients treated with APC had per protocol healing, compared with 0 (0%) of 9 controls (P < .001). Scores for symptom/globus assessment significantly improved in patients in the APC group, whereas patients in the control group did not perceive any symptom relief. Eight of the 10 patients who started in the control group crossed over to the APC group. Long-term efficacy (after a median follow-up of 17 months) was documented in 13 (76%) of 17 treated patients.CONCLUSIONS:Ablation of gastric inlet patches appears to be an effective therapy for alleviation of associated globus sensations. This new treatment modality might change the paradigm for treatment of these patients.

As a consequence of recent studies the treatment of gastrointestinal cancers has become challenging and is undergoing constant changes on the basis of the results of new trials. The steering committee of the working group on gastrointestinal cancers of the Deutsche Gesellschaft für Verdauungs- und Stoffwechselkrankheiten has decided to summarise and present recent updates of the current treatment guidelines and recommendations for the most relevant gastrointestinal malignancies. In this review we have included recent findings from large trials on esophageal, gastric, pancreatic, cholangiocellular and liver cancers, as well as colorectal cancers, neuroendocrine tumours and lymphomas. This includes an update on the combination with novel targeted agents and the introduction of potential predictive biomarkers in the selection of the appropriate treatment strategy.

Hintergund: Im Rahmen einer Pilotstudie konnten wir zeigen, dass die Ablation von heterotoper Magenschleimhaut (HMS) im zervikalen Ösophagus durch Argon-Plasma-Koagulation (APC) zu einer Besserung von Globussensationen im Hals führt. Ziel der vorliegenden multizentrischen Studie war es den Therapieeffekt durch eine Randomisierung und Scheinkontrolle zu evaluieren.

OBJECTIVE:Volume depletion and/or increased hematocrit are associated with poor prognosis in necrotizing pancreatitis. Several studies suggest that intrathoracic blood volume index (ITBI) might be superior to central venous pressure (CVP) with regard to preload assessment. Therefore, the aim of our study was to evaluate the predictive value of CVP and hematocrit with regard to ITBI, and to correlate these parameters to cardiac index (CI). DESIGN:Prospective study. SETTING:Medical intensive care unit, university hospital. PATIENTS AND INTERVENTIONS:Within 24 hrs of intensive care unit-admission, 96 hemodynamic measurements using the PiCCO system were performed in 24 patients with necrotizing pancreatitis. MAIN RESULTS:Mean CVP (12.11 +/- 5.97 mm Hg; median 11.5 normal: 1-9 mm Hg) was elevated, whereas mean ITBI (822.8 +/- 157.0 mL/m2; median 836 mL/m2; normal: 850-1000 mL/m2) was decreased. Fifty-one of 96 ITBI values were decreased (prevalence of hypovolemia of 53%). No CVP value was decreased. Fifty-three CVP measurements were elevated despite simultaneous ITBI levels indicating a normal or decreased preload. Sensitivity, specificity, positive predictive value, and negative predictive value of CVP with regard to volume depletion (ITBI <850 mL/m2), were 0%, 100%, 0%, and 47%, respectively. An increase in hematocrit (hematocrit >40% [female] or >44% [male]) was found in 11 of 51 measurements with decreased ITBI. Sensitivity, specificity, positive predictive value, and negative predictive value of an increase in hematocrit with regard to volume depletion according to ITBI were 22%, 82%, 58%, and 48%, respectively. ITBI and delta-ITBI significantly correlated to CI and delta-CI (r = .566, p < 0.001; r = .603, p < 0.001), respectively. CVP and delta-CVP did not correlate to CI and delta-CI, respectively. There was a significant correlation between ITBI and extravascular lung water index (r = .392; p < 0.001), but no correlation between CVP and extravascular lung water index (r = .074; p = 0.473). CONCLUSIONS:Volume depletion according to ITBI was found in more than half the patients. The predictive values of CVP and hematocrit with regard to volume depletion were low. ITBI and its changes significantly correlated to CI and its changes, which was not observed for CVP and delta-CVP. Therefore, ITBI appears to be more appropriate for volume management in necrotizing pancreatitis than CVP or hematocrit.

Ziele: CT-morphologisch kann eine Differenzierung zwischen malignen und benignen Veränderungen, insbesondere bei zystischen Veränderungen des Pankreas schwierig sein.

We have determined the ability of PET with the thymidine analog 3′-deoxy-3′-18F-fluorothymidine (FLT) to detect pancreatic cancer and to differentiate malignant from benign pancreatic lesions. Methods: In this prospective study, 18F-FLT PET was performed on 31 patients with undefined pancreatic lesions. Routine diagnostic procedures included endoscopic ultrasound, MRI, or multislice helical CT of the upper gastrointestinal tract in all patients. Uptake of 18F-FLT was evaluated semiquantitatively by calculation of mean and maximal standardized uptake values (SUVs). Results were correlated to the reference methods, which were histopathology (23/31) or cytology/clinical follow-up (8/31). Results: All 10 benign pancreatic lesions were negative on 18F-FLT PET and showed only background activity (specificity, 100%; 90% confidence interval, 74%−100%). On visual interpretation, 15 of 21 malignant tumors presented as focal 18F-FLT uptake higher than the surrounding background (sensitivity, 71.4%; 90% confidence interval, 52%−89%). 18F-FLT PET missed 4 well-differentiated and 2 T1 cancers. Mean 18F-FLT uptake was 3.1 in all malignant tumors (median, 2.8; range, 1.3–8.5), 3.7 in tumors with visual tracer uptake (median, 3.2; range, 2.1–8.5), and significantly higher in malignant than in benign tumors (mean/median, 1.4; range, 1.2–1.7; P < 0.001). For discriminating cancer from benign pancreatic lesions, receiver-operating-characteristic analysis indicated a sensitivity of 81% and specificity of 100% (area under the curve, 0.93) using a mean 18F-FLT SUV cutoff of 1.8 (maximal 18F-FLT SUV: area under the curve, 0.92; SUV cutoff, 2.1). Conclusion: In this pilot study, focal uptake of the in vivo proliferation marker 18F-FLT was detected exclusively in malignant tumors. 18F-FLT PET may therefore be useful as a diagnostic adjunct for differentiating cancer from benign pancreatic lesions.

To compare quality of life after subtotal gastrectomy (STG) and total gastrectomy of various types, in view of the fact that, with T1 and T2 gastric carcinoma of intestinal type in the distal third of the stomach, subtotal gastrectomy is similar to total gastrectomy regarding the extent of lymphadenectomy and prognosis.Quality of life was measured by standardised questionnaires given to 36 patients after subtotal gastrectomy (22 men, 14 women; mean age 63 [27-79] years): general physical complaints (GPC); contentment with life (CL); psychosocial stress (PSS). The results were compared with those previously obtained in 58 patients with total gastrectomy (46 men, 12 women; mean age 63.4 [36-74] years) and oesophagojejunostomy (OJS) (n = 29) or oesophagojejunoplication and pouch (OJPP) (n = 29).Weight loss of patients after OJPP was not significantly different from that of patients after STG, but it was significantly higher after OJS (13.5 +/- 8.6 kg; P < 0.0006). Patients with STG had significantly more general complaints (P < 0.05) and greater discontent with life (P < 0.05) than those with OJPP. Specific analysis of gastric complaints showed greatest dissatisfaction with gastrointestinal functions in patients after STG (P < 0.0004), less also after OJS compared with OJPP (P < 0.01).Subtotal gastrectomy for gastric carcinoma has no advantages over total gastrectomy with oesophagojejunoplication and pouch as regards weight loss, gastrointestinal complaints, psychosocial stress and general contentment. The poor quality of life seems to have its functional correlate in increased intestino-oesophageal reflux with incompetent cardia and after Billroth II reconstruction.