Introduction High-frequency electrical stimulation therapy (gastric electrical stimulation, GES) is a treatment option for gastroparesis of various genesis. The best indication and prognostic parameters have not yet been conclusively determined. Method Retrospective analysis of all gastroparesis patients implanted with a GES device between 2011 and 2020. Clinical response was measured before and after implantation using a validated Gastroparesis Cardinal Symptom Index (GCSI) (maximum score: 5, minimum score: 0). Other study endpoints included: subjective symptom course (no improvement, partial improvement, or severe improvement) and change in gastroparesis medication. Results A GES device was implanted in 42 patients (16 M: 26 F, mean age 45 years). The etiology of gastroparesis was diabetic (n=23), idiopathic (n=10) or postoperative (n=9). Eleven patients (26%) had undergone one or more invasive treatments before. GCSI score of the total group was 3.23 preoperatively. The median follow-up time was 12 months. In the overall group, significant improvement in GCSI score was found 3, 6, 9, and 12 months postoperatively-regardless of indication. In multivariate analysis, disease duration of >30 months was associated with a significantly decreased GCSI score at 12 months (p<0.001). Approximately 40% of patients were able to discontinue or significantly reduce gastroparesis medication. At the end of follow-up, 81% of patients reported partial or major improvement in symptoms. During the follow-up period, three patients (7%) died. Conclusion Gastric electrical neurostimulation is an effective and safe option for refractory gastroparesis-regardless of the underlying disease.

ZusammenfassungDie elektrische Hochfrequenzstimulations-Therapie (Gastric Electric Stimulation, GES) stellt eine Behandlungsoption der Gastroparese verschiedener Genese dar. Die beste Indikation und die Prognoseparameter sind noch nicht abschließend geklärt.Retrospektive Analyse aller Gastroparese – Patienten, bei denen zwischen 2011 und 2020 ein GES-Device implantiert wurde. Das klinische Ansprechen wurde vor und nach Implantation mittels eines validierten Gastroparesis Cardinal Symptom Index (GCSI) gemessen (maximale Punktzahl: 5, minimale Punktzahl: 0). Weitere Endpunkte der Studie waren: subjektiver Beschwerdeverlauf (keine Besserung, teilweise oder starke Besserung) und Änderung der Gastroparese-Medikation.Bei 42 Patienten (16 M: 26 F, durchschnittliches Alter 45 Jahre) wurde ein GES-Device implantiert. Die Genese der Erkrankung war diabetisch (n=23), idiopathisch (n=10) oder postoperativ (n=9). Elf Patienten (26%) hatten sich im Vorfeld bereits einer oder mehreren invasiven Behandlungen unterzogen. Der GCSI-Score der Gesamtgruppe lag präoperativ bei 3,23. Die Nachsorgezeit betrug im Median 12 Monate. In der Gesamtgruppe fand sich eine signifikante Besserung des GCSI-Scores 3, 6, 9 und 12 Monate postoperativ, unabhängig von der Indikation. In der multivariaten Analyse war die Erkrankungsdauer von >30 Monaten mit einem signifikant schlechteren GCSI-Score nach 12 Monaten assoziiert (p<0,001). Etwa 40% der Patienten konnten die Gastroparese-Medikation absetzen oder wesentlich reduzieren. Am Ende der Nachsorge berichteten 81% der Patienten über eine teilweise oder starke Besserung der Symptome. Während der Nachsorgezeit starben drei Patienten (7%).Die elektrische Neurostimulation des Magens ist eine effektive und sichere Option bei therapierefraktärer Gastroparese – unabhängig von der zugrunde liegenden Erkrankung.

Background In patients with altered upper gastrointestinal anatomy, conventional endoscopic retrograde cholangiography is often not possible and different techniques, like enteroscopy-assisted or percutaneous approaches are required. Aim of this study was to analyze success and complication rates of these techniques in a large collective of patients in the daily clinical practice in a pre-endosonographic biliary drainage era. Patients and methods Patients with altered upper gastrointestinal anatomy with biliary interventions between March 1st, 2006, and June 30th, 2014 in four tertiary endoscopic centers in Munich, Germany were retrospectively analyzed. Results At least one endoscopic-assisted biliary intervention was successful in 234/411 patients (56.9%)-in 192 patients in the first, in 34 patients in the second and in 8 patients in the third attempt. Success rates for Billroth-II/Whipple-/Roux-en-Y reconstruction were 70.5%/56.7%/49.5%. Complication rates for these reconstructions were 9.3%/6.5%/6.3%, the overall complication rate was 7.1%. Success rates were highest in patients with Billroth-II reconstruction where use of a duodenoscope was possible, complication rates were also highest in this scenario. Success rates were lowest in longer-limb anatomy like Roux-en-Y reconstruction. Percutaneous biliary drainages (PTBD) were inserted 268 times with substantially higher success (90.7%) as well as complication rates (11.6%) compared to the endoscopic approach. Compared to patients treated endoscopically, patients with PTBD had a lower performance status, more severe cholestasis and a significant higher rate of malignant underlying disease. Conclusion In patients with altered upper gastrointestinal anatomy, success rates of endoscopic-assisted biliary interventions are lower compared to PTBD. Still, due to the beneficial complication rates of the endoscopic approach, this technique should be preferred whenever possible and in selected patients who still need to be defined in detail, repeated endoscopic attempts are useful to help achieve the desired result.

The aim of the study was to investigate the predictive impact of extracranial metastatic patterns on course of disease and survival in patients with colorectal cancer (CRC) and brain metastasis (BM). A total of 228 patients (134 male [59%], 94 female [41%]) with histologically proven CRC and BM were classified into different groups according to extracranial metastatic patterns. Time intervals to metastatic events and survival times from initial CRC diagnosis, extracranial and intracranial metastasis were analyzed. Extracranial organs mostly affected were liver (102 of 228 [44.7%]) and lung (96 of 228 [42.1%]). Liver and lung metastases were detected in 31 patients (13.6%). Calculated over the entire course of disease, patients with lung metastasis showed longer overall survival (OS) than patients with liver metastasis or patients without lung metastasis (43.9 vs 34.6 [P = .002] vs 35.0 months [P = .002]). From the date of initial CRC diagnosis, lung metastasis occurred later in CRC history than liver metastasis (24.3 vs 7.5 months). Once lung metastasis was diagnosed, BM occurred faster than in patients with liver metastasis (15.8 vs 26.0 months; Delta 10.2 months). Accordingly, OS from the diagnosis of liver metastasis was longer than from lung metastasis (27.1 vs 19.6 months [P = .08]). Once BM was present, patients with lung metastasis lived longer than patients with liver metastasis (3.8 vs 1.1 months [P = .028]). Shortest survival times in all survival categories analyzed revealed patients with concurrent liver and lung metastasis. Patients with CRC and BM form a heterogeneous cohort where extracranial metastasis to liver or lungs predicts survival.

The cleansing procedure with PEG 3350 + ascorbic acid (PEG + Asc; Moviprep®) requires the additional ingestion of clear liquids. We aimed to determine the effects on serum electrolytes, osmolality and cleansing quality, and in a prospective “real world” trial. Patients underwent a standardized split-dose bowel preparation for colonoscopy with PEG + Asc. Serum electrolytes and osmolality were measured before and after the prep procedure. The volume of prep solution (PA) and additional clear liquid (CL) was recorded. Prep quality was assessed using the Ottawa Bowel Prep Grading Scale (OBPS). The primary outcome measures were changes of serum electrolytes and osmolality during the cleansing procedure. A secondary end point was the OPBS. One hundred ninety-one of 219 patients entered the per protocol analysis. Prep quality was considered excellent in 57.6%, moderate in 20.9%, and insufficient in 21.5%. The number of patients with hyponatremia increased from 12 (6.3%) before to 25 (13.2%) after the prep procedure. Mean sodium concentration did not change significantly. The volume of CL correlated inversely with Na+ concentration (r =  − 0.409, p < 0.01) and a worse OBPS (r = 0.198, p < 0.01). Bowel preparation with PEG-Asc in clinical routine is generally safe, but patients should be advised not to drink more than 2 l of clear liquid because of imminent electrolyte disturbances. Additionally, the quality of cleansing either remains unchanged or may even worsen.

OBJECTIVES:Angiodysplasia (AD) is a common source of gastrointestinal bleeding. Yet, little is known about factors forwarding bleeding in these vascular malformations. The presented study aims to determine risk factors for bleeding that occurs only in patients with symptomatic, but not with asymptomatic, AD. METHODS:Case-control study in patients with AD and either a positive or a negative history of gastrointestinal bleeding in Munich, Germany. Groups were compared by clinical, laboratory, and endoscopic features. RESULTS:80 patients with (58, f 31, med. age 72) or without bleeding AD (22, f 12, med. age 61) were included. Bleeding from AD was significantly associated with the total number of AD (OR 1.4 (95 % CI 1.1-1.7) p = 0.01) and closure time in PFA/collagen-epinephrine test (OR 1.0 (95 % CI 1.0-1.0) p < 0.01). The total number of AD correlated significantly with age (r = 0.36; p = 0.01). AD were mainly detected in the upper small intestine (> 30 %). Although patients with aortic stenosis suffered not significantly more frequently from bleeding from AD, they demonstrated a loss of high molecular multimers of VWF. CONCLUSIONS:The amount of AD is clearly correlated to the age of the patient. A higher number of ADs and inhibition of primary hemostasis increase the risk of bleeding.

Introduction Hepatic encephalopathy (HE) represents a frequent complication of liver cirrhosis with negative effects on patients' lives. The prevalence of clinical HE is estimated to be between 30-45 %. Regardless of its clinical and prognostic relevance HE is considered to be underdiagnosed. Methods Beyond a systematic analysis of mortality of HE, we investigated the economic impact and reimbursement situation for HE in patients with liver cirrhosis in Germany. For the retrospective analysis, anonymized data (2011-2015) concerning expenses and diagnoses (</n> 21-4 KHEntgG) were obtained from 74 participating hospitals of the Diagnosis Related Groups (DRG) Project of the German Gastroenterological Association (DGVS). Furthermore, results were compared with case data from all German hospitals provided by the German Federal Authority on Statistics (Statistische Bundesamt (Destatis), Wiesbaden). Results In participating hospitals 59 093 cases with liver cirrhosis were identified of which 14.6 % were coded as having HE. Hospital mortality was threefold increased compared to cirrhosis-patients without HE (20.9 versus 7.5 %). Cases with cirrhosis as well as the proportion with HE increased over time. Compared to all patients with cirrhosis, reimbursement for HE patients produced a deficit (of up to 634 euro for HE grade 4). Discussion Mortality is threefold increased in patients with cirrhosis when an additional HE is diagnosed. Hospitals participating in the DGVS-DRG-project coded 2 % more HE cases among their cirrhosis cases than the rest of hospitals either because of a selection bias for greater disease severity or because of better coding quality. At present, reimbursement for HE patients on the basis of F-DRG-system produced a deficit.

Introduction: Hepatic encephalopathy (HE), in the context of liver cirrhosis, seems to result from low-grade cerebral edema of the astrocytes. Serum brain biomarkers S-100-beta und neuron-specific enolase (NSE) are often elevated in brain injury. We hypothesized that neuromarkers S-100-beta and NSE can be used in the diagnosis of HE, compared with standardized diagnostic tools. Material and Methods: A prospective non-randomized intervention study was performed using L-ornithine-L-aspartate (LOLA) for HE treatment. Primary endpoint was the evaluation of neuromarkers S-100-beta and NSE for detection and diagnosis of follow-up of HE. As secondary endpoints, the efficacy of LOLA on the course of HE and the diagnostic role of Portosystemic-Encephalopathy-Syndrome score (PHES) and critical flicker frequency (CFF) were analyzed. For diagnosis of covert (CHE) and overt (OHE) HE, West-Haven criteria (WHC), PHES and CFF were assessed at study entry. LOLA was applied (20 g i.v.) for 6 days. At the end of the study, HE evaluation was repeated. S-100-beta, NSE and ammonia were assessed in each patient before, during and after therapy with LOLA. Results: 30 patients were included. At study entry, CHE was diagnosed in 50% and OHE in 50% of all subjects. A total of 25 participants completed the study. After LOLA therapy, deterioration of HE occurred in <11%, while most patients showed improvement (e.g. improved CFF in 79%). No significant correlation with HE severity (as diagnosed by WHC, PHES and CFF) could be demonstrated for any biochemical parameter. In addition, there were no significant changes in brain biomarkers during the treatment period. Discussion: While CFF as well as PHES showed good correlation with treatment response, S-100-beta and NSE did not significantly correlate with HE severity compared to proven diagnostic methods, and do not seem reliable biochemical markers for the follow-up under therapy.

Abstract Introduction Altered small intestinal motility has been observed in various manometry studies in patients with cirrhosis. Since small bowel manometry is available only in a few centers, interpretation of dysmotility in cirrhosis is controversial. Patients and Methods In this study, both fasting and postprandial manometric tracings of 24-hour antroduodenojejunal manometries were analyzed using both visual analysis and computer-aided analysis. Results In 34 patients (83 %), the mean migrating motor complex (MMC) cycle length was different compared with healthy controls. Phase II was prolonged in 27 patients (66 %), while phase I showed a reduced duration in 23 (56 %) and in phase III in 13 individuals (32 %). We also observed special motor patterns, e. g., migrating clustered contractions (MCCs) or retrograde clustered contractions (RCCs), which were present during fasting (69 %) and postprandial (92 %) motility, while none of the healthy controls showed any special motor patterns. Special motor patterns showed a significant correlation with the severity of cirrhosis (Child-Score; p > 0.05) and the existence of ascites (p < 0.05). Discussion This study in a large cohort of patients with cirrhosis by using 24-hour, solid state portable manometry showed in most individuals disturbances of cyclic fasting motility. Special motor patterns like RCCs during fasting and postprandial motility could be observed exclusively in the cirrhosis group, showing a significant correlation with severity of cirrhosis and the occurence of associated complications.

Introduction Endoscopic full-thickness resection (eFTR) using the full-thickness resection device (FTRD®) is a novel minimally invasive procedure that allows the resection of various lesions in the gastrointestinal tract including the colorectum. Real-world data outside of published studies are limited. The aim of this study was a detailed analysis of the outcomes of colonoscopic eFTR in different hospitals from different care levels in correlation with the number of endoscopists performing eFTR. Material and methods In this case series, the data of all patients who underwent eFTR between November 2014 and June 2019 (performed by a total of 22 endoscopists) in 7 hospitals were analyzed retrospectively regarding rates of technical success, R0 resection, and procedure-related complications. Results Colonoscopic eFTR was performed in 229 patients (64.6% men; average age 69.3 ± 10.3 years) mainly on the basis of the following indication: 69.9% difficult adenomas, 21.0% gastrointestinal adenocarcinomas, and 7.9% subepithelial tumors. The average size of the lesions was 16.3 mm. Technical success rate of eFTR was achieved in 83.8% (binominal confidence interval 78.4–88.4%). Overall, histologically complete resection (R0) was achieved in 77.2% (CI 69.8–83.6%) while histologically proven full-wall excidate was confirmed in 90.0% (CI 85.1–93.7%). Of the resectates obtained ( n = 210), 190 were resected en bloc (90.5%). We did not observe a clear improvement of technical success and R0 resection rate over time by the performing endoscopists. Altogether, procedure-related complications were observed in 17.5% (mostly moderate) including 2 cases of acute gangrenous appendicitis requiring operation. Discussion In this pooled analysis, eFTR represents a feasible, effective, and safe minimally invasive endoscopic technique.

Objective Hepatocellular carcinoma (HCC) is a major cause of death worldwide and its incidence is expected to increase globally. Aim of this study was to assess whether the implementation of screening policies and the improvement of treatment options translated into a real-world survival benefit in HCC patients. Design 4078 patients diagnosed with HCC between 1998 and 2016 from the Munich Cancer Registry were analysed. Tumour characteristics and outcome were analysed by time period and according to age and presence of metastases at diagnosis. Overall survival (OS) was analysed using Kaplan-Meier method and relative survival (RS) was computed for cancer-specific survival. Cox proportional hazard models were conducted to control for prognostic variables. Results While incidence of HCC remained substantially stable, tumours were diagnosed at increasingly earlier stages, although the median age at diagnosis increased. The 3 years RS in HCC improved from 19.8% in 1998–2002, 22.4% in 2003–2007, 30.6% in 2008–2012 up to 31.0% in 2013–2016. Median OS increased from 6 months in 1998–2002 to 12 months in 2008–2016. However, analysis according to the metastatic status showed that survival improved only in patients without metastases at diagnosis whereas the prognosis of patients with metastatic disease remained unchanged. Conclusion These real-world data show that, in contrast to the current assumptions, the incidence of HCC did not increase in a representative German region. Earlier diagnosis, likely related to the implementation of screening programmes, translated into an increasing employment of effective therapeutic options and a clear survival benefit in patients without metastases at diagnosis, irrespective of age.

Zusammenfassung Einleitung Systematische Untersuchungen zum objektiven Verständnis von Patienten bezüglich häufiger medizinischer Begriffe in Deutschland sind selten. Methodik 196 Patienten (38 % weiblich, 62 % männlich) in stationären Fachabteilungen an einem kommunalen Krankenhaus wurden mittels eines zuvor entwickelten Fragebogens untersucht. Dieser enthielt 43 Fragen zu häufig im Alltag vorkommenden medizinischen Fachbegriffen. Untersucht wurden der subjektive und objektive Bekanntheitsgrad. Zusätzlich wurde eine Assoziation mit verschiedenen potenziellen Einflussfaktoren (u. a. Ausbildung, Versicherungsstatus, Konsum bestimmter Informationsmedien) durchgeführt. Ergebnisse Durchgehend gaben mehr Patienten an, die Bedeutung medizinischer Begriffe zu kennen, als dies bei objektiver Überprüfung der Fall war. Die Assoziation des medizinischen Kenntnisstandes mit verschiedenen Einflussfaktoren ergab, dass Frauen häufiger über korrektes medizinisches Wissen verfügten als Männer (51,1 vs. 47,2 %, p = 0,12). Das Lebensalter war negativ mit dem medizinischen Kenntnisstand korreliert (p < 0,001). Die Länge der Schulbildung war mit einem besseren medizinischen Kenntnisstand assoziiert (p < 0,001). Privat versicherte Patienten waren besser medizinisch gebildet als gesetzlich Versicherte (p = 0,001). Männliche Patienten mit eher mentaler Arbeit hatten einen besseren Kenntnisstand als solche mit körperlicher Arbeit (51,1 vs. 41,8 %; p = 0,002). Zeitungs- und Fernsehkonsum sowie Anzahl der Arztkontakte waren nicht mit einer Verbesserung des medizinischen Kenntnisstandes vergesellschaftet. Fazit Ein hoher Bekanntheitsgrad medizinischer Begriffe kann Ärzte im Anamnesegespräch dazu verleiten, das Verständnis dieser Begriffe auch von Seiten des Patienten stillschweigend vorauszusetzen. Ärzte sollten daher durch aktives Nachfragen das Verständnis beim Patienten sicherstellen. Zukünftige Erhebungen zur Gesundheitskompetenz auf Patientenseite sollten diese Divergenz zwischen subjektiver Einschätzung und objektivem Wissen berücksichtigen.

Zusammenfassung Einleitung Die Stuhltransplantation (Fäkaler Mikrobiota-Transfer, FMT) stellt eine mögliche Behandlungsoption für die rezidivierende pseudomembranöse Colitis dar. Zusätzlich gibt es Hinweise, dass die FMT auch in der Behandlung der Colitis ulcerosa wirksam ist. Ziel dieser Studie ist die Untersuchung hinsichtlich Akzeptanz auf Patientenseite anhand eines Fragebogens. Methodik Ein standardisierter Fragebogen aus 27 geschlossenen Fragen wurde an eine Patientenkohorte von 262 Patienten mit Colitis ulcerosa versendet. Inhalt waren Fragen u. a. zu Ablauf der FMT, Spendern sowie möglichen Bedenken. Zusätzlich wurden Aspekte des sozialen Hintergrunds sowie zur Krankheitsaktivität der Colitis ulcerosa evaluiert. Ergebnis Die Rücklaufrate der Fragebögen lag bei 31,3 % (n = 82). 48 (58,5 %) der Patienten war die FMT bekannt. 46 (56,1 %) gaben an, bei entsprechender Indikation eine FMT durchführen zu lassen. Als Hauptmotivation wurde von 33 Patienten (40,2 %) die (vorausgesetzte) Wirksamkeit des Verfahrens sowie von 14 (17,1 %) Patienten ein Versagen aller anderen Therapien (17,1 %) genannt. Bedenken bestanden im Hinblick auf die mangelnde Testung des Transplantats hinsichtlich möglicher Infektionserreger (22, 28,9 %) sowie eine potenzielle Kontamination des Transplantats mit Gefahr einer möglichen (nachteiligen) Beeinflussung des aktuellen Krankheitsverlaufs (17, 20,7 %). Als Verabreichungsform bevorzugten 55 Patienten (67,1 %) die FMT in Tablettenform, gefolgt von einer koloskopischen Applikation (36, 43,9 %). Als Spender wurde die vom behandelnden Arzt vorgeschlagene Person (43, 52,4 %) favorisiert. Die Bereitschaft zur FMT unterschied sich bei beiden Geschlechtern nicht signifikant (56,4 % bei ♀ vs. 57,1 % bei ♂). Bei Rauchern (88,9 %), Patienten, die auf Fernsehkonsum verzichten (77,8 %) sowie Patienten mit privater Krankenversicherung (70,6 %) war die Akzeptanz der FMT besonders hoch. Schlussfolgerung Die FMT stellt für die Mehrheit der durch uns befragten Patienten mit Colitis ulcerosa eine erwägenswerte Therapieform mit bereits hohem Bekanntheitsgrad dar. Knapp die Hälfte der Befragten würden unter bestimmten Voraussetzungen trotz mindestens zufriedenstellenden Ansprechens auf die bisherige (konventionelle) Therapie eine FMT als alternative Behandlung erwägen. Erwartungsgemäß bestehen Bedenken im Hinblick auf die Übertragung möglicher Krankheitserreger sowie hinsichtlich der hygienekonformen Durchführung des Verfahrens.

Introduction Fecal microbiota transplantation (FMT) represents a treatment option for recurring Clostridium difficile-associated colitis. However, there is also evidence that FMT can be effective in treating ulcerative colitis. This study examined the approval and willingness of affected patients who underwent FMT.Methods A standardized questionnaire containing 27 polar and open questions was dispatched to a cohort of 262 patients suffering from UC. It included questions regarding the FMT process, donors, and possible concerns. Additionally, aspects of social background and disease activity were addressed.Results The response rate was 31.3 % (n = 82). Forty-eight (58.5 %) patients were already aware of FMT. Forty-six (56.1 %) were willing to undergo FMT if given a respective indication. The effectiveness of the procedure (40.2 %), followed by failure of all other therapies (17.1 %), formed the principal motivation. The transmission of possible infectious agents (26.8 %), and the potential contamination of the stool graft leading to a deterioration of clinical symptoms, raised the most concerns. (20.7 %). The preferred delivery system of FMT was capsules (67.1 %), followed by colonoscopic application (47.6 %). The patients were in favour of a donor proposed by the physician (52,4 %). Willingness to undergo FMT did not differ significantly between genders (56.4 % women vs. 57.1 % men). Smokers (88.9 %), patients who did not watch television at all (77.8 %) and those with private health insurance, showed an increased willingness to undergo FMT.Conclusion For the majority of the UC patients surveyed, FMT represents a feasible treatment option. Approximately half of the respondents would consider FMT as an alternative treatment option, even inspite of a satisfactory disease response to current standard therapies. Unsurprisingly, there are concerns regarding the transmission of possible infectious agents and the hygienic implementation of FMT itself.

Zusammenfassung Einleitung Der systemische Lupus erythematodes (SLE) stellt eine klinisch sehr variabel verlaufende Autoimmunerkrankung dar, welche zahlreiche Organsysteme befallen kann. Eine Manifestation an der Leber gilt als selten. Unklar ist insbesondere, ob eine Hepatopathie bei SLE von prognostischer Bedeutung ist und z. B. mit der Aktivität der Erkrankung korreliert. Methodik Unser Patientenkollektiv umfasste 172 Patienten mit gesichertem SLE, welche am Klinikum Bogenhausen im Zeitraum 01.01.2009 bis 31.12.2015 behandelt wurden. Ausgewertet wurden retrospektiv alle ambulanten und/oder stationären Patientenvorstellungen (n = 671; durchschnittlich 3,9 pro Patient). Eine Leberschädigung wurde laborchemisch anhand von pathologischen Leberenzymprofilen oder bildgebend diagnostiziert. Die Krankheitsaktivität des SLE wurde anhand des European Consensus Lupus Activity Measurement (ECLAM)-Score ermittelt. Zusätzlich wurden Parameter der Grunderkrankung wie Krankheitsdauer, Organschädigung sowie immunsuppressive Medikation ausgewertet und die mögliche Assoziation mit einer Hepatopathie analysiert. Ergebnisse Erhöhte Leberwerte (ASAT, ALAT, GGT, AP) als Ausdruck einer Hepatopathie waren bei 109 Patienten (63,4 % der Gesamtpopulation) nachweisbar und waren signifikant mit Krankheitsaktivität (auf der Basis des ECLAM-Score, p < 0,001), Behandlungsdauer, Häufigkeit der Vorstellungen (jeweils p < 0,01), Anzahl der eingesetzten Immunsuppressiva (p < 0,018), erhöhter Blutsenkungsgeschwindigkeit (p < 0,001) sowie Erniedrigung des Serumkomplements (p < 0,03) assoziiert. Pathologische Sonografiebefunde an der Leber (z. B. nicht-alkoholische Fettleber) waren in 19,8 % der Fälle nachweisbar. Diskussion Erhöhte Leberwerte kommen bei Patienten mit SLE sehr häufig vor, insbesondere bei erhöhter Krankheitsaktivität (basierend auf ECLAM-Score oder intensivierter immunsuppressiver Therapie) und längerer Erkrankungsdauer. Leberwertbestimmungen sollten daher bei Patienten mit SLE regelmäßig erfolgen und eine weitere differenzialdiagnostische Abklärung angestrebt werden. Zukünftige prospektive Studien könnten klären, ob pathologische Leberwerte in Aktivitätsindizes zur Beurteilung der Krankheitsaktivität bei SLE einbezogen werden müssen.

Introduction Systemic lupus erythematodes (SLE) represents an autoimmune disease with a highly variable clinical course affecting numerous organs. Hepatic manifestation seems to be rare. It is not clear whether hepatic disease in SLE is of any prognostic importance or whether it correlates with disease activity. Methods Our patient cohort included 172 patients with proven SLE, all treated at Bogenhausen Hospital between 01.2009 and 12.2015. Retrospectively, all admissions as inpatients and outpatients were analyzed (n =671: mean 3.9 per patient). Liver damage was diagnosed by evaluation of laboratory parameters on the basis of pathological liver enzymes and by imaging methods. Disease activity of SLE was calculated by using European Consensus Lupus Activity Measurement-(ECLAM-)Score. Additionally, parameters of SLE including disease duration, organ damage and immune suppressive medication and their possible association with hepatopathy were analyzed. Results Elevated liver parameters (ASAT, ALAT, GGT, AP) indicating liver damage were detectable in 109 patients (63.4 % of total population) demonstrating significant association with disease activity (on the basis of ECLAM-score, p <0.001), duration of treatment, frequency of admissions (p < 0.01, respectively), number of used immunosuppressive agents (p <0.018), increased blood sedimentation rate (p <0.001) and reduction of serum complement (p<0.03). Abnormal ultrasound findings of the liver (e.g., non-alcoholic fatty liver disease) were diagnosed in 19.8%. Discussion Elevated liver parameters occur frequently in patients with SLE, especially in context with increased disease activity (on the basis of ECLAM-Score or intensified immunosuppressive therapy) and prolonged course of the disease. Liver enzymes should be obtained regularly in patients with SLE and, if necessary, further diagnostic steps should be initiated. Further prospective studies might clarify whether abnormal liver parameters must be included in activity indices to judge disease activity in SLE.

A 55-year-old woman presented to our department because of new-onset retrosternal pain on swallowing. She had been on continuous successful proton pump inhibitor treatment of gastroesophageal reflux disease for years. An esophageal pH metry/impedance study on proton pump inhibitor showed neither abnormal acidic nor nonacidic reflux. Correspondingly, esophagogastroduodenoscopy confirmed the absence of any erosions at the gastroesophageal junction. However, shredded whitish membranes covered almost the full length of the tubular esophagus, even forming 4- to 5-cm-long tubes, which were easily detached from the underlying intact mucosa and pulled out perorally (Figure A; Video). Histology of the esophageal wall detected only a mild submucosal inflammation without eosinophilic infiltration, candidiasis, viral infection, or deposits of immunoglobulins/complement suggesting pemphigoid (immunohistochemistry). Histopathologically, the membranes consisted of superficial layers of squamous epithelium lacking a basal cell layer and any signs of inflammation (Figure B). Empiric treatment with oral budesonide failed to improve both the symptoms and endoscopic findings. Our patient denied taking any medication other than pantoprazole and atorvastatin. However, on extensive interrogation she mentioned that for several months she had accustomed herself to drinking extremely hot coffee. Thus, we made the diagnosis of exfoliative esophagitis caused by thermal injury. Twelve weeks after consequently abstaining from hot beverages esophageal mucosal exfoliation completely disappeared (Figure C). eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJmNDk3NWI4Nzc1MmI4ZWQ2ZjY4OWZkNjEyMmIxYTdiMiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjc4OTQzNjE1fQ.mCeuBD27_Y7knp5XnRcfdowvnKxUu_rf8GohDfgPIBIA8PDo-d8vSZww9dibDl5YuemTc4OZ_L0_nUaKPW_tsEqHVfqFmOxr2KCToJD9F1MCFUYOOqdYZqaVke8dlpYRg08E5u8C7FCGoiv7zphKWzthnj3xOCg_OAO_iwIN087dPoasmdulm26fRN2-5yADFuBMAXNXVsA6FE2T5jLg763IGjres7ZCq1NZEYtsISf07avtY1aWWsxouf8COCj0WQD5vJni7cViX1tfrwcr_tImLVRS0de9AEqIktFvOpYTDuLx_ibUzNK1mFV3oLhXE23cwne5sIveTF4dS-Vmdw Download .mp4 (216.03 MB) Help with .mp4 files Video

To date, it remains unclear whether locally advanced adenocarcinoma of the gastroesophageal junction (AEG) should be treated with neoadjuvant chemoradiation (nCRT), analogous to esophageal cancer, or with perioperative chemotherapy (pCT), analogous to gastric cancer. The purpose of this study was to analyze the data of the Munich Cancer Registry (MCR) and to compare pCT and nCRT in AEG patients.A total of 2,992 AEG patients, treated between 1998 and 2014, were included in the study. Baseline and tumor parameters as well as overall survival (OS) and tumor recurrence were compared between 56 patients undergoing nCRT and 64 patients undergoing pCT with UICC stage II/III cancer. In addition, uni- and multivariate analyses using Cox regression models were performed to evaluate the effect of tumor characteristics and treatment regimens on OS.In patients with UICC stage II/III AEG treated with either nCRT or pCT, no significant differences were seen for baseline and tumor characteristics. While there was a significantly higher cumulative incidence of locoregional treatment failure after pCT (32.8%; 95% CI: 18.0-48.4%) compared with nCRT (7.4%; 95% CI: 2.3-16.5%; p = 0.007), there was no significant difference for distant treatment failure (52.9%; 95% CI: 35.4-67.7% and 38.4%; 95% CI: 23.7-52.9%; p = 0.347). When analyzing the whole cohort, patients who received pCT were younger (58.3 years vs. 63.0 years; p = 0.016), had a higher chance of complete tumor resection (81% vs. 67%; p = 0.033), more resected lymph nodes (p = 0.036), and fewer lymph node metastases (p = 0.038) compared with patients who received nCRT. Nevertheless, there was still a strong trend toward a higher incidence of local treatment failure after pCT (25.8%; 95% CI: 14.7-38.3% vs. 12.6%; 95% CI: 5.5-22.8%; p = 0.053). Comparable to the results for patients with UICC stage II/III, no difference was seen for the incidence of distant treatment failure. When excluding patients with UICC stage IV cancer, no significant difference was found for OS.For UICC stage II/III carcinoma, nCRT was associated with an improved locoregional tumor control compared with pCT, while no further significant differences were seen between nCRT and pCT for UICC stage II/III AEG. Moreover, there was a strong trend toward improved locoregional tumor control after nCRT when analyzing all patients treated with nCRT or pCT, despite these patients having higher risk factors.

Die Mortalität der akuten Ösophagusvarizenblutung ist seit den 80er-Jahren (ca. 40 – 50 %) deutlich rückläufig (aktuelle Schätzung ca. 20 %, nach Sung J., Vortrag Digestive Disease Week 2016). Dies liegt einerseits an der optimierten endoskopischen Überwachungsstrategie, welche auf eine frühzeitige Behandlung von blutungsgefährdeten Ösophagusvarizen (in der Regel mittels Gummibandligatur) vor Eintreten einer fulminanten Blutung abzielt, auf der anderen Seite an der verbesserten nicht endoskopischen Primärtherapie in der akuten Blutungssituation. Diese beinhaltet u. a. den Einsatz vasoaktiver Medikamente (z. B. Terlipressin) und eine gezielte Intensivund Volumentherapie (UK Guideline von Tripathi D et al. Gut 2015; 64: 1680 – 1704). Obgleich deutlich seltener geworden, stellt die akute endoskopisch nicht beherrschbare Ösophagusvarizenblutung nach wie vor ein relevantes Problem dar. Zeitnahe Rescue-Verfahren wie die Anlage eines transjugulären portsystemischen Stentshunts (TIPSS) sind in bestimmten Fällen kontraindiziert (z. B. fortgeschrittenes Child-Stadium) oder flächenmäßig nicht überall verfügbar, sodass Bridging-Verfahren angewendet werden müssen. Für diese spezielle Situation hat sich die Sengstaken-Blakemore-Sonde bewährt, welche seit ihrer erstmaligen Beschreibung vor fast 70 Jahren vom technischen Aufbau praktisch unverändert eingesetzt wird und über mechanische Kompression der Ösophaguswand eine Blutstillung ermöglicht (Sengstaken RW, Blakemore AH. Ann Surg 1950; 31: 781 – 789). Zur Vermeidung irreversibler Gewebeschädigungen ist der Einsatz dieser Sonde in der Regel auf 24 Stunden befristet, sodass Rezidivblutungen auftreten können (in bis zu 50 %, Mitchell K et al. Gut 1980; 21: 570 – 573). Außerdem wurden nach Ballontamponade verschiedene Komplikationen in bis zu 60 % beschrieben (u. a. Aspirationspneumonie, Ösophagusruptur, Gewebenekrosen; D’Amico M et al. Clin Liver Dis 2010; 14: 297 – 305). In verschiedenen Fallserien wurde als erfolgreiche Alternative der Einsatz eines speziell für diese Situation angefertigten, gecoverten selbstexpandierenden Ösophagusstents (SX-Ella Danis; EllaCS, Hradec Kralove, Tschechischen) demonstriert (Metaanalyse durch Shao XD et al. Biomed Res Int 2016; 4054 513: doi: 10.1155/2016/ 4054 513; Epub 2016 Jul 19). Im Gegensatz zu diesen unkontrollierten, retrospektiven Singlecenterstudien liegt mit der hier vorgestellten Studie von Escorsell et al. jetzt eine randomisierte kontrollierte Multicenterstudie vor, welche systematisch beide Verfahren – Ballontamponade vs. Ösophagusstent – bei der akuten, nicht konventionell (mittels Ligatur oder Sklerosierungstherapie) beherrschbaren Ösophagusvarizenblutung untersucht.