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Background: Non-anastomotic biliary strictures (NAS) are a common cause of morbidity and mortality after liver transplantation. Methods: All patients with NAS from 2008 to 2016 were retrospectively analyzed. The success rate and overall mortality of an ERCP-based stent program (EBSP) were the primary outcomes. Results: A total of 40 (13.9%) patients with NAS were identified, of which 35 patients were further treated in an EBSP. Furthermore, 16 (46%) patients terminated EBSP successfully, and nine (26%) patients died during the program. All deaths were caused by cholangitis. Of those, one (11%) patient had an extrahepatic stricture, while the other eight patients had either intrahepatic (3, 33%) or combined extra- and intrahepatic strictures (5, 56%). Risk factors of overall mortality were age (p = 0.03), bilirubin (p < 0.0001), alanine transaminase (p = 0.006), and aspartate transaminase (p = 0.0003). The median duration of the stent program was 34 months (ITBL: 36 months; IBL: 10 months), and procedural complications were rare. Conclusions: EBSP is safe, but lengthy and successful in only about half the patients. Intrahepatic strictures were associated with an increased risk of cholangitis.

Background and study aim: The incidence of wound infections after percutaneous endoscopic gastrostomy (PEG) varies widely in recent studies. The present study systematically investigates the underlying risk factors for the development of wound infections in a large cohort of patients over a long-term follow-up period. Patients and Methods: A retrospective cohort study of patients undergoing PEG insertion using either the pull or push technique was conducted and patients followed up for 3 years. Tube-related wound infections were identified, and pathogens regularly cultured from wound swabs. Adjusted analysis was performed via univariate and multivariate logistic regression analysis. Results: 616 patients were included in this study. A total of 25% percent of patients developed wound infections upon PEG tube insertion and 6.5% showed recurrent infections. Nicotine abuse (p = 0.01), previous ischemic stroke (p = 0.01) and head and neck cancer (p < 0.001) showed an increased risk for wound infection after PEG placement. Moreover, radio-chemotherapy was associated with the occurrence of wound infections (p < 0.001). Infection rates were similar between pull and push cohorts. The most common bacterial pathogen detected was Enterobacterales (19.2%). Staphylococcus aureus, Pseudomonas aeruginosa and enterococci were frequently detected in recurrent infection (14.2%, 11.4% and 9.6%, respectively). Antibiotic prophylaxis showed no effect on infection rates. Conclusions: Wound infections after PEG placement are common and occasionally occur as recurrent infections. There is potential for improvement in everyday clinical practice, particularly regarding antibiotic prophylaxis in accordance with guidelines.

The main disadvantage of plastic stents is the high rate of stent occlusion. The usual replacement interval of biliary plastic stents is 3 months. This study aimed to investigate if a shorter interval of 6-8 weeks impacts the median premature exchange rate (mPER) in benign and malignant biliary strictures.All cases with endoscopic retrograde cholangiopancreatography (ERCP) and plastic stent placement were retrospectively analyzed since establishing an elective replacement interval of every 6-8 weeks at our institution and mPER was determined.A total of 3979 ERCPs (1199 patients) were analyzed, including 1262 (31.7%) malignant and 2717 (68.3%) benign cases, respectively. The median stent patency (mSP) was 41 days (range 14-120) for scheduled stent exchanges, whereas it was 17 days (1-75) for prematurely exchanged stents. The mPER was significantly higher for malignant (28.1%, 35-50%) compared with benign strictures (15.2%, 10-28%), P 0.0001, respectively. mSP was significantly shorter in cases with only one stent (34 days [1-87] vs 41 days [1-120]) and in cases with only a 7-Fr stent (28 days [2-79]) compared with a larger stent (34 days [1-87], P = 0.001). Correspondingly, mPER was significantly higher in cases with only one stent (23% vs 16.2%, P 0.0001) and only a 7-Fr stent (31.3% vs 22.4%, P = 0.03).A shorter replacement interval does not seem to lead to a clinically meaningful reduction of mPER in benign and malignant strictures. Large stents and multiple stenting should be favored as possible.

Thyroid disease is the second most endocrinopathy during pregnancy 1. Thyroid dysfunction affects 2-3 % of pregnant women 2. Early diagnosis and initiation of therapy are important due to the potential complications in both mother and fetus. This article provides an overview of current recommendations regarding thyroid diagnostics and constellations during pregnancy that require therapy.

Autoimmune thyroiditis (AIT) is not only one of the most prevalent human autoimmune diseases, but also the most frequent cause of primary hypothyroidism. It is characterized by lymphocytic infiltration of the thyroid gland with subsequent gradual destruction and fibrous replacement of thyroid tissue. Genetic predisposition, epigenetic modifications and environmental factors are suspected as disease triggers. Signs and symptoms of hypothyroidism include fatigue, bradycardia, constipation and cold intolerance. In subclinical hypothyroidism, symptoms may be absent. The diagnosis of AIT is based on the presence of antibodies against thyroid specific antigens, primarily anti-thyroid peroxidase antibodies and on a sonographically proven reduced echogenicity of the thyroid parenchyma. The diagnosis of concomitant hypothyroidism is primarily based on clinical signs and symptoms as well as measurement of thyroid-stimulating hormone (TSH)-concentration. Subclinical hypothyroidism is characterized by elevated TSH with normal serum free thyroxine (fT4) and triiodothyronine (fT3) levels, while in manifest hypothyroidism serum fT4 and fT3 levels are reduced. Levothyroxine (LT4) treatment in subclinical hypothyroidism is a controversy in the scientific literature and should be discussed individually. It not only depends on the level of TSH-elevation, but also on other factors, such as patient age, presence of comorbidities and clinical symptoms of hypothyroidism. In contrast, overt hypothyroidism and subclinical hypothyroidism with a TSH-level > 10 mIU/L is a strong indication for LT4 administration, aiming at rapid achievement of euthyroidism. In patients with dissatisfaction due to persistence of symptoms despite optimal LT4-treatment LT4/T3-combination therapy should be considered, based on expert opinion.

Background Before performing endoscopy to remove prophylactic pancreatic stents placed in patients with high risk of post‐endoscopic retrograde cholangiopancreatography pancreatitis (PEP), X‐ray imaging is recommended to confirm the stents position in the pancreatic duct. Objectives The aim of the present study was to investigate the feasibility of prophylactic pancreatic stent detection by transabdominal ultrasonography, to reduce the burden of X‐ray imaging, which is currently the golden standard. Methods All patients who received a pancreatic stent for PEP prophylaxis were included in the present prospective trial. First, stent position was determined by transabdominal ultrasonography. Afterwards, it was verified by X‐ray imaging. Retained stents were removed by esophagogastroduodenoscopy. Dislocated stents needed no further intervention. Results Fourty‐one patients were enrolled in this study. All prophylactic pancreatic stents were straight 6 cm long 5 Fr stents with external flap. All stents were removed between day 1 and 10 (median: 3 days) in all cases. In 34 of 41 cases (83.0%), the pancreatic stent was still in place on the day of examination. Twenty‐nine of 34 (85.3%) stents were detected correctly by transabdominal ultrasonography. Overlying gas prevented visualization of the pancreas in 3/41 (7.3%) cases. Sensitivity of sonographic detection of the stent was 93.5% (29/31). Six of seven stents were determined correctly as dislocated by ultrasonography. Here, specificity was 85.7%. A positive predictive value of 96.7% (29/30) was examined. The negative predictive value was 75.0% (6/8). Conclusion Transabdominal ultrasonography detects the majority of prophylactic pancreatic stents. Thereby, it helps to identify patients with an indication for endoscopy sufficiently. X‐ray imaging could subsequently be omitted in about 70% of examinations, reducing the radiation exposure for the patient and the endoscopy staff.

Although non-functioning pituitary tumors are frequent, diagnostic and therapeutic concepts are not well standardized. We here present the first German multidisciplinary guideline on this topic. The single most important message is to manage the patients by a multidisciplinary team (consisting at least of an endocrinologist, a neurosurgeon, and a (neuro-) radiologist). The initial diagnostic work-up comprises a detailed characterization of both biochemical (focusing on hormonal excess or deficiency states) and morphological aspects (with magnetic resonance imaging of the sellar region). An ophthalmological examination is only needed in presence of symptoms or large tumors affecting the visual system. Asymptomatic, hormonally inactive tumors allow for a 'wait and scan' strategy. In contrast, surgical treatment by an experienced pituitary surgeon is standard of care in case of (impending) visual impairment. Therapeutic options for incompletely resected or recurrent tumors include re-operation, radiotherapy, and observation; the individual treatment plan should be developed multidisciplinary. Irrespective of the therapeutic approach applied, patients require long-term follow-up. Patient with larger pituitary tumors or former surgery/radiotherapy should be regularly counseled regarding potential symptoms of hormonal deficiency states.

Die nichtalkoholische Fettlebererkrankung (NAFLD) stellt eine haufige, aber oft unterschatze Komorbiditat des Diabetes mellitus dar. Sie kann nicht nur Folge eines Diabetes sein, sondern diesem auch vorausgehen. Durch kardiovaskulare, maligne und hepatische Komplikationen ist die NAFLD mit einer gesteigerten Morbiditat und Mortalitat verbunden. Patienten aus Risikogruppen sollten daher hinsichtlich einer NAFLD untersucht werden. Neben der Bestimmung der Steatose mittels Sonographie wird insbesondere eine Evaluation bezuglich des Vorliegens einer Leberfibrose anhand von Risikoscores empfohlen. Eine fortgeschrittene NAFLD geht mit einem erhohten Risiko fur ein hepatozellulares Karzinom (HCC) einher, sodass ein entsprechendes Screening zu erwagen ist. Neben Allgemeinmasnahmen zur Therapie einer Adipositas und einer Insulinresistenz konnen Antidiabetika, Statinen und Inhibitoren des Renin-Angiotensin-Systems sowie Azetylsalizylsaure einen gunstigen Einfluss auf die NAFLD zeigen.

In ACLF patients, an adequate risk stratification is essential, especially for liver transplant allocation, since ACLF is associated with high short-term mortality. The CLIF-C ACLF score is the best prognostic model to predict outcome in ACLF patients. While lung failure is generally regarded as signum malum in ICU care, this study aims to evaluate and quantify the role of pulmonary impairment on outcome in ACLF patients.In this retrospective study, 498 patients with liver cirrhosis and admission to IMC/ICU were included. ACLF was defined according to EASL-CLIF criteria. Pulmonary impairment was classified into three groups: unimpaired ventilation, need for mechanical ventilation and defined pulmonary failure. These factors were analysed in different cohorts, including a propensity score-matched ACLF cohort.Mechanical ventilation and pulmonary failure were identified as independent risk factors for increased short-term mortality. In matched ACLF patients, the presence of pulmonary failure showed the highest 28-day mortality (83.7%), whereas mortality rates in ACLF with mechanical ventilation (67.3%) and ACLF without pulmonary impairment (38.8%) were considerably lower (p .001). Especially in patients with pulmonary impairment, the CLIF-C ACLF score showed poor predictive accuracy. Adjusting the CLIF-C ACLF score for the grade of pulmonary impairment improved the prediction significantly.This study highlights that not only pulmonary failure but also mechanical ventilation is associated with worse prognosis in ACLF patients. The grade of pulmonary impairment should be considered in the risk assessment in ACLF patients. The new score may be useful in the selection of patients for liver transplantation.

ZusammenfassungNeben der eigentlichen definitiven Therapie einer akuten Blutung (z. B. durch endoskopische/operative Blutstillung oder Angiografie mit Coiling) kommt in der Akut- und Intensivmedizin der Optimierung der Blutgerinnung eine Schlüsselrolle zu. Dazu ist die Kenntnis der gängigen Gerinnungstests und ihrer Schwächen ebenso notwendig wie die korrekte Anwendung und Dosierung von Gerinnungsprodukten. Das Gerinnungsmanagement kann insbesondere bei Patienten mit Leberzirrhose, angeborenen und erworbenen Gerinnungsstörungen sowie bei Patienten unter Antikoagulation herausfordernd sein. Dieses Review beleuchtet die wichtigsten Elemente der Gerinnungsdiagnostik und -therapie in der gastroenterologischen Intensiv- und Notfallmedizin inklusive neuer Antidote und erweiterter Gerinnungsdiagnostik bei Patienten mit Leberzirrhose, wie z. B. die Thrombelastometrie.

Purpose ERGO2 is the first randomized clinical trial on a calorically restricted ketogenic diet (KD) and intermittent fasting (KD-IF) in addition to reirradiation for recurrent malignant gliomas. Methods and Materials Fifty patients were randomized 1:1 to reirradiation combined with either a calorically unrestricted diet or KD-IF. The KD-IF schedule included 3 days of KD (21-23 kcal/kg/d), followed by 3 days of fasting and again 3 days of KD. Primary endpoint was progression-free survival (PFS) at 6 months (PFS6). Secondary endpoints were PFS, local PFS, overall survival (OS), frequency of epileptic seizures, rate of ketosis and quality of life. Results Four patients quit the trial before treatment and 3 patients stopped KD-IF prematurely. Of the 20 patients who completed KD-IF, 17 patients developed ketosis at day 6 and glucose levels declined significantly. KD-IF was well-tolerated with a modest weight loss of –2.1 ± 1.8 kg. No severe adverse events attributable to the diet occurred. PFS6 was not significantly different between the 2 groups (KD-IF: 20%; calorically unrestricted diet: 16%). Similarly, no difference in PFS, local PFS6, or OS was observable. Explorative analysis revealed that patients in the KD-IF group who had a glucose level of less than the median (83.5 mg/dL) on day 6 had significantly longer PFS and OS compared with those above the median (P Conclusions KD-IF is feasible and effective in inducing ketosis in heavily pretreated patients with recurrent glioma. However, the short schedule reported here failed to increase the efficacy of reirradiation. Clinicaltrials.gov number NCT01754350.

Standard monitoring of heart rate, blood pressure and arterial oxygen saturation during endoscopy is recommended by current guidelines on procedural sedation. A number of studies indicated a reduction of hypoxic (art. oxygenation 15 s) and severe hypoxic events (art. oxygenation 10 s, partial pressure of end-tidal carbon dioxide [PetCO2]). The aim of this paper was to analyze the value of IPI as parameter to monitor the respiratory status in patients receiving propofol sedation during PEG-procedure. Patients reporting for PEG-placement under sedation were randomized 1:1 in either standard monitoring group (SM) or capnography monitoring group including IPI (IM). Heart rate, blood pressure and arterial oxygen saturation were monitored in SM. In IM additional monitoring was performed measuring PetCO2, respiratory rate and IPI. Capnography and IPI values were recorded for all patients but were only visible to the endoscopic team for the IM-group. IPI values range between 1 and 10 (10 = normal; 8–9 = within normal range; 7 = close to normal range, requires attention; 5–6 = requires attention and may require intervention; 3–4 = requires intervention; 1–2 requires immediate intervention). Results on capnography versus standard monitoring of the same study population was published previously. A total of 147 patients (74 in SM and 73 in IM) were included in the present study. Hypoxic events occurred in 62 patients (42%) and severe hypoxic events in 44 patients (29%), respectively. Baseline characteristics were equally distributed in both groups. IPI = 1, IPI 2 = 0 mmHg and apnea > 10 s had a high sensitivity for hypoxic and severe hypoxic events, respectively (IPI = 1: 81%/81% [hypoxic/severe hypoxic event], IPI 2: 69%/68%, apnea > 10 s: 84%/84%). All four parameters had a low specificity for both hypoxic and severe hypoxic events (IPI = 1: 13%/12%, IPI 2: 29%/27%, apnea > 10 s: 7%/7%). In multivariate analysis, only SM and PetCO2 = 0 mmHg were independent risk factors for hypoxia. IPI (IPI = 1 and IPI 2 = 0 mmHg and apnea > 10 s allow a fast and convenient conclusion on patients’ respiratory status in a morbid patient population. Sensitivity is good for most parameters, but specificity is poor. In conclusion, IPI can be a useful metric to assess respiratory status during propofol-sedation in PEG-placement. However, IPI was not superior to PetCO2 and apnea > 10 s.

Nichtalkoholische Fettlebererkrankungen (NAFLD) bzw. eine Leberzirrhose (LCI) und Diabetes mellitus konnen sich wechselseitig bedingen. Da die weltweite Pravalenz des Diabetes zunimmt, wird auch die Anzahl der Menschen mit Diabetes und chronischer Lebererkrankung (CLD) zunehmen. Kenntnisse in der Behandlung von Menschen mit Diabetes und CLD sind wichtig, um eine sichere und effektive Therapie durchfuhren zu konnen. Eine adaquate Blutzuckerkontrolle bei Patienten mit Diabetes ist wichtig, um ein Fortschreiten der CLD sowie kardiovaskulare Komplikationen zu verhindern, die Lebensqualitat zu verbessern und die Sterblichkeit zu senken. Viele Antidiabetika mussen bei CLD jedoch dosisangepasst werden oder sollten nicht bei der Einstellung oder beim Fortschreiten einer CLD verwendet werden, insbesondere bei Patienten mit einer Leberzirrhose und signifikant eingeschrankter Leberfunktion. Ein wichtiges Ziel in der Behandlung ist zudem die Risikosenkung fur die Entstehung, fruhe Erkennung und Behandlung des hepatozellularen Karzinoms. In dieser Ubersicht wird ein Uberblick uber die Verwendung und Ziele einer Diabetestherapie bei Vorliegen einer NAFLD bzw. LCI gegeben.

Hypoparathyreoidismus ist eine seltene und den Patienten beeintrachtigende Erkrankung, die durch eine Hypokalzamie in Verbindung mit einem niedrigen Parathormon gekennzeichnet ist. Meist ist sie Folge der Entfernung oder Verletzung der Nebenschilddrusen wahrend einer Operation im Halsbereich, seltener liegen nicht-chirurgische, z. B. autoimmune bzw. genetische Ursachen zugrunde. In dieser Ubersichtsarbeit stellt eine Expertenrunde den aktuellen Stand der Diagnostik und Therapie des Hypoparathyreoidismus dar und erlautert praktische Aspekte der Betreuung der betroffenen Patienten. Typische Symptome eines Hypoparathyreoidismus sind subjektive Uberempfindlichkeit und gesteigerte Erregbarkeit im Bereich der distalen Extremitaten, periorale Parasthesien und nachtliche Muskelkrampfe in den Beinen. Renale Komplikationen treten haufig auf, aber auch Basalganglienverkalkungen und Katarakte kommen vor. Die Therapie besteht in der Gabe von Vitamin-D-Analoga in Kombination mit 0,5—1,0 g Kalzium taglich; als Zusatztherapie ist bei schwierig einzustellenden Patienten eine Ersatzbehandlung mit dem im April 2017 zugelassenen rekombinanten humanen Parathormon (1-84) eine Option. Verlaufskontrollen sollten initial und nach Dosisanderung mindestens alle 2 Wochen erfolgen, nach erfolgter Einstellung oder bei chronischem Verlauf alle 3—6 Monate.

Autoimmune thyroiditis (AIT) is not only one of the most prevalent human autoimmune diseases, but also the most frequent cause of primary hypothyroidism. It is characterized by lymphocytic infiltration of the thyroid gland with subsequent gradual destruction and fibrous replacement of thyroid tissue. Genetic predisposition, epigenetic modifications and environmental factors are suspected as disease triggers. Signs and symptoms of hypothyroidism include fatigue, bradycardia, constipation and cold intolerance. In subclinical hypothyroidism, symptoms may be absent. The diagnosis of AIT is based on the presence of antibodies against thyroid specific antigens, primarily anti-thyroid peroxidase antibodies and on a sonographically proven reduced echogenicity of the thyroid parenchyma. The diagnosis of concomitant hypothyroidism is primarily based on clinical signs and symptoms as well as measurement of thyroid-stimulating hormone (TSH)-concentration. Subclinical hypothyroidism is characterized by elevated TSH with normal serum free thyroxine (fT

MEN1 mutations can inactivate or disrupt menin function and are leading to multiple endocrine neoplasia type 1, a rare heritable tumor syndrome.We report on a MEN1 family with a novel heterozygous germline mutation, c.674delG; p.Gly225Aspfs*56 in exon 4 of the MEN1 gene. Diagnosis and clinical phenotyping of MEN1 was established by laboratory tests, ultrasound, biopsy, MRI imaging and endosonography. The clinical course of the disease was followed in the index patient and her family members for eight years. The mutation was associated with distinct clinical phenotypes in the index patient and three family members harboring p.Gly225Aspfs*56. Family members affected showed primary hyperparathyroidism but variable patterns of associated endocrine tumors, adrenal cortical adenomas, prolactinoma, multifocal pancreatic neuroendocrine tumors, insulinoma and nonsecretory neuroendocrine tumors of the pancreas. The mutation c.674delG; p.Gly225Aspfs*56 leads to a frameshift from codon 225 with early truncation of the menin protein. In silico analysis predicts loss of multiple protein-menin interactions in p.Gly225Aspfs*56, potentially rendering menin insufficient to control cell division and replication. However, no aggressive neuroendocrine tumors were observed in the follow-up of this family.We report a novel heterozygous MEN1 frameshift mutation, potentially causing (at least partial) inactivation of menin tumor suppression potential but lacking a genotype-phenotype correlation. Our study highlights the importance of personalized care with appropriate testing and counseling in MEN1 families.

Die Schilddrüsenfunktion spielt eine wichtige Rolle nicht nur in der Entwicklung des Fetus, sondern bereits präkonzeptionell. Eine Kontrolle des TSH-Werts vor Schwangerschaftsbeginn ist insbesondere bei unerfülltem Kinderwunsch sowie bekannter Schilddrüsenhormonsubstitution sinnvoll, um einen möglicherweise bestehenden Substitutionsbedarf zu erkennen und entsprechend auszugleichen. Bei erfolgreicher Konzeption lässt sich ein typischer, trimenonspezifischer Verlauf der Schilddrüsenaktivität beobachten, welcher beeinflusst ist durch schwangerschaftsbedingte Hormonveränderungen. Physiologisch sind ein TSH-Abfall im 1. Trimenon, der selten in eine transiente Gestationshyperthyreose übergehen kann, sowie ein geringgradiger Abfall der fT4-Konzentration im 3. Trimenon. Abzugrenzen von physiologischen Veränderungen der Schilddrüsenhormonkonstellation in der Schwangerschaft sind die eine Behandlung erforderlich machende Hypo- und Hyperthyreose. Sowohl eine Schilddrüsenüber- als auch eine Schilddrüsenunterfunktion hat potenziell schädigende Auswirkungen auf das Ungeborene. Eine therapiebedürftige Hypothyreose in der Schwangerschaft ist mit abhängig vom vorliegenden Antikörperstatus und sollte in Abhängigkeit vom TSH-Wert über die Schwangerschaft hinweg kontrolliert und angepasst werden. Eine weitere besondere Herausforderung besteht bei Notwendigkeit einer thyreostatischen Therapie, beispielsweise im Rahmen eines Morbus Basedow. Hier gilt es, aufgrund der Nebenwirkungsprofile zur Verfügung stehender Thyreostatika trimenonspezifische Medikamentenwechsel zu vollziehen. Der folgende Artikel soll anhand aktueller Daten einen Überblick über aktuelle schilddrüsenbezogene Therapie- und Diagnostikempfehlungen in der Schwangerschaft geben. La fonction thyroïdienne joue un rôle important non seulement pour le développement du fœtus, mais aussi déjà avant la conception. Un contrôle du taux de TSH avant le début de la grossesse est judicieux notamment lors d’un désir d’enfant inassouvi et d’une substitution thyroïdienne en cours, car il permet de détecter un éventuel besoin de substitution et de compenser en conséquence. Si la conception a eu lieu, une évolution typique de l’activité thyroïdienne conformément au trimestre de la grossesse peut être observée, qui est influencée par les modifications hormonales dues à la grossesse. L’évolution physiologique consiste en une baisse du taux de TSH dans le 1er trimestre, pouvant dans de rares cas entraîner une hyperthyroïdie gestationnelle transitoire, et en une baisse du taux de fT4 dans le 3e trimestre. Ces modifications physiologiques de la constellation hormonale thyroïdienne, dues à la grossesse, doivent être distinguées des cas d’hypothyroïdie et d’hyperthyroïdie exigeant un traitement. L’hyperthyroïdie et l’hypothyroïdie peuvent toutes deux avoir des effets nuisibles pour l’enfant à naître. Une hypothyroïdie exigeant un traitement chez la femme enceinte dépend entre autres du statut d’anticorps et doit être contrôlée et adaptée en fonction du taux de TSH tout au long de la grossesse. Une nécessité de traitement thyréostatique, par exemple dans le cadre d’une maladie de Basedow, est un autre défi particulier. Il faut en ce cas procéder à des changements de médicaments en fonction du trimestre de la grossesse, avec prise en compte des profils d’effets indésirables des thyréostatiques disponibles. L’article suivant, s’appuyant sur les données actuelles, entend donner un aperçu des recommandations actuelles concernant le traitement et le diagnostic des problèmes thyroïdiens pendant la grossesse.

Purpose The prospective, randomized ERGO2 trial investigated the effect of calorie-restricted ketogenic diet and intermittent fasting (KD-IF) on re-irradiation for recurrent brain tumors. The study did not meet its primary endpoint of improved progression-free survival in comparison to standard diet (SD). We here report the results of the quality of life/neurocognition and a detailed analysis of the diet diaries. Methods 50 patients were randomized 1:1 to re-irradiation combined with either SD or KD-IF. The KD-IF schedule included 3 days of ketogenic diet (KD: 21–23 kcal/kg/d, carbohydrate intake limited to 50 g/d), followed by 3 days of fasting and again 3 days of KD. Follow-up included examination of cognition, quality of life and serum samples. Results The 20 patients who completed KD-IF met the prespecified goals for calorie and carbohydrate restriction. Substantial decreases in leptin and insulin and an increase in uric acid were observed. The SD group, of note, had a lower calorie intake than expected (21 kcal/kg/d instead of 30 kcal/kg/d). Neither quality of life nor cognition were affected by the diet. Low glucose emerged as a significant prognostic parameter in a best responder analysis. Conclusion The strict caloric goals of the ERGO2 trial were tolerated well by patients with recurrent brain cancer. The short diet schedule led to significant metabolic changes with low glucose emerging as a candidate marker of better prognosis. The unexpected lower calorie intake of the control group complicates the interpretation of the results. Clinicaltrials.gov number: NCT01754350; Registration: 21.12.2012.

Background: HNC patients often experience weight loss during treatment. To date, there is only limited data on patient quality of life (QLQ) and subjective benefit of the PEG insertion. Objective: To investigate the nutritional status, QLQ, and overall benefit. Methods: 181 patients fitting our inclusion criteria (01/2012-12/2012) were enrolled. Utilization rate, nutritional status, QLQ, and subjective PEG assessment were determined with electronic charts and the Quality of life-questionnaire (EORTC-QLQ-C30). Results: The utilization rate of the entire cohort was 91.7%. The PEG was used full-time by 149 patients. No statistical differences in QLQ were observed between the groups. Of the patients that used the PEG entirely (99.7%), partially (85.3%) or not all (55.3%) would 99.7%, 85.3 and 55.8% undergo the procedure in the future if necessary. Conclusions: QLQ was not significantly reduced by insertion. Especially patients using the PEG full-time had an objective and subjective benefit from the inserted PEG tube.

Steigende Inzidenzen von nichtalkoholischer Fettlebererkrankung (NAFLD) und Diabetes mellitus Typ 2 erfordern Aufmerksamkeit fur die Zusammenhange beider Erkrankungen und das sollte bei Betroffenen diagnostische und therapeutische Interventionen nach sich ziehen. Allem voran stehen Lebensstilmasnahmen. Erfreulich: Die bei NAFLD empfohlene mediterrane Ernahrung lasst auch noch viel Raum fur den Genuss.

Was ist neu? Pathophysiologie, Besonderheiten bei Diagnose und Therapiezielen Eine eingeschränkte Nierenfunktion wirkt sich nicht nur auf die Clearance exogen zugeführten Insulins und die Ausscheidung von Medikamenten aus, sondern auch auf diagnostische Verfahren wie die Bestimmung des HbA1c. Eine adäquate Blutzuckerselbstkontrolle ist daher für Patienten mit Diabetes und chronischer Nierenerkrankung (CKD, chronic kidney disease) besonders wichtig. Diabetiker mit CKD haben zudem ein deutlich höheres Risiko für Hypoglykämie als Diabetiker mit normaler Nierenfunktion. Pharmakologie und Zulassung von Antidiabetika bei eingeschränkter Nierenfunktion Viele Antidiabetika müssen bei CKD entsprechend der glomerulären Filtrationsrate (GFR) dosisangepasst werden oder sollten nicht bei vorliegender oder fortschreitender CKD verwendet werden, insbesondere bei Patienten mit einer CKD G5 und bei Dialysepatienten. Eine Insulintherapie ist für Patienten geeignet, die sich einer Dialyse unterziehen. Bei diesen Patienten können jedoch auch einige oral verabreichte glukosesenkende Mittel sicher eingesetzt werden. Auswahl der Präparate und praktisches Vorgehen Entsprechend der europäischen Konsensus- und deutschen Praxisempfehlungen sollte bei Patienten mit CKD eine individualisierte Diabetestherapie erfolgen, die auch Komorbiditäten, wie z. B. kardiovaskuläre Erkrankungen und Übergewicht, berücksichtigt.

Background and aim A number of studies were able to show a reduction of hypoxemia episodes during procedural sedation through the use of capnography (CA). The present study investigates the number of episodes of hypoxemia during percutaneous endoscopic gastrostomy (PEG) placement with propofol sedation comparing standard monitoring (SM) versus SM with additional CA surveillance. Methods In this single center randomized controlled trial, 150 patients were prospectively randomized 1:1 in either the SM group or the CA group after stratification for ASA class, PEG method (push or pull method), presence of head and neck tumor, and tracheostomy. CA analysis was performed for all patients but was blinded for the endoscopic team in the SM group. Results In the SM group, 57% episodes of hypoxemia (SpO2 15 s) and 41% episodes of severe hypoxemia (SpO2 15 s) were observed in comparison with 28% and 20% in the CA group, respectively. Odds ratios for hypoxemia and severe hypoxemia were 0.29 (confidence interval 0.15-0.57; P = 0.0005) and 0.35 (confidence interval 0.17-0.73; P = 0.008) in favor of the CA group. On average, CA was able to detect imminent mild and severe hypoxemia 83 and 99 s before standard monitoring. Standard monitoring represented an independent risk factor for hypoxemia and severe hypoxemia. Conclusions Respiratory complications of sedation during PEG placement are frequent events. CA is able to detect imminent hypoxemia at an early time point. This allows an early intervention and consecutively the avoidance of mild and severe hypoxemia. Therefore, CA monitoring can be recommended particularly during PEG insertion procedures.

This manuscript describes the use of ultrasound elastography, with the exception of liver applications, and represents an update of the 2013 EFSUMB (European Federation of Societies for Ultrasound in Medicine and Biology) Guidelines and Recommendations on the clinical use of elastography.Diese Arbeit beschreibt den Einsatz der Ultraschall-Elastografie mit Ausnahme der Leberanwendungen und ist eine Aktualisierung der Leitlinien und Empfehlungen der EFSUMB (European Federation of Societies for Ultrasound in Medicine and Biology) von 2013 zum klinischen Einsatz der Elastografie.

BACKGROUND: The use of an indwelling peritoneal catheter system in hospitalized patients with ascites could facilitate patient management by the prevention of repetitive abdominal paracentesis. Despite these possible benefits, the use of indwelling catheters is not widely established. OBJECTIVE: This retrospective study aimed to evaluate the feasibility, effectiveness and safety of the use of an indwelling catheter for ascites drainage in the clinical routine. METHODS: This retrospective study included all indwelling peritoneal catheter placements in our department in hospitalized patients with cirrhosis between 2014 and 2017. RESULTS: A total of 324 indwelling catheter placements for ascites in 192 hospitalized patients with cirrhosis were included. The catheter (7F, 8 cm) was placed ultrasound-assisted bed-side on the hospital ward. The technical success rate of the catheter placement was 99.7% (323/324). In 17.5% (64/324) the catheter was placed to optimize ascitic drainage prior to an abdominal intervention (e.g. transjugular intrahepatic portosystemic shunt). The median time of catheter retention was 48 hours (8–168 hours) and the median cumulative amount of drained ascites 8000 ml (550–28,000). The most common adverse event was acute kidney injury (49/324, 15.1%); the risk was particularly higher in patients with a Model for End-Stage Liver Disease (MELD) score ≥ 16 (p = 0.028; odds ratio 2.039). Ascitic fistula after catheter removal was observed in 9.6% (31/324). Catheter-related infections occurred in 4.3% (14/324), and bleeding was documented in three cases (0.8%) with one major bleeding (0.3%). CONCLUSION: The placement of an indwelling catheter for repetitive ascitic drainage in hospitalized patients with cirrhosis can be established in the clinical routine, facilitating patient management. High-MELD patients especially have to be monitored for acute kidney injury.

Background It remains unclear whether liver resection as part of multimodal therapy of neuroendocrine liver metastases (NELM) is superior to non-surgical (interventional and medication-based) treatment alone. This study should determine if patients with NELM undergoing hepatic surgery in addition to non-surgical treatment have improved overall survival compared to patients undergoing non-surgical therapy alone. Methods 123 patients undergoing treatment of NELM between 1995 and 2014 were included in this retrospective cohort study. Two groups were formed: (A) surgery and non-surgical therapy and (B) non-surgical treatment alone. To minimize the bias of patient selection propensity score matching was used. Results There was significantly better overall survival for group A (152 months, 95%CI: 119–185) compared to group B (63 months, 95%CI: 45–81) measured from the initial diagnosis of the metastases (P = 0.003). After propensity score matching, 37 patients undergoing surgical resection of NELM within a multimodal treatment were compared to 37 patients undergoing non-surgical treatment. Under these circumstances, surgery had no significant influence on survival (group A: 134 months, 95% CI: 94–173; group B: 76 months, 95% CI: 53–99, P = 0.23). Based on a multivariate Cox proportional hazard model, only Ki-67 of primary tumor >20% (HR, 50.776; 95%CI, 4.056–635.71; P = 0.002) and no resection of primary tumor (HR, 10.464; 95%CI, 1.873–58.448; P = 0.007) remained independent risk factors. Conclusion After minimizing patient selection bias, patients with hepatic resection as integral of multimodal therapy of NELM do not have better overall survival than those receiving non-surgical treatment alone.

ZusammenfassungSchilddrüsenknoten sind ein häufiger Befund insbesondere in Regionen mit unzureichender Iodversorgung. Ultraschall ist das sensitivste Verfahren zum Nachweis von Schilddrüsenknoten, hat aber eine nicht ausreichende Genauigkeit bei der Unterscheidung zwischen gutartigen und bösartigen Schilddrüsenknoten. Daher ist bei auffälligen Knoten in der Sonografie derzeit die Feinnadel-Aspiration-Biopsie (FNAB) diagnostisches Verfahren der Wahl. Dennoch wird bei einer relevanten Anzahl von Patienten mit letztlich gutartigen Schilddrüsenknoten eine Operation mehr aus diagnostischer als aus therapeutischer Intention durchgeführt. Ein klassisches Kriterium der Bösartigkeit ist eine harte oder feste Konsistenz bei Palpation. Bisher war dieses Kriterium subjektiv und abhängig von der Erfahrung des Untersuchers. Mit der Einführung der ultraschallbasierten Elastografie steht eine reproduzierbare Beurteilung der Gewebekonsistenz zur Verfügung. Ziel des vorliegenden Artikels ist eine aktuelle Darstellung der verschiedenen verfügbaren Techniken sowie deren Ergebnisse, sowohl für die Differenzierung von Schilddrüsenknoten als auch für diffuse Schilddrüsenerkrankungen. Vorteile und Grenzen der Elastografie werden kritisch diskutiert.

Objectives The risk of post-ERCP pancreatitis (PEP) can be reduced effectively by the placement of a self dislodging pancreatic stent. The present study analyzed whether a prolonged interval until stent passage evaluation and removal of retained stents is associated with an increased risk for clinically relevant complications. Methods In the retrospective study 182 patients receiving a pancreatic stent for PEP prophylaxis were included and clinical data and complications until documented spontaneous stent dislodgement or removal were analyzed. Results The main indication for ERCP was choledocholithiasis (40.1%) followed by malignant stenosis (30.8%). Stent passage evaluation was performed in 34.1% at day 1–4, 23.6% at day 5–10, 17.6% at day 11–28 and 24.7% at day >28. PEP occurred in 13.1% of patients with no case of severe PEP. No association between PEP and day of stent passage evaluation (p = 0.719), retention of the pancreatic stent at time of evaluation (0.867) or prolonged stent retention >10 days (0.234) was observed. Only the duration of the procedure was associated with risk for PEP (p = 0.037). Besides PEP only one clinically relevant complication was observed in the cohort (0.5%) which was a late possibly stent related pancreatitis at day 9 after the procedure that resolved completely. Conclusions A prolonged interval for stent passage evaluation and stent retention is not associated with an increase of clinically relevant complications. A later evaluation and extraction of retained stents might be acceptable in selected cases where an additional endoscopic procedure can be saved due to a planned follow-up endoscopy.