Transanale endoskopische Mikrochirurgie

Transanal endoscopic microsurgery (TEM) was introduced in 1983 as a minimally invasive technique allowing the resection of adenomas and early rectal carcinomas unsuitable for local or colonoscopic excision which would otherwise require major surgery. After 25 years, there is still much debate about the procedure. This article presents the TEM technique, indications, results and complications, focusing on its role in rectal cancer. The controversial points addressed include long-term results, TEM in high-risk T1 lesions, TEM associated with combined modality therapy (CMT) for invasive rectal cancer and salvage therapy after TEM. The future perspectives for TEM are promising and its association with CMT will probably expand the select group of patients who will benefit from the procedure.     

Neue endoskopische Therapieverfahren

Zum Thema Die Palette der endoskopischen Verfahren, die zur kurativen oder palliativen Therapie benigner oder maligner Erkrankungen innerhalb der letzten 3 Jahrzehnte entwickelt wurden, ist umfangreich und für den Internisten nicht einfach zu gewichten. Die vorliegende übersicht soll vor allem dazu beitragen, neuere und speziellere operativ-endoskopische Verfahren vorzustellen und im Licht der publizierten Daten zu werten. Gerade weil die beschriebenen Techniken in der Regel lediglich endoskopisch-gastroenterologischen Zentren mit ausreichender Erfahrung vorbehalten werden, soll der Internist über die M?glichkeiten und Grenzen dieser Verfahren informiert werden.     

Die endoskopische Vollwandresektion

Conventional endoscopic resection techniques such as endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) are powerful tools for the treatment of gastrointestinal (GI) neoplasms. However, those techniques are limited to the superficial layers of the GI wall (mucosa and submucosa). Lesions without lifting sign (usually arising from deeper layers) or lesions in difficult anatomic positions (appendix, diverticulum) are difficult – if not impossible – to resect using conventional techniques, due to the increased risk of complications. For larger lesions (>2 cm), ESD appears to be superior to the conventional techniques because of the en bloc resection, but the procedure is technically challenging, time consuming, and associated with complications even in experienced hands. Since the development of the over-the-scope clips (OTSC), complications like bleeding or perforation can be endoscopically better managed. In recent years, different endoscopic full-thickness resection techniques came to the focus of interventional endoscopy. Since September 2014, the full-thickness resection device (FTRD) has the CE marking in Europe for full-thickness resection in the lower GI tract. Technically the device is based on the OTSC system and combines OTSC application and snare polypectomy in one step. This study shows all full-thickness resection techniques currently available, but clearly focuses on the experience with the FTRD in the lower GI tract.     

Moderne Herzschrittmachertherapie

Since pacemakers first have been implanted in 1958 considerable technical progress has been achieved. The devices are more efficient today, have complex diagnostic functions, memory capacity and it is even possible to get telemetric software updates. Automatic mode switch due to changing heart rhythm, adaptation of AV-delay, auto sensing and auto stimulation threshold are available and facilitate pacemaker follow up. Because of continuously progress in pacing therapy guidelines have to be updated very often. The newest German and international guidelines for pacing therapy have been published in 2005 by Deutsche Gesellschaft für Kardiologie/ Herz- und Kreislaufforschung (DGK). Indications for pacing therapy increases continuously. Not only bradycardia, but also heart failure, prophylactic pacing to prevent and to terminate tachyarrhythmias are modern fields of pacing therapy.     

Moderne Antikoagulation

Zusammenfassung Die Antikoagulation ist ein bewährtes und effektives Prinzip zur Prophylaxe und Therapie von Thromboembolien. Für lange Zeit waren Vitamin-K-Antagonisten die einzigen oral wirksamen Antikoagulanzien. Diese sind zwar sehr effektiv, aber im praktischen Einsatz durchaus problematisch: ein engmaschiges Monitoring ist wegen des schmalen therapeutischen Fensters, individuellen Dosisunterschieden und zahlreichen Wechselwirkungen erforderlich. Der Zielbereich liegt für die meisten Indikationen bei einer INR von 2–3. Derzeit werden weitere oral wirksame Antithrombotika untersucht. Der orale direkte Thrombininhibitor Ximelagatran erscheint in Studien zur Prophylaxe und Therapie von Thromboembolien niedermolekularem Heparin und Vitamin-K-Antagonisten ebenbürtig.Als parenteral wirksames Antikoagulans wird seit Jahren unfraktioniertes Heparin (UFH) eingesetzt. Mit niedermolekularen Heparinen konnten einige Nachteile des UFH reduziert werden, wie eingeschränkte Bioverfügbarkeit, variable Dosiswirkung und heparininduzierte Thrombozytopenie, bei der sich Heparinoide und Hirudine bewährt haben. In den letzten Jahren konnte durch synthetische Pentasaccharide (z. B. Fondaparinux) in der Hochrisikoprophylaxe eine Wirkungssteigerung gegenüber niedermolekularen Heparinen erzielt werden.     

Moderne Tuberkulosetherapie

Based on estimates from the World Health Organization (WHO), there were 8.7 million new cases of tuberculosis (TB) and 1.4 million deaths globally in 2011. In Germany, TB has become a rare disease (incidence 5.3/100,000). Therefore, experience regarding the management and treatment of TB patients is decreasing. In this review, standard therapy of TB and the drugs administered are described. Prior to initiation of therapy, a thorough patient history must be taken to evaluate the risk factors for a drug-resistant TB. In addition, bacterial confirmation via microscopic and culture analyses and phenotypic drug susceptibility testing are also recommended. Treatment of TB is always based on combined antibiotic therapy. The selection of the drugs is determined by the resistance status of the strains. For detailed recommendations refer to the current recommendations of the German Central Committee against Tuberculosis e. V. (DZK) and the German Respiratory Society (DGP).     

Moderne Mitralklappenchirurgie

At the beginning of the 20th century, Cutler and Levine performed the first successful surgical treatment of a stenotic mitral valve, which was the only treatable heart valve defect at that time. Mitral valve surgery has evolved significantly since then. The introduction of the heart–lung machine in 1954 not only reduced the surgical risk, but also allowed the treatment of different mitral valve pathologies. Nowadays, mitral valve insufficiency has become the most common underlying pathomechanism of mitral valve disease and can be classified into primary and secondary mitral insufficiency. Primary mitral valve insufficiency is mainly caused by alterations of the valve (leaflets and primary order chords) itself, whereas left ventricular dilatation leading to papillary muscle displacement and leaflet tethering via second order chords is the main underlying pathomechanism for secondary mitral valve regurgitation. Valve reconstruction using the “loop technique” plus annuloplasty is the surgical strategy of choice and normalizes life expectancy in patients with primary mitral regurgitation. In patients with secondary mitral regurgitation, implanting an annuloplasty is not superior to valve replacement and results in high rates of valve re-insufficiency (up to 30?% after 3 months) due to ongoing ventricular dilatation. In order to improve repair results in these patients, we add a novel subvalvular technique (ring–noose–string) to the annuloplasty that aims to prevent ongoing ventricular remodeling and re-insufficiency. In modern mitral surgery, a right lateral thoracotomy is the approach of choice with excellent repair and cosmetic results.     

Die laparoskopisch assistierte endoskopische Polypektomie

A new technique of endoscopic excision of unfavorably located colonic polyps within the rectosigmoideal transition with simultaneous employment of laparoscopic assistence is described. In 2 cases a regular endoscopic excision of a colonic polyp was impossible to perform because of a location just proximal to the recto-sigmoideal transition. These 2 patients should be treated with laparoscopic segmental colon resection. With the use of laparoscopy the sigmoid colon could be mobilized and extended. This manoeuvre led to a sucessful removing of polyps with the employment of colonoscopy without an increased risk. This new technique enables to perform a difficult and precarious excision of colonic polyps more safely and to avoid segmental colon resection with its possible complications as an alternative treatment.     

Moderne antirheumatische Pharmakotherapie

Rheumatoid arthritis potentially causes joint destruction, organ failures, and accompanying disorders. Therefore initiating therapeutic measures as early as possible is crucial, whereby symptomatic treatment only is definitely insufficient. Among the traditional disease-modifying antirheumatic drugs (DMARD) Methotrexate is regarded the gold standard. Increasing knowledge of cell-interactions, particularly of the cytokine-cascade, resulted in new therapeutic options. Direct impact via "biologicals" on key inflammatory mediators, primarily TNF-alpha, offers the possibility of effectively modulating or even arresting disease progression. Nowadays, those substances are applied in non-responders to traditional DMARD. Despite their benefits, cons like an increased risk for infections, for exacerbating latent tuberculosis and possibly for malignancies must be considered. Thus, a thorough patient check-up before initiating these therapies is mandatory. Pharmacoeconomic aspects influence the discussion about these "new therapies". The high costs of biologicals, however, should be related to the possible reduction of the diseases psychological, social and economic burdens.     

Moderne Pankreasdiagnostik bei Tumorverdacht

This review on suspected tumors essentially focuses on malignant ductal adenocarcinoma of the head of the pancreas. Men are more often affected than women (ratio 2:1). The incidence in Germany is approximately 10-15 cases per 100,000 inhabitants and is generally increasing. The only potentially curative therapy for adenocarcinoma of the pancreas is surgical R0 resection; however, currently only approximately 20 % of patients are potentially resectable at the time of diagnosis and even after successful resection the long-term 5-year survival of approximately 20 % is soberingly poor. In total only 5 % of patients with the diagnosis of pancreatic cancer survive longer than 5 years. It is therefore a special challenge to make an early diagnosis. Likewise, the differential diagnosis of patients with pre-existing chronic pancreatitis is a special difficulty in the diagnostics because these patients very often also have an enlarged pancreas head. A third core question is the surgical resectability. This article describes the technical principles of the most commonly used diagnostic tools endoscopic ultrasound (EUS), computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET)/CT and elucidates their advantages and limitations.     

Moderne Differenzialtherapie mit Diuretika

Diuretics block different electrolyte transporters in renal tubular cells. Their predominant action is inhibition of renal sodium chloride reabsorption, however, and achievement of a negative body sodium balance is the principal goal of diuretic therapy in patients with hypertension and edema. Several classes of diuretics can be distinguished with respect to the sites of sodium reabsorption along the nephron, but loop diuretics and distal-tubular diuretics (incl. thiazides) are the most widely used. The latter have a less potent natriuretic effect than loop diuretics, but their long duration of action predispose them for treatment of patients with uncomplicated hypertension. In conditions of gross edema, e.g. heart and/or renal failure, distal-tubular diuretics lose their efficacy and must be replaced by or combined with loop diuretics ("sequential nephron blockade"). Aldosterone antagonists are unique among diuretics because they improve survival in patients with heart failure independently of their effect on sodium metabolism.     

Moderne Chemotherapie beim Bronchialkarzinom

Nach wie vor bestehen entscheidende Unterschiede in der Effektivit?t und in der Indikation zu einer Chemotherapie beim Bronchialkarzinom in Abh?ngigkeit vom histologischen Subtyp. Kleinzellige Bronchialkarzinome sprechen in der Mehrzahl der F?lle auf eine Chemotherapie an, w?hrend die Ergebnisse in der Gruppe der nichtkleinzelligen Bronchialkarzinome (NKBK) trotz der Entwicklung neuer Zytostatika immer noch wesentlich schlechter sind. Im Folgenden wird daher zun?chst die Chemotherapie des kleinzelligen Bronchialkarzinoms und anschlie?end die Chemotherapie bei den fortgeschrittenen und/oder metastasierten nichtkleinzelligen Bronchialkarzinome besprochen. Die neuen Ans?tze der sequenziellen oder simultanen Radiochemotherapie lokal fortgeschrittener inoperabler NKBK, der postoperativen adjuvanten und der pr?operativen Chemotherapie werden hier nicht berücksichtigt, da sonst der Rahmen dieser übersicht gesprengt werden würde.     

Moderne Therapie der Divertikelkrankheit

New concepts are developed in the therapy of diverticular disease. 5-aminosalicylates can be administered in patients with slight forms of diverticulitis. In moderate diverticulitis antibiotics should be applied alternatively or additionally. In cases of severe diverticulitis patients should be kept fasting with parenteral nutrition and intravenous broad spectrum antibiotics. Small abscesses can be treated conservatively while abscesses larger than 4 cm should be drained in a first step and than treated surgically. A free perforation is still an absolute indication for emergency operation. In recurring diverticulitis indication for resection of the affected segment of the bowel should be considered depending on the extent of former attacks.     

Konservative und interventionelle endoskopische Therapie des Gallenwegskarzinoms

Zusammenfassung Beim inoperablen Gallengangskarzinom ist die endoskopische Therapie von zentraler Bedeutung. Sie ist wenig invasiv, bessert die Symptome des Verschlussikterus, beugt Komplikationen vor und ist wesentlicher Bestandteil der Cholangitistherapie. Hauptkomplikation ist der Stentverschluss mit nachfolgender Cholangitis. Eine prophylaktische Langzeitantibiose hat sich nicht bewährt. Technische Fragen bezüglich Stentmaterial, Anzahl und Platzierung der Stents sind noch nicht abschließend geklärt. Die photodynamische Therapie könnte die Gallengangsdrainage zukünftig möglicherweise sinnvoll ergänzen. Präoperativ ist die Gallengangsdrainage bei Verschlussikterus keine Routineindikation, kann aber zur zeitlichen Überbrückung oder zur Rekompensation der Leberfunktion vor Leberteilresektionen hilfreich sein. Auch in der Therapie postoperativer Gallengangsstenosen gewinnt die endoskopische Stentversorgung zunehmend an Stellenwert.