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1.
Background
Gallstones are present in approximately 10–20?% of the German population. Up to one fourth of them will develop symptoms or complications during their lifetime.Objective
Based on recent guidelines, this paper reviews the evidence-based management of patients with gallstone disease.Materials and methods
Most relevant recommendations of the updated S3 guidelines on the diagnosis and treatment of gallstone disease are provided. Developments are depicted in relation to the 2007 version of these guidelines. Complementary recommendations of the S2k guidelines on quality requirements for gastrointestinal endoscopy and of the European Federation of Societies of Ultrasound in Medicine and Biology (EFSUMB) guidelines on interventional ultrasound in gallstone disease are referred to.Results
Based on recent scientific evidence, the guideline recommendations for diagnosis and treatment of patients with gallstone disease are presented. Requirements are rising for early surgical treatment of patients with acute cholecystitis (24 h), the timely management of patients with acute cholangitis and biliary pancreatitis (depending on severity) and on the sequential treatment of patients with simultaneous gallbladder and common bile duct stones (laparascopic cholecystectomy within 72 h after endoscopic bile duct clearance).Conclusions
Up-to-date guideline-based management of patients with gallstone disease is an interdisciplinary task and requires comprehensive management concepts. A guideline-based algorithm is introduced.2.
Purpose of Review
Nonalcoholic steatohepatitis (NASH) is a spectrum of nonalcoholic fatty liver disease (NAFLD). It is defined as the presence of fatty liver along with inflammation and hepatocyte injury. To date, weight loss achieved via lifestyle intervention remains the mainstay of NASH treatment. However, given the known benefit of weight loss on NASH and the known effect of bariatric surgery on weight loss, several studies have explored the potential role of bariatric surgery on the treatment of NASH.Recent Findings
This review article summarizes the evidence on the effect of Roux-en-Y gastric bypass (RYGB), a common bariatric surgery, on NASH therapy. Specifically, studies show that RYGB is associated with an improvement of all NASH histologic features at 1 year.Summary
Compared to adjustable gastric band, RYGB appears to be superior at treating NASH. Randomized controlled trials and long-term studies are underway to better clarify the role of these procedures specifically for NASH therapy.3.
Laura Jopson Amardeep Khanna Patricia Peterson Elaine Rudell Margaret Corrigan David Jones 《Digestive diseases and sciences》2018,63(10):2547-2554
Background
Primary Biliary Cholangitis (PBC, formerly cirrhosis), is a chronic cholestatic liver disease which until spring 2016 had a single licensed therapy, Ursodeoxycholic acid (UDCA). Approximately 30% of patients do not respond to UDCA, and are high-risk for progressing to end stage liver disease, transplantation or death. A new era of stratified medicine with second-line therapies to treat high-risk disease is emerging, with the first such second-line agent obeticholic acid recently receiving FDA and EMA approval and entering practice. Recent experience in the USA of inappropriate use and associated deaths has highlighted concerns as to whether clinicians have the knowledge to implement second-line therapies appropriately and safely.Methods
Online survey of knowledge regarding optimal PBC management in Gastroenterologists and Hepatologists in the USA; the first 100 completed responses from each group used for analysis.Results
80% of Hepatologists felt they were highly competent in their understanding of the importance of early diagnosis and early UDCA therapy in PBC compared with 65% of gastroenterologists. However, only 36% of Hepatologists and 30% of gastroenterologists felt competent at assessing response to UDCA. Competence in knowledge (mode of action, efficacy, and side effects) of second-line therapies and enrollment into trials was low among both groups.Conclusion
Significant knowledge gaps in clinicians managing PBC presents a problem in optimizing care. It is perhaps not surprising that knowledge of emerging second-line therapies is low, however more concerning is sub-optimal use of UDCA in real-life practice and the lack of confidence at assessing treatment response which should be a routine part of clinical practice to assess risk of disease progression and will be key in delivering stratified medicine.4.
Amanda R. Vest 《Current heart failure reports》2018,15(3):171-180
Purpose of Review
Obesity is a strong risk factor for the development of heart failure (HF). Diet, exercise, and weight-loss pharmacotherapies have limited potential to achieve significant and sustainable weight loss, especially in patients with symptomatic systolic HF. This review seeks to determine the role of bariatric surgery for patients with systolic HF and obesity.Recent Findings
Bariatric surgeries such as the laparoscopic sleeve gastrectomy (LSG) and Roux-en-Y gastric bypass (RYGB) represent the most successful long-term strategy for achieving weight loss and diabetes and hypertension remission in the general obese population. These benefits translate to reductions in cardiovascular events and mortality, as well as improvements in myocardial structure and function. There is also now data supporting the safety of LSG or RYGB in patients with systolic dysfunction and a reduction in HF admissions post-operatively.Summary
Current literature and clinical experience suggest that the most appropriate bariatric surgery candidates with HF are patients aged <?50–60 years, with severely depressed systolic function and NYHA II-III symptoms, who have failed non-surgical strategies and have a high likelihood of future cardiac transplantation candidacy after weight loss. This review seeks to determine the role of bariatric surgery for patients with systolic HF and obesity.5.
Purpose of Review
Obesity is a global epidemic that continues to grow and results in related conditions such as hypertension and diabetes despite established interventions, thus suggesting the importance of new technologies.Recent Findings
Endoscopic interventions are vast in scope and effectiveness. Intra-gastric balloons appear to dominate the field at this time, but a recent FDA-approved technique, the Aspire device, may soon cause a shift in the treatment paradigm. Short-term studies demonstrate optimistic results, yet long-term studies have not been performed. In addition, complications from these procedures are severe, resulting in significant morbidity when they occur. Treatment of bariatric surgery complications with endoscopic techniques is an expanding field that relies heavily on new innovation.Summary
The next few years in bariatric endoscopy promise to be turbulent and controversial. Endoscopic procedures for obesity will undoubtedly increase but are anticipated to do so at a slower rate than many projects. Bariatric surgery complications will continue to be treated by endoscopic means, and optimization of these procedures is on the horizon. This review will provide those who treat obesity-related hypertension on the current state of bariatric endoluminal procedures.6.
Purpose of Review
The rising prevalence of obesity in general and non-alcoholic steatohepatitis (NASH) specifically as an indication for liver transplantation has occurred in parallel with an increase in the consideration and performance of bariatric surgery before and after liver transplantation. We review the impact and relative merits of bariatric surgery before, during, and after liver transplantation.Recent Findings
The sleeve gastrectomy approach has several practical advantages over other forms of weight loss surgery and has been shown to improve metabolic parameters. Bariatric surgical procedures inevitably affect immunosuppression pharmacokinetics, with the least impact being observed following sleeve gastrectomy. In the non-transplant setting, bariatric surgery has been shown to be an effective therapy for histological features of NASH.Summary
When compared to lifestyle changes alone, bariatric surgery performed during or after liver transplantation results in sustained weight loss and improved metabolic parameters associated with liver disease, cardiovascular risk, and overall mortality. Further studies are needed to confirm which surgical procedures, timing, and NASH patients will receive most benefit.7.
Purpose of Review
The purpose of this review paper is to provide an overview of the relationship between obesity, osteoarthritis, arthroplasty outcomes, and the potential use of bariatric surgery to improve these outcomes.Recent Findings
Unfortunately, the findings in the currently available literature evaluating the role of bariatric surgery prior to arthroplasty surgery largely rely on retrospective data and their results are somewhat conflicting.Summary
Future prospective studies are needed to further evaluate whether or not bariatric surgery prior to arthroplasty surgery may be of benefit for patients. Additional research is needed to identify other methods to minimize complications that obese patients are particularly prone to developing following arthroplasty surgery.8.
Colleen M. Craig Li-Fen Liu Carolyn F. Deacon Jens J. Holst Tracey L. McLaughlin 《Diabetologia》2017,60(3):531-540
Aims/hypothesis
Post-bariatric hypoglycaemia (PBH) is a rare, but severe, metabolic disorder arising months to years after bariatric surgery. It is characterised by symptomatic postprandial hypoglycaemia, with inappropriately elevated insulin concentrations. The relative contribution of exaggerated incretin hormone signalling to dysregulated insulin secretion and symptomatic hypoglycaemia is a subject of ongoing inquiry. This study was designed to test the hypothesis that PBH and associated symptoms are primarily mediated by glucagon-like peptide-1 (GLP-1).Methods
We conducted a double-blinded crossover study wherein eight participants with confirmed PBH were assigned in random order to intravenous infusion of the GLP-1 receptor (GLP-1r) antagonist. Exendin (9-39) (Ex-9), or placebo during an OGTT on two separate days at the Stanford University Clinical and Translational Research Unit. Metabolic, symptomatic and pharmacokinetic variables were evaluated. Results were compared with a cohort of BMI- and glucose-matched non-surgical controls (NSCs).Results
Infusion of Ex-9 decreased the time to peak glucose and rate of glucose decline during OGTT, and raised the postprandial nadir by over 70%, normalising it relative to NSCs and preventing hypoglycaemia in all PBH participants. Insulin AUC and secretion rate decreased by 57% and 71% respectively, and peak postprandial insulin was normalised relative to NSCs. Autonomic and neuroglycopenic symptoms were significantly reduced during Ex-9 infusion.Conclusions/interpretation
GLP-1r blockade prevented hypoglycaemia in 100% of individuals, normalised beta cell function and reversed neuroglycopenic symptoms, supporting the conclusion that GLP-1 plays a primary role in mediating hyperinsulinaemic hypoglycaemia in PBH. Competitive antagonism at the GLP-1r merits consideration as a therapeutic strategy.Trial registration:
ClinicalTrials.gov NCT025501459.
Michael Feichtinger Tina Stopp Sandra Hofmann Stephanie Springer Sophie Pils Alexandra Kautzky-Willer Herbert Kiss Wolfgang Eppel Andrea Tura Latife Bozkurt Christian S. Göbl 《Diabetologia》2017,60(1):153-157
Aims/hypothesis
A history of gastric bypass surgery can influence the results of the OGTT recommended during pregnancy. Therefore, we compared OGTT glucose kinetics and pregnancy outcome between pregnant gastric bypass patients and BMI-matched, lean and obese controls.Methods
Medical records were used to collect data on glucose measurements during the 2 h 75 g OGTT as well as on pregnancy and fetal outcome for 304 women (n?=?76 per group, matched for age and date of delivery).Results
Women after bariatric surgery had lower fasting glucose levels compared with lean, obese and BMI-matched controls, and showed altered postprandial glucose kinetics, including a rise at 60 min followed by hypoglycaemia with serum glucose of <3.34 mmol/l (which occurred in 54.8%). Moreover, their risk of pre-eclampsia or gestational hypertension was reduced, with an increased risk of delivering small for gestational age infants.Conclusions/interpretation
Alternative strategies to accurately define impaired glucose metabolism in pregnancies after bariatric surgery should be explored.10.
Background
Nonalcoholic fatty liver disease (NAFLD) is defined by hepatocellular fat accumulation of more than 5?% (fatty liver, NAFL, steatosis) and also comprises steatohepatitis (NASH), cirrhosis and hepatocellular carcinoma. No specific drug treatment for NAFLD in type 2 diabetes mellitus (T2D) is approved.Methods
In a Medline search, randomized controlled trials on weight- and/or blood glucose-lowering therapies in NAFLD and T2D with the primary endpoints reduction of liver fat content and/or improvement in liver histology were identified.Results
Lifestyle modification (weight loss of >7?%) and bariatric surgery reduce inflammation and hepatocellular ballooning in NASH. Pioglitazone therapy can improve inflammation and ballooning in prediabetes or T2D within 6 months. This effect remains for at least 3 years. Liraglutide results in reduction of liver fat content and improvement of inflammation and ballooning in NASH, with fewer liraglutide-treated individuals showing an aggravation of fibrosis. Metformin, sulfonylureas and insulin have no clinically relevant effect on liver fat content and liver histology.Conclusions
Beyond lifestyle modification, the benefit of pioglitazone, liraglutide and bariatric surgery for reduction of liver fat content and NASH must be balanced against the risks and costs. Further specific therapeutic recommendations will require studies on novel drugs and longer-term controlled prospective trials.11.
Background
Bouveret's syndrome is an unusual presentation of duodenal obstruction caused by the passage of a large gallstone through a cholecystoduodenal fistula. Endoscopic therapy has been used as first-line treatment, especially in patients with high surgical risk.Case presentation
We report a 67-year-old woman who underwent an endoscopic attempt to fragment and retrieve a duodenal stone using a Holmium: Yttrium-Aluminum-Garnet Laser (Ho:YAG) which resulted in small bowel obstruction. The patient successfully underwent enterolithotomy without cholecystectomy or closure of the fistula.Conclusion
We conclude that, distal gallstone obstruction, due to migration of partially fragmented stones, can occur as a possible complication of laser lithotripsy treatment of Bouveret's syndrome and might require urgent enterolithotomy.12.
Background
It is believed that loosing ileocecal valve is well tolerated in patients who do not have short bowel syndrome or Crohn disease. From the hypothesis of colonic peristalsis and transit is regulated by that ileocecal valvular mechanism, we try to find out if the creation of a new pseudo-valvular mechanism as antiperistaltic anastomosis could be considered after right hemicolectomy can cause any short- or long-term changes in gastrointestinal habits.Purpose
The purpose of the study at primary endpoint is to compare early (occurring within 30 days of surgery) and late (occurring during the follow-up) postoperative complications between both groupsThe purpose of the study at secondary endpoint is to compare intraoperative and postoperative events between experimental and control groups in terms of operating time, first oral tolerance day, first flatus and faeces, length of hospital stay and orocecal transit; comparing rates of gastrointestinal life quality and comparing mortality rates between both groups.Methods
The ISOVANTI trial is a randomized controlled single-centre trial comparing isoperistaltic versus antiperistaltic side-to-side anastomosis after right laparoscopic hemicolectomy. It is designed as a parallel group superiority trial.Conclusions
It is unknown if a pseudo-valvular mechanism as antiperistaltic anastomosis can be considered has short- or long-term consequences in gastrointestinal habit. Considering the impact that ileocolic anastomosis configuration could have on the restitution of bowel transit after right hemicolectomy, we think it is indicated and necessary a randomized trial comparing iso- and antiperistaltic modalities.Trial registration
NCT0230993113.
Piyush Gupta Mehul Choksi Ashish Goel Uday Zachariah Kattiparambil Gangadharan Sajith Jeyamani Ramachandran George Chandy George Kurian Grace Rebekah Chundamannil Eapen Eapen 《Indian journal of gastroenterology》2018,37(1):31-38
Background
Experience with zinc in treating symptomatic hepatic Wilson’s disease (WD) is limited.Aim
To study the efficacy of Penicillamine followed by zinc in treating symptomatic hepatic Wilson’s disease.Methods
We retrospectively analyzed case records of 31 symptomatic hepatic WD patients for whom disease severity scores (Child’s, model for end-stage liver disease (MELD), Nazer’s, and New Wilson Index (NWI) score) and 24-h urinary copper were compared at 3-time points—baseline at presentation, at transition from penicillamine to zinc and at end of follow up.Results
Thirty-one patients (median age 11 [5–24] years) with symptomatic hepatic WD were studied; ten had associated neuropsychiatric manifestations of WD. Penicillamine was changed to zinc sulfate either due to financial constraints (28 patients) or due to adverse effects of penicillamine (3 patients). At presentation (baseline), six patients belonged to Child’s class A, five to Child’s B, and 17 to Child’s C. Duration of initial penicillamine chelation therapy was 134 (2–320) weeks, and of subsequent zinc therapy was 363 (35–728) weeks. There was a significant improvement in liver function tests and disease severity scores (Child’s, MELD, Nazer’s, and NWI score) at the transition from penicillamine to zinc compared to baseline. This improvement was maintained until the end of study period with 90% survival at 10 (2–20) years. Fifteen of the 17 Child’s C cirrhotic patients showed significant improvement in disease severity scores from baseline until end of follow up.Conclusions
Penicillamine followed by zinc may be a safe and effective treatment in resource-constrained setting for symptomatic hepatic WD patients in all grades of baseline disease severity. Some patients with decompensated cirrhosis due to WD may be managed with medical treatment, avoiding liver transplantation.14.
Joseph Donnelly James Gabriels Andrew Galmer Jonathan Willner Stuart Beldner Laurence M. Epstein Apoor Patel 《Current treatment options in cardiovascular medicine》2018,20(8):64
Purpose of review
A variety of complex vascular pathologies arise following the implantation of electronic cardiac devices. Pacemaker and defibrillator lead insertion may cause proximal venous obstruction, resulting in symptomatic venous congestion and the compromise of potential future access sites for cardiac rhythm lead management.Recent findings
Various innovative techniques to recanalize the vein and establish alternate venous access have been pioneered over the past few years.Summary
A collaborative team of electrophysiologists and vascular specialists strategically integrate the patient’s vascular disease into the planning of electrophysiology procedures. When vascular complications occur after device implantation, the same team effectively manages both the resulting vascular sequelae and related cardiac rhythm device challenges. This review will outline the various vascular challenges related to device therapy and offer an effective strategy for their management.15.
Thierry H. Le Jemtel Rohan Samson Gregory Milligan Abhishek Jaiswal Suzanne Oparil 《Current hypertension reports》2018,20(9):77
Purpose of the Review
Low-grade systemic inflammation increases residual cardiovascular risk. The pathogenesis of low-grade systemic inflammation is not well understood.Recent Findings
Visceral adipose tissue accumulates when the subcutaneous adipose tissue can no longer store excess nutrients. Visceral adipose tissue inflammation initially facilitates storage of nutrients but with time become maladaptive and responsible for low-grade systemic inflammation. Control of low-grade systemic inflammation requires reversal of visceral adipose tissue accumulation with intense and sustained aerobic exercise or bariatric surgery. Alternatively, pharmacologic inhibition of the inflammatory signaling pathway may be considered.Summary
Reversal visceral adipose tissue accumulation lowers residual cardiovascular risk.16.
17.
Christopher Caputo Alexander Uhr Alana Murphy 《Current Bladder Dysfunction Reports》2018,13(4):262-266
Purpose of Review
We sought to explore the relationship between obesity and overactive bladder (OAB) and to review the available literature that supports weight loss as a means to alter OAB severity and bother.Recent Findings
Over the past 15 years, several population-based human studies and animal models have identified obesity as a risk factor for the development of OAB. The bariatric surgery literature demonstrates that substantial weight loss following some form of gastric bypass can lead to at least subjective improvement in OAB symptoms. Ongoing research seeks to further elucidate the role of anti-inflammatory agents, anti-oxidants, and β3-receptor agonists in obesity-associated OAB.Summary
The currently available literature has identified obesity as a risk factor for the development OAB. Data taken from the bariatric surgery literature indicates that surgical weight loss can lead to a significant improvement in OAB severity and bother. Future studies will determine if less dramatic weight changes can lead to significant and sustained changes in OAB parameters. Based on the available literature, clinicians should start to counsel their obese patients with OAB that weight loss can help improve their OAB severity and bother.18.
Background
A therapeutic strategy for symptomatic patients with chronic gastritis has not been established. Gastric acid has been reported to induce a variety of unpleasant abdominal symptoms. We investigated whether the histamine H2 receptor antagonist famotidine attenuated upper abdominal symptoms in patients with chronic gastritis.Methods
In this multicenter prospective single-arm open-label study, 10,311 patients with a clinical diagnosis of chronic symptomatic gastritis were enrolled and each patient was administered famotidine at 20 mg/day for 4 weeks. The intensity levels of upper abdominal symptoms, epigastralgia, epigastric fullness, and heartburn were evaluated using a face scale (grade 0–4). Abdominal symptom-related quality of life (QOL) impairment was also evaluated, using an Izumo scale before and after famotidine administration. In a subgroup analysis, symptomatic responses in patients diagnosed with functional dyspepsia (FD) according to the Rome III criteria were analyzed.Results
In 8,460 patients who completed the protocol, famotidine administration significantly attenuated epigastralgia, epigastric fullness, and heartburn, and famotidine also attenuated abdominal symptom-related QOL impairment in all patients with chronic symptomatic gastritis, in those with FD-like symptoms without organic disease, and in those with FD as defined by the Rome III criteria.Conclusion
Famotidine is effective to relieve abdominal symptoms and improve QOL, not only in patients with Rome III-defined FD, but also in those with chronic symptomatic gastritis.19.
Elliott J. Goytia David W. Lounsbury Mary S. McCabe Elisa Weiss Meghan Newcomer Deena J. Nelson Debra Brennessel Bruce D. Rapkin M. Margaret Kemeny 《Journal of general internal medicine》2009,24(2):451
INTRODUCTION
Many cancer centers and community hospitals are developing novel models of survivorship care. However, few are specifically focused on services for socio-economically disadvantaged cancer survivors.AIMS
To describe a new model of survivorship care serving culturally diverse, urban adult cancer patients and to present findings from a feasibility evaluation.SETTING
Adult cancer patients treated at a public city hospital cancer center.PROGRAM DESCRIPTION
The clinic provides comprehensive medical and psychosocial services for patients within a public hospital cancer center where they receive their oncology care.PROGRAM EVALUATION
Longitudinal data collected over a 3-year period were used to describe patient demographics, patient needs, and services delivered. Since inception, 410 cancer patients have been served. Demand for services has grown steadily. Hypertension was the most frequent comorbid condition treated. Pain, depression, cardiovascular disease, hyperlipidemia, and bowel dysfunction were the most common post-treatment problems experienced by the patients. Financial counseling was an important patient resource.DISCUSSION
This new clinical service has been well-integrated into its public urban hospital setting and constitutes an innovative model of health-care delivery for socio-economically challenged, culturally diverse adult cancer survivors.20.