German Respiratory Society guidelines for diagnosis and treatment of adults suffering from acute, subacute and chronic cough.

The present 2019 S2k consensus guideline of the German Respiratory Society was written for pneumologists - in contrast to the more general predecessor's S3 guidelines from 2004 to 2010 -, since 2014 the German College of General Practitioners and Family Physicians (DEGAM) published their own cough guidelines. The guidelines contain 48 recommendations agreed upon the consensus and 16 statements, which are explained in the background text in the following nine chapters: epidemiology, physiology, classification, acute, subacute or chronic cough, diagnostics and therapy; an extra chapter was dedicated to chronic idiopathic/refractory cough. Further emphasis of the guidelines is the physiology of cough in anticipation of the introduction of new drugs, as well as detailed treatment for cough triggered by affectations of the upper respiratory tract or gastroesophageal reflux. The guideline should provide the pneumologist with the latest knowledge for neighboring disciplines required for diagnosis and therapy of cough. The clinical chapters also contain a short summary, practical recommendations and a bibliography of their own. Three new simplified algorithms for acute, subacute and chronic cough, round off the diagnostics chapter.

[Guidelines of the German Respiratory Society for Diagnosis and Treatment of Adults Suffering from Acute, Subacute and Chronic Cough]. / Leitlinie der Deutschen Gesellschaft für Pneumologie und Beatmungsmedizin zur Diagnostik und Therapie von erwachsenen Patienten mit Husten.

The present 2019 S2k consensus guideline of the German Respiratory Society was written - in contrast to the predecessor more general S3 guidelines from 2004 and 2010 - for pneumologists, since 2014 the German College of General Practitioners and Family Physicians (DEGAM) published his own cough guidelines.The guideline contains 48 recommendations agreed by consensus and 16 statements, which are explained in the background text in the following nine chapters: epidemiology, physiology, classification, acute, subacute or chronic cough, diagnostics and therapy; an extra chapter was dedicated to chronic idiopathic cough. Further emphasis of the guideline is the physiology of cough in anticipation of the introduction of new drugs, as well as detailed treatises on cough triggered by affections in the upper respiratory tract or by gastroesophageal reflux. The guideline should provide the pneumologist with the latest knowledge from neighboring disciplines required for diagnosis and therapy of cough. The clinical chapters also contain a short summary, practical recommendations and a bibliography of their own. Three new, simplified algorithms for acute, subacute and chronic cough round off the Diagnostics chapter.

The 2018 ISDE achalasia guidelines

Achalasia is a relatively rare primary motor esophageal disorder, characterized by absence of relaxations of the lower esophageal sphincter and of peristalsis along the esophageal body. As a result, patients typically present with dysphagia, regurgitation and occasionally chest pain, pulmonary complication and malnutrition. New diagnostic methodologies and therapeutic techniques have been recently added to the armamentarium for treating achalasia. With the aim to offer clinicians and patients an up-to-date framework for making informed decisions on the management of this disease, the International Society for Diseases of the Esophagus Guidelines proposed and endorsed the Esophageal Achalasia Guidelines (I-GOAL). The guidelines were prepared according the Appraisal of Guidelines for Research and Evaluation (AGREE-REX) tool, accredited for guideline production by NICE UK. A systematic literature search was performed and the quality of evidence and the strength of recommendations were graded according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE). Given the relative rarity of this disease and the paucity of high-level evidence in the literature, this process was integrated with a three-step process of anonymous voting on each statement (DELPHI). Only statements with an approval rate >80% were accepted in the guidelines. Fifty-one experts from 11 countries and 3 representatives from patient support associations participated to the preparations of the guidelines. These guidelines deal specifically with the following achalasia issues: Diagnostic workup, Definition of the disease, Severity of presentation, Medical treatment, Botulinum Toxin injection, Pneumatic dilatation, POEM, Other endoscopic treatments, Laparoscopic myotomy, Definition of recurrence, Follow up and risk of cancer, Management of end stage achalasia, Treatment options for failure, Achalasia in children, Achalasia secondary to Chagas' disease.

Foregut symptoms, somatoform tendencies, and the selection of patients for antireflux surgery.

A large variety of foregut symptoms can occur in patients with gastroesophageal reflux disease (GERD), which can overlap with other disorders such as somatoform disorders and dyspepsia. Due to unclear diagnostic situations, these patients are often not adequately treated. The aim of this study was the evaluation of patients with foregut symptoms, referred for possible antireflux surgery, regarding their relationship with GERD and somatization tendencies based on control data from an unselected population. Symptom evaluation and somatization screening were initiated both in volunteers and in patients with foregut symptoms and GERD. Unselected volunteers from a village population were also evaluated by symptom analysis and for somatisation tendency. In addition, patients with foregut symptoms were diagnosed for GERD, and symptom analysis and psychodiagnostic evaluation were performed. There is no major significant difference in the symptom-spectrum in patients with foregut symptoms, whether they have a proven pathologic acid exposure from GERD or not. The probability for the risk of somatization was 5.6% in the unselected population of nonpatient volunteers (n = 267). In patients with foregut symptoms (n = 750), the probability for the presence of somatoform tendencies was approximately 20%, independent whether these patients had a documented GERD or a normal esophageal acid exposure, implicating further diagnostic work-up for the selection of patients for antireflux surgery. There is a remarkable symptom load and variety in patients with GERD, in patients with foregut symptoms, and in an unselected population of volunteers. There is no difference in the risk for somatization between patients with foregut symptoms and those with documented GERD. Therapeutic decision making especially prior to antireflux surgery requires an awareness of mental and emotional challenges.

Jackhammer esophagus: high-resolution manometry and therapeutic approach using peroral endoscopic myotomy (POEM).

We present the first report on peroral endoscopic myotomy (POEM) in the treatment of jackhammer esophagus. A 34-year-old female patient was newly diagnosed with a jackhammer esophagus. After failure of medical treatment, the patient underwent POEM procedure for myotomy of the spastic segment. Postoperatively, a mild emphysema and pneumothorax occurred that required drainage and antibiotic therapy until full recovery. Discharge was possible after 5 days. Six months later, she presented with recurrent but mild pain due to a remnant spastic segment proximal to the myotomy. Endoscopic balloon dilation was performed twice within 6 weeks with full symptomatic relief of pain and mild symptoms of dysphagia.

[Benign esophageal disorders. Gastroesophageal reflux disease, diffuse esophageal spasm, achalasia]. / Benigne Erkrankungen des Ösophagus. Refluxkrankheit, diffuser Ösophagusspasmus, Achalasie.

Gastroesophageal reflux disease (GERD) is the most frequent benign disorder of the upper gastrointestinal (GI) tract and other defined disease entities, such as achalasia and diffuse esophageal spasm, also belong to this group. In addition to surgical therapy, medicinal therapy also has an important role in all 3 of these disorders. Therefore, it is very important to follow precise indication criteria based on diagnostic evaluation and patient selection as well as to use an optimal operative technique.The therapeutic spectrum for achalasia varies from Botox injections and endoscopic dilatation to laparoscopic myotomy which achieves a success rate up to 90%.Patients with diffuse spasm suffer from severe dysphagia, thoracic pain and burning sensations and even respiratory problems. Surgical therapy consists of thoracoscopic long myotomy and in selective cases with persisting pain even esophagectomy and gastric pull-up.Therapeutic options for GERD predominantly involve conservative medicinal therapy with proton pump inhibitors and selective laparoscopic antireflux procedures. Minimally invasive techniques have led to a higher acceptance of surgical therapy. The two major procedures most frequently used are total Nissen fundoplication and posterior partial Toupet fundoplication.

Guidelines of the German Respiratory Society for diagnosis and treatment of adults suffering from acute or chronic cough.

The first set of German guidelines for diagnosis and treatment of patients suffering from acute or chronic cough was published in 2004. Scientific developments over the past five years necessitate an update. The purpose of this document is to assist in ascertaining underlying causes and treating cough, in order to eliminate or minimize impairments of patients' health. The guidelines aim to introduce scientifically founded, evidence-based steps for the diagnosis and treatment of cough and optimize cost-effectiveness. Recommendations are assessed through the GRADE system (The Grades of Recommendation, Assessment, Development and Evaluation). Cough as a symptom is categorized as either acute (lasting up to 8 weeks) or chronic (lasting more than 8 weeks) and attributed to distinct diseases. For acute and chronic cough the diagnostic algorithms are updated; cost effectiveness is also taken into account. Additionally, the most frequent diagnostic errors are highlighted. Finally, available therapeutic options are discussed.

[Gallbladder duplication--laparoscopic cholecystectomy 17 years after open cholecystectomy]. / Doppelt angelegte Gallenblase--Laparoskopische Cholezystektomie 17 Jahre nach konventioneller Cholezystektomie.

INTRODUCTION: Duplication of the gallbladder is a rare congenital anomaly. An incidence of 2.5:10,000 has been published in autoptic studies. METHODS: We carried out an analysis of the published case reports of the last 30 years to examine those cases in which an accessory gallbladder was pre- or intraoperatively detected or missed and to evaluate the implications of the time of diagnosis of the duplication on the surgical therapy. RESULTS: 28 case reports were analysed. If the duplication of the gallbladder was recognised pre-operatively or during operation, both gallbladders could be removed via laparoscopy in 80 % of the cases. Missing the second gallbladder can lead to persisting symptoms, postoperative complications as well as a recrudescence of the cholecystolithiasis with following reoperation. If a reoperation for a missed second gallbladder was necessary, only 14.3 % of these operations could be performed via laparoscopy. CASE REPORT: We report the case of a missed gall-bladder duplication with an acute cholecystitis causing a reoperation 17 years after the initial operation. A laparoscopic cholecystectomy was possible even though the initial operation was performed through open surgery. CONCLUSION: If recognised in preoperative examinations or during surgery a laparoscopic cholecystectomy of both gallbladders is possible in the majority of cases with duplicated gallbladder.

Ten-year outcome of laparoscopic antireflux surgery.

BACKGROUND: Reflux recurrence is the most common long-term complication of fundoplication. Its frequency was independent from the type of fundoplication in randomized studies. Results for different techniques of laparoscopic antireflux surgery were retrospectively evaluated after 10 years. METHODS: From 1992 to 1997, 120 patients had primary laparoscopic fundoplication with a "tailored approach" (type of wrap chosen according to esophageal peristalsis): 88 received a Nissen, 22 an anterior, and 10 a Toupet fundoplication. Follow-up of 87% of the patients included disease-related questions and the gastrointestinal quality-of-life index (GIQLI). RESULTS: Of the patients, 89% would select surgery again. Heartburn was reported by 30% of the patients. Regurgitations were noted from 15% of patients after a Nissen, 44% after anterior fundoplication, and 10% after a Toupet (p = 0.04). Twenty-eight percent were on acid-suppressive drugs again. Following Nissen fundoplication, proton pump inhibitors were less frequently used (p = 0.01) and on postoperative pH-metry reflux recurrence rate was lower (p = 0.04). The GIQLI was 110 +/- 24 without significant differences for the type of fundoplication. DISCUSSION: Ten years after laparoscopic fundoplication, overall outcome is good. A quarter of the patients are on acid-suppressive drugs. Nissen fundoplication appears to control reflux better than a partial fundoplication.

[Less reflux recurrence following Nissen fundoplication : results of laparoscopic antireflux surgery after 10 years]. / Weniger Refluxrezidive nach Nissen-Fundoplikation : 10-Jahres-Ergebnisse der laparoskopischen Antirefluxoperation.

BACKGROUND: Reflux recurrence is the most common long-term complication following fundoplication. Results for different techniques of laparoscopic antireflux surgery were retrospectively compared after 10 years. METHODS: From 1992 to 1997, the 120 patients studied had laparoscopic fundoplication with 'tailored' approaches: 88 Nissen, 22 anterior, and ten Toupet fundoplications. Follow-up of 87% of these patients included disease-related questions and the gastrointestinal quality of life index (GIQLI). RESULTS: Of the patients, 89% would select surgery again. Regurgitations after fundoplication were noted from 15% of patients after Nissen, 44% after anterior, and 10% after Toupet types (P=0.04). Twenty-eight percent were on acid suppression therapy. Proton pump inhibitors were used less frequently following Nissen fundoplication (P=0.01). The GIQLI score was 110+/-24 without significant differences for type of fundoplication. DISCUSSION: Overall results are satisfactory after 10 years of experience with fundoplication. Total fundoplication appears to control reflux better than partial fundoplication.

Importance of duodenogastric reflux in gastro-oesophageal reflux disease.

BACKGROUND: Bile in the oesophagus occurs frequently in patients with gastro-oesophageal reflux disease (GORD) and has been linked to Barrett's metaplasia and cancer. Although duodenogastric reflux is a prerequisite for bile in the oesophagus, little is known about its importance in GORD. METHODS: Some 341 patients with GORD were assessed by simultaneous 24-h gastric and oesophageal bilirubin monitoring. Definitions of increased bilirubin exposure were based on the 95th percentiles in healthy volunteers. The relationship between gastric and oesophageal bilirubin exposure and the correlation with disease severity were analysed. RESULTS: Of the 341 patients with GORD, 130 (38.1 per cent) had increased gastric and 173 (50.7 per cent) had increased oesophageal bilirubin exposure. Of the 173 patients with bile in the oesophagus, 89 (51.4 per cent) had normal and 84 (48.6 per cent) had increased gastric bilirubin exposure. Of these 84 patients, 75 (89 per cent) had oesophagitis or Barrett's oesophagus (P = 0.003). These effects were mainly related to differences in supine reflux. CONCLUSION: Bile in the oesophagus originates from either normal or increased gastric bilirubin exposure. Patients with increased duodenogastric reflux are more likely to have oesophagitis or Barrett's oesophagus. These findings highlight the role of duodenogastric reflux as an additional factor in the pathogenesis of GORD.

[Conventional and minimally invasive surgical methods for gastroesophageal reflux]. / Konventionelle und minimal-invasive chirurgische Therapie der gastroösophagealen Refluxkrankheit.

UNLABELLED: The introduction of minimally invasive techniques has had great influence on the indication and surgical therapy for gastroesophageal reflux disease. This analysis is an overview of the current evidence-based status and a critical reprisal of open and laparoscopic antireflux surgery. RESULTS: The analysis of randomized trials showed an advantage for patients after laparoscopy for total and partial fundoplication because of reduced morbidity, shorter postoperative hospitalization due to faster recovery, and significantly fewer scar and wound problems. The functional results of open and laparoscopic techniques were similar. Five-year follow-up results for the latter showed effective reflux control in at least 85% of patients. Randomized trials regarding technical variations did not show an advantage for division of the short gastric vessel. A bougie for the cardia calibration can prevent postoperative dysphagia after fundoplication.

[Usefulness of anal endosonography in the assessment of fistula-in-ano]. / Wertigkeit der analen Endosonographie in der Diagnostik anorektaler Fisteln.

AIM: The purpose of the present study was to define the diagnostic value of anal endosonography in the diagnostic work-up of fistula-in-ano. METHODS: A retrospective study was carried out on 191 consecutive patients (m: 121; f: 70; mean age: 44.0 +/- 12.5 years; range: 0.5-77 years) who were diagnosed to suffer from fistula-in-ano by performing anal endosonography in an outpatient setting. All images were obtained with a Combison 310A ultrasound scanner (Kretz GmbH, Zipf, Osterreich) and 5-Mhz and 7.5-MHz transducer. 131 patients underwent surgery. According to the endosonographic findings fistulas were classified as transsphincteric in 44 %, intersphincteric in 22 %, subanodermal in 16 %, anovaginal in 8 %, suprasphincteric in 5 %, extrasphincteric in 1 % and others in 4 %. RESULTS: In 125 patients (95 %) the preoperative diagnosis was confirmed intraoperatively. This cohort included 12 patients with a complex fistula system. In only 6 patients the preoperative ultrasound finding was misinterpreted. CONCLUSION: In conclusion this study has shown that anal endosonography is a useful and reliable tool in the preoperative evaluation of uncomplicated and complicated anorectal fistulas.

Endoscopic ultrasound-guided transrectal aspiration of pelvic fluid collections.

BACKGROUND: The aim of this study was to evaluate the feasibility, safety, and diagnostic accuracy of endorectal ultrasound-guided aspiration and drainage of pelvic fluid collections. METHODS: All patients who underwent endorectal ultrasound-guided aspiration and/or drainage of pelvic fluid collections were included in this prospective study. Patients were prepared using bowel lavage and a single-dose antibiotic combination. The procedure was carried out in the lithotomy position usually without sedation. All aspirates were examined microbiologically and/or cytologically. RESULTS: Twenty-nine patients [18 females and 11 males; median age, 67 years (range, 18-79)] underwent 33 endosonographic controlled aspirations. No procedure-related complications were encountered. In 22 cases (76%) the lesions were encountered following a surgical procedure. Fluid amounts varied between 5 and 750 ml. Fluids were sterile in 14 cases (42%). These fluid collections were hematomas, seromas, peritoneal cysts, and a mucocele. Microorganisms were found in the remaining 19 aspirations (58%), i.e., abscesses (n = 16) and infected hematomas (n = 3). A transrectal (n = 14) or transvaginal (n = 2) drainage catheter was placed in 16 patients under endosonographic guidance. Only two patients required a subsequent laparotomy for definitive treatment of their septic focus, whereas all other patients could be treated successfully by this conservative approach. CONCLUSION: Endoscopic ultrasound-guided transrectal aspiration and drainage of pelvic fluid collections is a safe method with a favorable outcome because it avoids unnecessary operations in selected patients.

[Perineal hernia: an undescribed complication following operative repair of vault vaginal prolaps]. / Ausgedehnte perineale Hernie bei Zustand nach wiederholter operativer Therapie eines Vaginalprolapses.

The presented case reports the treatment of a 80-year-old V gravida IV para suffering from a large perineal hernia and rectocele after vaginal hysterectomy and subsequently performed threefold colpocleisis due to recurrent vault vaginal prolaps.[nl]Since perioperative morbidity and mortality of geriatric patients differ not significantly from thoses of younger women age should not be used as an argument to withhold elderly organ preserving operative strategies with low recurrence rates.

[Tumescent local anesthesia in proctologic surgery]. / Tumeszenz-Lokalanästhesie bei proktologischen Eingriffen.

INTRODUCTION: Tumescent local anesthesia (TLA) was introduced to facilitate liposuction and other procedures mainly in plastic surgery. The aim of our study was to evaluate if this new technique can also be safely applied in proctologic surgery. METHODS: The following 50 proctologic procedures were performed using TLA as day surgery cases: perianal vein thrombectomy (n=15), subanodermal fistula resection (n=7), anal polyp resection (n=7), fissurectomy ( n=6), perianal abscess revision (n=6), excision of anal skin tags (n=3), hemorrhoidectomy for thrombosed piles (n=3), intersphincteric fistula extirpation (n=1), pilonidal sinus (n=1), and perianal tumor excision (n=1). The subcutaneously infused solution contained 200 ml of Ringer's solution, 50 ml of 2% Mepivacain, and 2.5 ml of epinephrine diluted 1:10,000. RESULTS: During an average application time of 14.3+/-4.9 min, a mean of 93.1+/-40.7 ml tumescent solution was infused. This dosage resulted in complete pain relief after 18.3+/-5.0 min. Local anesthesia was maintained up to 14 h postoperatively, with a mean duration of 6.7+/-1.9 h. Two patients developed moderate hematomas which required no further treatment. CONCLUSIONS: Our pilot study demonstrates that slow infusion tumescent local anesthesia can be widely and safely applied in proctologic surgery and enables the performance of these procedures on an outpatient basis.

[Which functional diagnostic tools do German coloproctologists favour?]. / Praktischer Stellenwert der Funktionsdiagnostik in der Koloproktologie.

AIM: We tried to evaluate the role of anorectal functional diagnostic tools according to the judgement of German coloproctologists. METHOD: Questionnaires concerning accuracy of different diagnostic tests were sent to 585 physicians specialized in coloproctology. RESULTS: 261 (44.6 %) completed forms were returned. An analysis of the answers revealed that endorectal sonography is widely (73 %) regarded as useful and reliable diagnostic tool. Though manometry is still frequently used, only 50.5 % of the coloproctologists made their decision concerning the further treatment depending on the results of this method. Other radiologic methods as defecography and colon transit time are still regularly performed, though video-defecography is not accepted by most coloproctologists. Neurological investigations as pudendal nerve terminal latency, surface-EMG and needle-EMG are exclusively applied in specialized departments. DISCUSSION: Regarding the variety of diagnostic tools and its different appraisal a consensus should be defined. The usefulness of neurological examination techniques needs to be clarified before their performance can be recommended for a wide-spread routine work up.