Incidence and risk factors of symptomatic Petersen's hernias in bariatric and upper gastrointestinal surgery: a systematic review and meta-analysis.

PURPOSE: The aim of this study was to investigate the actual incidence of symptomatic Petersen's hernias (PH) as well as identify risk factors for their occurrence. METHODS: Search was performed in Medline (via PubMed), Web of Science, and Cochrane library, using the keywords "Petersen Or Petersen's AND hernia" and "Internal hernia." Only studies of symptomatic PH were eligible. Fifty-three studies matched our criteria and were included. Risk of bias for each study was independently assessed using the checklist modification by Hoy et al. Analysis was performed using random-effects models, with subsequent subgroup analyses. RESULTS: A total of 81,701 patients were included. Mean time interval from index operation to PH diagnosis was 17.8 months. Total small bowel obstruction (SBO) events at Petersen's site were 737 (0.7%). SBO incidence was significantly higher in patients without defect closure (1.2% vs 0.3%, p < 0.01), but was not significantly affected by anastomosis fashion (retrocolic 0.7% vs antecolic 0.8%, p = 0.99). SBO incidence was also not significantly affected by the surgical approach (laparoscopic = 0.7% vs open = 0.1%, p = 0.18). However, retrocolic anastomosis was found to be associated with marginally, but not significantly, increased SBO rate in patients with Petersen's space closure, compared with the antecolic anastomosis (p = 0.09). CONCLUSION: PH development may occur after any gastric operation with gastrojejunal anastomosis. Contrary to anastomosis fashion and surgical approach, defect closure was demonstrated to significantly reduce SBO incidence. Limitations of this study may include the high heterogeneity and the possible publication bias across the included studies.

Outpatient Hysterectomy versus Inpatient Hysterectomy: A Systematic Review and Meta-analysis.

OBJECTIVE: The aim was to investigate whether outpatient hysterectomy (OH) has benefits when compared with inpatient hysterectomy (IH) regarding postoperative complications, readmissions, operative outcomes, cost, and patient quality of life. DATA SOURCES: A systematic search for studies comparing OH with IH was conducted through PubMed, SAGE, and Scopus from January 2010 to March 2020, without limitations regarding language and study design. METHODS OF STUDY SELECTION: Studies reporting on the differences between same-day discharge and overnight stay after hysterectomy were included. The study outcomes were overall complication rate, type of complication, readmission after discharge, surgery duration, estimated blood loss, payer savings, hospital savings, and health-related quality of life (HrQoL). Median and range are used to describe non-normal data, while mean ± SD and confidence interval are used to descibe data with normal distribution. A meta-analysis with sensitivity analysis and subgroup analyses was performed. TABULATION, INTEGRATION, AND RESULTS: Eight studies published between 2011 and 2019 with 104,466 patients who underwent hysterectomy were included in this systematic review and meta-analysis. All included studies except 1 were found to have a high risk of bias. OH in comparison with IH had a lower overall complication rate (odds ratio [OR] 0.70; 95% confidence interval [CI], 0.60-0.82) and lower rates of wound infection (OR 0.60; 95% CI, 0.43-0.84), urinary tract infection (OR 0.64; 95% CI, 0.52-0.78), need for transfusion (OR 0.36; 95% CI, 0.22-0.59), sepsis (OR 0.33; 95% CI, 0.17-0.64), uncontrolled pain (OR 0.79; 95% CI, 0.66-0.95), and bleeding requiring medical attention (OR 0.82; 95% CI, 0.73-0.94). In addition, patients who underwent OH had a lower readmission rate (OR 0.81; 95% CI, 0.75-0.87), surgery duration (standardized mean difference -0.35; 95% CI, -0.61 to -0.08), and estimated blood loss (standardized mean difference -0.63; 95% CI, -0.93 to -0.33) than those who underwent IH. A qualitative analysis found that OH had a poorer patient HrQoL and a lower cost for the hospital as well as the payer. CONCLUSION: OHs present fewer complications and have a lower readmission rate and estimated blood loss as well as a shorter surgery duration than IHs. OHs also have a cost benefit in comparison with IHs. But patients seem to have a worse HrQoL in the first postoperative week after OH. The high risk of bias of the included studies indicates that well-designed clinical trials and standardization of surgical complication reporting are essential to better address this issue.

Diagnostic Performance of Pancreatic Cytology with the Papanicolaou Society of Cytopathology System: A Systematic Review, before Shifting into the Upcoming WHO International System.

The Papanicolaou Society of Cytopathology (PSC) reporting system classifies pancreatobiliary samples into six categories (I-VI), providing guidance for personalized management. As the World Health Organization (WHO) has been preparing an updated reporting system for pancreatobiliary cytopathology, this systematic review aimed to evaluate the risk of malignancy (ROM) of each PSC category, also the sensitivity and specificity of pancreatic FNA cytology using the current PSC system. Five databases were investigated with a predefined search algorithm. Inclusion and exclusion criteria were applied to select the eligible studies for subsequent data extraction. A study quality assessment was also performed. Eight studies were included in the qualitative analysis. The ROM of the PSC categories I, II, III, IV, V, VI were in the ranges of 8-50%, 0-40%, 28-100%, 0-31%, 82-100%, and 97-100%, respectively. Notably, the ROM IVB ("neoplastic-benign") subcategory showed a 0% ROM. Four of the included studies reported separately the ROMs for the IVO subcategory ("neoplastic-other"; its overall ROM ranged from 0 to 34%) with low (LGA) and high-grade atypia (HGA). ROM for LGA ranged from 4.3 to 19%, whereas ROM for HGA from 64 to 95.2%. When the subcategory IVO with HGA was considered as cytologically positive, together with the categories V and VI, there was a higher sensitivity of pancreatic cytology, at minimal expense of the specificity. Evidence suggests the proposed WHO international system changes-shifting the IVB entities into the "benign/negative for malignancy" category and establishing two new categories, the "pancreatic neoplasm, low-risk/grade" and "pancreatic neoplasm, high-risk/grade"-could stratify pancreatic neoplasms more effectively than the current PSC system.

Hybrid Laparoscopic and Endoscopic Partial Gastrectomy for Ulcerated GIST: Surgical Technique with Video.

INTRODUCTION: Gastrointestinal stromal tumors of the gastric cardia pose several technical difficulties to their resection because they are difficult to access, and they must be removed respecting oncological principles, and due to their proximity to the gastroesophageal junction, excessive removal of gastric tissue may cause deformation with gastric dysfunction, or gastroesophageal reflux. METHOD: Hybrid laparoscopic endoscopic partial gastrectomy is a technique that avoids these problems making use of three principles. First the tumor is pinpointed, marked, and resected under combined laparoscopic and endoscopic control to assure that it is completely resected without compromising the structure of the gastroesophageal junction. Second, a dissection of the abdominal esophagus is performed as during a Nissen fundoplication in order to increase the distance between the tumor and the gastroesophageal junction. Third the lesser curvature of the stomach is dissected, and the terminal branches of the left gastric vessels are controlled from the gastric incisura to the gastroesophageal junction exposing the lesser curvature and the posterior wall of the stomach. The tumor is resected under endoscopic control, tangentially with an endoscopic stapler applied parallel to the lesser curvature similarly to a sleeve partial gastrectomy. RESULTS: No abdominal drain is used, and a nasogastric tube is left in place for the first 24 h after surgery. The patient receives fluid diet on the first postoperative day, is discharged on the second postoperative day, and is followed up in the outpatient department for a week. CONCLUSION: In this technical paper, the procedure is described in detail and demonstrated with video.

Gastric ischemic preconditioning may reduce the incidence and severity of anastomotic leakage after οesophagectomy: a systematic review and meta-analysis.

Anastomotic leakage after esophagectomy is a severe and life-threatening complication. Gastric ischemic preconditioning is a strategy for the improvement of anastomotic healing. Aim of this systematic review and meta-analysis is to investigate the impact of gastric ischemic preconditioning on postoperative morbidity. A systematic literature search was performed to identify studies comparing patients undergoing gastric ischemic preconditioning before esophagectomy with nonpreconditioned patients. Meta-analysis was conducted for the overall incidence of anastomotic leakage, severe anastomotic leakage, anastomotic stricture, postoperative morbidity, and mortality. Mantel-Haenszel odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. Subgroup analyses were performed concerning preconditioning technique, the interval between preconditioning and surgery and the extent of preconditioning. Fifteen cohort studies were identified. Gastric preconditioning was associated with reduced overall incidence of anastomotic leakage (OR 0.73; 95% CI, 0.53-1.0; P = 0.050) and severe anastomotic leakage (OR 0.27; 95% CI, 0.14-0.50; P < 0.010), but not with anastomotic stricture (OR 1.18; 95% CI 0.38 to 3.66; P = 0.780), major postoperative morbidity (OR 1.03; 95% CI 0.45 to 2.36; P = 0.940) or mortality (OR 0.69; 95% CI 0.39 to 1,23; P = 0.210). Subgroup analyses did not identify any differences between embolization and ligation while increasing the interval between preconditioning and esophagectomy as well as the extent of preconditioning might be beneficial. Gastric ischemic preconditioning may be associated with a reduced incidence of overall and severe anastomotic leakage. Randomized studies are necessary to further evaluate its impact on leakage, refine the technique and define patient populations that will benefit the most.

Arc of Bühler: the surgical significance of a rare anatomical variation.

PURPOSE: The arc of Bühler, an anastomotic vessel between celiac artery and superior mesenteric artery, is a rare anatomic variation. Various radiologic and surgical procedures can be affected by its existence. We aim to review all available information and identify possible clinical implications. METHODS: A systematic review was conducted in accordance to the Preferred Reporting Items for Systematic reviews and Meta-Analysis (PRISMA) guidelines. The following terms were utilized in various combinations: "Bühler", "arc of Bühler", "visceral aneurysm", "pancreaticoduodenal arcades". RESULTS: Only 53 cases have been described until today in the literature. The arc of Bühler enhances collateral circulation between celiac artery and superior mesenteric artery alongside with pancreaticoduodenal arcades and dorsal pancreatic artery. Computerized tomography and angiography are the main studies used for its detection and evaluation. Aneurysms of Bühler's arc have been rarely described and seem to share common pathophysiological mechanisms with aneurysms of the pancreaticoduodenal arcades. CONCLUSIONS: Various radiologic and surgical procedures such as embolization or pancreaticoduodenectomy are potentially affected by its existence.

Augmented Reality Guidance for the Resection of Missing Colorectal Liver Metastases: An Initial Experience.

BACKGROUND: Modern chemotherapy achieves the shrinking of colorectal cancer liver metastases (CRLM) to such extent that they may disappear from radiological imaging. Disappearing CRLM rarely represents a complete pathological remission and have an important risk of recurrence. Augmented reality (AR) consists in the fusion of real-time patient images with a computer-generated 3D virtual patient model created from pre-operative medical imaging. The aim of this prospective pilot study is to investigate the potential of AR navigation as a tool to help locate and surgically resect missing CRLM. METHODS: A 3D virtual anatomical model was created from thoracoabdominal CT-scans using customary software (VR RENDER(®), IRCAD). The virtual model was superimposed to the operative field using an Exoscope (VITOM(®), Karl Storz, Tüttlingen, Germany). Virtual and real images were manually registered in real-time using a video mixer, based on external anatomical landmarks with an estimated accuracy of 5 mm. This modality was tested in three patients, with four missing CRLM that had sizes from 12 to 24 mm, undergoing laparotomy after receiving pre-operative oxaliplatin-based chemotherapy. RESULTS: AR display and fine registration was performed within 6 min. AR helped detect all four missing CRLM, and guided their resection. In all cases the planned security margin of 1 cm was clear and resections were confirmed to be R0 by pathology. There was no postoperative major morbidity or mortality. No local recurrence occurred in the follow-up period of 6-22 months. CONCLUSIONS: This initial experience suggests that AR may be a helpful navigation tool for the resection of missing CRLM.

Adhesions and Healing of Intestinal Anastomoses: The Effect of Anti-Adhesion Barriers.

Background Postoperative adhesions are the result of aberrant peritoneal healing. As they are the leading cause of postoperative bowel obstruction, anti-adherence barriers are advocated for their prevention. This study looks into the effect of these biomaterials on the healing of intestinal anastomoses. Materials and Methods Thirty-three New Zealand White rabbits underwent laparotomy, transection of the terminal ileum, and creation of an end-to-end anastomosis. Animals were randomized into 3 groups: the Control group (n = 11); the Icodextrin group, receiving icodextrin 4% intraperitonealy (n = 11); and the HA/CMC group, having the anastomosis wrapped with a hyaluronic acid/carboxymethylcellulose film (n = 11). All animals were sacrificed on the seventh postoperative day. Macroscopic adhesions were graded and anastomotic strength was tested by the burst pressure. Histological healing was assessed in a semiquantitative way for the presence of ulceration, reepithelization, granulation tissue, inflammation, eosinophilic infiltration, serosal inflammation, and microscopic adhesions. Univariate and multivariate analysis was used. Results are given as medians with interquartile range. Results The median adhesion scores were the following: Control 1 (0-3), Icodextrin 0 (0-1), HA/CMC 0 (0-0), P = .017. The burst pressure did not differ between the groups; however, all except one bowel segments tested burst away from the anastomosis. The macroscopic and histological anastomotic healing was comparable in all 3 groups. A poor histological anastomotic healing score was associated with a higher adhesion grade (odds ratio = 1.92; 95% confidence interval = 1.06-3.47; P = .032). Conclusion Adhesion formation was inhibited by the materials tested without direct detrimental effects on anastomotic healing. Poor anastomotic healing provokes adhesions even in the presence of anti-adhesion barriers.

Robotic spleen preserving distal pancreatectomy: how I do it (with video).

Laparoscopic hepatobiliary surgery, although technically demanding, gains popularity due to the patient benefits of a mini-invasive approach. Laparoscopic distal pancreatectomy is a technically feasible and reproducible operation that doesn't require complex digestive reconstruction. It requires advanced laparoscopic skill for vascular dissection and control. Due to the absence of trials proving its oncological results it is mainly indicated for benign or borderline tumours of the pancreatic body and tail. Since for these tumours there is no indication for a lymph node dissection, there are benefits for the patient if the spleen is preserved. There is some evidence that robotic assistance facilitates the procedure and makes it accessible to surgeons diminishing the necessity of advanced laparoscopic skills. In this technical multimedia article, we present our method for a robotic mini-invasive spleen preserving distal pancreatectomy with preservation of the splenic vessels. The technique is presented in a stepwise approach with an accompanying video. We believe that the use of the Da Vinci robotic platform facilitates this demanding procedure.

Burnout and motivation to study medicine among students during the COVID-19 pandemic.

Aim: To investigate medical students' burnout and motivation levels in each of the six years of their studies during the COVID-19 pandemic and identify independent predictors of burnout and motivation. Methods: An anonymous cross-sectional survey was sent to the students of all six years within our school. Burnout was measured with the adapted Oldenburg Burnout Inventory questionnaire (OLBI-S) and motivation with the updated Strength of Motivation for Medical School (SMMS-R) questionnaire. Univariate analysis was performed with the Kruskal-Wallis test and Spearman's correlation, while multivariable analysis with linear regression models. Results: A total of 333 medical students (52% of student body) responded. Higher burnout levels correlated with lower motivation to study medicine (rho = -0.30, p < 0.001). Burnout levels differed between the six years of medical studies, peaking in years two and four whereas being the lowest in year one (p = 0.01). Motivation levels differed significantly as well, peaking in years one and four whereas being the lowest in years five and six (p = 0.012). In the multivariable linear regression models, being a female (b = 2.22, p = 0.016), studying in the fourth year vs. first year (b = 2.54, p = 0.049), having a perceived beginner/intermediate vs. advanced/expert technology level (b = 2.05, p = 0.032) and a perceived poor school support system (b = 6.35, p < 0.001) were independently associated with higher burnout levels. Furthermore, studying in the fifth year vs. first year (b = -5.17, p = 0.019) and a perceived poor school support system (b = -3.09, p = 0.01) were independently associated with a reduced motivation to study medicine. Conclusion: Our study highlighted potential areas for intervention to decrease the rate of burnout and low motivation among medical students. However, further research is needed to unravel the full effect of the pandemic on medical students.

A Standardized Workshop for Peer-Teaching Simple Interrupted Sutures to Medical Students: Analysis of the Student Factors That Affect Outcomes.

The aim of this study is to demonstrate whether the implementation of standardized Peer Assisted Learning (PAL) suturing workshops can aid the attainment of a technically competent interrupted suturing technique by medical students.The European University Cyprus (EUC) Division of Surgery and the students of the EUC Surgery Club compiled a standardized 1 hour and 15 minutes suturing workshop. During a one-week period 14 peer-teacher school of medicine students trained 147 fellow students. At the end of each workshop the students were assessed for the learning outcome of simple interrupted suturing with instruments by two peer-teachers, with the use of a standardized scoring rubric. The workshop primary outcomes were the rubric score and the time to complete a suture. These were correlated to student characteristics such as sex, year of studies, prior experience in suturing, previous participation in a similar workshop, previous training at home or in a hospital, and an interest in pursuing a surgical career. Univariate and multivariate statistical analysis was performed.Statistical analysis showed that gender and previous suturing experience did not impact the rubric score of students, nor the time required. The student year of studies, having recently passed the course of General Surgery and having interest to pursue a surgical specialization positively affected the students' score.Surgical peer teaching provided an effective method of teaching of the simple interrupted suturing technique. Interest in surgery, previous workshop experience and having recently completed the general surgery module helped students score higher in the assessment.

Robotic left pancreatectomy for pancreatic solid pseudopapillary tumor.

BACKGROUND: Solid pseudopapillary pancreatic tumors of pancreas are a rare entity, seen most often in females in their second or third decades. Although previously believed to be benign, this tumor is currently considered a low-grade malignant epithelial neoplasm with low metastatic rate and high overall survival.1,2 Its resection could be performed by robotic technique with respect to oncological principles to avoid tumor cell dissemination.3 METHODS: In this multimedia article, we present a 28-year-old female with a history of hyperthyroidism who underwent a computed tomography (CT) scan because of a persistent high C-reactive protein level following caesarean section. This CT scan revealed a 7-cm cystic lesion of the pancreatic tail. The serum tumor marker CA 19-9 was normal. Further investigation with an magnetic resonance imaging (MRI) scan showed that the lesion was macrocystic with internal septas compatible with a solid pseudopapillary neoplasm.4 The patient was treated with robotic distal splenopanceatectomy (video). RESULTS: The operative time was 5 h with an estimated blood loss of 250 mL. No blood transfusion was necessary. The postoperative period was uneventful, and she was discharged on postoperative day 8. The histological finding revealed a solid pseudopapillary tumor of the pancreas pT2pN0 (0/14 lymph nodes removed). There was no evidence of clinical, biological, and radiological pancreatic fistula, and a control CT scan on postoperative day 8 did not show any abdominal fluid collection. The patient's 1 month follow-up was normal. DISCUSSION: The robotic distal splenopancreatectomy is a procedure that offers some technical and oncological advantages over the already described minimally invasive techniques for distal pancreatic tumors.5,6 These advantages are mainly due to the stability of the operative field, to the 3D and magnified vision, and to the articulated robotic arms.7-9 The 3D representation and the stability of the operative field facilitate the performance of operative steps, as the creation of the retropancreatic tunnel and vascular identification. Moreover, the robotic articulated arms permit a superior handling of vascular structures, allowing a fine dissection that is extremely useful during lymphadenectomy. Articulated instruments easily achieve the correct rotation axis, thus minimizing peri-pancreatic tissue retraction and manipulation of the pancreatic gland. This smooth and no-touch technique in theory minimizes the risk of pancreatic capsule rupture as well as tumor cell dissemination, respecting oncological surgical standards. However, robotic surgery needs an adequate learning curve, especially concerning the installation and the lack of force feedback. CONCLUSION: The robotic distal pancreatectomy is a possible minimally invasive technique for patients with solid pseudopapillary pancreatic tumors. It presents some advantages over the laparoscopic approach. Nevertheless its oncological indications are yet to be defined.10.

Hinchey Ia acute diverticulitis with isolated pericolic air on CT imaging; to operate or not? A systematic review.

BACKGROUND: Colonic diverticulitis is one of the most common gastrointestinal pathologies and its prevalence increases with the aging of the population in Western countries. Approximately 15% of patients with Hinchey Ia acute diverticulitis present with concomitant isolated pericolic air bubbles that denote intestinal perforation and thus prompting a more "aggressive" treatment attitude, including emergency surgery, despite the absence of evidence-based indications. This study is trying to delineate whether this approach is justified or whether a conservative treatment would suffice for this group of patients. MATERIALS AND METHODS: PubMed and Cochrane CENTRAL databases were systematically searched in order to identify all studies that reported the need for emergency surgery and for percutaneous drainage in patients presenting with Hinchey Ia colonic diverticulitis with extraluminal pericolic gas on CT imaging who were initially treated conservatively. The last database search was performed on November 29, 2019 and no language or study type restriction criteria were applied. The Newcastle-Ottawa scale was used to assess the risk of bias of selected studies. RESULTS: Nine observational cohort studies with 411 patients reported the need for emergency surgery, with a pooled rate of 5.1%. Among these studies, four studies comprising 165 patients reported the need for percutaneous drainage separately with a pooled rate of 1.2%. CONCLUSION: Non-operative management of Hinchey Ia acute diverticulitis with isolated pericolic air is feasible and safe with a success rate of 94.9%. Abscess formation requiring percutaneous drainage is present in only 1.2% of patients, thus rendering the conservative initial treatment of these patients justified. Nevertheless, low quality of included studies indicates further research to validate the outcomes of this review.

The learning experience for endoscopic submucosal dissection in a non-academic western hospital: a single operator's untutored, prevalence-based approach.

BACKGROUND: Studies of learning experience in endoscopic submucosal dissection (ESD) commonly originate from the East. Little is known about the performance of ESD in low-volume western centers. Furthermore, it is unclear whether ESD can be self-taught without a tutored approach. METHODS: We performed a retrospective analysis of consecutive ESDs, performed in an untutored prevalence-based fashion by a single operator at a private Greek hospital from 2016-2020. Out of 60 lesions, standard ESD was applied for 54 and enucleation for 6; 41 were mucosal and 19 submucosal; 3 esophageal, 24 gastric, one duodenal, 12 colonic, and 20 rectal. RESULTS: Pathology revealed carcinoma (n=14), neuroendocrine tumor (n=7), precancerous lesion (n=27), or other submucosal tumors (n=12). The rates of en bloc and R0 resection were 98% and 91%, respectively. The median resection speed was <3 cm2/h for the first 20 cases, but improved progressively to ≥9 cm2/h after 40 cases. Two patients underwent laparoscopic surgery for colonic perforation, and one received a blood transfusion because of delayed bleeding (serious adverse event rate: 5%). No deaths occurred. The median hospital stay was 1.3 days. Variables associated with improvement in ESD speed during the second period of the study were the application of countertraction and the experience acquired through other endosurgical techniques. CONCLUSIONS: ESD was safe and effective in a low-volume center, with an acceptable adverse events rate. At least 40 mixed cases were needed to achieve a high resection speed. Additive experience gained through other endosurgical procedures probably contributed to the improvement in performance.

LINX® reflux management system to bridge the "treatment gap" in gastroesophageal reflux disease: A systematic review of 35 studies.

BACKGROUND: Gastroesophageal reflux disease (GERD) occurs when the reflux of stomach contents causes troublesome symptoms and/or complications. When medical therapy is insufficient, surgical therapy is indicated and, until now, Laparoscopic fundoplication (LF) constitutes the gold-standard method. However, magnetic sphincter augmentation (MSA) using the LINX® Reflux Management System has recently emerged and disputes the standard therapeutic approach. AIM: To investigate the device's safety and efficacy in resolving GERD symptoms. METHODS: This is a systematic review conducted in accordance to the PRISMA guidelines. We searched MEDLINE, Clinicaltrials.gov, EMBASE, Cochrane Central Register of Controlled Trials CENTRAL databases from inception until September 2019. RESULTS: Overall, 35 studies with a total number of 2511 MSA patients were included and analyzed. Post-operative proton-pump inhibitor (PPI) cessation rates reached 100%, with less bloating symptoms and a better ability to belch or vomit in comparison to LF. Special patient groups (e.g., bariatric or large hiatal-hernias) had promising results too. The most common postoperative complication was dysphagia ranging between 6% and 83%. Dilation due to dysphagia occurred in 8% of patients with typical inclusion criteria. Esophageal erosion may occur in up to 0.03% of patients. Furthermore, a recent trial indicated MSA as an efficient alternative to double-dose PPIs in moderate-to-severe GERD. CONCLUSION: The findings of our review suggest that MSA has the potential to bridge the treatment gap between maxed-out medical treatment and LF. However, further studies with longer follow-up are needed for a better elucidation of these results.

New insights into irritable bowel syndrome: from pathophysiology to treatment.

Irritable bowel syndrome (IBS) is the most common reason to visit a gastroenterologist. IBS was believed to be a functional disease, but many possible pathophysiologic mechanisms can now explain the symptoms. IBS patients are classified into subtypes according to their predominant bowel habit, based on the Rome IV criteria. These include diarrhea-predominant and constipation-predominant IBS, as well as the mixed type, a combination of the two. Usually, IBS treatment is based on the predominant symptoms, with many options for each subtype. A new promising treatment option, fecal microbiota transplantation, seems to have beneficial effects on IBS. However, treating the pathophysiological causative agent responsible for the symptoms is an emerging approach. Therefore, before the appropriate therapeutic option is chosen for treating IBS, a clinical evaluation of its pathophysiology should be performed.

Adrenal Aging and Its Implications on Stress Responsiveness in Humans.

Normal aging results in subtle changes both in ACTH and cortisol secretion. Most notable is the general increase in mean daily serum cortisol levels in the elderly, without a noteworthy alteration in the normal circadian rhythm pattern. Glucocorticoid excess seen in the elderly population can have serious consequences in both the structural and functional integrity of various key areas in the brain, including the hippocampus, amygdala, prefrontal cortex, with consequent impairment in normal memory, cognitive function, and sleep cycles. The chronically elevated glucocorticoid levels also impinge on the normal stress response in the elderly, leading to an impaired ability to recover from stressful stimuli. In addition to the effects on the brain, glucocorticoid excess is associated with other age-related changes, including loss of muscle mass, hypertension, osteopenia, visceral obesity, and diabetes, among others. In contrast to the increase in glucocorticoid levels, other adrenocortical hormones, particularly serum aldosterone and DHEA (the precursor to androgens and estrogens) show significant decreases in the elderly. The underlying mechanisms for their decrease remain unclear. While the adrenomedullary hormone, norephinephrine, shows an increase in plasma levels, associated with a decrease in clearance, no notable changes observed in plasma epinephrine levels in the elderly. The multiplicity and complexity of the adrenal hormone changes observed throughout the normal aging process, suggests that age-related alterations in cellular growth, differentiation, and senescence specific to the adrenal gland must also be considered.