[Endoscopic Ultrasound Drainage of the Gallbladder in Acute Cholecystitis in Patients at High Surgical Risk]. / Endosonografische Drainage der Gallenblase wegen akuter Cholezystitis bei Patienten mit hohem Operationsrisiko.

BACKGROUND: The standard treatment for acute cholecystitis is laparoscopic cholecystectomy. Alternative procedures are used for patients at high surgical risk. Percutaneous drainage is widely available. The alternative of transpapillary drainage of the gallbladder via the ductus cysticus has only limited prospects of success. With the widespread use of interventional endoscopic ultrasound and the development of new stent systems, endoscopic ultrasound gallbladder drainage has proven to be a safe and reliable procedure. MATERIAL AND METHOD: We retrospectively report on our experiences in 11 consecutive patients with endoscopic ultrasound gallbladder drainage in acute cholecystitis between December 2018 and January 2021. RESULTS: 11 patients with acute cholecystitis with a mean age of 84.5 years (70-95 years) are reported. All patients had severe general comorbidities or advanced abdominal tumours or a combination of these conditions. After interdisciplinary debate, the indication for interventional therapy was made. This was carried out in 9 cases by means of endosonographic drainage alone and in 2 cases by means of percutaneous and two-stage endosonographic drainage. Technical success was achieved in 10 cases (91%), clinical success in 9 cases (82%). In 2 cases there were procedural complications that led to the operation. CONCLUSION: In the case of high surgical risks, endosonographic drainage of the gall bladder is a safe and definitive therapy. This can be performed alone or in combination with percutaneous drainage. Endoscopic ultrasound drainage is superior to percutaneous drainage alone, due to its lower complication rates and lower rates of necessary follow-up interventions. Therefore, in cases of relatively high surgical risk, endoscopic ultrasound drainage of the gall bladder should be preferred to percutaneous drainage, especially when definitive therapy is required.

Decreased Antibody Response After Severe Acute Respiratory Syndrome Coronavirus 2 Vaccination in Patients With Down Syndrome.

The risk of a severe course of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection in adults with Down syndrome is increased, resulting in an up to 10-fold increase in mortality, in particular in those >40 years of age. After primary SARS-CoV-2 vaccination, the higher risks remain. In this prospective observational cohort study, SARS-CoV-2 spike S1-specific antibody responses after routine SARS-CoV-2 vaccination (BNT162b2, messenger RNA [mRNA]-1273, or ChAdOx1) in adults with Down syndrome and healthy controls were compared. Adults with Down syndrome showed lower antibody concentrations after 2 mRNA vaccinations or after 2 ChAdOx1 vaccinations. After 2 mRNA vaccinations, lower antibody concentrations were seen with increasing age. CLINICAL TRIALS REGISTRATION: NCT05145348.

Use of over-the-scope clips (OTSC) for hemostasis in gastrointestinal bleeding in patients under antithrombotic therapy.

Background and study aims In patients taking different regimens of antithrombotic and/or anticoagulant therapy, endoscopic management of gastrointestinal bleeding represents a major challenge due to failing endogenous hemostasis. In this retrospective study we report on success rates with the over-the-scope clip (OTSC) system in upper and lower gastrointestinal bleeding in this high-risk patient population. Patients and methods Between February 2011 and June 2014, 75 patients were treated with an OTSC for active gastrointestinal bleeding. Success rates with the first endoscopic therapy, rebleeding episodes, their management and the influence of antithrombotic or anticoagulant therapy were analyzed retrospectively. Results Application of the OTSC resulted in immediate hemostasis (primary success rate) in all 75 patients. However, in 34.7 % a rebleeding episode was noted that could be treated by further endoscopic interventions. Only 3 patients had to be sent to the operating room because of failure of endoscopic therapy. In the rebleeding group the use of antiplatelet therapies was higher (73.1 % vs. 48.9 %). Conclusions Application of the OTSC in GI bleeding results in a high rate of primary hemostasis. Rebleeding occurs in up to 35 % of patients receiving antithrombotic/anticoagulant therapy but can be managed successfully with further endoscopic treatments. Patients in the rebleeding group were more frequently treated with antiplatelet agents. Radiological or surgical therapy was reserved for a small subgroup not successfully managed by repeated endoscopic therapies. OTSC application is the treatment of choice in high-risk patients when conventional clips used as first-line treatment fail.

Systematic comparison of sporadic and syndromic pancreatic islet cell tumors.

Pancreatic islet cell tumors (ICTs) occur as sporadic neoplasias or as a manifestation of multiple endocrine neoplasia type 1 (MEN1) and von Hippel-Lindau disease (VHL). Molecular classification of ICTs is mandatory for timely diagnosis and surveillance. Systematic comparison of VHL-ICTs and sporadic ICTs has been lacking. Our registry-based approaches used the German NET-Registry with 259 patients with neuroendocrine tumors (NETs), who were primarily diagnosed with NETs, and the German VHL-Registry with 485 molecular genetically confirmed patients who had undergone magnetic resonance imaging or computed tomography of the abdomen. All patients provided blood DNA for testing of the MEN1 and VHL genes for intragenic mutations and large deletions. In the NET-Registry, 9/101 patients (8.9%) with ICTs had germline mutations, 8 in MEN1 and 1 in VHL. In the VHL-Registry, prevalence of NETs was 52/487 (10.6%), and all were ICTs. Interestingly, of those with VHL p.R167W, 47% developed ICTs, compared to 2% of those with p.Y98H. In total, there were 92 truly sporadic, i.e. mutation-negative ICT patients. Comparing these with the 53 VHL-ICT patients, the statistically significant differences were predominance of female gender (P=0.01), multifocal ICTs (P=0.0029), and lower malignancy rate (P<0.001) in VHL-ICTs compared to sporadic cases. VHL was prevalent in <0.5% of NETs, while NETs occur in ∼10% of VHL, virtually exclusively as ICTs, which are rarely the first presentation. Patients with NETs should not be subjected to genetic testing of the VHL gene, unless they have multifocal ICTs, other VHL-associated tumors, and/or a family history for VHL.

Benefit of anatomical-functional image fusion in the diagnostic work-up of neuroendocrine neoplasms.

The aim of this prospective study was to evaluate anatomical-functional image fusion using the new technology of combined transmission and emission tomography (SPET/CT) in patients with neuroendocrine tumours (NET). Fifty-four patients with known or suspected NET prospectively underwent both tumour scintigraphy with (111)In-octreotide (n=43) or (123)I-MIBG (n=11) and contrast-enhanced high-end spiral CT. Scintigraphy was performed using a gamma camera (Millennium VG & Hawkeye, GE) with an integrated X-ray tube for combined transmission and emission tomography. SPET and high-end CT were interpreted blinded with regard to localisation and classification of lesions. Analysis of fused images (SPET/CT) was done on a lesion-by-lesion basis, followed by re-evaluation of SPET and high-end CT by consensus. The standard of reference for confirming the presence or absence of malignancy was either histopathology or clinical and imaging follow-up data. A total of 120 lesions were identified by CT and/or scintigraphy. This group included four patients with negative SPET but eight liver lesions on CT that were proven to be metastases. We excluded from the analysis two patients with no evidence of tumour on either modality, two lesions that lacked comparison with the standard of reference and two patients, each with two lesions, who were lost to follow-up. In 56 of the 114 evaluated lesions (49%), the results of SPET and CT were concordant; all lesions were interpreted as malignant. In 58 of 114 lesions (51%), consensus reading of fused images changed the image interpretation of 39 CT scans and 19 SPET studies: 31 lesions previously interpreted as equivocal (n=10) or benign (n=21) were re-classified as malignant and 27 lesions previously interpreted as equivocal (n=19) or malignant (n=8) were re-evaluated as benign. The highest accuracy (99%) in classifying NET lesions was achieved by combined analysis of SPET/CT ("hawkeye") and high-end CT. The specificity of SPET/CT was significantly higher than that of CT alone (P=0.0026) and slightly higher than that of SPET alone, but the accuracy of SPET/CT was inferior to that of side-by-side analysis of SPET and high-end CT (P=0.013) or visual correlation of SPET/CT and high-end CT (P<0.0001). Therapy was changed in 14 of 50 patients (28%) owing to the results of image fusion: in five patients tumour could be excluded, three patients were spared unnecessary surgery because of additional lesions indicating systemic tumour spread, in four patients the surgical approach was changed owing to precise tumour localisation and minimising of the surgical field, and in two patients medical and radiopeptide therapy was changed. Anatomical-functional image fusion allows for improved localisation and characterisation of NET with resultant alteration of the treatment approach in a substantial proportion of patients.

Spontaneous, self-limited, non-atherosclerotic dissection of the superior mesenteric artery.

A case of spontaneous, non-atherosclerotic dissection of the superior mesenteric artery is described. The patient presented with severe abdominal pain. An initial computed tomography scan did not disclose any pathology, namely the major mesenteric arteries were perfused. The patient's initial symptoms resolved during the first 48 h under conservative treatment. Sagittal reconstruction from a follow-up computed tomography scan disclosed a 7 cm long dissection of the proximal superior mesenteric artery with thrombosis of the false lumen and residual blood flow through the true lumen. There were no signs of transmural infarction of the bowel. Anticoagulation with heparin and later with phenprocoumon was initiated and the patient is well after 6 months. Together with several other cases reported recently, and in contrast to previous experience, this case adds evidence that conservative treatment of spontaneous, non-atherosclerotic dissection of the superior mesenteric artery may be an alternative to surgery if residual blood flow is maintained.