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Endoscopic retrograde cholangiopancreatography [ERCP] is a complex procedure with a flat learning curve. It is associated with the risk of serious complications such as pancreatitis, bleeding, cholangitis and perforation. Endosonography should therefore also be offered for the precise indication of the higher-risk ERCP. Numerous factors influence the success of ERCP. In addition to structured training for the initial acquisition of skills and a minimum number of ERCPs of varying degrees of difficulty, maintaining a good quality of ERCP also requires a regular minimum number of examinations performed per year. There is extensive evidence that shows a significant correlation between ERCP volumes and primary success rates, lower lengths of hospital stay, fewer unwanted readmissions and fewer complications. The cut-offs for differentiating between high-volume and low-volume centers were chosen inconsistently in the studies, with the highest evidence for a cut-off value of 200 ERCPs/year. The question of specialization in ERCP has been given a relevance by the current developments in german hospital reform. Here, a minimum number of ERCPs should be defined for groups of different specialization. However, a minimum number alone will not be able to achieve good treatment quality. In terms of high-quality patient care, it is necessary to offer ERCPs in specialized gastroenterology center, which, in addition to a sufficient number of ERCPs for training and to maintain competence, offer an on-call service and complementary procedures such as EUS and which are embedded in appropriately accessible clinics that have the necessary resources for complication management., Competing Interests: Alle Autoren und Autorinnen sind Mitglieder der DGVS. Die Autoren und Autorinnen 1–6 und 8–12 arbeiten in leitenden Funktionen in Gastroenterologien in denen auch ERCPs durchgeführt werden., (Thieme. All rights reserved.)

Gastroenterology has made crucial advances in diagnostic and interventional endoscopic procedures, opening up improvements in the treatment of many patients. Thus, organ-preserving treatments are increasingly being made possible, replacing more invasive organ resecting surgical procedures. At the same time, the degree of complexity and risks varies widely between different endoscopic procedures. In many cases, simpler endoscopic procedures are now offered on an outpatient basis. Further potential for cross-sectoral performance of endoscopic procedures exists in the case of complex endoscopic procedures, which, however, require special structural, procedural and personnel requirements in order to provide quality-assured treatment, enable post-interventional monitoring and, if necessary, take measures to ensure the success of the treatment. We summarize the essential prerequisites and limitations for cross-sector performance of endoscopic procedures in gastroenterology., Competing Interests: LL, UD, TF, RJ, SF, HL, JM, JO, UT, BT, HW und JA sind in ehrenamtlicher Tätigkeit für die DGVA an dem Manuskript beteiligt, PL als Geschäftsführerin der DGVS. Es liegen keine weiteren Interessenskonflikte vor., (Thieme. All rights reserved.)

Competing Interests: LL, UD, TF, RJ, SF, HL, JM, JO, UT, BT, HW und JA sind in ehrenamtlicher Tätigkeit für die DGVA an dem Manuskript beteiligt, PL als Geschäftsführerin der DGVS. Es liegen keine weiteren Interessenskonflikte vor.

Liver cirrhosis is associated with an increased risk of developing hepatocellular carcinoma (HCC). However, other benign and malignant liver lesions may co-exist or may be the only focal liver lesion (FLL) detected. Compared to HCC, comparatively little is known about the frequency and natural history of benign FLL in patients with established liver cirrhosis.This review analyses the prevalence and frequency of benign and malignant FLL others than hepatocellular carcinoma (HCC) in liver cirrhosis including imaging and autopsy studies. Understanding these data should be helpful in avoiding misdiagnoses., Competing Interests: C. Görg received funding from Bracco Imaging. Bracco Imaging supported CEUS workshops at the University Hospital Marburg., (Thieme. All rights reserved.)

Introduction: For motorized spiral enteroscopy, only limited data are available. We report about our early experiences with the motorized spiral enteroscopy in a retrospective case series. The present worldwide study reported the results of motorized spiral enteroscopy in 68 patients with small bowel diseases and in 15 patients with ERCP and surgically altered anatomy., Patients and Methods: This retrospective single-centre study was performed between 01/2020 and 09/2021 in 83 consecutive patients. Indications were known or suspected small bowel diseases or diseases of the bile or pancreatic duct after surgical altered anatomy with Roux-Y anastomosis., Results: In 68 patients (38 m/30 f; mean age 66.4 years) with an indication for small bowel enteroscopy, diagnostic and therapeutic yield was 86.8% and 41.2%, respectfully. The average depth of maximum insertion was 279 cm with an average insertion time of 64.3 min. In 13 patients (19.7%), complete panenteroscopy was achieved. In patients without prior abdominal surgery, the rate of complete enteroscopy was 46.2%.In 15 patients (9 m; 6 f; mean age 61.8 years) with surgically altered anatomy and Roux-Y anastomosis (the papilla resp.), the biliodigestive anastomosis could be reached in 60%.In the entire case series, the total complication rate was 15.7%. There were no severe complications, such as perforation or major bleeding., Discussion: The present case series shows a high rate of panenteroscopies with a short examination time. To confirm these data, further comparative studies for ERCPs in patients with surgically altered anatomy are necessary., Competing Interests: S.F. bekommt Honorare für Beratertätigkeiten sowie für Vortrags- und Schulungstätigkeiten von der Fa. Olympus, (Thieme. All rights reserved.)

Histological classifications of tumorous lesions together with adequate staging are necessary for stage-appropriate and personalized therapies. The indications, technical possibilities, and limitations as well as potential complications of image-guided needle biopsy by ultrasound, computed tomography, and endosonography are described. Which procedure for which organ and which lesion?, Competing Interests: Die Autorinnen/Autoren geben an, dass kein Interessenkonflikt besteht., (Thieme. All rights reserved.)

Background: The German hospital reimbursement system (G-DRG) is incomplete for endoscopic interventions and fails to differentiate between complex and simple procedures. This is caused by outdated methods of personnel-cost allocation., Methods: To establish an up-to-date service catalogue 50 hospitals made their anonymized expense-budget data available to the German-Society-of-Gastroenterology (DGVS). 2.499.900 patient-datasets (2011-2013) were used to classify operation-and-procedure codes (OPS) into procedure-tiers (e.g. colonoscopy with biopsy/colonoscopy with stent-insertion). An expert panel ranked these tiers according to complexity and assigned estimates of physician time. From June to November 2014 exact time tracking data for a total 38.288 individual procedures were collected in 119 hospitals to validate this service catalogue., Results: In this three-step process a catalogue of 97 procedure-tiers was established that covers 99% of endoscopic interventions performed in German hospitals and assigned validated mean personnel-costs using gastroscopy as standard. Previously, diagnostic colonoscopy had a relative personnel-cost value of 1.13 (compared to gastroscopy 1.0) and rose to 2.16, whereas diagnostic ERCP increased from 1.7 to 3.62, more appropriately reflecting complexity. Complex procedures previously not catalogued were now included (e.g. gastric endoscopic submucosal dissection: 16.74)., Discussion: This novel service catalogue for GI-endoscopy almost completely covers all endoscopic procedures performed in German hospitals and assigns relative personnel-cost values based on actual physician time logs. It is to be included in the national coding recommendation and should replace all prior inventories for cost distribution. The catalogue will contribute to a more objective cost allocation and hospital reimbursement - at least until time tracking for endoscopy becomes mandatory., (© Georg Thieme Verlag KG Stuttgart · New York.)

Introduction: Worldwide endoscopic submucosal dissection (ESD) of early GI cancers or premalignant neoplasia is becoming increasingly important. In Germany ESD is restricted to larger endoscopic institutions and only a few literature reports are available. The aim of the present study is to describe the results of 46 ESDs conducted in a German endoscopic centre., Material and Methods: Between June 2007 and May 2012 46 ESDs in 45 patients (33 men, 12 women, mean age 66.1 years) were performed in the oesophagus (n = 17), stomach (n = 23) and rectum (n = 6). Data were collected for the en-bloc, R0 and R0 en-bloc resection rates as well as for complications, the curative resection and the local recurrence rates. In order to demonstrate a learning curve, results were evaluated for two periods (June 2007 to November 2010 vs. December 2010 to May 2012)., Results: ESD was technically possible in 93.5%. En-bloc, R0, R0 en-bloc and curative resection rates were 90.7%, 74.4%, 67.4% and 65.1%, respectively. The complication rate was 13%. In the second period en-bloc and R0 en-bloc resection rates increased from 81% to 100% and, respectively, from 52.4% to 81.8%. After a medium follow-up of 11.4 months, local tumour recurrence occurred in 10%. In cases of curative R0 en bloc resection of malignant tumours no tumour recurrence occurred., Discussion: Despite the small number of patients, the present data underline the value of ESD, especially in cases of R0 en-bloc resections in the therapy for premalignant and early malignant GI tumours. Due to the required learning curve, ESD should be restricted to larger endoscopic centres in Germany., (© Georg Thieme Verlag KG Stuttgart · New York.)

We report on the case of a segmentally emphasised, ulcerous chronic haemorrhagic colitis with the development of granulation tissue und scarred fibrosis with consecutive resulting stenosis of the colon. A 49-year-old male patient was infected with enterohaemorrhagic Escherichia coli bacteria during the EHEC-epidemic in northern Germany in early summer 2011. In the course of the infection the patient suffered from haemolytic uraemic syndrome (HUS) with acute renal failure and neurological symptoms. Haemodialysis and plasmapheresis had become mandatory. A simultaneous ileus was estimated to be of paralytic origin. One month after treatment of the acute phase of the infection a CT scan of the abdomen was performed and discovered a symptomatic stenosis of the proximal colon transversum. This obstruction needed to be treated by performing a right hemicolectomy with an ileo-transverso anastomosis. After surgery the patient recovered continuously. The histopathological examination verified an ulcerous-chronic haemorrhagic colitis on the background of an EHEC infection., (© Georg Thieme Verlag KG Stuttgart · New York.)

The sensitivity of small-bowel capsule endoscopy in visualizing a single finding present in everyone, the duodenal papilla, is limited. In this retrospective case series study we evaluated whether the duodenal papilla can be better visualized by a capsule endoscope equipped with cameras on both ends. The recordings of 45 colonic capsule endoscopies (PillCam Colon) performed in a single tertiary center were re-evaluated seeking for the duodenal papilla. The two-hour sleeping period of the colon capsule endoscopy system led to the imaging of duodenum in 10 / 45 patients. The duodenal papilla was identified in 6 / 10 (60 %) patients while the number of frames where the papilla was clearly visualized ranged from 2 - 9. Consequently, a small-bowel capsule endoscope containing two cameras could better identify the duodenal papilla and theoretically other obscure areas of the small bowel, expanding its diagnostic accuracy.

Background: Endoscopic ultrasonography is a widely used technique in Germany and not restricted to highly specialised centres. Complementary to the traditional radial scanners, longitudinally scanning echo endoscopes have gained considerable acceptation. Multicentre data on the complications of endoscopic ultrasound and endoscopic ultrasound-guided interventions at German centres do not exist., Method: From 2004 to 2006 all German centres performing endoscopic ultrasonography were surveyed and asked to report on their complications., Results: From 1991 to 2006 100 604 endosonographic procedures had been performed in 67 centres (85,084 diagnostic endosonographies without any intervention, 13,223 endoscopic ultrasound-guided finde-needle aspiration biopsies, 2297 endoscopic ultrasound-guided therapeutic interventions). 38 centres reported on 104 complications, of which 88 were considered to be severe (overall complication rate 0.1 %). Complications of diagnostic endoscopic ultrasound occurred at a rate of 0.034 %, almost all of them were duodenal and oesophageal perforations. There had been complications in 0.29 % of all endoscopic ultrasound-guided fine-needle aspiration biopsies and subsequent to 1.61 % of all endoscopic ultrasound-guided therapeutic interventions. The overall mortality of non-interventional and interventional endosonographic procedures was 0.01 %., Conclusions: Under the specific circumstances in Germany, endoscopic ultrasound, both conventional and interventional, was confirmed to be a safe diagnostic and therapeutic technique. In future, the prospective assessment of complications should become an essential part of quality management of endoscopic ultrasound.

In Germany the incidence of esophageal cancer is 6 - 10 per 100,000. At the time of diagnosis about 75 % of the patients suffer from UICC stage III or IV esophageal cancer. Less than 10 % of patients are diagnosed with early (T1) cancer. Diagnosis and staging relies on esophagoscopy including biopsies, endoscopic ultrasonography, and computerized tomography of the chest and abdomen. Intramucosal early cancer (T1a) and high-grade dysplasia can be treated either by surgery or by endoscopic mucosal resection. Chemoradiation is the definitive treatment of choice for localized squamous cell cancer of the proximal esophagus. As far as overall survival is concerned definitive chemoradiation is not inferior to esophagectomy even in patients with localized squamous cell cancer of the middle or lower esophagus. In case of high surgical risk chemoradiation should be offered to those patients as the therapy of choice. Esophagectomy should be performed in operable patients suffering from resectable adenocarcinoma of the esophagus. Preoperative chemoradiation is recommended in locally advanced (non-resectable) adenocarcinoma. If staging reveals distant metastases, palliative therapy is indicated. Palliative chemotherapy with 5-fluorouracil and cisplatin should be offered to patients with good performance status. Esophageal intubation (with expandable metal stents) is the palliative treatment of choice for firm stenosing, non-resectable tumors, where rapid relief of dysphagia is required.

Localization of gastroenteropancreatic neuroendocrine tumors with conventional imaging techniques can be difficult. With the advent of the somatostatin-receptor scintigraphy the diagnosis of these could be improved. In this study 76 patients with immunohistologically proven neuroendocrine tumors were analysed by comparing somatostatin-receptor scintigraphy with conventional imaging techniques. Somatostatin-receptor-positive lesions were observed in 61 of all patients. Conventional imaging techniques (transabdominal ultrasonography, computerized tomographic scanning of the abdomen, magnetic resonance imaging of the abdomen) revealed neuroendocrine tumors in 42 patients (69%). A follow up of 19 patients with initially false positive somatostatin-receptor scintigrams showed that at least 6 patients had escaped the initial diagnosis by conventional techniques. All in all, our data support previous findings and demonstrate that somatostatin-receptor scintigraphy is a safe and sensitive procedure for in vivo imaging of gastroenteropancreatic neuroendocrine tumors. In addition, in certain cases, somatostatin-receptor scintigraphy is able to detect tumors that had escaped conventional imaging techniques.