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ZusammenfassungBlutungen aus dem Gastrointestinaltrakt werden in obere, mittlere und untere gastrointestinale Blutung unterschieden. Die Diagnostik kann eine Herausforderung sein und ist eine Domäne der Koloskopie, der Kapselendoskopie oder der flexiblen Enteroskopieverfahren. Als endoskopische Therapieoptionen stehen die Injektionstherapie, Metallclips, eine thermische Behandlung sowie die Gummibandligatur zur Verfügung, eine chirurgische Resektion ist nur selten erforderlich.

Contains fulltext : 238998.pdf (Publisher’s version ) (Open Access) BACKGROUND: Pancreatic duct disruption or disconnection is a potentially severe complication of necrotizing pancreatitis. With no existing treatment guidelines, it is unclear whether there is any consensus among experts in clinical practice. We evaluated current expert opinion regarding the diagnosis and treatment of pancreatic duct disruption and disconnection in an international case vignette study. METHODS: An online case vignette survey was sent to 110 international expert pancreatologists. Expert selection was based on publications in the last 5 years and/or participation in development of IAP/APA and ESGE guidelines on acute pancreatitis. Consensus was defined as agreement by at least 75% of the experts. RESULTS: The response rate was 51% (n = 56). Forty-four experts (79%) obtained a MRI/MRCP and 52 experts (93%) measured amylase levels in percutaneous drain fluid to evaluate pancreatic duct integrity. The majority of experts favored endoscopic transluminal drainage for infected (peri)pancreatic necrosis and pancreatic duct disruption (84%, n = 45) or disconnection (88%, n = 43). Consensus was lacking regarding the treatment of patients with persistent percutaneous drain production, and with persistent sterile necrosis. CONCLUSION: This international survey of experts demonstrates that there are many areas for which no consensus existed, providing clear focus for future investigation.

Background/Aims Reliable and especially widely accepted preventive measures are crucial to further reduce the incidence of colorectal cancer (CRC). Colon capsule endoscopy (CCE) might increase the screening numbers among patients unable or unwilling to undergo conventional colonoscopy. This registry trial aimed to document and determine the CCE indications, findings, complications, and adverse events in outpatient practices and clinics throughout Germany. Methods Patients undergoing CCE between 2010 and 2015 were enrolled in this prospective multicenter registry trial at six German centers. Patient demographics, outcomes, and complications were evaluated. Results A total of 161 patients were included. Of the CCE evaluations, 111 (68.9%) were considered successful. Pathological findings in the colon (n=92, 60.1%) and in the remaining gastrointestinal tract (n=38, 24.8%) were recorded. The main finding was the presence of polyps (n=52, 32.3%). Furthermore, five carcinomas (3.1%) were detected and histologically confirmed later. Adequate bowel cleanliness was more likely to be achieved in the outpatient setting (p

Background: The main factor that limits wider utilization of capsule endoscopy (CE) in Crohn's disease (CD) is the potential risk of retention. The aim of this systematic review was to evaluate capsule retention rates in adult and pediatric CD and determine if retention risk is reduced in established CD (ECD) with patency capsule (PC) or magnetic resonance/computed tomography (MR/CT) enterography. Methods: Studies of CD patients undergoing CE that reported retention were identified. Pooled estimates for retention rates and relative risk in ECD to suspected CD (SCD) were calculated. All hypothesis tests were 2-sided; statistical significance was set at a P value of

Zusammenfassung Einleitung Die hepatische Enzephalopathie (HE) ist eine häufige Komplikation der Leberzirrhose, die für betroffene Patienten mit vielfältigen negativen Auswirkungen im Alltag verbunden ist. Die Prävalenz klinisch manifester Stadien wird auf 30–45 % geschätzt. Ungeachtet ihrer klinischen und prognostischen Bedeutung gilt die HE als unterdiagnostiziert. Methoden Ziele der Studie waren neben der systematischen Analyse der Krankenhausletalität der HE erstmals eine Untersuchung der ökonomischen Auswirkungen und der Vergütungssituation einer HE bei Leberzirrhose in Deutschland. Für die retrospektive Studie standen die anonymisierten Fall- und Kostendaten (§ 21 Abs. 4 KHEntgG) von 74 Krankenhäusern des DRG-Projekts der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselkrankheiten (DGVS) aus den Jahren 2011 bis 2015 zur Verfügung. Außerdem wurden diese Ergebnisse mit denen aller deutschen Krankenhäuser auf der Basis der Falldaten des Statistischen Bundesamtes (Destatis, Wiesbaden) verglichen. Ergebnisse In den Häusern des DRG-Projekts der DGVS wurden 59 093 Behandlungsfälle mit Leberzirrhose erfasst, bei denen in 14,6 % eine HE kodiert war. Die Krankenhausletalität von Zirrhose-Patienten mit HE war gegenüber derjenigen von Patienten ohne HE nahezu dreifach erhöht (20,9 versus 7,7 %). Die Zahl der Behandlungsfälle mit Leberzirrhose ebenso wie der Anteil von Patienten mit HE stieg kontinuierlich über den Erfassungszeitraum an. Im Gegensatz zu Patienten mit Zirrhose allgemein ist die Behandlung von Patienten mit HE nicht kostendeckend (Unterdeckung bis zu 634 € bei HE Grad 4). Diskussion Die Letalität war bei Patienten mit Zirrhose dreifach erhöht, wenn gleichzeitig eine HE diagnostiziert wurde. In den am DGVS-DRG-Projekt teilnehmenden Häusern wurde die HE um 2 % häufiger erfasst als im Rest der Kalkulationshäuser, was entweder in einer höheren Fallschwere oder in einer besseren Kodierqualität begründet ist. Gegenwärtig ist die Behandlung der HE bei Zirrhose nicht kostendeckend im DRG-System.

ZusammenfassungPatienten mit unklarer Gallengangsstenose stellen regelhaft eine Herausforderung an den klinisch tätigen Gastroenterologen dar. So sollten Patienten mit malignen und potenziell resektablen Erkrankungen so bald wie möglich einer kurativen Operation zugeführt werden. Gleichzeitig sollte bei Patienten mit benignen und potenziell konservativ behandelbaren Erkrankungen eine umfangreiche Operation vermieden werden. Diese Arbeit soll eine Übersicht vermitteln über die Aussagekraft der zurzeit verfügbaren endoskopischen Diagnostik sowie einen Ausblick geben auf potenziell in der Zukunft relevante Verfahren.

Background and aim A number of studies were able to show a reduction of hypoxemia episodes during procedural sedation through the use of capnography (CA). The present study investigates the number of episodes of hypoxemia during percutaneous endoscopic gastrostomy (PEG) placement with propofol sedation comparing standard monitoring (SM) versus SM with additional CA surveillance. Methods In this single center randomized controlled trial, 150 patients were prospectively randomized 1:1 in either the SM group or the CA group after stratification for ASA class, PEG method (push or pull method), presence of head and neck tumor, and tracheostomy. CA analysis was performed for all patients but was blinded for the endoscopic team in the SM group. Results In the SM group, 57% episodes of hypoxemia (SpO2 15 s) and 41% episodes of severe hypoxemia (SpO2 15 s) were observed in comparison with 28% and 20% in the CA group, respectively. Odds ratios for hypoxemia and severe hypoxemia were 0.29 (confidence interval 0.15-0.57; P = 0.0005) and 0.35 (confidence interval 0.17-0.73; P = 0.008) in favor of the CA group. On average, CA was able to detect imminent mild and severe hypoxemia 83 and 99 s before standard monitoring. Standard monitoring represented an independent risk factor for hypoxemia and severe hypoxemia. Conclusions Respiratory complications of sedation during PEG placement are frequent events. CA is able to detect imminent hypoxemia at an early time point. This allows an early intervention and consecutively the avoidance of mild and severe hypoxemia. Therefore, CA monitoring can be recommended particularly during PEG insertion procedures.

Background and study aims Adherence to colorectal cancer (CRC) screening is still unsatisfactory in many countries, thereby limiting prevention of CRC. Colon capsule endoscopy (CCE), a minimally invasive procedure, could be an alternative to fecal immunochemical tests or optical colonoscopy for CRC screening, and might increase adherence in CRC screening. This systematic review and meta-analysis evaluates the diagnostic accuracy of CCE compared to optical colonoscopy (OC) as the gold standard, adequacy of bowel preparation regimes and the patient perspective on diagnostic measures. Methods We conducted a systematic literature search in PubMed, EMBASE and the Cochrane Register for Clinical Trials. Pooled estimates for sensitivity, specificity and the diagnostic odds ratio with their respective 95 % confidence intervals (CI) were calculated for studies providing sufficient data. Results Of 840 initially identified studies, 13 were included in the systematic review and up to 9 in the meta-analysis. The pooled sensitivities and specificities for polyps ≥ 6 mm were 87 % (95 % CI: 83 %–90 %) and 87 % (95 % CI: 76 %–93 %) in 8 studies, respectively. For polyps ≥ 10 mm, the pooled estimates for sensitivities and specificities were 87 % (95 % CI: 83 %–90 %) and 95 % (95 % CI: 92 %–97 %) in 9 studies, respectively. A patients’ perspective was assessed in 31 % (n = 4) of studies, and no preference of CCE over OC was reported. Bowel preparation was adequate in 61 % to 92 % of CCE exams. Conclusions CCE provides high diagnostic accuracy in an adequately cleaned large bowel. Conclusive findings on patient perspectives require further studies to increase acceptance/adherence of CCE for CRC screening.

Introduction: Aortoesophageal fistula (AEF) is a life-threatening complication associated with endovascular aortic repair (EVAR) and occurs mostly in patients who undergo thoracic EVAR (TEVAR). To date, surgical treatment of AEF has been considered the most promising therapeutic approach. New endoscopic techniques could contribute to the therapy of AEF. The aim of this study was to analyze the outcome after endoscopic treatment of EVAR-associated AEF. Methods: All patients who received endoscopic diagnostics and/or therapy for AEF after EVAR/TEVAR in our center between 2010 and 2019 were evaluated. Results: Seven suitable patients were included. Six of them had undergone TEVAR and 1 had EVAR. Fistula occurred at an average of 307 days (range 21–2,774 days) post-EVAR. Endoscopic treatment was performed on 4 patients by using an over-the-scope clip (OTSC®). However, fistula recurred in all patients who were initially treated endoscopically. They were then treated either by sequential application of further OTSCs® or by implantation of a fully coated, self-expanding metal stent. One of these patients underwent a partial esophageal resection in a subsequent treatment approach. All patients died during the observational period, 5 as a direct consequence of the AEF/aortoduodenal fistula and 2 due to comorbidities. The median survival time after fistula occurrence was 120 days (range 5–823 days). Conclusion: Endoscopic treatment of AEF with OTSC® should be considered as a possible interim solution, especially in patients with severe comorbidities. However, surgical remediation still appears to be the only procedure with intermediate to long-term therapeutic success.

Good patient management already starts in advance with careful evaluation of the patient's history and condition with all comorbidities and strict indication of the endoscopic procedure, either for endoscopic ultrasonography (EUS) or endoscopic retrograde cholangiopancreatography (ERCP). This is necessary to avoid complications of these potentially risky endoscopic interventions. Another important requirement before endoscopy is informed written consent of the patient. During the endoscopic procedure, excellent patient management includes cautious sedation, simultaneous monitoring, radiation protection, an experienced endoscopy team considering prophylaxis and management of potential complications. Only by considering all these aspects a successful procedure and full patient satisfaction will be achieved.

Iatrogenic bile duct injury (BDI) might be sequel of surgical interventions and requires ERCP to establish a diagnosis and—in many cases—to offer an effective treatment. Patients’ presentation in post-operative biliary complications is often non-specific and symptoms may range from pruritus, fatigue, jaundice, and abdominal pain to frank cholangitis and sepsis. The treatment plan should be based on an interdisciplinary discussion amongst interventionalists and hepato-biliary surgeons. This survey highlights several classification systems of BDI to illustrate differential indication of interventional vs. surgical repair. Thereby, a high overall success rate can be achieved by tailoring percutaneous, endoscopic, and surgical approaches to the types of lesions. Transpapillary plastic stent insertion together with sphincterotomy is usually preferred, bridging the leakage if feasible and—most important—decreasing the intraductal pressure by opening the sphincter. The role of covered metal stents is promising for sealing a leak (e.g., from the cystic stump) or to treat concurrent CBD stricture and leak, but still experimental. For plastic stents, 6–8 weeks stenting is usually sufficient. Initial percutaneous drainage can usually be removed shortly after successful ERCP. For large defects and refractory leakage, hepato-jejunal anastomosis or other reconstructive surgery might be necessary.

ERC-PTC rendezvous techniques are used as a salvage technique after failed ERC or anticipating a complex intervention that might not be resolved by ERC alone. A main advantage of PTC over ERCP is the opportunity to drain obstructed bile duct segments externally, even if the obstructing stricture is not passed by the draining catheter, as PTC uses a percutaneous antegrade access route. In patients with multiple and large bile duct stones and severe comorbidity, PTCD and/or PTC-ERC rendezvous might be an alternative in multistep approaches through the established percutaneous access. This combined procedure may resolve difficult to treat bile duct obstruction and/or infection. With a tailored approach, the interventionalists are able to drain externally or internally and may excellently treat infected bilioma with downstream bile duct obstruction. An experienced, dedicated team is required.

Biliary complications are considered the Achilles’ heel of orthotopic liver transplantation and significantly influence the outcome of the patient. Ischemia, rejection of the donor tissue, and recurring underlying disease contribute to the etiology of biliary complications. Biliary strictures constitute 40–60% of biliary complications after liver transplantation. They are more common after living donor–related liver transplantation (LDLT) than orthotopic liver transplantation (OLT). Thereby, anastomotic biliary stricture (ABS) needs differentiation from non-anastomotic stricture (NAS), such as ischemic-type biliary lesions (ITBL) that occur within the intrahepatic and proximal bile ducts.

Colonoscopy with polypectomy has been shown to reduce the risk of colon cancer development. It is considered a fundamental skill for all endoscopists who perform colonoscopy. A variety of polypectomy techniques and devices are available, and their use can vary greatly based on local availability and preferences. Polyps that are difficult to remove due to location or size require advanced resection techniques, such as endoscopic mucosal resection (EMR) and the use of special devices for safe and effective removal. However, colonic EMR is not routinely part of the standard endoscopic curriculum that is normally offered to gastroenterologists. It requires dedicated training in advanced endoscopic resection techniques, clinical and interpretive skills, and the knowledge and ability to manage complications.The two most common post-polypectomy complications are bleeding and perforation. Their frequency can be limited with the use of meticulous polypectomy techniques and the application of some prophylactic manoeuvres.This paper gives a review of the step by step technique of polypectomy and its complications from the perspective of the practicing gastroenterologist.

MAIN RECOMMENDATION 1 ESGE suggests using contrast-enhanced computed tomography (CT) as the first-line imaging modality on admission when indicated and up to the 4th week from onset in the absence of contraindications. Magnetic resonance imaging (MRI) may be used instead of CT in patients with contraindications to contrast-enhanced CT, and after the 4th week from onset when invasive intervention is considered because the contents (liquid vs. solid) of pancreatic collections are better characterized by MRI and evaluation of pancreatic duct integrity is possible. Weak recommendation, low quality evidence. 2 ESGE recommends against routine percutaneous fine needle aspiration (FNA) of (peri)pancreatic collections. Strong recommendation, moderate quality evidence. FNA should be performed only if there is suspicion of infection and clinical/imaging signs are unclear. Weak recommendation, low quality evidence. 3 ESGE recommends initial goal-directed intravenous fluid therapy with Ringer’s lactate (e. g. 5 – 10 mL/kg/h) at onset. Fluid requirements should be patient-tailored and reassessed at frequent intervals. Strong recommendation, moderate quality evidence. 4 ESGE recommends against antibiotic or probiotic prophylaxis of infectious complications in acute necrotizing pancreatitis. Strong recommendation, high quality evidence. 5 ESGE recommends invasive intervention for patients with acute necrotizing pancreatitis and clinically suspected or proven infected necrosis. Strong recommendation, low quality evidence.ESGE suggests that the first intervention for infected necrosis should be delayed for 4 weeks if tolerated by the patient. Weak recommendation, low quality evidence. 6 ESGE recommends performing endoscopic or percutaneous drainage of (suspected) infected walled-off necrosis as the first interventional method, taking into account the location of the walled-off necrosis and local expertise. Strong recommendation, moderate quality evidence. 7 ESGE suggests that, in the absence of improvement following endoscopic transmural drainage of walled-off necrosis, endoscopic necrosectomy or minimally invasive surgery (if percutaneous drainage has already been performed) is to be preferred over open surgery as the next therapeutic step, taking into account the location of the walled-off necrosis and local expertise. Weak recommendation, low quality evidence. 8 ESGE recommends long-term indwelling of transluminal plastic stents in patients with disconnected pancreatic duct syndrome. Strong recommendation, low quality evidence. Lumen-apposing metal stents should be retrieved within 4 weeks to avoid stent-related adverse effects.Strong recommendation, low quality evidence.

Zusammenfassung Hintergrund In der Abrechnungssystematik der deutschen Krankenhäuser (G-DRG-System) sind endoskopische Leistungen in der Kostenstellengruppe 8 gesondert ausgewiesen. Für die interne Leistungsverrechnung oder die Erstattung externer Anbieter werden häufig noch wenig aktuelle oder unvollständige Kataloge wie DKG-NT oder GOÄ verwendet. Wir haben die Kosten endoskopischer Leistungen im DRG-System ermittelt. Methodik Zur Erfassung endoskopischer Leistungen wurden der DGVS von 74 Kalkulationskrankenhäusern des Instituts für das Entgeltsystem im Krankenhaus (InEK) die kompletten gastroenterologischen Kostendatensätze (2011 – 2015; § 21 KHEntgG) anonymisiert überlassen (4873 809 Falldatensätze). Aus Fällen mit nur genau einer Endoskopie (n = 274 186) wurden die mittleren Kosten für 46 endoskopische Leistungsgruppen aus 5 Jahren ermittelt. Ergebnisse Es wurden belastbare Kostenwerte errechnet mit einer Spanne, die von 230,56 € für die Gastroskopie (n = 144 666), über die einfache Koloskopie (276,23 €, n = 32 294) bis zur ERCP mit Papillotomie und Kunststoffstenteinlage (844,07 €, n = 10 150) oder zur ERCP mit Einlage eines selbstexpandierenden Metallgitterstents (1602,37 €, n = 967) reichte. Höhere Kosten für Universitätsklinika fanden sich vor allem bei komplexen Leistungen. Diskussion Der Kostenkatalog endoskopischer Leistungen, der anhand der § 21 KHEntgG Datensätze von 74 Kalkulationskrankenhäusern des InEK errechnet wurde, erlaubt erstmals eine Abschätzung von realen Endoskopiekosten im Krankenhaus. Die höheren Kosten in Universitätsklinika sind am ehesten durch einen „referral bias“ für komplexe Fälle und Eingriffe im Nacht- und Notdienst zu erklären. Für 46 endoskopische Leistungsgruppen ist jetzt eine sachgerechtere Zuordnung der Kosten im DRG-System möglich. Im internationalen Vergleich sind die Kosten der Endoskopie in deutschen Krankenhäusern niedrig, was entweder in höherer Effizienz, geringerer Personalausstattung oder unvollständiger Kostendokumentation begründet ist.

Objectives Choosing the best treatment option at the optimal point of time for patients with walled-off necrosis (WON) is crucial. We aimed to identify imaging parameters and clinical findings predicting the need of necrosectomy in patients with WON. Methods All patients with endoscopically diagnosed WON and pseudocyst were retrospectively identified. Post hoc analysis of pre-interventional contrast-enhanced computed tomography was performed for factors predicting the need of necrosectomy. Results Sixty-five patients were included in this study. Forty patients (61.5%) were diagnosed with pseudocyst and 25 patients (38.5%) with WON. Patients with WON mostly had acute pancreatitis with biliary cause compared with more chronic pancreatitis and toxic cause in pseudocyst group (P = 0.002 and P = 0.004, respectively). Logistic regression revealed diabetes as a risk factor for WON. Computed tomography scans revealed 4.62% (n = 3) patients as false positive and 24.6% (n = 16) as false negative findings for WON. Reduced perfusion and detection of solid findings were independent risk factors for WON. Conclusions Computed tomography scans are of low diagnostic yield when needed to predict treatment of patients with pancreatic cysts. Reduced pancreatic perfusion and solid findings seem to be a risk factor for WON, whereas patients with diabetes seem to be at higher risk of developing WON.

Background and study aims: Direct retrograde cholangioscopy (DRC) enables high quality video imaging of the bile ducts and allows intraductal treatment with optical control. We evaluated the feasibility, success, and complications of a new third-generation prototype cholangioscope. Patients and Methods: All consecutive patients from two tertiary endoscopy centers who had undergone DRC with the prototype were included. Indications for DRC were: evaluation of indeterminate strictures, filling defects, and complex bile duct stones. Technical success was investigated in terms of indication and treatment performed. All adverse events were recorded. Results: DRC with the prototype was performed in 74 patients. Therapeutic interventions included laser or electrohydraulic lithotripsy and stone removal, among others. The papilla was entered in 72/74 patients (97 %). The targeted bile duct segment was reached in 62 /74 patients (84 %), with an anchoring balloon catheter needed in 21/74 (28 %). Mean investigation time was 21 minutes (15 – 27 minutes) Conclusions: DRC using the prototype is feasible, safe, and attains access to the bile ducts in almost all patients, with less need of an anchoring balloon catheter compared with the standard technique and short investigation and fluoroscopy times.

Aim To evaluate the ability of PillCamColon2 to visualize colonic segments missed by incomplete optical colonoscopy (OC) and to assess the diagnostic yield. Methods This prospective multicentre study included 81 patients from nine centres who underwent second-generation colon capsule endoscopy (CCE) following incomplete OC performed by an experienced gastroenterologist (> 1000 colonoscopies). Patients with stenosis were excluded. According to patient preferences, CCE was performed the following day (protocol A) after staying on clear liquids and 0.75 L Moviprep in the morning or within 30 d after new split-dose Moviprep (protocol B). Boosts consisted of 0.75 L and 0.25 L Moviprep, and phospho-soda was given as a rescue if the capsule was not excreted after seven hours. Results Seventy-four patients were analysed (51% of them in group A; 49% in group B). Bowel cleansing was adequate in 67% of cases, and CCE could visualize colonic segments missed by incomplete colonoscopy in 90% of patients under protocol A and 97% of patients under protocol B (P = 0.35, n.s.). Significant polyps including adenocarcinoma were detected in 24% of cases. Detection rates for all polyps and significant polyps per patient were similar in both protocols. Polyps were found predominantly in the right colon (86%) in segments that were not reached by OC. Extracolonic findings - such as reflux esophagitis, suspected Barrett esophagus, upper GI-bleeding, gastric polyps, gastric erosions and angiectasia - were detected in eight patients. PillCamColon2 capsule was retained in the ileum of one patient (1.4%) without symptoms and removed during an uneventful resection for unknown Crohn's disease that was diagnosed as the cause of anemia, which was the indication for colonoscopy. CCE was well tolerated. One patient suffered from self-limiting vomiting after consuming the phospho-soda. Conclusion Second-generation CCE using a low-volume preparation is useful after incomplete OC, and it allows for the detection of additional relevant findings, but cleansing efficiency could be improved.

Das Cholangiokarzinom (CCA) ist eine vergleichsweise seltene maligne Erkrankung des hepatobiliaren Systems. Aufgrund der geringen Inzidenz der Erkrankung ist eine generelle Vorsorgeuntersuchung der gesamten Bevolkerung weder aus Ressourcen- noch aus Evidenzgrunden zu empfehlen. In Westeuropa und in Deutschland stellen chronische Leberkrankungen wie die Leberzirrhose ursprunglicher Atiologie sowie die PSC Hauptrisikofaktoren fur die Entstehung des CCA dar. Diese Patientengruppen weisen das hochste Risiko auf, an einem CCA zu erkranken und sollten daher ahnlich der „HCC surveillance“ beim Hepatozellularen Karzinom engmaschig kontrolliert werden. Neue endoskopische Techniken wie die Cholangioskopie konnen insbesondere bei der Abklarung von unklaren Strikturen der extrahepatischen Gallenwege bei PSC-Patienten die Diagnostik unterstutzen. Eine grose Herausforderung stellt die Zunahme der Insulinresistenz, des metabolischen Syndroms und damit einhergehend der massive Anstieg der Fallzahl an Patienten mit nicht-alkoholischer Fettleber (NAFLD) dar. Da Patienten mit Diabetes mellitus ein erhohtes Risiko fur die Erkrankung an einem CCA haben, wird es eine grose Herausforderung darstellen unter dieser grosen Anzahl an Patienten diejenigen zu identifizieren, die das hochste Risiko fur die Erkrankung an einem CCA aufweisen, um sie dann Fruherkennungsmasnahmen zuzufuhren.

Verbesserte Diagnosemoglichkeiten haben in den letzten Jahren dazu gefuhrt, dass die Detektionsrate von adenomatosen Polypen weiter gesteigert werden konnte. Entscheidend hat dazu die Etablierung von hochauflosenden Videoendoskopen beigetragen. Weitere Neuerungen, wie die Nutzung eines vergroserten Bildausschnitts, erzielten in ersten Studien positive Ergebnisse hinsichtlich einer Steigerung der Adenomdetektionsrate. Durch die Verwendung von virtuellen Farbetechniken konnen kolorektale Polypen optisch charakterisiert und die pathologische Diagnose vorhergesagt werden. Eine Herausforderung stellt aber nach wie vor die Detektion von serratierten Adenomen dar. Diese Polypen kommen vermehrt im rechten Hemikolon vor, dem Ort, an dem die Rate ubersehener Adenome am grosten ist. Der Sorgfalt des Untersuchers kommt hier eine besondere Bedeutung zu. Bei der Entfernung von kolorektalen Polypen stehen unterschiedliche Resektionsmethoden zur Verfugung. Ein entscheidendes Kriterium bei der Auswahl der Methode ist die Grose des Polypen. Grundsatzlich ist immer die komplette Resektion anzustreben. Die endoskopische Mukosaresektion ist dafur eine etablierte Methode welche insbesondere ab einer Polypengrose von 6 mm zum Einsatz kommt. Bei sehr grosen Polypen des Rektums steht die ESD zur Verfugung, wobei der Einsatz der Methode angesichts der erhohten Invasivitat sorgsam abgewogen werden sollte. Neue Verfahren wie die endoskopische Vollwandresektion sind seit kurzem auch fur das Kolon verfugbar. Relevanz und Wertigkeit der Methode werden derzeit aber noch in klinischen Forschungsprojekten gepruft.

Patients are at increased risk of disease recurrence after surgical treatment of Crohn's disease. Endoscopic detection of postoperative, ileo-colonic inflammation is well established, but the potential of pan-intestinal endoscopy is yet unknown.This prospective multicenter pilot study assessed the value of pan-intestinal capsule endoscopy using a colon capsule endoscope for the detection of inflammatory recurrence of Crohn´s disease. Patients who had been operatively treated for Crohn´s disease were included. Colon capsule endoscopy was performed 4-8 weeks (d1) and 4-8 months (d2) postoperatively together with ileo-colonoscopy at d2 using a modified Ruttgeerts index for evaluating disease activity.Twenty-two patients were included into this study. At d1, significant disease activity (Ruttgeerts index ≥2) was detected in 3/16 (19%) of the patients. At d2, half of the patients (6/12) showed active disease, whereas ileo-colonoscopy revealed significant inflammation in 5/15 (33%). All patients rated as having active disease by ileo-colonoscopy had been revealed by PICE as well. These findings influenced the medical treatment in every case.Pan-intestinal capsule endoscopy seems to be feasible in the postoperative surveillance of Crohn's disease. Disease activity is reliably detected. Especially, the findings in the small bowl might be a significant advantage in comparison to ileo-colonoscopy, as they can have significant impact on clinical management. Further studies with a larger number of patients are needed to confirm these findings and might lead to a replacement of the flexible ileo-colonoscopy with pan-intestinal capsule endoscopy in this indication in the future.

Das Magenkarzinom ist ein aggressiver Tumor, der aufgrund spat auftretender Symptomatik insgesamt mit einer schlechten Prognose einhergeht. Wahrend das Magenfruhkarzinom durch endoskopische Abtragung behandelt werden kann, zeigten zahlreiche Studien, dass beim lokal fortgeschrittenen Magenkarzinom eine perioperative Chemotherapie die Prognose deutlich verbessert. Die chirurgische Therapie umfasst die subtotale bzw. totale Magenresektion mit Lymphadenektomie der Kompartimente 1 und 2 (D2). Eine zusatzliche Splenektomie oder Pankreasschwanzresektion erhoht die Morbiditat und sollte vermieden werden. Bei fehlender Resektabilitat kann eine palliative Chemotherapie (in Kombination mit Trastuzumab bei positivem HER2-Status) die Prognose verbessern. Zur Verbesserung der Lebensqualitat sind endoskopische oder ggf. operative Verfahren geeignet. Die Nachsorge nach onkologischer Behandlung erfolgt symptomorientiert, eine regelmasige Vitamin- B12-Substitution ist essenziell.

During endoscopic retrograde cholangiopancreatography (ERCP), a guidewire is used to cannulate biliary strictures and allow for therapeutic interventions. The aim of this study was to assess the success of stricture cannulation using a combination of a flexible guidewire and a stable nitinol wire vs. a novel, single, stiff-shaft, flexible-tip guidewire.Consecutive patients who were scheduled for ERCP for biliary obstruction were randomized to undergo the procedure with either a 260-cm long, angled-tip hydrophilic wire in combination with a nitinol wire as required (standard group), or a novel, 270-cm guidewire featuring a hyperflexible, hydrophilic tip with a stiff shaft (novel group). At unsuccessful negotiation of the stricture, patients in the standard group were switched to the novel guidewire and vice versa ("crossover"). Successful cannulation (primary success: as assigned; final success: after "crossover"), procedure time, and total number of wires needed per procedure were compared.A total of 222 patients were randomized and 197 were included in the study (97 in the standard group and 100 in the novel group). The primary success rate was significantly higher in the novel group (94/100, 94 %) compared with the standard group (77/97, 79 %; P = 0.00041), and final success was similar. Mean time (median, interquartile range) to stricture cannulation was 11.2 minutes (6.3, 3.7 - 14.6) in the standard group and 8.1 minutes (2.5, 0.9 - 7.7) in the novel group (P 0.0001). The mean total procedure time was 31.2 minutes (24.6, 16.5 - 40.8) vs. 24.3 minutes (16.9, 10.0 - 31.5), respectively (P = 0.0011). There were no complications observed with either of the guidewires.A guidewire that features a flexible tip with a stable shaft could replace the use of a combination of flexible and stable guidewires and increase the success rate of stricture cannulation while decreasing the procedure time.ClinicalTrials.gov Identifier: NCT 01382680.

Capsule endoscopy (CE) is the gold standard to diagnose small bowel bleeding. The "suspected blood indicator" (SBI) offers an automated detection of active small bowel bleeding but validity of this technique is unknown. The objective was to analyze specificity and sensitivity of the SBI using the second small bowel capsule generation for the detection of active bleeding.This is a retrospective analysis of all patients (199) who attended our clinic for CE from June 2008 through March 2013. The second-generation PillCam SB 2 capsule was used for detection of (1) luminal blood content and (2) potentially responsible small bowel lesions. The findings of an independent investigator were correlated to SBI findings and a number of SBI markings were analyzed by a receiver operating characteristic (ROC).In 157/199 cases, no sign of active bleeding or altered blood was detected. One hundred and thirty-seven of these 157 cases provided at least one SBI marking and a mean of 18.4 positive SBI markings per record were found. In 20 cases, neither SBI nor the human investigator detected abnormalities. Thirteen patients showed investigator-detected minor bleeding with mean SBI findings of 36 positive screenshots per record. When major bleeding was diagnosed by the investigator (n = 29), SBI detected a mean of 46.6 SBI-positive markings. SBI turned positive in 179 patients, whereas the investigator detected active bleeding in 42 cases. All patients with active bleeding were detected by SBI (sensitivity 100%, specificity 13%). ROC analysis revealed 51.0 SBI markings being the optimal cutoff for active versus no bleeding (sensitivity 79.1%, specificity 90.4%, misclassification of 15.3%).The new SBI software is a reliable tool to exclude active bleeding and/or major lesions but analysis of the CE video by a trained investigator is still important for the detection of lesions responsible for past bleeding.

Cholangiozellulare Karzinome (CCC) werden entsprechend ihrer Lokalisation in intrahepatische (iCCC), perihilare (pCCC) und distale (dCCC) Subgruppen eingeteilt, die unterschiedliche Charakteristika und Therapieoptionen aufweisen. Durch eine moderne Schnittbildgebung mit Magnetresonanzcholangiopankreatographie (MRCP) bestehen ausgezeichnete nichtinvasive diagnostische Optionen. Fur das iCCC kann nach Majorresektion der Leber ein medianes Uberleben von 36 bis 57 Monaten erzielt werden. Fur das pCCC bietet die radikale En-bloc-Resektion mit Pfortaderresektion uberlegene 5-Jahres-Uberlebensraten von 58%. Das dCCC weist nach Pankreatoduodenektomie 5-Jahres-Uberlebensraten von 27–33% auf. Die Domane der Endoskopie liegt in der palliativen Stenteinlage, ggf. in Kombination mit einer photodynamischen Therapie. Palliative Chemotherapiekonzepte weisen ein medianes Uberleben von maximal 13 Monaten auf, fur neoadjuvante oder adjuvante Therapien gibt es bisher kaum Evidenz.

Endoscopic treatment for stenosis of an anastomotic biliary stricture (ABS) after orthotopic liver transplantation (OLT) has been proven to be effective and safe, but the long-term outcomes and the risk factors for recurrence are unknown. All 374 patients who underwent OLT at Frankfurt University Hospital were screened for the occurrence of ABSs. ABSs were treated via the endoscopic insertion of a plastic endoprosthesis (29.8%), balloon dilation (12.8%), or a combination of the two (57.4%). The mean follow-up time was 151 weeks, and the mean survival time was 3.4 years. ABSs were observed in 47 patients (12.6%). The mean time from OLT to an ABS was 16.25 months (median = 3.25 months). The cumulative incidence rates for ABSs were 0.09 after 12 months, 0.10/24 m. and 0.11/36 m. In 12 cases (25.5%), ABSs were observed more than 12 months after OLT. ABSs recurred in 16 of the 47 patients (34%). The occurrence of an ABS 6 weeks or more after OLT was a significant predictor of ABS recurrence [P = 0.04, hazard ratio (HR) = 0.235]. There was a trend of hepatitis C virus (HCV) infections being predominant in patients experiencing ABS recurrence (30% for HCV etiology versus 4% for non-HCV etiology) in comparison with patients not experiencing recurrence (36% for HCV etiology versus 30% for non-HCV etiology, P > 0.05). The severity of the initial stricture predicted ABS recurrence (P = 0.046, HR = 2.78), but it did not influence overall survival. The long-term resolution of ABSs was observed in 45 of the 47 patients (95.7%), and ABS recurrence was treated with another attempt (n = 16 or 34%) or 2 more attempts (n = 1) at endoscopic treatment. In conclusion, the long-term success of the endoscopic treatment of ABSs is highly probable if recurrent strictures are again treated endoscopically. ABSs might occur late (>36 months) after OLT, and lifelong follow-up is essential for identifying OLT patients with ABSs. Liver Transpl 19:586–593, 2013. © 2013 AASLD.