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Background/Aims: Endoscopic transluminal therapy has become the standard of care as a less invasive alternative to surgery. In a retrospective case series of two tertiary referral centers we report on an individualized concept combining EUS-guided drainage with self-expanding metal stents, direct transluminal debridement und percutaneous drainage. Methods: We treated 13 patients with infected pancreatic necrosis. Initially in all patients an EUS-guided drainage with plastic stents was performed under antibiotic protection (transduodenal: 2, transgastral: 11). After clinical consolidation (after 9.6 ± 9.4 days) a covered self-expanding metal stent (Niti-S, Taewoong medical Co., Seoul, Korea) was inserted by performing direct endoscopic necrosectomy in 2.9 ± 1.7 sessions through the stent. In cases of disrupted duct syndromes a pancreatic plastic stent was inserted (5 of 13 patients). In 5 of 13 cases additional percutaneous drainage was applied because of extended necrosis. In one patient percutaneous endoscopic drainage using the percutaneous access was needed. Results: A sustained clinical success was achieved in 12 of 13 cases (CRP before therapy 23.5 ± 14.4 mg/L, after 3.1 ± 2.6 mg/lL). Discharge occurred after 2.5 ± 22.4 days. The self-expanding metal stent was extracted after 82.5 ± 56.6 days. Mean follow up was 8.5 ± 5.9 months. Conclusion: Our concept of combining transluminal drainage, direct endoscopic necrosectomy and percutaneuos drainage offers a safe and reliable alternative to surgery, even in case of extended necrosis.

Die Therapiemoglichkeiten bei Achalasie – Ballondilata-tion, Botulinumtoxin-Injektion und Heller'sche Myotomie – werden durch die neue, minimalinvasive Option der peroralen endoskopischen Myotomie (POEM) erganzt, die nun auf dem Prufstand steht.

Die Achalasie ist eine seltene Motilitatsstorung des Osophagus. Charakteristisch fur die klassische Achalasie sind eine fehlende propulsive Peristaltik des distalen Osophagus sowie eine inkomplette Relaxation des unteren Osophagussphinkters. Etablierte Verfahren zur Therapie der Achalasie sind die endoskopische Ballondilatation des unteren Osophagussphinkters oder die laparoskopische Myotomie nach Heller. Beide Therapieverfahren gelten als vergleichbar effektiv. Kurzlich wurde mit der peroralen endoskopischen Myotomie eine neue definitive Therapieoption eingefuhrt. Dieses minimalinvasive Verfahren wurde bisher erst in wenigen klinischen Studien evaluiert. In der folgenden Ubersicht wird die perorale endoskopische Myotomie vorgestellt und ihr Stellenwert in Abgrenzung zum chirurgischen Vorgehen herausgearbeitet. Zur Diagnosestellung der Achalasie ist eine klinische Anamnese und Symptomanalyse, eine Osophagusmanometrie sowie eine Rontgendarstellung des Osophagus sinnvoll. Endoskopisch sollte zudem eine andere Ursache der Dysphagie ausgeschlossen werden. Die Beschwerden sollten moglichst anhand eines Symptom-Scores erfasst werden. Bei der POEM wird endoskopisch zunachst im mittleren Osophagus eine Mukosainzision durchgefuhrt. Anschliesend erfolgt in Langsrichtung eine Tunnelung der Submukosa bis etwa 2 cm distal des gastroosophagealen Ubergangs mit nachfolgender Myotomie (zumindest) der zirkular verlaufenden Muskelschicht des distalen Osophagus und der angrenzenden Kardia. Abschliesend wird die Mukosainzision wieder mit Metallclips verschlossen. Die ersten Ergebnisse dieser Methode sind sehr vielversprechend und zeigen eine signifikante Besserung der Symptomatik und Reduktion des Ruhedrucks des unteren Osophagussphinkters. POEM ist eine neue, minimalinvasive Therapieoption der osophagealen Achalasie. Die ersten Ergebnisse sind sehr vielversprechend; Langzeitergebnisse sowie Vergleichsstudien mit etablierten Therapieverfahren mussen jedoch noch abgewartet werden.

Background EUS-guided FNA (EUS-FNA) is an established tissue-acquisition technique, with most studies concentrating on cytologic analyses of specimens, with only few data existing on histologic assessment. Objective To assess the sensitivity of a combined analysis of histologic followed by cytologic tissue diagnosis. Design A retrospective 3-center study. Methods In consecutive patients undergoing FNA of solid pancreatic masses, core specimens were harvested for histology; residual tissue was examined cytologically. Only unequivocally positive results were regarded as malignant. Criterion standards were positive results from EUS-FNA or other histologic findings, or, if negative, clinical follow-up data (minimum 12 months). Results Among 192 patients (110 men; mean age 63 years) with mostly pancreatic-head masses (72.4%), overall, adequate tissue was obtained in 98.9% of all cases, with a mean of 1.88 needle passes and an overall sensitivity of 82.9% (95% CI, 76.0%-88.5%). Histology and subsequent cytology provided adequate tissue and sensitivities of 86.5% and 60%, and 92.7% and 68.1%, respectively. Excluding cases with inadequate specimens, sensitivities rose by 4% to 10%. Histology showed a trend for superiority over cytology only in characterizing nonadenocarcinoma tumor types. No differences in sensitivity were found between the centers involved. Limitations Retrospective design, different processing of cytologic specimens. Conclusions At EUS-FNA in pancreatic masses, combined histologic-cytologic analysis achieved a sensitivity of more than 80%, despite a low number of needle passes and may thus save time. Histology alone did not reach higher sensitivity than cytology. In particular situations, eg, rare tumors, histology may still be required.

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.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.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).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.

Hintergrund: In der Abrechnungssystematik der Deutschen Krankenhauser (G-DRG-System) sind endoskopische Leistungen weder vollstandig noch kostengerecht abgebildet. Hauptursache ist eine Zuordnung der Personalkosten aufgrund veralteter Leistungskataloge sowie das Fehlen einer verpflichtenden Zeiterfassung der Personalbindung. Methodik: Zur Erstellung eines zeitgemasen Leistungskatalogs wurden der DGVS von 50 Kalkulationskrankenhausern des Instituts fur das Entgeltsystem im Krankenhaus (InEK) die kompletten gastroenterologischen Kostendatensatze (2011 – 2013; § 21,4 KHEntgG) anonymisiert uberlassen (2499 900 Falldatensatze) und aus diesen alle Operationen und Prozedurenschlussel (OPS) endoskopischer Leistungen in Leistungsgruppen (z. B. Koloskopie mit Biopsie/Koloskopie mit Stenteinlage) klassifiziert. Eine Expertengruppe ordnete die Leistungsgruppen nach Fallschwere und wies ihnen geschatzte Personalbindungszeiten zu. Von Juni bis November 2014 wurde der Leistungskatalog an 119 Krankenhausern mittels exakter Personalzeiterfassung in der Endoskopie validiert (38 288 Prozeduren). Ergebnisse: Dieses 3-stufige Vorgehen hat, in enger Abstimmung mit dem InEK, die Erstellung eines zeitgemasen Leistungskatalogs mit 97 Einzelleistungsgruppen ermoglicht, der uber 99 % aller durchgefuhrten endoskopischen Prozeduren abdeckt und diese anhand der gemessenen arztlichen Personalbindung gewichtet. Wahrend in der Vergangenheit eine diagnostische Koloskopie im Vergleich zur Osophagogastroduodenoskopie (Standardwert 1,0) ein Relativgewicht von 1,13 aufwies, wird der Personalaufwand im Leistungskatalog sachgerechter mit 2,16 abgebildet. Bei der diagnostischen ERCP andert sich das Relativgewicht von 1,7 auf 3,62. Leistungen mit hoher Personalbindung, die bisher nicht erfasst wurden, werden jetzt sachgerecht abgebildet (z. B. ESD im Magen 16,74). Diskussion: Der neue, in Zusammenarbeit von uber hundert Krankenhausern validierte Leistungskatalog bildet endoskopische Prozeduren in der Gastroenterologie nahezu vollstandig ab und weist diesen validierte Relativkostengewichte zu. Der Einsatz des Leistungskatalogs wird vom InEK als Ersatz fur veraltete GOA-, DKG-NT- und Hauskataloge empfohlen und wird, bis zum flachendeckenden Einsatz der Zeiterfassung in der Endoskopie, wesentlich zu einer sachgerechteren Zuordnung der Kosten im deutschen DRG-System beitragen.

Pancreatic necrosis and abscess are among the most severe complications of acute pancreatitis. Although open surgical necrosectomy for treatment of infected pancreatic necrosis is associated with high morbidity and mortality, endoscopic transgastric or transduodenal therapy with endoscopic necrosectomy is a safe and effective treatment for carefully selected patients. In case of unsuccessful necrosectomy and pseudocyst drainage, the implantation of a newly designed self expandable metal stent (SEMS) can help to provide a sufficiently large and secure access to ensure an adequate necrosectomy and necrotic cavity drainage. The case presented is of a 71-year-old patient with an infected pancreatic necrosis as a result of a biliary pancreatitis. Through the implantation of a newly designed SEMS, multiple dilations can be avoided and a large and easy access to the necrotic cavity for sufficient drainage and necrosectomy can be established. This article is part of an expert video encyclopedia.

Achalasia is a rare motility disorder of the oesophagus. Classic achalasia is characterised by a lack of propulsive peristalsis of the distal oesophagus and incomplete relaxation of the lower oesophageal sphincter (LES). Traditionally achalasia is treated either endoscopically by pneumatic balloon dilatation or laparoscopically by Heller's myotomy. Both therapeutic procedures show a comparable effectiveness. Recently, peroral endoscopic myotomy was introduced as a new definitive treatment option. So far, this minimally invasive therapy was evaluated in a few clinical studies only. In this survey, peroral endoscopic myotomy is presented and compared to the well established surgical treatment. The diagnosis of achalasia is based on the patient's medical history and analysis of symptoms and particularly on oesophageal manometry. In addition, a barium swallow (oesophagram) and upper endoscopy are performed to rule out other reasons causing dysphagia. The patient's complaints should be recorded by use of a symptoms score. The POEM procedure starts with an incision of the mucosa at the level of the mid-oesophagus. Then, a submucosal tunnel is created distally passing approximately 2 cm over the oesophagogastric junction. After this step, myotomy of (at least) the circular muscle bundle of the distal oesophagus is performed and should be extended to a distance of 2 cm over the cardiac. Finally the mucosal entry site at the level of the mid-oesophagus is closed with endoscopic clips. First results of this technique are very promising with significant symptom relief and reduction of the mean LES pressure. In conclusion, POEM is a new, minimally invasive therapeutic option for the treatment of oesophageal achalasia. First results are very promising; long-term results and results of comparative clinical trials with established treatment methods must be awaited.

Background and study aims: The majority of colonoscopies in Germany are performed under conscious sedation. Previous studies reported that pediatric colonoscopes reduce the demand for sedative drugs and may improve cecal intubation. The aim of this study was to compare a new ultrathin and a standard colonoscope in terms of propofol demand during colonoscopy. Patients and methods: A total of 203 patients were prospectively randomized to undergo colonoscopy with either a 9.5-mm ultrathin (UTC) colonoscope or a standard colonoscope of variable stiffness. Initially, 40 or 60 mg of propofol were administered according to body weight, followed by bolus injections of 20 mg as deemed necessary. Propofol was administered by a separate physician who was blinded to the endoscope used. Sedation levels were defined according to guidelines; pain and complaints were recorded on a numeric rating scale. Results: Significantly less propofol was required to reach the cecum with the UTC (adjusted mean 94.9 mg [95 % confidence interval (CI) 85.7 – 105.0] vs. 115.3 mg [95 %CI 105.8 – 124.7]; P = 0.003). The level of sedation and pain score were lower with the UTC (sedation level 1 76 % vs. 61 %; P = 0.003; pain score adjusted mean 2.0 [95 %CI 1.7 – 2.4] vs. 2.8 [95 %CI 2.5 – 3.1]; P = 0.001). The rate of ileal and cecal intubation, time to reach the cecum, number of external compressions, withdrawal time, polyp and adenoma detection rate, and patient satisfaction were not different between the two colonoscopes. The time to intubate the ileum was longer with the UTC (1.73 minutes [95 %CI 1.42 – 2.04] vs. 1.22 minutes [95 %CI 0.91 – 1.52]; P = 0.020). Conclusions: Use of a new ultrathin colonoscope was associated with reduced propofol consumption, lower patient sedation levels, and less pain than the standard colonoscope, but ileal intubation time was longer.

BACKGROUND AND STUDY AIMS: Endoscopic mucosal resection (EMR) of early gastrointestinal cancers has been shown to be effective in treating mucosal malignancies, but en bloc resection (where the entire tumor is removed in one piece) is often not achieved using conventional cap EMR. Other techniques, developed in Japan, include the application of different types of knife such as the insulated-tip instrument. We report our preliminary experience of the use of this knife, in conjunction with other techniques, in attempting en bloc resection of early mucosal cancers and adenomas and in the removal of submucosal tumors (SMTs) of the upper gastrointestinal tract. PATIENTS AND METHODS: A total of 37 patients (26 men, 11 women, age range 53 - 86) were included in the study; 23 patients had 24 mucosal lesions amenable to EMR, and 14 patients had SMTs shown on endosonography to spare the muscularis propria. Lesions were located in the esophagus (n = 13), the stomach (n = 24), and the duodenum (n = 1); 40 % of the mucosal lesions were 20 mm or larger (mean size 18mm), whereas the mean size of the submucosal lesions was 23 mm. After submucosal saline injection, circumcision and dissection of the mucosal lesions was attempted with the aim of achieving en bloc resection. For SMTs, cap mucosectomy of the overlying mucosa was done first, and the tumors were then freed using saline injection, and finally resected using snare polypectomy. RESULTS: The strict aim of the study, i. e. complete tumor removal in a single piece, was achieved in only 25 % of the mucosal lesions (some failures were due to unrecognized submucosal infiltration) and 36 % of the SMTs. When a more liberal definition of success was assumed, this rate increased to 65 % for mucosal lesions (piecemeal, no tumor found at surgery or follow-up endoscopy with biopsy) and 79 % for SMTs (piecemeal). No severe complications necessitating surgery or leading to major morbidity occurred. However, clinically significant complications were found in six patients (minor perforation managed conservatively (n = 1), severe pain without perforation (n = 1), bleeding requiring reintervention (n = 3), and aspiration (n = 1)). CONCLUSIONS: Although we are convinced that methods of achieving en bloc resection of mucosal cancers and SMTs must be pursued, the insulated-tip knife in conjunction with conventional endoscopes still has limitations. Innovative endoscope design (double-channel scopes) as well as the development of new accessories will help to overcome the current limitations and further promote endoscopic tumor resection.