Jörg Albert

Role of endoscopy in primary sclerosing cholangitis: European Society of Gastrointestinal Endoscopy (ESGE) and European Association for the Study of the Liver (EASL) Clinical Guideline

This guideline is an official statement of the European Society of Gastrointestinal Endoscopy (ESGE) and of the European Association for the Study of the Liver (EASL) on the role of endoscopy in primary sclerosing cholangitis. The Grading of Recommendations Assessment, Development and Evaluation (GRADE) system was adopted to define the strength of recommendations and the quality of evidence. Main recommendations.

Direct retrograde cholangioscopy with a new prototype double-bending cholangioscope

BACKGROUND AND STUDY AIMSnDirect 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.nnnPATIENTS AND METHODSnAll 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.nnnRESULTSnDRC 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 (97u200a%). The targeted bile duct segment was reached in 62u200a/74 patients (84u200a%), with an anchoring balloon catheter needed in 21/74 (28u200a%). Mean investigation time was 21 minutes (15u200a-u200a27 minutes)nnnCONCLUSIONSnDRC 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.

The Periprocedural Management of Anticoagulation and Platelet Aggregation Inhibitors in Endoscopic Interventions

BACKGROUNDnIn Germany, more than half a million persons, most of them elderly, are under long-term treatment with anticoagulants. The approval of new oral anticoagulants and platelet aggregation inhibitors, as well as new data on periprocedural bridging with heparins, have introduced marked complexity to the management of treatment with anticoagulants and platelet aggregation inhibitors for endoscopic interventions in visceral surgery.nnnMETHODSnThis review is based on pertinent publications retrieved by a selective literature search in PubMed, as well as on the relevant guidelines.nnnRESULTSnRobust data are available on the management of vitamin K antagonists (VKA) and platelet aggregation inhibitors for endoscopic procedures; on the other hand, the data on the periprocedural management of non-VKA oral anticoagulants (NOAC) are still inadequate. Endoscopic procedures that carry a low risk of bleeding can be performed under treatment with anticoagulants or platelet aggregation inhibitors. Before any procedure with a high risk of bleeding (≥ 1.5%) oral anticoagulants of any type and P2Y12 inhibitors should generally be discontinued. Patients in whom VKA are temporarily discontinued for this reason need bridging treatment with heparin only if they are at high risk of thromboembolic events (≥ 10% per year). For patients who are anticoagulated with NOAC, timely discontinuation of the drug depending on renal function is of key importance, and bridging is usually unnecessary.nnnCONCLUSIONnAdequate scientific evidence supports the current recommendations and treatment algorithms for the periprocedural management of oral anticoagulants and platelet aggregation inhibitors in endoscopic procedures. Larger-scale studies are still needed to provide a sound basis for the corresponding recommendations about NOAC.

Endoscopic management of acute necrotizing pancreatitis: European Society of Gastrointestinal Endoscopy (ESGE) evidence-based multidisciplinary guidelines

1: u2002ESGE 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: u2002ESGE 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: u2002ESGE recommends initial goal-directed intravenous fluid therapy with Ringers lactate (e.u200ag. 5u200a-u200a10u200amL/kg/h) at onset. Fluid requirements should be patient-tailored and reassessed at frequent intervals. Strong recommendation, moderate quality evidence. 4: u2002ESGE recommends against antibiotic or probiotic prophylaxis of infectious complications in acute necrotizing pancreatitis. Strong recommendation, high quality evidence. 5: u2002ESGE 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 4xa0weeks if tolerated by the patient. Weak recommendation, low quality evidence. 6: u2002ESGE 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: u2002ESGE 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: u2002ESGE 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 4xa0weeks to avoid stent-related adverse effects.Strong recommendation, low quality evidence.

Eosinophilic cholangitis is a potentially underdiagnosed etiology in indeterminate biliary stricture

AIM To investigate presence and extent of eosinophilic cholangitis (EC) as well as IgG4-related disease in patients with indeterminate biliary stricture (IBS). METHODS All patients with diagnosis of sclerosing cholangitis (SC) and histopathological samples such as biopsies or surgical specimens at University Hospital Frankfurt from 2005-2015 were included. Histopathological diagnoses as well as further clinical course were reviewed. Tissue samples of patients without definite diagnosis after complete diagnostic work-up were reviewed regarding presence of eosinophilic infiltration and IgG4 positive plasma cells. Eosinophilic infiltration was as well assessed in a control group of liver transplant donors and patients with primary sclerosing cholangitis. RESULTS one hundred and thirty-five patients with SC were included. In 10/135 (13.5%) patients, no potential cause of IBS could be identified after complete diagnostic work-up and further clinical course. After histopathological review, a post-hoc diagnosis of EC was established in three patients resulting in a prevalence of 2.2% (3/135) of all patients with SC as well as 30% (3/10) of patients, where no cause of IBS was identified. 2/3 patients with post-hoc diagnosis of EC underwent surgical resection with suspicion for malignancy. Diagnosis of IgG4-related cholangitis was observed in 7/135 patients (5.1%), whereas 3 cases were discovered in post-hoc analysis. 6/7 cases with IgG4-related cholangitis (85.7%) presented with eosinophilic infiltration in addition to IgG4 positive plasma cells. There was no patient with eosinophilic infiltration in the control group of liver transplant donors (n = 27) and patients with primary sclerosing cholangitis (n = 14). CONCLUSION EC is an underdiagnosed benign etiology of SC and IBS, which has to be considered in differential diagnosis of IBS.

Narrow-band imaging vs. high definition white light for optical diagnosis of small colorectal polyps: a randomized multicenter trial.

BACKGROUND AND STUDY AIMnThe aim of the study was to compare the latest narrow-band imaging (NBI) device with high-definition white light (HDWL) endoscopy for accuracy of real-time optical diagnosis of small colorectal polyps.nnnPATIENTS AND METHODSnWe conducted a randomized, prospective, multicenter trial at three study sites in Germany. In the NBI arm, endoscopists used NBI for the prediction of polyp pathology on the basis of the NBI International Colorectal Endoscopic classification. In the HDWL arm, NBI was not used for optical classification of polyp histology. The primary outcome was accuracy of optical diagnoses (neoplastic vs. non-neoplastic) in small polyps measuring <u200a10u200amm. Secondary end points included sensitivity and negative predictive value (NPV).nnnRESULTSnA total of 380 patients were randomized 1:1 to either the NBI or HDWL arm. A total of 421 polyps measuring <u200a10u200amm were detected (55.8u200a% neoplastic, 44.2u200a% non-neoplastic). Accuracy, sensitivity, and NPV were 73.7u200a%, 82.4u200a%, and 75.5u200a%, respectively, in the NBI arm and 79.2u200a%, 79.8u200a%, and 73.4u200a%, respectively, in the HDWL arm (Pu200a=u200a0.225, Pu200a=u200a0.667, Pu200a=u200a0.765). More polyps were assessed with high confidence in the HDWL arm (82.6u200a%) than in the NBI arm (73.7u200a%; Pu200a=u200a0.038). The NPV of the prediction of neoplastic histology in diminutive polyps (≤u200a5u200amm) rated with high confidence was 90.3u200a% in the NBI arm. We detected significant differences between the participating study sites in the performance data of predictions.nnnCONCLUSIONnThe levels of accuracy for real-time prediction of polyp histology (<u200a10u200amm) did not differ between NBI and HDWL for optical diagnosis. Variation in the performance of optical diagnosis was apparent between study centers.nnnTRIAL REGISTRATIONnClinicalTrials.gov (NCT02009774).

Endoskopische Therapie der Choledocholithiasis

ZusammenfassungEine Cholezystolithiasis (CCL) ist häufig und betrifft 15–20u2009% der erwachsenen Bevölkerung. In 10–15u2009% der Patienten mit CCL kommt es zu einer Choledocholithiasis (CDL) als Folge einer Steinmigration aus der Gallenblase. Die endoskopische Therapie der CDL mittels endoskopischer retrograder Cholangiopankreatikographie (ERCP) hat weitgehend die chirurgische Steinentfernung abgelöst und die Mortalität bei endoskopisch behandelbaren Erkrankungen halbiert. Bei der Cholangitis sowie bei der biliären Pankreatitis mit begleitender Cholangitis ist eine ERCP notfallmäßig indiziert. Vor der Steinextraktion erfolgt in westlichen Ländern standardmäßig eine endoskopische Sphinkterotomie (EST), jedoch zeigt die in Asien favorisierte Sphinkteroplastie mittels hydrostatischer Ballondilatation vergleichbare Ergebnisse. Die Steinextraktion erfolgt mittels Steinextraktionskörbchen oder Steinextraktionsballonkatheter. Bei größeren Gallengangsteinen ist häufig eine Lithotripsie notwendig. Hierzu stehen die unterschiedlichen Verfahren der mechanischen oder elektrohydraulischen Lithotripsie bzw. Laserlithotripsie zur Verfügung. Der aktuelle Artikel behandelt die Indikationsstellung und technische Durchführung der endoskopischen Therapie der CDL sowie das Komplikationsmanagement in besonderen Fällen.AbstractGallstones are common and affect 15–20% of the adult population. Moreover, 10–15% of patients with gallbladder stones develop bile duct stones (CBD). Endoscopic treatment with use of endoscopic retrograde cholangiography (ERCP) has replaced surgical stone removal and has cut mortality for endoscopically treated patients by half. For patients with cholangitis or acute biliary pancreatitis, ERCP has to be performed as an urgent emergency procedure. Endoscopic sphincterotomy and stone extraction is the preferred treatment option in Western countries. However, endoscopic papillary balloon dilatation, as typically used in Asian countries, shows comparable results. Stone extraction is performed using balloon catheters or extraction baskets. For the removal of bigger stones, lithotripsy is frequently needed. Different techniques, such as mechanical or electrohydraulic lithotripsy, are available for this indication. The article includes current guidelines for the application of endoscopic CBD therapy and describes the technical execution as well as complication management.

Kosten endoskopischer Leistungen der Gastroenterologie im deutschen DRG-System – 5-Jahres-Kostendatenanalyse des DGVS-Projekts

Backgroundu2002In the German hospital reimbursement system (G-DRG) endoscopic procedures are listed in cost center 8. For reimbursement between hospital departments and external providers outdated or incomplete catalogues (e.u200ag. DKG-NT, GOÄ) have remained in use. We have assessed the cost for endoscopic procedures in the G-DRG-system. Methodsu2002To assess the cost of endoscopic procedures 74 hospitals, annual providers of cost-data to the Institute for the Hospital Remuneration System (InEK) made their data (2011u200a-u200a2015; §u200a21 KHEntgG) available to the German-Society-of-Gastroenterology (DGVS) in anonymized form (4873u200a809 case-data-sets). Using cases with exactly one endoscopic procedure (nu200a=u200a274u200a186) average costs over 5 years were calculated for 46 endoscopic procedure-tiers. Resultsu2002Robust mean endoscopy costs ranged from 230.56u200a€ for gastroscopy (144u200a666 cases), 276.23u200a€ (nu200a=u200a32u200a294) for a simple colonoscopy, to 844.07u200a€ (nu200a=u200a10u200a150) for ERCP with papillotomy and plastic stent insertion and 1602.37u200a€ (nu200a=u200a967) for ERCP with a self-expanding metal stent. Higher costs, specifically for complex procedures, were identified for University Hospitals. Discussionu2002For the first time this catalogue for endoscopic procedure-tiers, based on §u200a21 KHEntgG data-sets from 74 InEK-calculating hospitals, permits a realistic assessment of endoscopy costs in German hospitals. The higher costs in university hospitals are likely due to referral bias for complex cases and emergency interventions. For 46 endoscopic procedure-tiers an objective cost-allocation within the G-DRG system is now possible. By international comparison the costs of endoscopic procedures in Germany are low, due to either greater efficiency, lower personnel allocation or incomplete documentation of the real expenses.

Predictive Value of Computed Tomography Scans and Clinical Findings for the Need of Endoscopic Necrosectomy in Walled-off Necrosis From Pancreatitis

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.

Combined percutaneous retrograde and peroral antegrade esophagoscopy for the treatment of complete upper esophageal obstruction.

Complete upper esophageal obstruction is a rare but significant complication of, for example, radiotherapy or caustic ingestion. It may be resolved by endoscopic techniques [1–4]. Here, we report three patients with complete or nearly complete upper esophageal obstruction after curative radiochemotherapy for head and neck cancers, in whom classic peroral insertion of a guidewire for esophageal dilation failed. However, in all of these patients, esophageal stenosis was successfully treated by the combinination of a percutaneous retrograde and a peroral antegrade endoscopic approach. The length of the stenoses in these patients ranged from 2 to 20mm (● Fig.1). Retrograde esophagoscopy was accomplished with an ultraslim gastroscope through an existing percutaneous gastrostomy. At the same time, peroral antegrade esophagoscopy was performed to enable diaphanoscopy-guided recanalization of the esophageal stenosis with a needle knife (● Fig.1,● Video 1). Afterward, a stomach tube was placed, and the reconstructed esophageal neolumen was allowed to heal for 2 to 4 weeks. Subsequently, the patients have undergone conventional esophageal dilation procedures, which have been ongoing for 4 to 24 months (● Fig.1). Meanwhile, all the patients can be nourished orally and have experienced a significant increase in body weight and improvement in quality of life. No relevant complications have been observed in these patients during the entire course of endoscopic treatment. In conclusion, the combination of a percutaneous retrograde and a peroral antegrade endoscopic approach can be safe and efficient for the treatment of complete upper esophageal stenosis.