Juergen Maiss

Training with the compactEASIE biologic endoscopy simulator significantly improves hemostatic technical skill of gastroenterology fellows: a randomized controlled comparison with clinical endoscopy training alone

BACKGROUND The Erlangen Active Simulator for Interventional Endoscopy (EASIE) was introduced in 1997 for interventional endoscopy training. compactEASIE developed in 1998 is a modified, light-weight version of the original model. Objective evidence of the benefits of training with these models is limited. A randomized controlled study, therefore, was conducted to compare the effects of intensive 7-month, hands-on training in hemostatic techniques by using the compactEASIE model (in addition to clinical endoscopic training) vs. pure clinical training in endoscopic hemostatic methods. METHODS Thirty-seven fellows in gastroenterology in New York City area training programs were enrolled. Baseline skills were assessed on the simulator for the following techniques: manual skills, injection and electrocoagulation, hemoclip application, and variceal ligation. Twenty-eight fellows were then randomized into two comparable groups. Those randomized to Group A received purely clinical training in endoscopic hemostatic techniques at their hospitals. Those in Group B, in addition, were trained by experienced tutors in 3 full-day hemostasis workshops over 7 months. Both groups underwent a final evaluation on the compactEASIE simulator conducted by their tutors and additional evaluators who were blinded to the method of training. Initial and final evaluation scores were compared for each group and between groups. Outcomes of actual clinical hemostatic procedures performed during the study period also were analyzed. RESULTS Ten of 14 fellows randomized to Group A (standard training) and 13 of 14 in Group B (intensive training) returned for the final evaluation. For Group B, scores for all techniques were significantly improved. In Group A, a significant improvement was noted for variceal ligation alone. CONCLUSIONS compactEASIE simulator training (3 sessions over 7 months), together with clinical endoscopic training resulted in objective improvement in the performance by fellows of all 4 endoscopic hemostatic techniques, whereas significant improvement was noted for variceal ligation alone for fellows who had standard clinical training. In clinical practice, fellows who had intensive simulator/clinical training had a significantly higher success rate and a nonsignificant reduction in the frequency of occurrence of complications.

Double-balloon-enteroscopy-based endoscopic retrograde cholangiopancreatography in post-surgical patients.

AIM To evaluate double balloon enteroscopy (DBE) in post-surgical patients to perform endoscopic retrograde cholangiopancreatography (ERCP) and interventions. METHODS In 37 post-surgical patients, a stepwise approach was performed to reach normal papilla or enteral anastomoses of the biliary tract/pancreas. When conventional endoscopy failed, DBE-based ERCP was performed and standard parameters for DBE, ERCP and interventions were recorded. RESULTS Push-enteroscopy (overall, 16 procedures) reached enteral anastomoses only in six out of 37 post-surgical patients (16.2%). DBE achieved a high rate of luminal access to the biliary tract in 23 of the remaining 31 patients (74.1%) and to the pancreatic duct (three patients). Among all DBE-based ERCPs (86 procedures), 21/23 patients (91.3%) were successfully treated. Interventions included ostium incision or papillotomy in 6/23 (26%) and 7/23 patients (30.4%), respectively. Biliary endoprosthesis insertion and regular exchange was achieved in 17/23 (73.9%) and 7/23 patients (30.4%), respectively. Furthermore, bile duct stone extraction as well as ostium and papillary dilation were performed in 5/23 (21.7%) and 3/23 patients (13.0%), respectively. Complications during DBE-based procedures were bleeding (1.1%), perforation (2.3%) and pancreatitis (2.3%), and minor complications occurred in up to 19.1%. CONCLUSION The appropriate use of DBE yields a high rate of luminal access to papilla or enteral anastomoses in more than two-thirds of post-surgical patients, allowing important successful endoscopic therapeutic interventions.

Evaluation of sensitivity and inter- and intra-observer variability in the detection of intestinal metaplasia and dysplasia in Barrett's esophagus with enhanced magnification endoscopy

Objective. Magnification endoscopy with acetic acid or dye for diagnosis of Barretts esophagus is presently undergoing clinical evaluation. Current studies report good accuracy in predicting specialized intestinal metaplasia. To date, however, there is no definitive information on the inter- and intra-observer variability of these methods applied to the diagnosis of normal and dysplastic Barretts mucosa. Material and methods. Sixty patients with endoscopically suspected Barretts esophagus were investigated prospectively with the zoom endoscope after contrast enhancement of the mucosa with 1.5% acetic acid. Two hundred and twenty-three enlarged and histologically investigated areas of gastric, cardiac, normal and dysplastic Barretts mucosa were photodocumented and in randomized sequence presented to 4 endoscopists in a blinded manner (2 with and 2 without experience of zoom endoscopy for evaluation). The reference for the first evaluation (A1) was standard endoscopic photographs of the respective, histologically confirmed mucosal entity. In a second evaluation (A2), the pictures were again interpreted by the same blinded investigators, but this time a modified pit-pattern classification as proposed by Sharma et al. was employed as the evaluation reference. Results. The diagnostic sensitivity for specialized intestinal metaplasia and dysplasia in Barretts esophagus calculated for the A1 evaluation ranged – investigator dependently – from 54.9% to 80.7% and for A2 from 42.2% to 81.5%. The inter- and intra-observer variability for the evaluation procedure A1 and A2 was high (all kappa values <0.4). In particular, the inexperienced investigators demonstrated high intra-observer variability and low sensitivity in comparison with the experienced investigators. Conclusions. The diagnosis of Barretts mucosa using enhanced magnification endoscopy after acetic acid instillation is associated with a high level of interobserver variability. One reason is a frequent mismatch between cardiac mucosa and non-dysplastic Barretts mucosa.

Successful laserlithotripsy in Bouveret's syndrome using a new frequency doubled doublepulse Nd:YAG laser (FREDDY).

Gastric outlet obstruction as a result of gallstone (Bouveret syndrome) is a rare but serious complication of cholelithiasis. In many cases, surgery has been conducted for treatment. In recent years, minimal invasive treatment modalities (e.g. shockwave lithotripsy) have been shown to be effective in some of those patients. Laserlithotripsy has so far been described in two cases with a Rhodamine‐6G dye laser. We present the case of a 90‐year‐old woman with duodenal obstruction due to a huge gallstone. The patient was referred to our hospital because attempts at endoscopic extraction and extracorporeal shockwave lithotripsy had failed. The man was treated successfully in just one session with a new cost‐efficient frequency doubled doublepulse Nd:YAG laser (FREDDY) using a total of 5726 laser pulses (120 mJ pulse energy, 10 Hz pulse repetition rate) and recovered rapidly. Laserlithotripsy can be considered an effective non‐invasive therapeutic alternative to surgical treatment in Bouverets syndrome, especially in old or high‐risk patients.

Refinement of ERCP by using the Olympus V-scope system with a 0.025 in. compatible and complete fixable Visiglide ® guidewire

AIM Prospective evaluation of the new 0.025 in. Visiglide(®) guidewire to facilitate endoscopic retrograde cholangiopancreaticography using the Olympus V-scope. MATERIALS AND METHODS Interventional endoscopic retrograde cholangiopancreaticography was performed in 9 patients with the Olympus V-scope and the 0.025 in. Visiglide(®) guidewire (VS group), whilst 9 other patients underwent endoscopic retrograde cholangiopancreaticography with a conventional Olympus duodenoscope using 0.035 in. conventional guidewires (controls). Exchange time of accessories, X-ray time, dose and endoscopic retrograde cholangiopancreaticography examination time were investigated. RESULTS The VS group showed a significantly lower exchange time of endoscopic retrograde cholangiopancreaticography accessories (9; 4-10s, p<0.0001) than controls (29; 19-44s). The Visiglide(®) guidewire was complete fixable by the elevator in 35/36 instrument exchanges (97%) compared to 16/31 exchanges (52%) using conventional guidewires. LIMITATIONS Single-centre study, small patient numbers, two investigators. CONCLUSIONS Endoscopic retrograde cholangiopancreaticography using the Olympus V-scope with the new 0.025 in. Visiglide(®) guidewire enables a 3-fold faster exchange of accessories due to a nearly complete fixation of the guidewire.

⁎3367 A prospective evaluation of 10 easie team-training workshops on endoscopic hemostasis.

Introduction:The Erlangen Active Simulator for Interventional Endoscopy (EASIE®) is a new close to life training model permitting for the first time the creation of artierial spurting ulcer bleedings, varices and polyps in a specially prepared pig stomach. Overall about 25 different interventional techniques in the upper GI-tract and hepatobiliary system can be trained. Methods:10 systematically structured EASIE team-training courses (21.3.98-8.5.99) on endoscopic hemostasis were evaluated prospectively by the participants according to a questionnaire at the end of one day training. The courses were designed as a team-training for groups of 3 doctors and 3 nurses per simulator. 207 of 283 participants (73.1%) filled in the questionnaire (133 doctors, 65 nurses). As training models 4x EASIE®, 3x miniEASIE®, 3x compactEASIE® were used all equipped with the same, specially prepared pig esophago-gastro-duodenal organ package. For the training of ulcer hemostasis, vessels, polyps and submucosal varices were created. Perfusion was achieved by a roller-pump with the addition of an on demand bypass regulating the pressure of the blood surrogate. Workshop structure: 30 min. theoretical introduction on treatment of ulcer bleeding, 2 hours practical training of injection techniques (epinephrine, fibrin glue) and hemoclip application, 30 min. theoretical introduction of variceal therapy, 2 hours practical training of sclerotherapy (including cyanoacrylat) and banding techniques. Results: Most trainees rated themselves as advanced (39%) or experienced (35%) endoscopists. 19% were endoscopic novices, 7% no statement. Previous experience in endoscopic hemostasis was distributed as follows: No experience 19%, 6 years 20%, 9% no statement. Nearly all trainees assessed the training as excellent or good (83% excellent (++), 14% good (+), 0% unsatisfactory(-), 3% no statement Φ). Single techniques were evaluated as follows: Injection therapy: 73% (++), 18% (+), 0% (-), 9% Φ; Clip application: 83% (++), 9% (+), 1% (-), 7% Φ; Sclerotherapy: 60% (++), 18%(+), 1%(-), 21%Φ; Multiband ligation: 77%(++), 17% (+), 0% (-),. 6% Φ; Closeness to realitywas assessed as good, specifically: 72% (++), 22% (+), 0% (-), 6% Φ. Conclusion: EASIE team-training endoscopic hemostasis has a high acceptance by the trainees. A prospective comparison between conventional endoscopic education and practical education in interventional endoscopy using EASIE will be done soon.