Prioritization and resource allocation in the context of the COVID-19 pandemic. Recommendations for colorectal and pancreatic cancer in Germany.

In the context of the COVID-19 pandemic, there has been a scarcity of resources with various effects on the care of cancer patients. This paper provides an English summary of a German guideline on prioritization and resource allocation for colorectal and pancreatic cancer in the context of the pandemic. Based on a selective literature review as well as empirical and ethical analyses, the research team of the CancerCOVID Consortium drafted recommendations for prioritizing diagnostic and treatment measures for both entities. The final version of the guideline received consent from the executive boards of nine societies of the Association of Scientific Medical Societies in Germany (AWMF), 20 further professional organizations and 22 other experts from various disciplines as well as patient representatives. The guiding principle for the prioritization of decisions is the minimization of harm. Prioritization decisions to fulfill this overall goal should be guided by 1. the urgency relevant to avoid or reduce harm; 2. the likelihood of success of the diagnostic or therapeutic measure advised; and 3. the availability of alternative treatment options. In the event of a relevant risk of harm as a result of prioritization, these decisions should be made by means of a team approach. Gender, age, disability, ethnicity, origin and other social characteristics, such as social or insurance status, as well as the vehemence of a patient's treatment request and SARS-CoV-2 vaccination status should not be used as prioritization criteria. The guideline provides concrete recommendations for 1. diagnostic procedures, 2. surgical procedures for cancer, and 3. systemic treatment and radiotherapy in patients with colorectal or pancreatic cancer within the context of the German healthcare system.

Updated German guideline on diagnosis and treatment of squamous cell carcinoma and adenocarcinoma of the esophagus.

Diagnosis and therapy of esophageal carcinoma is challenging and requires a multidisciplinary approach. The purpose of the updated German guideline "Diagnosis and Treatment of Squamous Cell Carcinoma and Adenocarcinoma of the Esophagus-version 3.1" is to provide practical and evidence-based advice for the management of patients with esophageal cancer. Recommendations were developed by a multidisciplinary expert panel based on an extensive and systematic evaluation of the published medical literature and the application of well-established methodologies (e.g. Oxford evidence grading scheme, grading of recommendations). Accurate diagnostic evaluation of the primary tumor as well as lymph node and distant metastases is required in order to guide patients to a stage-appropriate therapy after the initial diagnosis of esophageal cancer. In high-grade intraepithelial neoplasia or mucosal carcinoma endoscopic resection shall be performed. Whether endoscopic resection is the definitive therapeutic measure depends on the histopathological evaluation of the resection specimen. Esophagectomy should be performed minimally invasive or in combination with open procedures (hybrid technique). Because the prognosis in locally advanced esophageal carcinoma is poor with surgery alone, multimodality therapy is recommended. In locally advanced adenocarcinomas of the esophagus or esophagogastric junction, perioperative chemotherapy or preoperative radiochemotherapy should be administered. In locally advanced squamous cell carcinomas of the esophagus, preoperative radiochemotherapy followed by complete resection or definitive radiochemotherapy without surgery should be performed. In the case of residual tumor in the resection specimen after neoadjuvant radiochemotherapy and R0 resection of squamous cell carcinoma or adenocarcinoma, adjuvant immunotherapy with nivolumab should be given. Systemic palliative treatment options (chemotherapy, chemotherapy plus immunotherapy, immunotherapy alone) in unresectable or metastastic esophageal cancer depend on histology and are stratified according to PD-L1 and/or Her2 expression.

Factors Associated with Polyp Detection Rate in European Colonoscopy Practice: Findings of The European Colonoscopy Quality Investigation (ECQI) Group.

Background: The European Colonoscopy Quality Investigation (ECQI) Group aims to raise awareness for improvement in colonoscopy standards across Europe. We analysed data collected on a sample of procedures conducted across Europe to evaluate the achievement of the polyp detection rate (PDR) target. We also investigated factors associated with PDR, in the hope of establishing areas that could lead to a quality improvement. Methods: 6445 form completions from 12 countries between 2 June 2016 and 30 April 2018 were considered for this analysis. We performed an exploratory analysis looking at PDR according to European Society of Gastrointestinal Endoscopy (ESGE) definition. Stepwise multivariable logistic regression analysis was conducted to determine the most influential associated factors after adjusting for the other pre-specified variables. Results: In our sample there were 3365 screening and diagnostic procedures performed in those over 50 years. The PDR was 40.5%, which is comparable with the ESGE minimum standard of 40%. The variables found to be associated with PDR were in descending order: use of high-definition equipment, body mass index (BMI), patient gender, age group, and the reason for the procedure. Use of HD equipment was associated with a significant increase in the reporting of flat lesions (14.3% vs. 5.7%, p < 0.0001) and protruded lesions (34.7% vs. 25.4%, p < 0.0001). Conclusions: On average, the sample of European practice captured by the ECQI survey meets the minimum PDR standard set by the ESGE. Our findings support the ESGE recommendation for routine use of HD colonoscopy.

[Helicobacter pylori-New aspects of forthcoming guidelines]. / Helicobacter pylori ­ neue Aspekte kommender Leitlinien.

The diagnostics and treatment of Helicobacter pylori infections are subject to continuous changes and adaptations. Due to the increase of resistance rates to frequently used antibiotics, especially clarithromycin and the lack of new antibacterial substances as well as new developments in the diagnostics, particularly new procedures for resistance testing, the guidelines have to be updated regularly. In this article new directions and trends of the forthcoming European and German guidelines are summarized, categorized and discussed by the authors involved in the compilation of future guidelines.

Factors Associated with Withdrawal Time in European Colonoscopy Practice: Findings of the European Colonoscopy Quality Investigation (ECQI) Group.

The European Colonoscopy Quality Investigation (ECQI) Group aims to raise awareness for improvement in colonoscopy standards across Europe. We analyzed data collected on a sample of procedures conducted across Europe to evaluate the achievement of the European Society of Gastrointestinal Endoscopy (ESGE) mean withdrawal time (WT) target. We also investigated factors associated with WT, in the hope of establishing areas that could lead to a quality improvement. METHODS: 6445 form completions from 12 countries between 2 June 2016 and 30 April 2018 were considered for this analysis. We performed an exploratory analysis looking at WT according to the ESGE definition. Stepwise multivariable logistic regression analysis was conducted to determine the most influential associated factors after adjusting for the other pre-specified variables. RESULTS: In 1150 qualifying colonoscopies, the mean WT was 7.8 min. Stepwise analysis, including 587 procedures where all inputs were known, found that the variables most associated with mean WT were a previous total colonoscopy in the last five years (p = 0.0011) and the time of day the colonoscopy was performed (p = 0.0192). The main factor associated with a WT < 6 min was the time of day that a colonoscopy was performed. Use of sedation was the main factor associated with a higher proportion of WT > 10 min, along with a previous colonoscopy. CONCLUSIONS: On average, the sample of European practice captured by the ECQI survey met the minimum standard set by the ESGE. However, there was variation and potential for improvement.

[Appropriateness of Proton pump inhibitor (PPI) recommendation in discharge letters of a gastroenterological department]. / Untersuchung zur indikationsgerechten Empfehlung einer Protonenpumpeninhibitor (PPI)-Medikation in Entlassungsbriefen einer gastroenterologischen Klinik.

BACKGROUND AND STUDY AIMS: Proton pump inhibitors (PPI) are one of the most often prescribed drugs worldwide. They were thought to have a great safety profile before adverse effects in case of long-term medication were discussed recently. Undoubtedly, the use of PPI has to be based on a clear indication. In this retrospective analysis, we investigated the number of patients being discharged from a gastroenterological department with a PPI medication. We also analyzed if this recommendation was based on an established indication and if dose and duration of therapy were correct. PATIENTS AND METHODS: 1612 discharge letters from the period January 1st to June 30th 2011 were evaluated. Patients being discharged with a recommendation of PPI use were assigned to one of four groups: (1) PPI recommendation correct according to guidelines indication, dose and duration of treatment; (2) PPI recommendation correct according to guidelines indication, but with failing or false dose or duration of treatment; (3) PPI recommendation rational but not based on guidelines; (4) Failing indication, wrong recommendation. For a more detailed analysis the patients of group 1 to 4 were then assigned to various subgroups according to comorbidities and concomitant medication. RESULTS: 808 of 1612 discharge letters (50,1%) recommended a PPI use. Assignment to the four groups were as follows: (1) n=344 (42,6%); (2) n=115 (14,2%); (3) n=159 (19,7%); (4) n=190 (23,5%). CONCLUSIONS: At time of discharge, PPI are frequently and partially uncritically recommended. Therefore, there is a need for a more intensive education of training interns and for a more critical review of the discharge letters by senior physicians. Even in case of optimal realization of these needs about 20% of debatable recommendations are not based on current guidelines.

[Gastric MALT lymphoma - from pathogenetic insights to consequent deescalation of therapy]. / Gastrale MALT-Lymphome ­ von pathogenetischen Erkenntnissen zu konsequenter Deeskalation der Therapie.

Gastric MALT- (mucosa-associated-lymphoid-tissue) lymphoma represents the most frequent gastrointestinal lymphoma. For decades, surgery and later on radiation and chemotherapy were regarded as established therapy. Some 30 years ago, the pathogenetic role of Helicobacter pylori infection for the development of gastric MALT-lymphoma became evident. During the following years, the pathogenetic insights were consequently implemented into clinical medicine. This lead to a radical change of the therapeutic approach to these lymphoma. Nowadays, Helicobacter pylori eradication is the internationally established therapy of first choice. It is followed by lymphoma regression in most cases. The long-term prognosis of patients after exclusive eradication therapy is excellent, even if endoscopic and/or histological residuals persist and a watch-and-wait strategy is favored.The pathogenetic insights und their clinical application implicated a consequent deescalation of therapy of gastric MALT-lymphoma. This review summarizes the single steps of this development and gives a recommendation for the actual management of patients with gastric MALT lymphoma.

Colonoscopy quality across Europe: a report of the European Colonoscopy Quality Investigation (ECQI) Group.

Background and study aims The European Colonoscopy Quality Investigation (ECQI) Group comprises expert colonoscopists and investigators with the aim of raising colonoscopy standards. We assessed the levels of monitoring and achievement of European Society of Gastrointestinal Endoscopy (ESGE) performance measures (PMs) across Europe using responses to the ECQI questionnaires. Methods The questionnaire comprises three forms: institution and practitioner questionnaires are completed once; a procedure questionnaire is completed on multiple occasions for individual total colonoscopies. ESGE PMs were approximated as closely as possible from the data collected via the procedure questionnaire. Procedure data could provide rate of adequate bowel preparation, cecal intubation rate (CIR), withdrawal time, polyp detection rate (PDR), and tattooing resection sites. Results We evaluated ECQI questionnaire data collected between June 2016 and April 2018, comprising 91 practitioner and 52 institution questionnaires. A total of 6445 completed procedure forms were received. Institution and practitioner responses indicate that routine recording of PMs is not widespread: adenoma detection rate (ADR) is routinely recorded in 29 % of institutions and by 34 % of practitioners; PDR by 42 % and 47 %, CIR by 62 % and 64 %, bowel preparation quality by 56 % and 76 %, respectively. Procedure data showed a rate of adequate bowel preparation of 84.2 %, CIR 73.4 %, PDR 40.5 %, mean withdrawal time 7.8 minutes and 12.2 % of procedures with possible removal of a non-pedunculated lesion ≥ 20 mm reporting tattooing. Conclusions Our findings clearly show areas in need of quality improvement and the importance of promoting quality monitoring throughout the colonoscopy procedure.

Acute gastrointestinal bleeding: results from the prospective German electronic registry of nearly 11 000 endoscopies (ALGK GI-bleeding registry).

BACKGROUND AND STUDY AIMS: Gastrointestinal bleeding is frequently observed in the German population. However, recent epidemiological data are not available. This study aimed to elucidate gastrointestinal bleeds under real-life conditions in 3 German hospitals. By using a standardized electronic documentation system, a large number of consecutive endoscopies could be established, thus offering representative data. PATIENTS AND METHODS: From June 2017 to December 2018, all upper and lower gastrointestinal tract endoscopies were recorded consecutively in the 3 hospitals. The electronic documentation system used included a case report form for storing data on bleeding as obligatory input for completion of the endoscopy report. In the case of gastrointestinal bleeding, specific data on the bleeding source and intensity, as well as individual characteristics, were documented. RESULTS: A total of 10 948 consecutive endoscopies were recorded, and 10 904 could be analyzed. Signs of gastrointestinal bleeding were found in 863 patients (7.9 % of all endoscopies performed), 538 patients with an intake of hemostasis-affecting drugs, and 325 patients without (62.3 % and 37.7 %, respectively). Platelet inhibitors and anticoagulants were the most frequently used hemostasis-affecting medication. There was a significant increase in age from patients without bleeding (median 68.5 years) to patients with bleeding (73.5 years) and to patients with bleeding who took hemostasis-affecting medication (80.4 years). Among the patients, 257 (29.8 %) and 606 (70.2 %) presented with major and minor bleeding, respectively. CONCLUSIONS: About 8 % of all patients undergoing upper or lower gastrointestinal endoscopy reveal signs of bleeding. A considerable number are older patients taking hemostasis-affecting drugs.

Platelet Inhibition and Anticoagulation in Visceral Interventions.

BACKGROUND: Platelet inhibition and anticoagulation are widely used therapeutic approaches in many patients. Despite their undoubted cardiovascular benefits, they may cause gastrointestinal harm either spontaneously or as part of endoscopic procedures. Strategies which harmonize both aspects are, therefore, of clinical interest. METHOD: The websites of the German (DGVS), European (ESGE), and American (ASGE) Societies of Gastroenterology and Endoscopy were searched for guidelines on antithrombotic agents and endoscopic procedures. Over and beyond this, PubMed was analyzed for originals and reviews by using the keywords "hemostasis affecting drugs," "antithrombotic drugs," "platelet inhibition," "anticoagulation," AND endoscopy. CONCLUSION: If elective endoscopy is planned, we should consider postponing the procedure in cases of temporally restricted platelet inhibition therapy or anticoagulation. Urgent endoscopy must balance the procedural risk against the risk of continuing or stopping the medication, with respect to thromboembolic events on the one hand and gastrointestinal bleeding on the other. There are decision criteria which facilitate individual risk stratification as a basis for diagnostic and therapeutic algorithms. KEY MESSAGE: If endoscopic interventions under platelet inhibition and/or anticoagulation cannot be postponed for a limited period of time, diagnostic and therapeutic strategies have to be performed against the background of well-defined decision criteria. These include the procedural risk (low vs. high) and the risk of thromboembolic events occurring (low vs. high) if the medication is stopped. In cases where both risks are considered to be high, an interdisciplinary approach should be favored.