Prophylactic clipping using the over-the-scope clip (OTSC) system after complex ESD and EMR of large colon polyps.

BACKGROUND: Delayed bleeding is the most frequent complication after endoscopic submucosal dissection (ESD) and endoscopic mucosal resection (EMR) of large colon polyps. Today, prophylactic clipping with through-the-scope clips (TTSCs) is commonly used to reduce the risk of bleeding. However, the over-the-scope clip (OTSC) system might be superior to TTSCs in achieving hemostasis. This study aims to evaluate the efficacy and safety of prophylactic clipping using the OTSC system after ESD or EMR of large colon polyps. METHODS: This is a retrospective analysis of a prospective collected database from 2009 until 2021 of three endoscopic centers. Patients with large (≥ 20 mm) colon polyps were enrolled. All polyps were removed by either ESD or EMR. After the resection, OTSCs were prophylactically applied on parts of the mucosal defect with a high risk of delayed bleeding or/and perforation. The main outcome measurement was delayed bleeding. RESULTS: A total of 75 patients underwent ESD (67%, 50/75) or EMR (33%, 25/75) in the colorectum. The mean resected specimen diameter was 57 mm ± 24.1 (range 22-98 mm). The mean number of OTSCs placed on the mucosal defect was 2 (range 1-5). None of the mucosal defects were completely closed. Intraprocedural bleeding occurred in 5.3% (ESD 2.0% vs. EMR 12.0%; P = 0.105), and intraprocedural perforation occurred in 6.7% (ESD 8% vs. EMR 4%; P = 0.659) of the patients. Hemostasis was achieved in 100% of cases of intraprocedural bleeding, whereas two patients required surgical conversion due to intraprocedural perforation. Among the remaining 73 patients who received prosphylactic clipping, delayed bleeding occurred in 1.4% (ESD 0% vs. EMR 4.2%; P = 0.329), and delayed perforation occurred in 0%. CONCLUSIONS: The prophylactic partial closure of large post-ESD/EMR mucosal defects using OTSCs could serve as an effective strategy to reduce the risk of delayed bleeding and perforation. The prophylactic partial closure of large complex post-ESD/EMR mucosal defects using OTSCs could serve as an effective strategy to reduce the risk of delayed bleeding and perforation.

Multicenter evaluation of first-line endoscopic treatment with the OTSC in acute non-variceal upper gastrointestinal bleeding and comparison with the Rockall cohort: the FLETRock study.

INTRODUCTION: The over-the-scope clip (OTSC) overcomes limitations of standard clips and achieves a more efficient and reliable hemostasis in non-variceal upper gastrointestinal bleeding (NVUGIB). The study aims to evaluate mortality, rebleeding, and mortality after rebleeding of patients in whom the OTSC was used as the first-line endoscopic treatment (FLET) of NVUGIB. PATIENTS AND METHODS: In total, 118 patients (FLET cohort) with a median age of 73.5 years (range 29-93 years; mean (±SD) 71.39 ± 12.39 years) were included. The distribution of patients with respect to risk category revealed a median Rockall score of 7 (range 3-10). For hypothesis testing, the FLET cohort was categorized into three risk groups taking into account the Rockall score: low risk [Rockall risk category (RRC ≤3)], moderate risk (RRC 4-7), and high risk (RRC ≥8). Event rates (mortality, rebleeding, and mortality after rebleeding) observed per risk group were compared to predicted event rates (Rockall cohort) using Fisher's Exact Test. RESULTS: Primary successful hemostasis (PSH) was achieved in 92.4% either by FLET alone or in combination with an additional hemostasis technique in 1.7% (SCS = secondary clinical success). In 7.5% of the FLET cohort PSH could not be achieved. Compared to RRC prediction, mortality after rebleeding was significantly reduced from 27.9 to 10.9% in the high-risk group (RRC ≥8) treated with FLET (p < 0.011). Furthermore, the occurrence of rebleeding or continued bleeding was significantly lower in the moderate risk group (RRC 4-7) with 4.9% as well as in the high-risk group (RRC ≥8) with 21.4% compared to the Rockall cohort 24.0 and 53.2%, respectively (p < 0.001). CONCLUSIONS: This study shows that OTSC is superior to standard care and FLET reduces significantly rebleeding and rebleeding-associated mortality in NVUGIB. For this reason, OTSC could be the treatment of choice as the first-line treatment as an alternative to standard hemostasis techniques in high-risk patients.

[Endoscopic submucosal dissection]. / Endoskopische Submukosadissektion.

Endoscopic submucosal dissection (ESD) was developed in Japan but has now also become permanently established in various centers in Europe. ESD is an endoscopic en bloc mucosal resection technique for the treatment of early cancers with a diameter >1 cm and also superficial precancerous lesions, which could only be removed unsatisfactorily in several fragments or with uncertain lateral safety margins using previous loop excision procedures. Using ESD a lesion is excised after circular marking and generous submucosal injection with a safety margin of approximately 5 mm and subsequently resected at the level of the submucosa with a 1-3 mm short diathermic knife. ESD requires high technical skills in interventional endoscopy and is more time-consuming than snare resection techniques. However, numerous studies have shown a clear superiority for ESD with respect to the R0 resection rate and the local recurrence rate. The present article gives a current review of the use of ESD in the upper and lower gastrointestinal tract and demonstrates perspectives of the procedure.

[Natural orifices transluminal endoscopic surgery (NOTES) in Germany: summary of the working group reports of the "D-NOTES meeting 2009"]. / Endoskopisches Operieren über natürliche Körperöffnungen (NOTES) in Deutschland: Zusammenfassung der Arbeitsgruppensitzungen der "D-NOTES 2009"

The D-NOTES-group met in June 2009 for an evaluation of ongoing preclinical and clinical activities in natural orifice endoscopic surgery and the further coordination of research in Germany. Different working groups with various topics were formed. Consensus statements among various participants with different scientific and medical background were initiated. In summary, important topics were handled such as the correct handling of bacterial contamination and related complications, the question of the ideal entry point and a secure closure, interdisciplinary cooperation, and matters related to training and education. Furthermore, participants agreed on terminological basics. A to-do-list for medical engineering was formulated.

[Diagnostic and interventional endoscopy in gastroenterology : from high-resolution chips and procedures for endoscopic resection to NOTES]. / Diagnostische und interventionelle Endoskopie in der Gastroenterologie : Von "High-resolution-Chips" über endoskopische Resektionsverfahren zu NOTES.

In the past 10 years endoscopic diagnostics has benefited from technologies such as big chips, high-definition television (HDTV) and narrow band imaging (NBI). Video capsule endoscopy and double balloon enteroscopy have facilitated visualization of the entire small bowel. A number of studies on mucosal Barrett's and gastric cancers could prove that endoscopic mucosal resection (EMR) is oncologically equivalent to surgical resection when certain criteria are respected. However, EMR is less invasive and carries a substantially lower complication risk and mortality compared to surgery. Endoscopic submucosal dissection (ESD) facilitates en bloc resection with thorough histopathologic evaluation of the specimen, e.g. for mucosal lesions in the stomach and rectum. Endosonography (EUS) guided transgastric necrosectomy using a flexible gastroscope has set a milestone in the treatment of infected pancreatic necroses and has replaced open surgery in many centers. Natural orifice transluminal endoscopic surgery (NOTES) uses natural body openings as minimally invasive access to the abdomen and mediastinum. Interventional GI endoscopists and minimally invasive surgeons have profited from these innovations in micromechanics and microelectronics.

Endoscopic submucosal dissection with a novel high viscosity injection solution (LiftUp) in an ex vivo model: a prospective randomized study.

Introduction Endoscopic submucosal dissection (ESD) is increasingly being used in the western world. Submucosal injectates are an essential tool for the ESD procedure. In this study, we evaluated a novel copolymer injectate (LiftUp, Ovesco, Tübingen Germany) in an established ESD model (EASIE-R) in comparison to existing submucosal injectables. Materials and methods We conducted a prospective, randomized ex vivo study performing ESD with three injectates: LiftUp, hydroxyethyl starch (HAES 6 %) and normal saline solution (NaCl 0.9 %). A total of 60 artificial lesions, each 3 × 3 cm in size, were resected in an ex vivo porcine model, utilizing one of the three studied injectates (n = 20 ESDs per injectate). Study parameters were: en bloc resection rate, perforation rate, lifting property, time of injection, injectate volume, general ESD procedure time, and overall procedure time. Results All 60 lesions were successfully resected using the standard ESD technique. LiftUp had no procedure related perforations, one perforation occurred in the HAES group, and two perforations in the NaCl group ( P  > 0.05). Furthermore, adequate lifting was achieved in 16/20 (80 %) using LiftUp, 6/20 (30 %) in the HAES group and 6/20 (30 %) in the NaCl group ( P  < 0.0002). En bloc resection was achieved in 19 (95 %) with LiftUp, in 20 (100 %) with HAES, and in 16 (80 %) with NaCl. General ESD procedure time and overall procedure time were not different among the three groups. Conclusion LiftUp appears to be a safe alternative to established fluids for ESD. It had a significantly improved lifting effect and required significantly less injected volume compared to well-established lifting solutions.

A novel model for training in ERCP with double-balloon enteroscopy after abdominal surgery.

BACKGROUND: Since the first presentation of the compactEASIE in 1997, this training model has become established for nearly all interventional techniques in upper gastrointestinal endoscopy including ERCP. So far, training using double-balloon enteroscopy (DBE) for ERCP has not become established. AIMS: This paper presents a special organ preparation for the compactEASIE model which for the first time allows simulation of ERCP in patients who have had prior abdominal surgery. Two abdominal organ packages from freshly slaughtered pigs were used to create a postsurgical anatomic situation. RESULTS: A life-like training model was established for ERCP training in a postsurgical anatomic situation. A Roux-en-Y anastomosis was created such that the papilla was located around 100 cm beyond the pylorus. The duodenum was closed shortly above the pig papilla at the level of the pylorus. The papilla was successfully reached by DBE after 40 minutes. The papilla was cannulated and regular contrasting of the biliary system using fluoroscopy was achieved. Sphincterotomy, stent placement and exchange, and needle-knife sphincterotomy over a 7-Fr stent were conducted successfully. CONCLUSION: Modified organ preparations allow the simulation of and training in ERCP in postsurgical anatomic situations in training models using animal parts.

The compactEASIE is a feasible training model for endoscopic novices: a prospective randomised trial.

BACKGROUND: The objective benefit of a training using the compact Erlangen Active Simulator for Interventional Endoscopy-simulator was demonstrated in two prospective educational trials (New York, France). The present study analysed whether endoscopic novices are able to reach a comparable level of endoscopic skills as in the above-described projects. METHODS: Twenty-seven endoscopic novices (medical students, first year residents) were enrolled in this prospective, randomised trial. The compact Erlangen Active Simulator for Interventional Endoscopy-simulator with an upper GI-organ package and blood perfusion system was used as a training tool. Basic evaluation of endoscopic skills was performed after a practical and theoretical course in diagnostic upper GI endoscopy followed by a stratified randomisation according to the rating in endoscopic skills into intensive (n=14) and control group (n=13). The intensive group was trained 12 times every second week over 7 months in 4 endoscopic disciplines (manual skills, injection therapy, haemoclip, band ligation) by skilled endoscopist (three trainees/simulator). Assessment was performed (single steps/overall) using an analogue scale from 1 to 10 (1=worst, 10=optimal performance) by expert tutors. The control group was not trained. Blinded final evaluation of all participants was performed in January 2003. RESULTS: We observed in all techniques applied a significant improvement of endoscopic skills and of the performance time in the intensive group compared to the control group (p<0.001). The comparison with the previous projects showed that the intensively trained novices achieved comparable levels of performance to the GI fellows in the New York and France Project (at least 80% of the median score in three out of four techniques). CONCLUSION: Endoscopic novices acquired notable skills in interventional endoscopy in the simulator by an intensive, periodical training using the compactEASIE.

Management of difficult common bile duct stones.

More than 80% of all CBD stones can be effectively treated by endoscopic sphincterotomy and stone extraction using baskets or balloon catheters. For stones up to 2.5 cm in diameter, mechanical lithotripsy is the method of choice as a next step. Very large, impacted, or very hard concretions, however, often make mechanical lithotripsy cumbersome or even impossible. For these stones laser lithotripsy, EHL, and ESWL are nonoperative options, especially for elderly patients and patients with an elevated surgical risk. Because these methods are often only available at endoscopic centers, stenting is a treatment modality for immediate stone therapy, but as a definitive treatment it should be restricted to selected cases. ESWL, EHL, and laser lithotripsy yield similar success rates of 80% to 95% and may be used complementarily in endoscopic centers. ESWL is the preferred therapy in intrahepatic lithiasis. Laser lithotripsy shows the best results in CBD stones. Electrohydraulic lithotripsy is rarely used because of its high potential for tissue damage and bleeding. Laser lithotripsy using smart laser systems such as the rhodamine 6G dye laser and the FREDDY laser system can simplify the treatment of these difficult bile duct stones. The rhodamine 6G-dye laser allows blind fragmentation of these stones by exclusive insertion of a 7-F metal marked standard catheter into the bile duct by standard duodenoscopes using intermittent fluoroscopy. An oSTDS safely cuts off the laser pulse if contact with the stone is lost, thus preserving the bile duct from potential damage. Unfortunately the system is no longer produced. The new FREDDY laser lithotriptor with a piezoacoustic stone/tissue discrimination system offers an alternative to the rhodamine 6G dye laser system at less than half the financial investment. Effective stone fragmentation is accompanied by only low tissue alteration. The holmium:YAG laser is an effective multidisciplinary lithotriptor, but it can be used only under cholangioscopic control, limiting its use to gastroenterologic centers.

[Laser lithotripsy of ureteral stones. Personal experiences]. / Laserlithotripsie von Harnleitersteinen. Eigene Erfahrungen.

The in vitro evaluation of a pulsed Nd:YAG laser, showed an effective and fine fragmentation of urinary calculi and showed only minimal subepithelial bleeding in the directly irradiated canine ureter. Since 1989 we have treated ureteral calculi in 30 patients. The laser pulses of 15-20 mJ (at fiber tip), 20 ns, 20-25 cps are transmitted by a 300-microns quartz fiber with a specially formed tip focusing the light. The fiber is passed through an 11.5-F ureteroscope within a guide tube, or, without a guide tube, through one of the new minimized ureteroscopies and is placed in front of the calculus. In 27 patients the procedure was successful, without any residual concretions after 1 day. In our opinion the advantages of this method are the very fine-grained, complete fragmentation of all sorts of calculi, the highly atraumatic procedure, and the absence of either optical or acoustic irritation to the operator.

Assessing the functional level of rehabilitation teams and facilitating team development.

This article describes a research-based method for assessing team effectiveness and for facilitating the development of rehabilitation teams. The authors used a 60-item self-report instrument to measure the developmental level of a group or a team. Two examples of the use of this instrument with rehabilitation teams are discussed.

A discharge group for chronically mentally ill. Easing the way.

1. Chronically mentally ill clients have unique needs for discharge planning due to their lack of resources and poor social skills. 2. A weekly group focused on discharge needs can assist patients in planning and solving problems. 3. A psychoeducational approach is used, including video tapes, role playing, group discussion, and guest speakers. 4. Topics for discussion include medication compliance, employment, housing, loneliness, aftercare, and fear of failure.

[Laser lithotripsy in the treatment of bile duct calculi]. / Laserlithotripsie zur Behandlung von Gallengangsteinen.

Currently more than 90% of all common bile duct stones can be removed non-surgically by means of endoscopic sphincterotomy, stone extraction and mechanical lithotripsy. For impacted, very large or very hard concrements intracorporeal shock wave lithotripsy by means of pulsed lasers represents a clinically newly established treatment procedure. Most clinical experience exists using the pulsed dye laser applied cholangioscopically via the endoscopic-retrograde or percutaneous-transhepatic route. The development of commercially available fine-caliber-endoscopes allows a relatively easy access to the stone compared to conventional mother-baby-scope-systems. A new stone-tissue-detection-system (STDS) in combination with a rhodamine-6G dye laser is promising for "blind" laser-lithotripsy using standard ERCP- or balloon catheters or a special lithotriptor basket. After successful conclusion of our in vitro and animal studies concerning the STD system we report on 18 patients with giant common bile duct stones using STDS in combination with a Rhodamin-6G dye laser.

Reassigning staff: effects on team members.

What happens when an employee becomes a new member of an existing work team? A study compared work teams at a psychiatric hospital after reorganization. Study results measure the groups' development, productivity, and perception of effectiveness.

[Percutaneous and trans-papillary cholangioscopy: current diagnostic and therapeutic possibilities]. / Perkutane und transpapilläre Cholangioskopie: neue diagnostische und therapeutische Möglichkeiten.

Peroral and transhepatic cholangioscopy represent a substantial enrichment of the diagnostic and therapeutic spectrum in gastroenterology. The use of cholangioscopy in the diagnostics of hepato-biliary disease seems to make especially sense in those cases where ERCP, sonography and CT do not lead to a sufficient clarification of the pathological findings and inspection, biopsy and cytology are required. An essential field of application for cholangioscopy consists today in the lithotripsy of giant common bile duct stones where laser lithotripsy means an important progress in the complication-free removal of these concrements. Percutaneous-transhepatic cholangioscopy as the more invasive procedure is especially indicated in those cases where due to former operations or special anatomical situations the endoscopic retrograde access is difficult or impossible. Further fields of application like endoluminal ultrasound via miniaturized probes or photodynamic diagnostics and photodynamic therapy (PDT) of cholangiocarcinoma seem to be valuable aims for the future.