[The gastroenterology during the first and second wave of corona pandemic - two surveys by the working group of the guiding gastroenterologic clinicians (ALGK)]. / Die Gastroenterologie in der ersten und zweiten Corona-Welle ­ zwei Umfragen der Arbeitsgemeinschaft Leitender Gastroenterologischer Krankenhausärzte (ALGK).

BACKGROUND: An evaluation of the non-university hospitals in Germany with regard to the actual and follow-up working condition, alterations and perspectives during the Corona-crisis is missing. The working group of the guiding gastroenterologic clinicians (ALGK) comprises more than 70% of the head physicians of gastroenterological units leading to representative informations. METHODS: The ALGK conducted two surveys among its members in 2020 during the first and 2021 during the second Corona-wave. 369 members with correct email adresses were contacted. The first survey included 17 and the second survey 21 questions. RESULTS: 58 % of the respondent represented primary and standard care hospitals, 36 % secondary care hospitals, 6 % tertiary hospitals of maximum care, 43 % communal, 38 % confessional and 18 % private hospitals. 87 % of the respondent reported about cancellation of the hospital appointments by the patients (87 %/85 %). In the second survey, appointment cancellation by the physican (58 % vs. 84 %), reduction of emergency cases (16 % vs. 29 %), postponement of diagnostic or therapeutic appointments (85 % vs. 99 %) and reduction of programmed inpatient (65 vs. 91 %) or outpatient treatment (15 % vs. 84 %) were lesser compared to the first survey. Mean reduction of endoscopic procedures per unit were 337/month to 151/month (55 %) for diagnostic endoscopy, 174/month to 84/month (52 %) for therapeutic endoscopy and 56/month to 7/month (87,5 %) for prevention colonoscopy. The comparison between hospital operators revealed more reports on staff to be under quarantine, more very strong or strong feeling of psychological stress, more fear of corona-infection and more suspicion of ambulatory maintenance in gastroenterology in private hospitals. Willingness for vaccination was very high among physicians and nursing staff (92 %/89 %) and not different between the hospital operators. 38 % of the repsondent reported on the fear of existential risk of their hospital because of the Corona-crisis. CONCLUSION: The two ALGK surveys give a reprensentative picture of the situation of non-university gastroenterological units during Corona-pandemic in Germany.

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.

[Interprofessional knowledge and skills training of the insertion technique for the PEG placement on simulators - development and testing of a national curriculum for physicians and nurses]. / Interprofessionelles Wissens- und Skillstraining der PEG-Anlage an Simulatoren ­ Entwicklung und Testung eines nationalen Curriculums für Ärzte und spezialisierte Pflegende.

INTRODUCTION: Expert opinion within the field of gastroenterology mandates a national training curriculum to be completed prior to performing a percutaneous endoscopic gastrostomy (PEG).The goal of the present study is both the development and evaluation of such a curriculum, thus aiming to provide physicians and nurses with the necessary knowledge and skills to safely perform the PEG procedure. METHODS: Testing was performed using a non-randomized, interventional pilot study on simulators. This included a: (1) preparatory, (2) theoretical, and (3) practical phase. Following the theoretical phase, cognitive skills were assessed with a knowledge test. During the practical phase, each participant's puncture procedure was recorded with a multi-channel video, and sensorimotor skills were evaluated with an assessment instrument (AS-PEG). Finally, participant satisfaction was evaluated using a questionnaire. RESULTS: Seven physicians and 17 nurses completed all phases and final examinations, as defined in the curriculum. An average of 70.3 ±â€Š3.7 (61-75) of 76 points and 37.1 ±â€Š2.1 (32-40) of 42 points were achieved in the knowledge and acquired sensorimotor skills tests, respectively. Overall, the evaluation revealed a high level of satisfaction among the participants with respect to content, achievement of learning objectives, and acquired practical skills. CONCLUSION: Dissemination of the curriculum is deemed useful and necessary to provide the theoretical and practical knowledge for physicians and nurses through a structured inter-professional knowledge and skills-training format and to offer nurses a legally secure framework.

Acute sedation-associated complications in GI endoscopy (ProSed 2 Study): results from the prospective multicentre electronic registry of sedation-associated complications.

OBJECTIVES: Sedation has been established for GI endoscopic procedures in most countries, but it is also associated with an added risk of complications. Reported complication rates are variable due to different study methodologies and often limited sample size. DESIGNS: Acute sedation-associated complications were prospectively recorded in an electronic endoscopy documentation in 39 study centres between December 2011 and August 2014 (median inclusion period 24 months). The sedation regimen was decided by each study centre. RESULTS: A total of 368 206 endoscopies was recorded; 11% without sedation. Propofol was the dominant drug used (62% only, 22.5% in combination with midazolam). Of the sedated patients, 38 (0.01%) suffered a major complication, and overall mortality was 0.005% (n=15); minor complications occurred in 0.3%. Multivariate analysis showed the following independent risk factors for all complications: American Society of Anesthesiologists class >2 (OR 2.29) and type and duration of endoscopy. Of the sedation regimens, propofol monosedation had the lowest rate (OR 0.75) compared with midazolam (reference) and combinations (OR 1.0-1.5). Compared with primary care hospitals, tertiary referral centres had higher complication rates (OR 1.61). Notably, compared with sedation by a two-person endoscopy team (endoscopist/assistant; 53.5% of all procedures), adding another person for sedation (nurse, physician) was associated with higher complication rates (ORs 1.40-4.46), probably due to higher complexity of procedures not evident in the multivariate analysis. CONCLUSIONS: This large multicentre registry study confirmed that severe acute sedation-related complications are rare during GI endoscopy with a very low mortality. The data are useful for planning risk factor-adapted sedation management to further prevent sedation-associated complications in selected patients. TRIAL REGISTRATION NUMBER: DRKS00007768; Pre-results.

[Comparison of safety insertion techniques of percutaneous endoscopic gastrostomy in nurses and physicians - a non-randomized interventional pilot study on a simulation model]. / Vergleich der Sicherheit der perkutan gastralen Punktion im Rahmen der PEG-Anlage zwischen Ärzten und spezialisierten Pflegenden ­ eine nicht randomisierte, interventionelle Pilotstudie an Simulatoren.

Percutaneous endoscopic gastrostomy (PEG) insertion represents a standardized procedure for enteral nutrition in patients with long-term eating difficulties for various reasons. In a clinical setting, delegation of stomach puncture and placement of a PEG tube, within the context of percutaneous endoscopic gastrostomy amongst nurses, occurs. In Germany, there are no studies yet showing the differences between physicians and nurses regarding the safety of percutaneous stomach puncture.In a non-randomized quasi-experimental interventional study on a simulation model, the safety of stomach puncture within the context of percutaneous endoscopic gastrostomy between physicians and nurses with special training was compared. Technical skills were recorded with video cameras and provided the basis for the following analysis. The study contained: (1) a theoretical preparation phase, (2) training on simulation model and a repeated practice of the skills, and (3) stomach puncture on the simulation model. The actions were recorded with a multichannel video technique. As part of the concept, nurses and physicians were trained together in theory and practice. The analysis was conducted with the newly designed Assessment Instrument Percutaneous Endoscopic Gastrostomy (AS-PEG). Seven physicians and 17 nurses took part in the pilot study. On average, the physicians reached a score of 36.4 ±â€Š2.2 (33 - 39) and nurses 37.4 ±â€Š2 (32 - 40), while the maximum score was 42. The evaluation of technical skills on the recorded videos by means of Assessment Instrument Percutaneous Endoscopic Gastrostomy (AS-PEG) showed no tendency to significant differences between physicians and nurses after theoretical and practical training. The study contributes a first objective evaluation of technical skills on stomach puncture within the context of percutaneous endoscopic gastrostomy with the newly designed AS-PEG.

S2k-Guideline hand antisepsis and hand hygiene.

The consensus-based guideline "hand antisepsis and hand hygiene" for Germany has the following sections: Prevention of nosocomial infections by hygienic hand antisepsis, prevention of surgical site infections by surgical hand antisepsis, infection prevention in the community by hand antisepsis in epidemic or pandemic situations, hand washing, selection of alcohol-based hand rubs and wash lotions, medical gloves and protective gloves, preconditions for hand hygiene, skin protection and skin care, quality assurance of the implementation of hand hygiene measures and legal aspects. The guideline was developed by the German Society for Hospital Hygiene in cooperation with 22 professional societies, 2 professional organizations, the German Care Council, the Federal Working Group for Self-Help of People with Disabilities and Chronic Illness and their Family Members, the General Accident Insurance Institution Austria and the German-speaking Interest Group of Infection Prevention Experts and Hospital Hygiene Consultants.

Development and Pilot Validation of an Instrument Assessing Sensorimotor Skills for Percutaneous Gastral Puncture.

INTRODUCTION: The acquisition of sensorimotor skills, so-called "technical skills", plays an essential part in the professional and continuing educational training of medical and nursing staff. Facilities turn to simulator training to promote the safe and accurate performance of endoscopic examinations. Thus, this study aimed to develop and pilot-test a corresponding assessment instrument to monitor necessary sensorimotor or "technical" skills of the examiner for a safe percutaneous endoscopic gastrostomy (AS-PEG). MATERIALS AND METHODS: Instrument development and pilot validation involved four stages: identification of potential items and initial draft of the AS-PEG; expert panel with 11 experts (content validity index [CVI] calculated); empirical validation using a quasi-experimental intervention on simulators; revision of the pilot AS-PEG taking expert assessment, and empirical testing into consideration. RESULTS: The initial instrument yielded 13 categories and 44 items describing the PEG procedure. Experts rated 30 out of 44 items (68%) extremely or very important for the safety of the puncture of the stomach. Initial item-CVIs ranged from 0.00 to 1.00; scale-CVI was 0.61. Twenty-four trainees (7 physicians, 17 nurses) participated in the pilot simulation study. On average, 8:25 min were required for PEG placement (min-max 5:59-13:38 min, SD = 1:43). The revised AS-PEG version was reduced to 14 items with a range of the item CVI from 0.8 to 1.0, and a scale-CVI of 0.90. CONCLUSION: The AS-PEG instrument facilitates the evaluation of sensorimotor skills during percutaneous gastric puncture procedures within the context of PEG placement, across professions and without relating to the number of procedures previously performed. The instrument is economical and shows satisfying content validity.

The preoperative placement of transjugular intrahepatic portosystemic shunt for treatment of a patient with portal hypertension and gastric cancer.

The case report describes the placement of a TIPSS preceding surgery of the upper gastrointestinal tract in a patient with liver cirrhosis and gastric carcinoma. Following two unsuccessful exploratory laparotomies, the decreased portal hypertension facilitated a curative resection of the tumor.

Optimizing time management after perforation by colonoscopy results in better outcome for the patients.

BACKGROUND/AIMS: Perforation during colonoscopy is a rare but severe complication. The aim of this study was to assess the time management and laparoscopic therapy of this complication and to evaluate patient outcomes. METHODOLOGY: A retrospective analysis was done on 15 patients operated for a perforation from colonoscopy between January 2000 and December 2006. RESULTS: Three perforations occurred during diagnostic and 12 perforations during interventional colonoscopy. Two perforations occurred as transmural thermal injury to the colon wall. Peritonitis was found in 4 cases and significantly correlated with the mean time between perforation and operation. Twelve perforations were oversewn laparoscopically and 3 perforations were oversewn by laparotomy. After laparoscopic treatment, hospital stay was significantly shorter than after laparotomy. One patient had a postoperative wound infection, mortality was 0%. CONCLUSIONS: Laparoscopic oversewing is a safe and effective method in the treatment of perforation from colonoscopy. Optimizing the time range between perforation and laparoscopic therapy results in a better outcome for the patients.

Clinical Management of Appendicitis.

BACKGROUND: Ever since the first appendectomy has been performed, surgery has been the standard of care for acute appendicitis, with antibiotic therapy being reserved for special situations. Recent studies have shown the feasibility of antibiotic therapy for uncomplicated appendicitis. METHODS: This clinical therapeutic review is based both on author expertise and a selective literature survey in PubMed based on the term 'appendicitis', combined with the terms 'acute', 'complicated', 'conservative', 'non-operative', 'therapy', 'surgery', and 'strategy'. According to these search results as well as to the treatment guidelines from the American College of Surgeons, Society for Surgery of the Alimentary Tract, Society of American Gastrointestinal and Endoscopic Surgeons, European Association of Endoscopic Surgery, and World Society of Emergency Surgery, we present an interdisciplinary treatment concept. RESULTS: Approximately 90% of patients treated with antibiotics are able to avoid surgery during the initial admission. The other 10% that fail to respond to antibiotics require a rescue appendectomy. Recurrence rates of non-operated patients within 1 year are as high as 20-30%. CONCLUSION: In uncomplicated appendicitis without risk factors for failure of non-operative management, a shared decision based on the patient's preferences should be made. In cases with risk factors, appendectomy is still the treatment recommended. If the diagnosis is uncertain or clinical symptoms are rather mild, antibiotic therapy should be started. In complicated appendicitis, management depends on the clinical state, with either immediate surgery or primarily antibiotic therapy and combined with drainage of abscess, being followed by interval appendectomy in some cases.

Effect of intravenous application of esomeprazole 40 mg versus pantoprazole 40 mg on 24-hour intragastric pH in healthy adults.

BACKGROUND: It has been demonstrated that therapy with proton pump inhibitors reduces recurrence of bleeding following initial endoscopic treatment of bleeding peptic ulcers. AIM: This study compared the effects of esomeprazole 40 mg and pantoprazole 40 mg on intragastric acid control. Both substances were administered intravenously as 15-min infusion and as bolus injection. METHODS: Healthy men and women volunteers were enrolled in this single-center, open, randomized, three-way crossover study. After administration of esomeprazole 40 mg and pantoprazole 40 mg intravenously as 15-min infusion, and pantoprazole 40 mg intravenously as bolus injection, continuous 24-h intragastric pH monitoring was carried out. RESULTS: pH data were available for 21 Helicobacter pylori-negative and seven H. pylori-positive volunteers. In H. pylori-negative volunteers, esomeprazole 40 mg intravenously resulted in 11.8 h with an intragastric pH>4 compared with 5.6 h for pantoprazole 40 mg intravenously as infusion (P<0.0001), and 7.2 h for pantoprazole 40 mg intravenously as bolus injection (P<0.001). During the first 6 h of administration, the corresponding values were 3.4, 1.1 (P<0.000001), and 2.1 h (P<0.001), respectively. CONCLUSIONS: In H. pylori-negative patients, a single dose of esomeprazole 40 mg intravenously provides an intragastric acid control that is faster and more pronounced than administration of pantoprazole 40 mg intravenously.

Follow-up of patients with obscure gastrointestinal bleeding after capsule endoscopy and intraoperative enteroscopy.

BACKGROUND/AIMS: Capsule endoscopy (CE) is highly sensitive to detect the bleeding source in patients with obscure gastrointestinal bleeding compared with intraoperative enteroscopy (IOE). Long-term follow-up information of patients undergoing CE and IOE for investigation and treatment of chronic gastrointestinal bleeding is lacking. METHODOLOGY: 50 patients with obscure gastrointestinal bleeding underwent CE and IOE. Follow-up data of 47 patients (30 men, 17 women, mean age 60.9 +/- 16.8 years) were available (3 patients lost in follow-up). Clinical outcome was assessed with a standardized patient questionnaire and personal communication with referring physicians. RESULTS: Bleeding sources were detected and effective treated during intraoperative enteroscopy (argon plasma coagulation or surgical resection) in 34 patients [(angiodysplasias (n = 22), ulcers (n = 5), malignant tumors (n = 3), Meckel's diverticulum (n = 1), jejunal varices (n = 1), bleeding ileum diverticulosis (n = 1), hyperplastic polyp (n = 1)]. Mean follow-up was 346.3 days (range 253-814 days). Clinical signs of recurrent gastrointestinal bleeding occurred in 12 of 47 patients (25.5%) [positive fecal occult blood test (n = 2), anemia (n = 2), melena (n = 3), hematochezia (= 5)]. In 3 patients (6.4%) no further therapy was necessary, 9 patients (19.1%) needed blood transfusions (range 2-62 units), endoscopic or surgical interventions to control rebleeding. CONCLUSIONS: The results of the present study support the proposal that capsule endoscopy could be used as the first-choice investigation in patients with obscure gastrointestinal bleeding.

[Acute Abdominal Pain]. / Das akute Abdomen.

Acute abdominal pain is a potentially life-threatening condition that requires a concise and quick workup. Patient history, physical examination and laboratory studies help to establish a working diagnosis. If abdominal Ultrasound is not conclusive, contrast-enhanced Computertomography should be performed. Every patient should be treated aggressively for pain control and fluid substitution independent of the diagnostic workflow. In cases of severe disease, initiation of broad spectrum antibiotic therapy should be considered early.