Esophagogastric Junction Morphology on Hill's Classification Predicts Gastroesophageal Reflux with Good Accuracy and Consistency.

INTRODUCTION: Hill's classification provides a reproducible endoscopic grading system for esophagogastric junction morphology and competence, specifically whether the gastroesophageal flap valve (GEFV) is normal (grade I/II) or abnormal (grades III/IV). However, it is not routinely used in clinical practice. We report a systematic review and meta-analysis to determine association between abnormal GEFV and gastroesophageal reflux disorder (GERD). METHODS: A comprehensive literature search of MEDLINE and Scopus databases was conducted to identify studies that reported the association between abnormal GEFV and GERD. The search and quality assessment were performed independently by two authors. Fixed- and random-effects meta-analyses were conducted using symptomatic GERD and erosive esophagitis as outcomes. RESULTS: A total of 11 studies met inclusion criteria that included a total of 5054 patients. In the general population, patients with abnormal GEFV had greater risk of symptomatic GERD compared to patients with a normal GEFV (risk ratio [RR] 1.88, 95% CI 1.57-2.24). Further, in patients with symptomatic GERD, patients with abnormal GEFV had greater risk of erosive esophagitis compared to patients with normal GEFV (RR 2.17, 95% CI 1.40-3.36). Finally, the specificity of abnormal GEFV for symptomatic GERD was 73.3% (95% CI 69.3-77.0%) and 75.7% (95% CI 65.9-83.4%) for erosive esophagitis in symptomatic GERD. CONCLUSION: Our systematic review and meta-analysis showed consistent association between abnormal GEFV indicated by Hill's classification III/IV and symptomatic GERD and erosive esophagitis. Our recommendation is to include Hill's classification in routine endoscopy reports and workup for GERD.

[Classifications and scores used in digestive endoscopy]. / Herramientas para la interpretación de informes endoscópicos: clasificaciones y escalas en endoscopía digestiva.

Interpretation and description of findings detected in upper-endoscopy and colonoscopy are qualitative processes which depend on the experience and skills of the endoscopist performing the procedure. This explains the high variability of endoscopic reports, hampering their interpretation, specially by general practitioners. Classifications, scores and scales give a quantitative support to these qualitative processes. The aim of this review is to describe the classifications, scores and scales most frequently reported in digestive endoscopy, specially those with the highest methodological support in terms of validation and reproducibility. These tools facilitate the description of findings related to gastroesophageal reflux, Barrett's esophagus, gastroesophageal varices, stigmas related to non-variceal gastrointestinal bleeding, advanced and incipient neoplasms, bowel preparation for colonoscopy and severity scores of inflammatory bowel diseases. In summary, these tools enable to standardize endoscopic reports, simplifying their interpretation.

The ASGE grading system for ERCP can predict success and complication rates in a tertiary referral hospital.

BACKGROUND: The utility of the American Society for Gastrointestinal Endoscopy (ASGE) grading scale assessing complexity of endoscopic retrograde cholangiopancreatography (ERCP) has not been evaluated in clinical practice. METHODS: Patients that underwent ERCP between January 2015 and December 2015 were included. Procedural difficulty was graded according to the grading system proposed by the ASGE workshop. Technical success rates and complications were recorded. RESULTS: A total of 1355 ERCPs were performed on 934 patients. Patients were equally divided with respect to gender and had a mean age of 58 years (range 29-86). 391 cases were grade 1, 2 (29%), 695 were grade 3 (51%), and 269 were grade 4 (20%). Altered anatomy was observed in 88% of grade 4 patients. Cannulation was achieved in 98% of cases graded 1-3 and in 88% of cases graded 4 (p < 0.05). Complications were recorded in 10% of all cases with post-ERCP pancreatitis (5.4%) and procedure-related bleeding (1.5%) being the more common ones. No statistically significant difference was noted between the groups with regard to complications. Three perforations were seen in grade 1-3 cases (0.3%) compared to 4 cases in grade 4 cases (1.5%), (p = 0.01). CONCLUSION: The grading system proposed by the ASGE workshop can aid in predicting cannulation success and perforation rates in ERCP. Based on this retrospective study, the most complex ERCP procedures can be achieved with encouraging rates of success. There is a need to validate our study with prospective ones performed in other high-volume centers.

A Survey of Expert Practice and Attitudes Regarding Advanced Imaging Modalities in Surveillance of Barrett's Esophagus.

BACKGROUND: Published guidelines do not address what the minimum incremental diagnostic yield (IDY) for detection of dysplasia/cancer is required over the standard Seattle protocol for an advanced imaging modality (AIM) to be implemented in routine surveillance of Barrett's esophagus (BE) patients. We aimed to report expert practice patterns and attitudes, specifically addressing the minimum IDY in the use of AIMs in BE surveillance. METHODS: An international group of BE experts completed an anonymous electronic survey of domains relevant to surveillance practice patterns and use of AIMs. The evaluated AIMs were conventional chromoendoscopy (CC), virtual chromoendoscopy (VC), volumetric laser endomicroscopy (VLE), confocal laser endomicroscopy (CLE), and wide-area transepithelial sampling (WATS3D). Responses were recorded using five-point balanced Likert items and analyzed as continuous variables. RESULTS: The survey response rate was 84% (61/73)-41 US and 20 non-US. Experts were most comfortable with and routinely use VC and CC, and least comfortable with and rarely use VLE, CLE, and WATS3D. Experts rated data from randomized controlled trials (1.4 ± 0.9) and guidelines (2.6 ± 1.2) as the two most influential factors for implementing AIMs in clinical practice. The minimum IDY of AIMs over standard biopsies to be considered of clinical benefit was lowest for VC (15%, IQR 10-29%) and highest for VLE (30%, IQR 20-50%). Compared to US experts, non-US experts reported higher use of CC for BE surveillance (p < 0.001). CONCLUSION: These results should inform benchmarks that need to be met for guidelines to recommend the routine use of AIMs in the surveillance of BE patients.

Medical Devices; General and Plastic Surgery Devices; Classification of the Hemostatic Device for Intraluminal Gastrointestinal Use. Final order.

The Food and Drug Administration (FDA or we) is classifying the hemostatic device for intraluminal gastrointestinal use into class II (special controls). The special controls that apply to the device type are identified in this order and will be part of the codified language for the hemostatic device for intraluminal gastrointestinal use's classification. We are taking this action because we have determined that classifying the device into class II (special controls) will provide a reasonable assurance of safety and effectiveness of the device. We believe this action will also enhance patients' access to beneficial innovative devices, in part by reducing regulatory burdens.

[Improvement of cost allocation in gastroenterology by introduction of a novel service catalogue covering the complete spectrum of endoscopic procedures]. / Verbesserung der Kostenkalkulation in der Gastroenterologie durch Einführung eines neuen Leistungskatalogs für alle endoskopischen Prozeduren.

BACKGROUND: The German hospital reimbursement system (G-DRG) is incomplete for endoscopic interventions and fails to differentiate between complex and simple procedures. This is caused by outdated methods of personnel-cost allocation. METHODS: To establish an up-to-date service catalogue 50 hospitals made their anonymized expense-budget data available to the German-Society-of-Gastroenterology (DGVS). 2.499.900 patient-datasets (2011-2013) were used to classify operation-and-procedure codes (OPS) into procedure-tiers (e.g. colonoscopy with biopsy/colonoscopy with stent-insertion). An expert panel ranked these tiers according to complexity and assigned estimates of physician time. From June to November 2014 exact time tracking data for a total 38.288 individual procedures were collected in 119 hospitals to validate this service catalogue. RESULTS: In this three-step process a catalogue of 97 procedure-tiers was established that covers 99% of endoscopic interventions performed in German hospitals and assigned validated mean personnel-costs using gastroscopy as standard. Previously, diagnostic colonoscopy had a relative personnel-cost value of 1.13 (compared to gastroscopy 1.0) and rose to 2.16, whereas diagnostic ERCP increased from 1.7 to 3.62, more appropriately reflecting complexity. Complex procedures previously not catalogued were now included (e.g. gastric endoscopic submucosal dissection: 16.74). DISCUSSION: This novel service catalogue for GI-endoscopy almost completely covers all endoscopic procedures performed in German hospitals and assigns relative personnel-cost values based on actual physician time logs. It is to be included in the national coding recommendation and should replace all prior inventories for cost distribution. The catalogue will contribute to a more objective cost allocation and hospital reimbursement - at least until time tracking for endoscopy becomes mandatory.

Standardized endoscopic reporting.

The need for standardized language is increasingly obvious, also within gastrointestinal endoscopy. A systematic approach to the description of endoscopic findings is vital for the development of a universal language, but systematic also means structured, and structure is inherently a challenge when presented as an alternative to the normal spoken word. The efforts leading to the "Minimal Standard Terminology" (MST) of gastrointestinal endoscopy offer a standardized model for description of endoscopic findings. With a combination of lesion descriptors and descriptor attributes, this system gives guidance to appropriate descriptions of lesions and also has a normative effect on endoscopists in training. The endoscopic report includes a number of items not related to findings per se, but to other aspects of the procedure, formal, technical, and medical. While the MST sought to formulate minimal lists for some of these aspects (e.g. indications), they are not all well suited for the inherent structure of the MST, and many are missing. Thus, the present paper offers a recommended standardization also of the administrative, technical, and other "peri-endoscopic" elements of the endoscopic report; important also are the numerous quality assurance initiatives presently emerging. Finally, the image documentation of endoscopic findings is becoming more obvious-and accessible. Thus, recommendations for normal procedures as well as for focal and diffuse pathology are presented. The recommendations are "minimal," meaning that expansions and subcategories will likely be needed in most centers. Still, with a stronger common grounds, communication within endoscopy will still benefit.

The endoscopic spectrum of segmental colitis associated with diverticulosis.

OBJECTIVE: An endoscopic classification of 'Segmental colitis associated with diverticulosis' (SCAD) is lacking. Our aim was therefore to assess the endoscopic spectrum of SCAD, comparing it with the histological and clinical features. METHOD: A prospective study was performed from January 2004 to October 2007. Diagnosis of SCAD was made on the basis of specific endoscopic and histological patterns. RESULTS: A total of 6230 consecutive colonoscopies were performed during the study period. SCAD was diagnosed in 92 (1.48%) patients, with four endoscopic patterns: pattern A, 'crescentic fold disease' (52.20%); pattern B, 'Mild-to moderate ulcerative colitis-like' pattern (30.40%); pattern C, 'Crohn's disease colitis-like' pattern (10.90%); pattern D, 'Severe ulcerative colitis-like' pattern (6.50%). Most patients with patterns A (58.33%, P < 0.018) and B (89.29%, P < 0.00001) showed histological alterations resembling moderate ulcerative colitis (UC). In pattern C, larger histological variability was found (P < 0.01). All patients showing pattern D showed the typical histological alteration changes of severe UC (P < 0.0001). In pattern A (60.42%, P = n.s.) and pattern B (46.43%, P = n.s.), diarrhoea was the most common symptom whilst abdominal pain was the most frequent in pattern C (50%, P = n.s.) and pattern D (83.33%, P = n.s.) patients. CONCLUSIONS: Endoscopic patterns of SCAD may range from mild to severe inflammation. The histopathological findings but not clinical features showed a statistically significant association with the degree of endoscopic severity.

Minimal standard terminology for gastrointestinal endoscopy - MST 3.0.

Standardization of the language of gastrointestinal endoscopy is becoming increasingly important on account of international collaboration, standardized documentation requirements, and computer-based reporting. Version 1 of the Minimal Standard Terminology (MST) was devised to facilitate this development, and, through broad international collaboration, the document was developed and tested further to produce version 2.0, published in 2000. The document forms the basis for computer software by offering standard minimal lists of terms to be used in the structured documentation of endoscopic findings. The ownership of the MST has been transferred to the World Organisation of Digestive Endoscopy (OMED) and in this context, a new revision of the MST document is now in place. Version 3.0 of the terminology includes terms for endoscopic ultrasound (EUS) and enteroscopy, as well as for adverse event reporting. In addition, acknowledged scoring systems have been included for specific findings, and some structural enhancements have been implemented. The entire document is freely available for noncommercial use from www.omed.org.

Web-based system for training and dissemination of a magnification chromoendoscopy classification.

AIM: To evaluate the use of web-based technologies to assess the learning curve and reassess reproducibility of a simplified version of a classification for gastric magnification chromoendoscopy (MC). METHODS: As part of a multicenter trial, a hybrid approach was taken using a CD-ROM, with 20 films of MC lasting 5 s each and an "autorun" file triggering a local HTML frameset referenced to a remote questionnaire through an Internet connection. Three endoscopists were asked to prospectively and independently classify 10 of these films randomly selected with at least 3 d apart. The answers were centrally stored and returned to participants together with adequate feedback with the right answer. RESULTS: For classification in 3 groups, both intra- [Cohen's kappa (kappa) = 0.79-1.00 to 0.89-1.00] and inter-observer agreement increased from 1st (moderate) to 6th observation (kappa = 0.94). Also, agreement with reference increased in the last observations (0.90, 1.00 and 1.00, for observers A, B and C, respectively). Validity of 100% was obtained by all observers at their 4th observation. When a 4th (sub)group was considered, inter-observer agreement was almost perfect (kappa = 0.92) at 6th observation. The relation with reference clearly improved into kappa (0.93-1.00) and sensitivity (75%-100%) at their 6th observations. CONCLUSION: This MC classification seems to be easily explainable and learnable as shown by excellent intra- and inter-observer agreement, and improved agreement with reference. A web system such as the one used in this study may be useful for endoscopic or other image based diagnostic procedures with respect to definition, education and dissemination.

Reimbursement for Endoscopic Bariatric Therapies.

Intragastric devices may be of benefit to patients who are unable to achieve weight loss through lifestyle modification and pharmaceuticals. With the help of every member of a multidisciplinary team and ongoing commitment from patients, small, practical steps and goals can lead to long-lasting, healthy weight loss.

Current procedural terminology, Resource-based Relative Value Scale, and the Center for Medicare and Medicaid Services: overview.

Coding and payment methodology for physician professional services has been standardized through the introduction of the Current Procedural Terminology, which is maintained by the American Medical Association. The codes contained within this dataset are used by health care professionals to describe their services to payers. Inherent in the development of the procedural codes, the Resource Based Relative Value Scale Update Committee recommends physician work relative value units and practice expense and professional liability inputs to the Center for Medicare and Medicaid Services. This article provides an overview of the processes in place that permit regular updates in physician payment continually to be updated.

Frequently asked coding questions.

Current Procedural Terminology (CPT) coding is not an exact science. Although the CPT code set was developed to describe clearly and comprehensively services provided by health care professionals, the intended application of individual codes is not always clear. In addition, coding that may be correct in terms of CPT definitions and instructions may contradict instructions from payment policies set by insurers. This article provides answers to the gastroenterologists' most commonly asked questions and provides primary sources for coding and payment policies when possible. Answers to the questions are accurate as of the date of publication but may be subject to change.

Herramientas para la interpretación de informes endoscópicos: clasificaciones y escalas en endoscopía digestiva / Classifications and scores used in digestive endoscopy

Interpretation and description of findings detected in upper-endoscopy and colonoscopy are qualitative processes which depend on the experience and skills of the endoscopist performing the procedure. This explains the high variability of endoscopic reports, hampering their interpretation, specially by general practitioners. Classifications, scores and scales give a quantitative support to these qualitative processes. The aim of this review is to describe the classifications, scores and scales most frequently reported in digestive endoscopy, specially those with the highest methodological support in terms of validation and reproducibility. These tools facilitate the description of findings related to gastroesophageal reflux, Barrett's esophagus, gastroesophageal varices, stigmas related to non-variceal gastrointestinal bleeding, advanced and incipient neoplasms, bowel preparation for colonoscopy and severity scores of inflammatory bowel diseases. In summary, these tools enable to standardize endoscopic reports, simplifying their interpretation.

Coding and billing for gastrointestinal endoscopy.

The complexities associated with the coding, billing, and reimbursement process seem to increase daily. Keeping abreast of the changes in this environment is, to say the least, a challenge. To succeed in today's billing environment the gastroenterologist should surround his or her practice with staff, resources, and education. Experienced skilled staff, preferably a certified professional coder should be employed. Certified coders bring advanced coding skills to ones practice, which allows increased proficiency with the coding and billing process. Provide the necessary resources for staff. Current coding material is crucial to the financial success of the practice. CPT-4, ICD-9, and Correct Coding Guide are the bare basics of the resource material available to staff. Maintaining a library of resource material (i.e., Medicare bulletins, managed care newsletters, and so forth) aids the staff with the necessary tools to carry out their duties. In addition, specific gastroenterology coding subscriptions are available to assist in staying ahead of the ever-changing billing and coding environment. Continuing education in the billing and coding process for both the physician and staff is essential. Numerous workshops are offered periodically. It is imperative that staff attends all Medicare-sponsored workshops in addition to gastroenterology-specific coding seminars. More and more physicians are now aware of their responsibility in the billing process and have begun to participate in the coding education along with their staff. This is a significant indicator of a physicians' intent to have a compliant and financially successful practice.

Coding and reimbursement for gastrointestinal endoscopic procedures in primary care.

Endoscopic diagnostic procedures have become part of the comprehensive care provided by many primary care physicians, and when these physicians interact with third-party payers, they must correctly report the endoscopic services they have provided. Included in this review are commonly used upper and lower gastrointestinal endoscopic procedure codes; corresponding reimbursement values from one state's Medicare and Medicaid program; lists of diagnosis codes used in reporting upper and lower endoscopy services; and instructions for reporting visits and intravenous anesthesia associated with endoscopy procedures.

Evaluation of reliability in the use of endoscopic terminology.

Variability in the reporting of gastrointestinal endoscopic findings may affect the validity of analyses of data collected from clinical reports of those findings. In this project, images of 10 endoscopic findings were collected from the data repository of the Clinical Outcomes Research Initiative (CORI), all of which had been described by the reporting endoscopist. These images were presented to 52 experienced endoscopists recruited from the clinical affiliates of CORI who were asked to assign each a term from the Minimum Standard Terminology for Digestive Endoscopy. Proportion of agreement with the endoscopist varied by finding from 84.3% to 51.0% (overall 67.6% with 95% CI 63.4-71.8%). Proportion of agreement among the subjects varied by finding from 76.3% to 38.5%.(overall 55.6% with 95% CI 52.4-58.8%). Possible reasons for this lack of agreement are discussed.

Gastrostomía endoscópica: técnicas básicas, técnicas nuevas, errores semánticos y sugerencias para una clasificación coherente / Endoscopic gastrostomy: basic techniques, new techniques, semantic errors and suggestions for a coherent classification

The use of the term “direct technique” to refer to a modified introducer-type technique; to call the “introducer technique” “push technique”, or the “push technique” “Seldinger technique” are the most common semantic errors we make when classifying endoscopic gastrostomy techniques. The sole criterion we consider appropriate for the classification of these techniques is the access used for the gastrostomy tube, which can be transoral or transabdominal. Gauderer transoral technique (pull-technique) is the most popular globally because it simple, successful, the procedure is shorter, less traumatic and less expensive. Transabdominal techniques, such as “introducer” and “combined techniques” help to prevent wound contamination, tumour spreedingin patients with head and neck tumors, and esophageal tear in low weight newborn babies. These techniques shall be implemented and taught in Endoscopy Centers. The other techniques described are just variations of the basic techniques.

Usar el término “direct technique” para referirse a una técnica “introducer modificada”, llamar técnica “push” a la técnica “introducer” o “Seldingertechnique” a la técnica “push” son los errores semánticos que se cometen con más frecuencia cuando se intenta clasificar las técnicas de la gastrostomía endoscópica. El único criterio que nos parece adecuado para clasificar las técnicas es la vía de acceso de la sonda que puede ser transoral y transabdominal. La técnica transoral por tracción de Gauderer (pull-technique) es la más popular en el mundo por ser simple, exitosa, más breve, menos traumática y menos costosa. Las técnicas transabdominales como “introducer” y las “técnicas combinadas” ayudan a prevenir la contaminación de la herida, la siembra tumoral en pacientes con tumores de cabeza y cuello, y el desgarro esofágico en recién nacidos de bajo peso. Estas técnicas debieran implementarse y enseñarse en los centros de endoscopia. Las otras técnicas descritas son sólo variaciones de las técnicas básicas.