Publications by authors named "Arthur Schmidt"

72 Publications

Over-the-scope clip versus transcatheter arterial embolization for refractory peptic ulcer bleeding-A propensity score matched analysis.

United European Gastroenterol J 2021 Aug 25. Epub 2021 Aug 25.

Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.

Background: Transcatheter arterial embolization (TAE) or surgery are standard treatment of peptic ulcer bleeding (PUB) refractory to endoscopic hemostasis. Over-the-scope clips (OTSC) have shown superiority to standard endoscopic treatment.

Objective: To compare OTSC treatment to TAE in refractory peptic ulcer bleeding.

Patients And Methods: In this retrospective, multicenter study, 128 patients treated with OTSC (n = 66) or TAE (n = 62) for refractory PUB between 2009 and 2019 in four academic centers were analyzed. Primary endpoint was clinical success (hemostasis + no rebleeding within 7 days). Secondary endpoints were adverse events, length of ICU stay, and mortality. Propensity score matching was performed to adjust for differences in baseline characteristics.

Results: Patients characteristics were similar in both groups but ulcers in the TAE group were larger, more often located in the duodenal bulb (85.5% vs. 65.2%; p = 0.014), and that the proportion of Forrest Ia bleedings was higher (38.7% vs. 19.7%; p = 0.018). Clinical success was comparable in both groups (74.2% vs. 59.7%; p = 0.092). Stay on the intensive care unit (ICU) was significantly longer in the TAE group (mean 8.0 vs. 4.7 days; p = 0.002). Serious adverse events after re-therapy (12.9% vs. 1.5%; p = 0.042) and in-hospital mortality were significantly higher in the TAE group (9.1 vs. 22.6%, OR 2.92 [95% CI 1.04-8.16]; p = 0.05). After propensity score matching, the differences found regarding ICU stay (4.9± 5.9 and 9.2 ± 11.2; p = 0.009) and in-hospital mortality (5% vs. 22.5%; OR 5.52 [95% CI: 1.11-27.43]; p = 0.048) stayed significant.

Conclusions: OTSC treatment for refractory PUB was superior to TAE in terms of ICU stay and in-hospital mortality.
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http://dx.doi.org/10.1002/ueg2.12135DOI Listing
August 2021

Telemetric capsule-based upper gastrointestinal tract - blood detection - first multicentric experience.

Minim Invasive Ther Allied Technol 2021 Aug 3:1-8. Epub 2021 Aug 3.

Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany.

Introduction: Risk stratification in upper gastrointestinal bleeding (UGIB) currently relies on clinical parameters and risk scores. HemoPill acute (Ovesco Endoscopy, Tuebingen, Germany) is a pill-shaped, orally administered sensor capsule for real-time blood detection. The aim of this study was to evaluate the system in clinical routine.

Material And Methods: Sixty-one consecutive patients in whom the HemoPill had been used at 12 international hospitals between July 2019 and March 2020 were retrospectively analysed. Indications for application were the clinical suspicion of UGIB, small bowel bleeding, of rebleeding after hemostasis. Primary endpoints were technical success and bleeding detection/exclusion. Secondary endpoints included adverse events and change of clinical course.

Results: The capsule was used in 45 (73%) patients with UGIB, in 12 (20%) patients with small bowel bleeding and in four (7%) patients for exclusion of rebleeding. Technical success was 98%. 35/60 (58%) cases were capsule-positive and among these, endoscopy showed bleeding in 20/35 (57%) cases. None of the 25 capsule-negative patients rebled. Emergency endoscopy could be avoided in 18/25 (72%) cases. Serious adverse events did not occur.

Conclusion: HemoPill-based blood detection is feasible and safe. Negative capsule results might 'downgrade' the need for urgent endoscopy.
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http://dx.doi.org/10.1080/13645706.2021.1954534DOI Listing
August 2021

Soil erosion as transport pathway of microplastic from agriculture soils to aquatic ecosystems.

Sci Total Environ 2021 Nov 6;795:148774. Epub 2021 Jul 6.

University of Augsburg, Institute of Geography, Alter Postweg 118, 86159 Augsburg, Germany. Electronic address:

Soil erosion is a potentially important source of microplastic (MP) entering aquatic ecosystems. However, little is known regarding the erosion and transport processes of MP from agricultural topsoils. The aim of this study is to analyze the erosion and transport behavior of MP during heavy rainfall events, whereas a specific focus is set to preferential MP transport and MP-soil interactions potentially leading to a more conservative transport behavior. The study is based on a series of rainfall simulations on paired-plots (4.5 m × 1.6 m) of silty loam and loamy sand located in Southern Germany. The simulations (rainfall intensity 60 mm h) were repeated 3 times within 1.5 years. An amount of 10 g m of fine (MP, size 53-100 μm) and 50 g m of coarse (MP, size 250-300 μm) high-density polyethylene as common polymer was added to the topsoil (<10 cm) of the plots. The experiments show a preferential erosion and transport of the MP leading to a mean enrichment ratio of 3.95 ± 3.71 (MP) and 3.17 ± 2.58 (MP) in the eroded sediment. There was a higher MP enrichment on the loamy sand but a higher sediment delivery on the silty loam resulting in nearly equal MP deliveries from both soil types. An increasing interaction with mineral soil particles or aggregates leads to a decreasing MP delivery over time. Within 1.5 years, up to 64% of the eroded MP particles were bound to soil particles. Overall, more of the MP was laterally lost via soil erosion, while for the MP the vertical transport below the plough layer was more important. In general, our study indicates that arable land susceptible to soil erosion can be a substantial MP source for aquatic ecosystems.
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http://dx.doi.org/10.1016/j.scitotenv.2021.148774DOI Listing
November 2021

Holmium laser enucleation of an esophageal leiomyoma in endoscopic tunnel technique.

VideoGIE 2021 Jun 13;6(6):250-251. Epub 2021 Mar 13.

Department of Urology, Faculty of Medicine, University of Freiburg Medical Centre, Freiburg, Germany.

Video 1We present a case of a 76 year old patient undergoing holmium laser enucleation of an esophageal leiomyoma in endoscopic tunnel technique.
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http://dx.doi.org/10.1016/j.vgie.2021.02.004DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8185999PMC
June 2021

Prognostic Value of the CLIF-C AD Score in Patients With Implantation of Transjugular Intrahepatic Portosystemic Shunt.

Hepatol Commun 2021 04 5;5(4):650-660. Epub 2021 Jan 5.

Department of Medicine II Medical Center University of Freiburg Faculty of Medicine University of Freiburg Freiburg Germany.

Prognostic assessment of patients with liver cirrhosis allocated for implantation of a transjugular intrahepatic portosystemic shunt (TIPS) is a challenging task in clinical practice. The aim of our study was to assess the prognostic value of the CLIF-C AD (Acute Decompensation) score in patients with TIPS implantation. Transplant-free survival (TFS) and 3-month mortality were reviewed in 880 patients who received TIPS implantation for the treatment of cirrhotic portal hypertension. The prognostic value of the CLIF-C AD score was compared with the Model for End-Stage Liver Disease (MELD) score, Child-Pugh score, and albumin-bilirubin (ALBI) score using Harrell's C concordance index. The median TFS after TIPS implantation was 40.0 (34.6-45.4) months. The CLIF-C AD score (c = 0.635 [0.609-0.661]) was superior in the prediction of TFS in comparison to MELD score (c = 0.597 [0.570-0.623],  = 0.006), Child-Pugh score (c = 0.579 [0.552-0.606],  < 0.001), and ALBI score (c = 0.573 [0.545-0.600],  < 0.001). However, the CLIF-C AD score did not perform significantly better than the MELD-Na score (c = 0.626 [0.599-0.653],  = 0.442). There were no profound differences in the scores' ranking with respect to indication for TIPS implantation, stent type, or underlying liver disease. Subgroup analyses revealed that a CLIF-C AD score >45 was a predictor of 3-month mortality in the supposed low-risk group of patients with a MELD score ≤12 (14.7% vs. 5.1%,  < 0.001). The CLIF-C AD score is suitable for prognostic assessment of patients with cirrhotic portal hypertension receiving TIPS implantation. In the prediction of TFS, the CLIF-C AD score is superior to MELD score, Child-Pugh score, and ALBI score but not the MELD-Na score.
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http://dx.doi.org/10.1002/hep4.1654DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8034565PMC
April 2021

[Esophageal Lichen Planus - an Underdiagnosed Disease].

Z Gastroenterol 2021 May 8;59(5):460-469. Epub 2021 Apr 8.

Klinik für Innere Medizin II, Gastroenterologie, Hepatologie, Endokrinologie und Infektiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg.

An involvement of the esophagus in patients with lichen planus was described for the first time in 1982. Ever since, it has been seen as a rarity. However, studies over the last 10 years have shown a higher prevalence than expected. It may even be supposed that esophageal lichen planus (ELP) is more common than eosinophilic esophagitis. ELP mostly affects middle-aged women. The principal symptom is dysphagia. Endoscopically, ELP is characterized by denudation and tearing of the mucosa, trachealization and hyperkeratosis and esophageal stenosis may occur in patients with long courses of the disease. Histologic findings including mucosal detachment, T-lymphocytic infiltrate, intraepithelial apoptosis (civatte bodies) and dyskeratosis are crucial. Direct immunofluorescence shows fibrinogen deposits along the basement membrane zone. So far, there is no well-established therapy but a treatment with topic steroids is effective in 2/3 of the patients. Common therapy of lichen planus of the skin seems to be ineffective for treatment of ELP. Symptomatic esophageal stenosis should be endoscopically dilated. ELP joins the group of "new" immunologic diseases of the esophagus.
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http://dx.doi.org/10.1055/a-1378-9380DOI Listing
May 2021

DNMT1 Inhibitor Restores RUNX2 Expression and Mineralization in Periodontal Ligament Cells.

DNA Cell Biol 2021 May 22;40(5):662-674. Epub 2021 Mar 22.

Health Science Institute, School of Dentistry, Paulista University-UNIP, São Paulo, Brazil.

Periodontal ligament cells (PDLCs) have well documented osteogenic potential; however, this commitment can be highly heterogenous, limiting their applications in tissue regeneration. In this study, we use PDLC populations characterized by high and low osteogenic potential (h-PDLCs and l-PDLCs, respectively) to identify possible sources of such heterogeneity and to investigate whether the osteogenic differentiation can be enhanced by epigenetic modulation. In h-PDLCs, low basal expression levels of pluripotency markers (, ), DNA methyltransferases (, ), and enzymes involved in active DNA demethylation (, ) were prerequisite to high osteogenic potential. Furthermore, these genes were downregulated upon early osteogenesis, possibly allowing for the increase in expression of the key osteogenic transcription factors, Runt-related transcription factor 2 () and , and ultimately, mineral nodule formation. l-PDLCs appeared locked in the multipotent state and this was further enhanced upon early osteogenic stimulation, correlating with low expression and impaired mineralization. Further upregulation of s was also evident, while pretreatment with RG108, the DNMTs' inhibitor, enhanced the osteogenic program in l-PDLCs through downregulation of s, increased RUNX2 expression and nuclear localization, accelerated expression of osteogenic markers, and increased mineralization. These findings point toward the role of DNMTs and Ten Eleven Translocations (TETs) in osteogenic commitment and support application of epigenetic approaches to modulate biomineralization in PDLCs.
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http://dx.doi.org/10.1089/dna.2020.6239DOI Listing
May 2021

Refining prediction of survival after TIPS with the novel Freiburg index of post-TIPS survival.

J Hepatol 2021 Jun 26;74(6):1362-1372. Epub 2021 Jan 26.

Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Hugstetter Str. 55, 79106 Freiburg, Germany; PraxisZentrum für Gastroenterologie und Endokrinologie, Freiburg, Germany.

Background & Aims: Transjugular intrahepatic portosystemic shunt (TIPS) implantation is an effective and safe treatment for complications of portal hypertension. Survival prediction is important in these patients as they constitute a high-risk population. Therefore, the aim of our study was to develop an alternative prognostic model for accurate survival prediction after planned TIPS implantation.

Methods: A total of 1,871 patients with de novo TIPS implantation for ascites or secondary prophylaxis of variceal bleeding were recruited retrospectively. The study cohort was divided into a training set (80% of study patients; n = 1,496) and a validation set (20% of study patients; n = 375). Further, patients with early (preemptive) TIPS implantation due to variceal bleeding were included as another validation cohort (n = 290). Medical data and overall survival (OS) were assessed. A Cox regression model was used to create an alternative prediction model, which includes significant prognostic factors.

Results: Age, bilirubin, albumin and creatinine were the most important prognostic factors. These parameters were included in a new score named the Freiburg index of post-TIPS survival (FIPS). The FIPS score was able to identify high-risk patients with a significantly reduced median survival of 5.0 (3.1-6.9) months after TIPS implantation in the training set. These results were confirmed in the validation set (median survival of 3.1 [0.9-5.3] months). The FIPS score showed better prognostic discrimination compared to the Child-Pugh, MELD, MELD-Na score and the bilirubin-platelet model. However, the FIPS score showed insufficient prognostic discrimination in patients with early TIPS implantation.

Conclusions: The FIPS score is superior to established scoring systems for the identification of high-risk patients with a worse prognosis following elective TIPS implantation.

Lay Summary: Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) is a safe and effective treatment for patients with cirrhosis and clinically significant portal hypertension. However, risk stratification is a major challenge in these patients as currently available scoring systems have major drawbacks. Age, bilirubin, albumin and creatinine were included in a new risk score which was named the Freiburg index of post-TIPS survival (FIPS). The FIPS score can identify patients at high risk and may guide clinical decision making.
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http://dx.doi.org/10.1016/j.jhep.2021.01.023DOI Listing
June 2021

A large cervical osteophyte causing dysphagia in an elderly patient.

Ann Gastroenterol 2020 Nov-Dec;33(6):687. Epub 2020 Jun 30.

Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine.

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http://dx.doi.org/10.20524/aog.2020.0509DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7599349PMC
June 2020

Endoscopic full-thickness resection in the colorectum: ready for prime time?

Authors:
Arthur Schmidt

Endoscopy 2020 11 27;52(11):1024-1025. Epub 2020 Oct 27.

Department of Medicine II, Medical Center, University of Freiburg, Freiburg.

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http://dx.doi.org/10.1055/a-1191-3247DOI Listing
November 2020

Full-thickness resection device (FTRD) for treatment of upper gastrointestinal tract lesions: the first international experience.

Endosc Int Open 2020 Oct 22;8(10):E1291-E1301. Epub 2020 Sep 22.

Division of Digestive Diseases, Department of Medicine, University of Mississippi Medical Center, Jackson, Mississippi, United States.

The Full-Thickness Resection Device (FTRD) provides a novel treatment option for lesions not amenable to conventional endoscopic resection techniques. There are limited data on the efficacy and safety of FTRD for resection of upper gastrointestinal tract (GIT) lesions. This was an international multicenter retrospective study, including patients who had an endoscopic resection of an upper GIT lesion using the FTRD between January 2017 and February 2019. Fifty-six patients from 13 centers were included. The most common lesions were mesenchymal neoplasms (n = 23, 41 %), adenomas (n = 7, 13 %), and hamartomas (n = 6, 11 %). Eighty-four percent of lesions were located in the stomach, and 14 % in the duodenum. The average size of lesions was 14 mm (range 3 to 33 mm). Deployment of the FTRD was technically successful in 93 % of patients (n = 52) leading to complete and partial resection in 43 (77 %) and 9 (16 %) patients, respectively. Overall, the FTRD led to negative histological margins (R0 resection) in 38 (68 %) of patients. A total of 12 (21 %) mild or moderate adverse events (AEs) were reported. Follow-up endoscopy was performed in 31 patients (55 %), on average 88 days after the procedure (IQR 68-138 days). Of these, 30 patients (97 %) did not have any residual or recurrent lesion on endoscopic examination and biopsy, with residual adenoma in one patient (3 %). Our results suggest a high technical success rate and an acceptable histologically complete resection rate, with a low risk of AEs and early recurrence for FTRD resection of upper GIT lesions.
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http://dx.doi.org/10.1055/a-1216-1439DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7508667PMC
October 2020

Efficacy and Safety of Endoscopic Full-Thickness Resection in the Colorectum: Results From the German Colonic FTRD Registry.

Am J Gastroenterol 2020 12;115(12):1998-2006

Department of Medicine II, Medical Center, University of Freiburg, Freiburg, Germany.

Introduction: Endoscopic full-thickness resection (EFTR) is a powerful option for resection of colorectal lesions not amenable to conventional endoscopic resection. The full-thickness resection device (FTRD) allows clip-assisted EFTR with a single-step technique. We report on results of a large nationwide FTRD registry.

Methods: The "German colonic FTRD registry" was created to further assess efficacy and safety of the FTRD System after approval in Europe. Data were analyzed retrospectively.

Results: Sixty-five centers contributed 1,178 colorectal FTRD procedures. Indications for EFTR were difficult adenomas (67.1%), early carcinomas (18.4%), subepithelial tumors (6.8%), and diagnostic EFTR (1.3%). Mean lesion size was 15 × 15 mm and most lesions were pretreated endoscopically (54.1%). Technical success was 88.2% and R0 resection was achieved in 80.0%. R0 resection was significantly higher for subepithelial tumor compared with that for other lesions. No difference in R0 resection was found for smaller vs larger lesions or for colonic vs rectal procedures. Adverse events occurred in 12.1% (3.1% major events and 2.0% required surgical treatment). Endoscopic follow-up was available in 58.0% and showed residual/recurrent lesions in 13.5%, which could be managed endoscopically in most cases (77.2%).

Discussion: To date, this is the largest study of colorectal EFTR using the FTRD System. The study demonstrated favorable efficacy and safety for "difficult-to-resect" colorectal lesions and confirms results of previous studies in a large "real-world" setting. Further studies are needed to compare EFTR with other advanced resection techniques and evaluate long-term outcome.
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http://dx.doi.org/10.14309/ajg.0000000000000795DOI Listing
December 2020

Endoscopic full-thickness resection and its treatment alternatives in difficult-to-treat lesions of the lower gastrointestinal tract: a cost-effectiveness analysis.

BMJ Open Gastroenterol 2020 08;7(1)

Department of Medicine II, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany

Objective: Endoscopic full-thickness resection (EFTR) has shown efficacy and safety in the colorectum. The aim of this analysis was to investigate whether EFTR is cost-effective in comparison with surgical and endoscopic treatment alternatives.

Design: Real data from the study cohort of the prospective, single-arm WALL RESECT study were used. A simulated comparison arm was created based on a survey that included suggested treatment alternatives to EFTR of the respective lesions. Treatment costs and reimbursement were calculated in euro according to the coding rules of 2017 and 2019 (EFTR). R0 resection rate was used as a measure of effectiveness. To assess cost-effectiveness, the average cost-effectiveness ratio (ACER) and the incremental cost-effectiveness ratio (ICER) were determined. Calculations were made both from the perspective of the care provider as well as of the payer.

Results: The cost per case was €2852.20 for the EFTR group, €1712 for the standard endoscopic resection (SER) group, €8895 for the surgical resection group and €5828 for the pooled alternative treatment to EFTR. From the perspective of the care provider, the ACER (mean cost per R0 resection) was €3708.98 for EFTR, €3115.10 for SER, €8924.05 for surgical treatment and €7169.30 for all pooled and weighted alternatives to EFTR. The ICER (additional cost per R0 resection compared with EFTR) was €5196.47 for SER, €26 533.13 for surgical resection and €67 768.62 for the pooled rate of alternatives. Results from the perspective of the payer were similar.

Conclusion: EFTR is cost-effective in comparison with surgical and endoscopic treatment alternatives in the colorectum.
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http://dx.doi.org/10.1136/bmjgast-2020-000449DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7437695PMC
August 2020

A prospective, multicentre study in acute non-cirrhotic, non-malignant portal vein thrombosis: comparison of medical and interventional treatment.

Aliment Pharmacol Ther 2020 07 7;52(2):329-339. Epub 2020 Jun 7.

Freiburg, Germany.

Background: To evaluate medical versus interventional treatment (transjugular thrombus fragmentation, local thrombolysis with or without stent implantation) in patients with acute non-cirrhotic, non-malignant portal vein thrombosis (PVT).

Methods: This prospective, observational study enrolled 65 patients with acute (<28 days since begin of symptoms, no cavernoma) PVT in nine centres. Thirty patients received medical treatment and 35 patients received interventional treatment. PVT was graded into grade 1: short thrombosis and incomplete occlusion of the vessel lumen and grade 2: extended thrombosis or complete occlusion. Treatment response was classified as partial or complete, if thrombosis was reduced by one grade or to <25% of the vessel diameter respectively.

Results: Partial and complete response rates were 7% and 30% in the medical compared to 17% and 54% (P < 0.001) in the interventional treatment group. In the multivariate analysis, interventional treatment showed a strong positive (OR 4.32, P < 0.016) and a myeloproliferative aetiology a negative (OR 0.09, P = 0.006) prediction of complete response. Complications were rare in the medical group and consisted of septicaemia and upper gastrointestinal bleeding of unknown origin in one patient each. Interventional treatment was accompanied by mild and self-limiting bleeding complications in nine patients, moderate intra-abdominal bleeding requiring transfusions (2 units) in one patient and peritoneal bleeding requiring surgical rescue in one patient. Four patients in each group developed intestinal gangrene requiring surgery. One patient died 52 days after unsuccessful interventional treatment.

Conclusions: Compared to medical treatment alone, interventional treatment doubled response rates at the cost of increased bleeding complications.
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http://dx.doi.org/10.1111/apt.15811DOI Listing
July 2020

ERCP in babies: Low risk of post-ERCP pancreatitis - results from a multicentre survey.

United European Gastroenterol J 2020 02 3;8(1):77-80. Epub 2019 Sep 3.

Klinik für Innere Medizin 6, Klinikum Nürnberg, Universitätsklinik der Paracelsus Medizinischen Privatuniversität, Nürnberg, Germany.

Background And Aims: Endoscopic retrograde cholangiopancreatography (ERCP) is rarely performed in newborns, and the risk of post-ERCP pancreatitis (PEP) has not been defined in this age group. We therefore performed a European multicentre analysis of PEP rates and risk factors in children aged ≤1 year.

Patients And Methods: Based on a sample size estimation, 135 consecutive ERCPs in 126 children aged ≤1 year were evaluated from five European centres, and the first ERCP per child analysed. All ERCPs and clinical reports were reviewed manually for PEP and associated risk factors. All ERCPs were performed by endoscopists with high ERCP expertise.

Results: No PEP was observed (0/126, 0.0%, CI 0-2.9%) despite the formal presence of multiple risk factors and despite lack of PEP prophylaxis (except one patient having received a pancreatic duct stent). The PEP rate was significantly lower than the PEP rate expected in adults with similar risk factors.

Conclusions: ERCP in children aged ≤1 year is safe in terms of PEP. The PEP risk is significantly lower in children aged ≤1 year than in adults, therefore no PEP prophylaxis seems to be needed in young children. Risk factors from adults may not apply to children under 1 year. Reluctance to perform diagnostic ERCP in suspected biliary anomalies should not be based on presumed PEP risk.
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http://dx.doi.org/10.1177/2050640619874187DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7006005PMC
February 2020

LMA Gastro™ airway is feasible during upper gastrointestinal interventional endoscopic procedures in high risk patients: a single-center observational study.

BMC Anesthesiol 2020 02 8;20(1):40. Epub 2020 Feb 8.

Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Center - University of Freiburg, University of Freiburg, Hugstetter Strasse 55, 79106, Freiburg im Breisgau, Germany.

Background: Nonoperating room anesthesia during gastroenterological procedures is a growing field in anesthetic practice. While the numbers of patients with severe comorbidities are rising constantly, gastrointestinal endoscopic interventions are moving closer to minimally invasive endoscopic surgery. The LMA Gastro™ is a new supraglottic airway device, developed specifically for upper gastrointestinal endoscopy and interventions. The aim of this study was to evaluate the feasibility of LMA Gastro™ in patients with ASA physical status ≥3 undergoing advanced endoscopic procedures.

Methods: We analyzed data from 214 patients retrospectively who received anesthesia for gastroenterological interventions. Inclusion criteria were upper gastrointestinal endoscopic interventions, airway management with LMA Gastro™ and ASA status ≥3. The primary outcome measure was successful use of LMA Gastro™ for airway management and endoscopic intervention.

Results: Thirtyone patients with ASA physical status ≥3, undergoing complex and prolonged upper gastrointestinal endoscopic procedures were included. There were 7 endoscopic retrograde cholangiopancreatographies, 7 peroral endoscopic myotomies, 5 percutaneous endoscopic gastrostomies and 12 other complex procedures (e.g. endoscopic submucosal dissection, esophageal stent placement etc.). Of these, 27 patients were managed successfully using the LMA Gastro™. Placement of the LMA Gastro™ was reported as easy. Positive pressure ventilation was performed without difficulty. The feasibility of the LMA Gastro™ for endoscopic intervention was rated excellent by the endoscopists. In four patients, placement or ventilation with LMA Gastro™ was not possible.

Conclusions: We demonstrated the feasibility of the LMA Gastro™ during general anesthesia for advanced endoscopic procedures in high-risk patients.

Trial Registration: German Clinical Trials Register (DRKS00017396) Date of registration: 23rd May 2019, retrospectively registered.
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http://dx.doi.org/10.1186/s12871-020-0938-9DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7007643PMC
February 2020

The Use of the Over the Scope Clips Beyond Its Standard Use: A Pictorial Description.

Gastrointest Endosc Clin N Am 2020 Jan;30(1):41-74

Department of Surgery, University of Heidelberg, Heidelberg, Germany.

Despite major improvements in endoscopic devices and therapeutic endoscopy, closure of gastrointestinal perforations, dehiscence, and fistulae had remained problematic. However, since the advent of devices such as the over the scope clip and others, endoscopic closure of gastrointestinal defects has become a routine approach. Furthermore, because of its strong apposition force, the over the scope clip may also be used to anchor fully covered self-expanding metal stents. In addition, the over the scope clip is an effective rescue therapy for various types of gastrointestinal bleeding pathologies. It is frequently used as an additional tool in complex gastrointestinal leak cases requiring internal and external drains.
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http://dx.doi.org/10.1016/j.giec.2019.09.003DOI Listing
January 2020

The Use of the Over the Scope Clip to Treat Upper Gastrointestinal Bleeding.

Gastrointest Endosc Clin N Am 2020 Jan 14;30(1):1-11. Epub 2019 Oct 14.

Department of Surgery, Prince of Wales Hospital, 30-32 Ngan Shing Street, Shatin, NT, Hong Kong SAR.

The over-the-scope clip is a novel endoscopic tool developed for tissue compression in the gastrointestinal tract. It has already revolutionized the management of acute perforations and leaks. In the past decade, it has also increasingly been used for treatment of severe and/or refractory gastrointestinal hemorrhage. Available studies report high rates of primary hemostasis and rebleeding. This article provides an overview on available literature, potential indications, and technical aspects of hemostasis with over-the-scope clip.
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http://dx.doi.org/10.1016/j.giec.2019.08.001DOI Listing
January 2020

Over-the-scope clips are cost-effective in recurrent peptic ulcer bleeding.

United European Gastroenterol J 2019 11 25;7(9):1226-1233. Epub 2019 Sep 25.

Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.

Background: A recent prospective randomised controlled trial ('STING') showed superiority of over-the-scope clips compared to standard treatment in recurrent peptic ulcer bleeding. Cost-effectiveness studies on haemostasis with over-the-scope clips have not been reported so far.

Objective: The aim of this study was to investigate whether the higher efficacy of the over-the-scope clips treatment outweighs the higher costs of the device compared to standard clips.

Methods: For the analysis, the study population of the STING trial was used. Costs for the hospital stay in total as well as treatment-related costs were obtained. The average cost-effectiveness ratio, representing the mean costs per designated outcome, and the incremental cost-effectiveness ratio, expressing the additional costs of a new treatment strategy per difference in outcome were calculated. The designated outcome was defined as successful haemostasis without rebleeding within seven days, which was the primary endpoint of the STING trial. Average cost-effectiveness ratio and incremental cost-effectiveness ratio were calculated for total costs of the hospital stay as well as the haemostasis treatment alone. The cost-effectiveness analysis is taken from the perspective of the care provider. Total costs and treatment-related costs per patient were 13,007.07 € in the standard group vs 12,808.56 € in the over-the-scope clip group ( = 0.812) and 2084.98 € vs 1984.71 € respectively ( = 0.663). The difference was not statistically significant. Total costs per successful haemostasis (average cost-effectiveness ratio) were 30,677.05 € vs 15,104.43 € and 4917.41 € vs 2340.46 € for the haemostasis treatment. The additional costs per successful haemostasis with over-the-scope clip treatment (incremental cost-effectiveness ratio) is -468.18 € for the whole treatment and -236.49€ for the haemostasis treatment.

Conclusions: Over-the-scope clip treatment is cost-effective in recurrent peptic ulcer bleeding.
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http://dx.doi.org/10.1177/2050640619871754DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6826528PMC
November 2019

Full-thickness resection of neuroendocrine tumors in the rectum.

Endoscopy 2020 01 15;52(1):68-72. Epub 2019 Oct 15.

Department of Gastroenterology, Klinikum Ludwigsburg, Ludwigsburg, Germany.

Background: Rectal neuroendocrine tumors (NETs) are subepithelial tumors with potential for malignancy. Depending on tumor characteristics, endoscopic or surgical resection is recommended. However, the optimal endoscopic approach is not defined. This is the first larger study evaluating endoscopic full-thickness resection (EFTR) of rectal NETs.

Methods: For resection, the full-thickness resection device (FTRD) was used. A registry was created as part of post-market clinical follow-up. All cases of rectal NETs in the registry were analyzed retrospectively.

Results: 31 German centers entered data of 501 FTRD procedures and 40 cases of rectal NETs were identified. The median lesion size was 8 mm. All lesions could be resected using FTRD. The median procedure time was 18.5 minutes. Resection was macroscopically and histologically complete in all cases. Full-thickness resection was achieved in 95 %. No major adverse events occurred. Endoscopic follow-up showed no evidence of residual or recurrent tumor.

Conclusion: EFTR is safe and effective for resection of smaller rectal NETs. Prospective comparative trials are needed to define the role of EFTR of rectal NETs.
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http://dx.doi.org/10.1055/a-1008-9077DOI Listing
January 2020

Esophageal lichen planus: towards diagnosis of an underdiagnosed disease.

Scand J Gastroenterol 2019 Oct 14;54(10):1189-1198. Epub 2019 Oct 14.

Department of Medicine II, Gastroenterology, Hepatology, Endocrinology and Infectious Diseases, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.

Although lichen planus (LP) is a common skin disorder, the prevalence of esophageal involvement (ELP) and its clinical manifestations are poorly defined. We aimed to establish diagnostic criteria and characterize disease outcomes of ELP. Clinical, endoscopic, histological, and immunofluorescence data from consecutive patients with known LP between 2013 and 2018 were analyzed. We established endoscopic (denudation and tearing of the mucosa, hyperkeratosis and trachealization) and histological criteria (mucosal detachment, T-lymphocytic infiltrate, intraepithelial apoptosis, dyskeratosis, and fibrinogen deposits along the basement membrane) to grade disease severity. Endoscopic findings were correlated with clinical symptoms. Response to medical therapy was monitored. Fifty-two consecutive patients (median age 59.5 years) were analyzed. According to our grading system, 16 patients were considered as severe and 18 as mild ELP. Dysphagia was the only symptom which differentiated patients with severe (14/16) or mild ELP (8/18) from patients without ELP (1/18). Concomitant oral and genital involvement of LP was associated with the presence of ELP, while oral involvement alone was not. Follow-up of 14/16 patients with severe EPL for at least one year revealed that most of these patients responded to topical corticosteroids (budesonide:  = 9/10 or fluticasone  = 2/2). Three budesonide patients experienced a resolution of symptomatic esophageal stenosis. Esophageal involvement of LP is frequent, but may be asymptomatic. ELP can be diagnosed using the diagnostic criteria proposed here. Dysphagia and combined oral and genital manifestation are associated with ELP. Therapy with topical corticosteroids appears to be a prudent therapeutic approach for ELP.
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http://dx.doi.org/10.1080/00365521.2019.1674375DOI Listing
October 2019

Response.

Gastrointest Endosc 2019 09;90(3):540

Department of Medicine II, Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany.

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http://dx.doi.org/10.1016/j.gie.2019.05.022DOI Listing
September 2019

Laboratory analysis on the surface runoff pollution reduction performance of permeable pavements.

Sci Total Environ 2019 Nov 4;691:1-8. Epub 2019 Jul 4.

College of Environmental Science and Engineering, Tongji University, 1239 Siping Road, Shanghai 200092, PR China. Electronic address:

Permeable pavements are used to address the water quality impacts of urbanization. However, few quantitative relations are available on their pollutant removal performance with respect to varying conditions, especially for different components of a permeable pavement. Individually, the water quality performance of the surface pavement layer and gravel layer of a permeable pavement under various conditions was determined in laboratory-scale pavement cells. Our aim was to reveal the manner in which different factors influence the ability of these two layers to remove total suspended solids (TSS), nutrients, including nitrate (NO-N), ammonia (NH-N) and phosphorous (TP), chemical oxygen demand (COD), and heavy metals (copper (Cu), lead (Pb), cadmium (Cd), and zinc (Zn)), and to provide quantitative understanding of these influences. The removal efficiencies of most stormwater runoff pollutants showed a significant variation with changing rainfall intensity. NH-N, NO-N, TP, and TSS removal exhibited statistically negative linear relationship with rainfall intensity. TSS removal was negatively correlated with TSS concentration for the gravel layer, whereas no obvious trend was observed for the surface pavement layer. The statistical results obtained demonstrate that TSS, NH-N, NO-N, TP, and COD were removed mainly by the surface pavement layer. A smaller gravel gradation was more effective for removing most pollutants, except for NO-N and COD. Positive linear relationships were observed between the gravel layer thickness and pollutant (TSS, TP, NH-N, Cu, and Cd) removal. More importantly, a simple mathematical model was developed to predict the overall performance of the permeable pavement system. By comparing with the overall measured performance, a good performance was achieved, illustrating its promising application in the design of permeable pavements.
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http://dx.doi.org/10.1016/j.scitotenv.2019.07.028DOI Listing
November 2019

Endoscopic full-thickness resection of gastric subepithelial tumors with the gFTRD-system: a prospective pilot study (RESET trial).

Surg Endosc 2020 02 11;34(2):853-860. Epub 2019 Jun 11.

Department of Gastroenterology, Klinikum Ludwigsburg, Posilipostraße 4, 71640, Ludwigsburg, Germany.

Background: Gastric subepithelial tumors (SET) are rare and usually benign. However, up to 13% are malignant. Histology after conventional biopsy often is inconclusive. Surveillance endoscopies are the consequence in the majority of gastric SET cases. For SET arising from deeper layers endoscopic resection (ER) with the standard techniques is difficult and associated with the risk of perforation. The RESET trial further evaluates feasibility, efficacy and safety of clip-assisted endoscopic full-thickness resection (EFTR) for gastric SET using the novel gastric full-thickness-resection device (gFTRD).

Materials And Methods: The RESET trial was initiated in March 2017 (NCT03096236) and designed as prospective observational multicenter pilot trial. Gastric SET up to 15 mm were included. Primary endpoint was technical success (complete enbloc resection). Secondary endpoints were R0 resection, full-thickness resection, adverse events and recurrency at 3-months follow-up. For resection we used the gFTRD (Ovesco Endoscopy, Tübingen, Germany).

Results: 29 patients underwent gastric EFTR. Histology prior EFTR after conventional biopsy could define histological tumor type in only 31.2%. Primary endpoint was reached in 89.7%. Histology of the full-thickness-resection specimen could define histological tumor type in 100%. 76% of all SET could be resected histologically complete (R0) and a full-thickness-resection specimen could be obtained in 65.5%. In 31% periprocedural minor bleeding was observed and managed endoscopically. Follow-up was available in 79.3% (OTSC detachment in 78.3%, OTSC in position in 21.7%). No signs of residual or recurrent tumors were observed after 3 months.

Conclusion: EFTR of gastric SET with gFTRD is feasible and safe. EFTR allows a definite histological diagnosis (including sufficient risk stratification in case of GIST or NET) in contrast to conventional biopsy. R0-resection is possible in most cases and might obviate the need for further surveillance endoscopies for selected patients.
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http://dx.doi.org/10.1007/s00464-019-06839-2DOI Listing
February 2020

Novel telemetric sensor capsule for EGD urgency triage: a feasibility study.

Endosc Int Open 2019 Jun 17;7(6):E774-E781. Epub 2019 May 17.

Department of Gastroenterology and Oncology, Klinikum Ludwigsburg, Germany.

Upper gastrointestinal bleeding (UGIB) is a frequent cause of hospitalization. Because of the lack of reliable noninvasive diagnostic tools, the decision to proceed with emergency endoscopy in these cases is made based on clinical parameters. A novel non-imaging telemetric real-time sensor capsule (HemoPill Acute, Ovesco Endoscopy AG) has shown promising results for noninvasive detection of UGIB in preclinical studies. We conducted a prospective non-randomized, single center, open-label study to investigate feasibility and safety of the novel sensor capsule in patients with symptoms of UGIB. The primary aim of the first clinical study was to investigate feasibility and safety of the device in a clinical setting. All patients underwent endoscopy within 12 hours after capsule ingestion. Sensor data from the capsule within 10 minutes after ingestion were compared with endoscopic findings. From April 2015 to February 2016, 30 consecutive patients with symptoms of acute UGIB were included; 27 were eligible for analysis. Capsule ingestion was well tolerated in all patients and there were no device-related adverse events. Endoscopy showed blood or hematin in the upper gastrointestinal tract of 10 of 27 patients; in 2 of 10 patients it was estimated to be more than 20 mL; in 4 of 8 patients it was between 5 and 20 mL and in 4 of 8 it was estimated to < 5 mL. The sensor capsule was positive in 2 of 2 patients (100 %) with > 20 mL of blood or hematin and in 1 of 8 patients (12.5 %) between 5 and 20 mL. All patients (17/17; 100 %) were correctly identified as non-bleeders. Both device and procedure proved to be safe and feasible. Larger studies will be necessary to evaluate the role of the sensor capsule in risk stratification of patients with acute UGIB.
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http://dx.doi.org/10.1055/a-0880-5312DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6524997PMC
June 2019

Efficacy of the OTSC System in the treatment of GI bleeding and wall defects: a PMCF meta-analysis.

Minim Invasive Ther Allied Technol 2020 Jun 7;29(3):121-139. Epub 2019 Apr 7.

Ovesco Endoscopy AG, Tuebingen, Germany.

Since its market launch in 2007, the endoscopic OTSC clipping system has been the object of intensive clinical research. These data were systematically collected for post-market clinical follow-up (PMCF). The aim of the study was the systematic review of the efficacy and safety of the OTSC System. The PMCF database was systematically searched for clinical data on OTSC therapy of GI hemorrhage (H), acute leaks/perforations (AL) and chronic leaks/fistulae (CL). Major outcomes were successful clip application and durable hemostasis/closure of defects. Comprehensive pooled success proportions were established by meta-analytical methods. Four-hundred-fifty-seven publications were reviewed. Fifty-eight articles comprising 1868 patients fulfilled criteria to be included in the analysis. These consisted of retrospective analyses, prospective observational trials, one randomized-controlled trial (STING) and one quasi-controlled study (FLETRock). The pooled proportion analysis revealed high overall proportions of technical success: H - mean 93.0% [95%CI 90.2-95.4], AL-mean 89.7% [95%CI 85.9-92.9] and CL-mean 83.8% [95%CI 76.9-89.7]. Pooled durable clinical success proportions were: H-mean 87.5% [95%CI 80.5-93.2], AL-mean 81.4% [95%CI 77.0-85.3] and CL-mean 63.0% [95%CI 53.0-72.3]. By pooling all clinical data gained, we conclude that OTSC application in GI hemorrhage and closure of GI lesions is safe and effective in real clinical use.
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http://dx.doi.org/10.1080/13645706.2019.1590418DOI Listing
June 2020

Adjuvant Transjugular Variceal Occlusion at Creation of a Transjugular Intrahepatic Portosystemic Shunt (TIPS): Efficacy and Risks of Bucrylate Embolization.

Cardiovasc Intervent Radiol 2019 May 20;42(5):729-736. Epub 2019 Feb 20.

Department of Gastroenterology, University Hospital of Freiburg, Hugstetter Str. 55, 79106, Freiburg, Germany.

Adjuvant embolization of varices may reduce rebleeding in patients with a transjugular intrahepatic portosystemic shunt (TIPS). The aim of this study was to investigate the efficacy and the risks of adjuvant variceal embolization at TIPS implantation using bucrylate.

Patients And Methods: The retrospective study evaluated 104 of 237 cirrhotic patients with TIPS for variceal bleeding who received adjuvant bucrylate embolization. For TIPS creation, bare stents were used in 35 patients (33.7%) and covered stents in 69 patients (66.3%) patients. Isolated gastric varices were seen in 10 patients (9.6%).

Results: Six patients (5.8%) rebled during a median follow-up time of 26 months (1-57 months). Rebleeding occurred in 14% (5/35) of patients with a bare stent but only in 1.4% (1/69) of patients with a covered stent. The 1- and 2-year rebleeding rates of all patients were 0.9 and 2.9% and of patients receiving a bare stent were 2.9 and 8.6%, respectively. Bucrylate migration was seen in 13 patients (12.5%). In 9 of these patients (8.7%), asymptomatic lung embolization occurred. This was rare in patients with esophageal varices (3.1%) but frequent (60%) in patients with isolated gastric varices and a spontaneous splenorenal shunt.

Conclusions: Our results suggest that adjuvant embolization using bucrylate is effective and delays variceal rebleeding. The general use of covered stents, however, alleviates the utility of adjuvant bucrylate embolization which may be restricted to patients with a high risk of rebleeding indicated by large varices, active, acute or recent variceal bleeding and advanced cirrhosis. Bucrylate should not be used in isolated gastric varices because it bears a high risk of migration into the lungs.
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http://dx.doi.org/10.1007/s00270-019-02176-yDOI Listing
May 2019

Endoscopic submucosal dissection of an esophageal granular cell tumor.

VideoGIE 2019 Feb 11;4(2):58-61. Epub 2019 Jan 11.

Faculty of Medicine, Department of Medicine II, University Hospital Freiburg, University of Freiburg, Freiburg, Germany.

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http://dx.doi.org/10.1016/j.vgie.2018.10.015DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6363592PMC
February 2019

Endoscopic full-thickness resection for early colorectal cancer.

Gastrointest Endosc 2019 06 14;89(6):1180-1189.e1. Epub 2019 Jan 14.

Department of Medicine II, Medical Center-University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg.

Background And Aims: Current international guidelines recommend endoscopic resection for T1 colorectal cancer (CRC) with low-risk histology features and oncologic resection for those at high risk of lymphatic metastasis. Exact risk stratification is therefore crucial to avoid under-treatment as well as over-treatment. Endoscopic full-thickness resection (EFTR) has shown to be effective for treatment of non-lifting benign lesions. In this multicenter, retrospective study we aimed to evaluate efficacy, safety, and clinical value of EFTR for early CRC.

Methods: Records of 1234 patients undergoing EFTR for various indications at 96 centers were screened for eligibility. A total of 156 patients with histologic evidence of adenocarcinoma were identified. This cohort included 64 cases undergoing EFTR after incomplete resection of a malignant polyp (group 1) and 92 non-lifting lesions (group 2). Endpoints of the study were: technical success, R0-resection, adverse events, and successful discrimination of high-risk versus low-risk tumors.

Results: Technical success was achieved in 144 out of 156 (92.3%). Mean procedural time was 42 minutes. R0 resection was achieved in 112 of 156 (71.8%). Subgroup analysis showed a R0 resection rate of 87.5% in Group 1 and 60.9% in Group 2 (P < .001). Severe procedure-related adverse events were recorded in 3.9% of patients. Discrimination between high-risk versus low-risk tumor was successful in 155 of 156 cases (99.3%). In Group 1, 84.1% were identified as low-risk lesions, whereas 16.3% in group 2 had low-risk features. In total, 53 patients (34%) underwent oncologic resection due to high-risk features whereas 98 patients (62%) were followed endoscopically.

Conclusions: In early colorectal cancer, EFTR is technically feasible and safe. It allows exact histological risk stratification and can avoid surgery for low-risk lesions. Prospective studies are required to further define indications for EFTR in malignant colorectal lesions and to evaluate long-term outcome.
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http://dx.doi.org/10.1016/j.gie.2018.12.025DOI Listing
June 2019
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