Publications by authors named "Markus Dollhopf"

19 Publications

  • Page 1 of 1

Endoscopic management of difficult common bile duct stones.

Minerva Gastroenterol (Torino) 2021 Jun 18. Epub 2021 Jun 18.

Endoscopy Section, Gastroenterology, München Klinik Neuperlach, Munich, Germany -

Introduction: Common bile duct stones are a very frequent problem in the western world and endoscopic stone clearance is the method of choice for treatment. Despite its common use, endoscopic clearance of common bile duct stones is not always trivial especially in cases involving large or multiple stones.

Evidence Acquisition: A literature review regarding different endoscopic techniques was performed for this article and a recommended therapeutic algorithm developed based on the guidelines of the European Society of Gastrointestinal Endoscopy (ESGE) and the German Gastroenterological Society (DGVS).

Evidence Synthesis: This review gives an overview of currently applied endoscopic techniques, their success and complication rates as well as alternative methods used for cases involving anatomic anomalies. The purpose of this review is to recommend a therapeutic algorithm for the treatment of difficult common bile duct stones.

Conlclusions: For the treatment of difficult common bile duct stones, combined sphincterotomy and endoscopic large balloon dilation should be first choice. Mechanical lithotripsy and cholangioscopy-guided lithotripsy are close alternatives with nearly equal clearance rates and should be used if accessible. The insertion of a temporary plastic stent is a good choice to gain time to explore further treatment options. Enteroscopy-based ERCP, PTCS or EUS-guided hepaticogastrostomy and stone treatment, while good alternatives for select cases involving anatomic anomalies, should be performed at specialised units.
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http://dx.doi.org/10.23736/S2724-5985.21.02876-XDOI Listing
June 2021

A structured Endoscopic Ultrasound training program in Germany improves knowledge and competence.

Med Ultrason 2021 Jun 10. Epub 2021 Jun 10.

Institut for Medical Education, University Hospital of LMU Munich, Munich, Germany.

Aims: Limited evidence on how to organize pre-patient training in Endoscopic Ultrasound (EUS) and how to evaluate its effect on knowledge and skills are available. The aim of our study was to assess the impact of a structured multi-site training program on EUS competence in Germany.

Material And Methods: In a prospective study design, evaluation of 64 trainees was conducted during four three-day training courses with equal curricula at three sites. Participants completed a structured pre- and post-test questionnaire consisting of 4 items to evaluate the relevance and acceptance of the training components (theoretical teaching, video sessions, live demonstration, hands-on experience) on a 5-point Likert scale, as well as a Likert scale to judge the self-rated improvement in EUS competence. To assess knowledge, 12 multiple choice (MC) questions had to be answered by all participants in a pre- and a post-test design. Also differences between beginners and advanced learners were analysed.

Results: Overall evaluation on acceptance received above-average results with a median of 4 or 5 (IQR 1-2) on Likert scale (1=completely disagree, 5=completely agree). In the post-test self-rated EUS skills improved from 4 to 2 on the Likert scale (IQR=1, p=0.001, 1=excellent EUS skills, 5=no EUS skills). Results of the MC-test of all trainees showed significant improvement in theoretical knowledge from 7.9±1.9 to 8.8±1.9 points (mean±SD, p=0.001).

Conclusions: Our study provides arguments for the usefulness of a structured EUS training program resulting in a positive acceptance and high self-rated EUS competence by the participants and significant improvements in knowledge.
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http://dx.doi.org/10.11152/mu-2892DOI Listing
June 2021

Endoscopic and percutaneous biliary interventions in patients with altered upper gastrointestinal anatomy-the Munich Multicenter Experience.

Surg Endosc 2021 Jan 4. Epub 2021 Jan 4.

Medizinische Klinik II, Krankenhaus Landshut-Achdorf, Akademisches Lehrkrankenhaus der TU München, Achdorferweg 3, 84036, Landshut, Germany.

Background: In patients with altered upper gastrointestinal anatomy, conventional endoscopic retrograde cholangiography is often not possible and different techniques, like enteroscopy-assisted or percutaneous approaches are required. Aim of this study was to analyze success and complication rates of these techniques in a large collective of patients in the daily clinical practice in a pre-endosonographic biliary drainage era.

Patients And Methods: Patients with altered upper gastrointestinal anatomy with biliary interventions between March 1st, 2006, and June 30th, 2014 in four tertiary endoscopic centers in Munich, Germany were retrospectively analyzed.

Results: At least one endoscopic-assisted biliary intervention was successful in 234/411 patients (56.9%)-in 192 patients in the first, in 34 patients in the second and in 8 patients in the third attempt. Success rates for Billroth-II/Whipple-/Roux-en-Y reconstruction were 70.5%/56.7%/49.5%. Complication rates for these reconstructions were 9.3%/6.5%/6.3%, the overall complication rate was 7.1%. Success rates were highest in patients with Billroth-II reconstruction where use of a duodenoscope was possible, complication rates were also highest in this scenario. Success rates were lowest in longer-limb anatomy like Roux-en-Y reconstruction. Percutaneous biliary drainages (PTBD) were inserted 268 times with substantially higher success (90.7%) as well as complication rates (11.6%) compared to the endoscopic approach. Compared to patients treated endoscopically, patients with PTBD had a lower performance status, more severe cholestasis and a significant higher rate of malignant underlying disease.

Conclusion: In patients with altered upper gastrointestinal anatomy, success rates of endoscopic-assisted biliary interventions are lower compared to PTBD. Still, due to the beneficial complication rates of the endoscopic approach, this technique should be preferred whenever possible and in selected patients who still need to be defined in detail, repeated endoscopic attempts are useful to help achieve the desired result.
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http://dx.doi.org/10.1007/s00464-020-08191-2DOI Listing
January 2021

Technical success, resection status, and procedural complication rate of colonoscopic full-wall resection: a pooled analysis from 7 hospitals of different care levels.

Surg Endosc 2021 Jul 9;35(7):3339-3353. Epub 2020 Jul 9.

Department of Gastroenterology, Hepatology and Gastrointestinal Oncology, Bogenhausen Academic Teaching Hospital, Technical University of Munich, Munich, Germany.

Introduction: Endoscopic full-thickness resection (eFTR) using the full-thickness resection device (FTRD®) is a novel minimally invasive procedure that allows the resection of various lesions in the gastrointestinal tract including the colorectum. Real-world data outside of published studies are limited. The aim of this study was a detailed analysis of the outcomes of colonoscopic eFTR in different hospitals from different care levels in correlation with the number of endoscopists performing eFTR.

Material And Methods: In this case series, the data of all patients who underwent eFTR between November 2014 and June 2019 (performed by a total of 22 endoscopists) in 7 hospitals were analyzed retrospectively regarding rates of technical success, R0 resection, and procedure-related complications.

Results: Colonoscopic eFTR was performed in 229 patients (64.6% men; average age 69.3 ± 10.3 years) mainly on the basis of the following indication: 69.9% difficult adenomas, 21.0% gastrointestinal adenocarcinomas, and 7.9% subepithelial tumors. The average size of the lesions was 16.3 mm. Technical success rate of eFTR was achieved in 83.8% (binominal confidence interval 78.4-88.4%). Overall, histologically complete resection (R0) was achieved in 77.2% (CI 69.8-83.6%) while histologically proven full-wall excidate was confirmed in 90.0% (CI 85.1-93.7%). Of the resectates obtained (n = 210), 190 were resected en bloc (90.5%). We did not observe a clear improvement of technical success and R0 resection rate over time by the performing endoscopists. Altogether, procedure-related complications were observed in 17.5% (mostly moderate) including 2 cases of acute gangrenous appendicitis requiring operation.

Discussion: In this pooled analysis, eFTR represents a feasible, effective, and safe minimally invasive endoscopic technique.
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http://dx.doi.org/10.1007/s00464-020-07772-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8195906PMC
July 2021

The safety and efficacy of a new 20-mm lumen apposing metal stent (lams) for the endoscopic treatment of pancreatic and peripancreatic fluid collections: a large international, multicenter study.

Surg Endosc 2021 04 22;35(4):1741-1748. Epub 2020 Apr 22.

Department of Surgical Gastroenterology, Aarhus University Hospital, Aarhus, Denmark.

Background: Lumen apposing metal stent (LAMS) allows an easy access to peripancreatic fluid collections (PPFCs) and the possibility of performing direct endoscopic necrosectomy (DEN). The aim of our study was to evaluate the safety and efficacy of a new 20-mm LAMS in the management of PPFCs. This novel stent represents the largest diameter LAMS available on the market to date.

Methods: This is an international, multicenter retrospective study involving 20 centers. Consecutive patients who underwent EUS-guided PPFC drainage using a 20-mm LAMS were included. Primary outcomes were technical and clinical success. Secondary outcomes were rate and the severity of adverse events.

Results: A total 105 patients underwent PPFC drainage using the new 20-mm LAMS and 106 LAMS were placed. Technical success was 100% (106/106). 7/105 patients died due to causes not related to the stent. Clinical success was achieved in 92/98 patients (93.9%). Significant adverse events occurred in 8/98 patients (8.16%): 4 cases (4.08%) of bleeding, 3 cases (3.06%) of suprainfection, 1 case of gastric outlet obstruction.

Conclusions: This multicenter study demonstrated acceptable rates of technical and clinical success using a new 20-mm LAMS for PPFC, including walled-off pancreatic necrosis (WOPN). The results of our study suggest that a new 20-mm LAMS is non-inferior in terms of safety, efficacy, and adverse events as compared to smaller diameter LAMS in the management of PPFCs, including pancreatic psuedocysts (PP) and WOPN. Randomized controlled studies will be needed to determine the ideal size of LAMS need to achieve the greatest clinical benefit with the minimized risk exposure for this high-risk patient population.
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http://dx.doi.org/10.1007/s00464-020-07567-8DOI Listing
April 2021

Risk factors for bleeding from gastrointestinal angiodysplasia: a case-control study in patients with bleeding and non-bleeding angiodysplasia.

Z Gastroenterol 2020 Mar 4;58(3):234-240. Epub 2020 Feb 4.

II. Medizinische Klinik, Krankenhaus Landshut, Germany.

Objectives:  Angiodysplasia (AD) is a common source of gastrointestinal bleeding. Yet, little is known about factors forwarding bleeding in these vascular malformations. The presented study aims to determine risk factors for bleeding that occurs only in patients with symptomatic, but not with asymptomatic, AD.

Methods:  Case-control study in patients with AD and either a positive or a negative history of gastrointestinal bleeding in Munich, Germany. Groups were compared by clinical, laboratory, and endoscopic features.

Results:  80 patients with (58, f 31, med. age 72) or without bleeding AD (22, f 12, med. age 61) were included. Bleeding from AD was significantly associated with the total number of AD (OR 1.4 (95 % CI 1.1-1.7) p = 0.01) and closure time in PFA/collagen-epinephrine test (OR 1.0 (95 % CI 1.0-1.0) p < 0.01). The total number of AD correlated significantly with age (r = 0.36; p = 0.01). AD were mainly detected in the upper small intestine (> 30 %). Although patients with aortic stenosis suffered not significantly more frequently from bleeding from AD, they demonstrated a loss of high molecular multimers of VWF.

Conclusions:  The amount of AD is clearly correlated to the age of the patient. A higher number of ADs and inhibition of primary hemostasis increase the risk of bleeding.
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http://dx.doi.org/10.1055/a-1068-3014DOI Listing
March 2020

Lumen apposing metal stents are superior to plastic stents in pancreatic walled-off necrosis: a large international multicenter study.

Endosc Int Open 2019 Mar 28;7(3):E347-E354. Epub 2019 Feb 28.

Division of Gastroenterology and Hepatology, Klinikum Neuperlach, Munich, Germany.

 The use of lumen apposing metal stents (LAMS) during EUS-guided transmural drainage (EUS-TD) of pancreatic walled-off necrosis (WON) has gained popularity. Data supporting their use in WON over plastic stents (PS), however, remain scarce. The aim of this study was to compare the clinical efficacy of LAMS (Axios, Boston Scientific) with PS in WON.  This was a multicenter, retrospective study involving 14 centers. Consecutive patients who underwent EUS-TD of WON (2012 - 2016) were included. The primary end point was clinical success defined as WON size ≤ 3 cm within a 6-month period without need for percutaneous drainage (PCD) or surgery.  A total of 189 patients (mean age 55.2 ± 15.6 years, 34.9 % female) were included (102 LAMS and 87 PS). Technical success rates were similar: 100 % in LAMS and 98.9 % in PS (  = 0.28). Clinical success was attained in 80.4 % of LAMS and 57.5 % of PS (  = 0.001). Rate of PCD was similar (13.7 % LAMS vs. 16.3 % PS,  = 0.62), while PS was associated with a greater need for surgery (16.1 % PS vs. 5.6 % LAMS,  = 0.02). Adverse events (AEs) were observed in 9.8 % of LAMS and 10.3 % of PS (  = 0.90) and were rated as severe in 2.0 % and 6.9 %, respectively (  = 0.93). After excluding patients with < 6 months follow-up, the rate of WON recurrence following initial clinical success was greater with PS (22.9 % PS vs. 5.6 % LAMS,  = 0.04).  When compared to PS, LAMS in WON is associated with higher clinical success, shorter procedure time, lower need for surgery, and lower rate of recurrence.
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http://dx.doi.org/10.1055/a-0828-7630DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6395102PMC
March 2019

Lumen-apposing stents versus plastic stents in the management of pancreatic pseudocysts: a large, comparative, international, multicenter study.

Endoscopy 2019 11 7;51(11):1035-1043. Epub 2018 Dec 7.

Division of Gastroenterology and Hepatology, Johns Hopkins Medical Institution, Baltimore, Maryland, USA.

Background: Larger caliber lumen-apposing stents (LAMSs) have been increasingly used in the management of pancreatic fluid collections, specifically when solid debris is present; however, their advantages over smaller caliber plastic stents in the management of pancreatic pseudocysts are unclear. The aim of this study was to investigate the safety and efficacy of LAMS specifically in the management of pancreatic pseudocysts compared with double-pigtail plastic stents (DPPSs).

Methods: We performed a multicenter, international, retrospective study between January 2012 and August 2016. A total of 205 patients with a diagnosis of pancreatic pseudocysts were included, 80 patients received LAMSs and 125 received DPPSs. Measured outcomes included clinical success, technical success, adverse events, stent dysfunction, pancreatic pseudocyst recurrence, and need for surgery.

Results: Technical success was similar between the LAMS and the DPPS groups (97.5 % vs. 99.2 %;  = 0.32). Clinical success was higher for LAMSs than for DPPSs (96.3 % vs. 87.2 %;  = 0.03). While the need for surgery was similar between the two groups (1.3 % vs. 4.9 %, respectively;  = 0.17), the use of percutaneous drainage was significantly lower in the LAMS group (1.3 % vs. 8.8 %;  = 0.03). At 6-month follow-up, the recurrence rate was similar between the groups (6.7 % vs 18.8 %, respectively;  = 0.12). The rate of adverse events was significantly higher in the DPPS group (7.5 % vs. 17.6 %;  = 0.04). There was no difference in post-procedure mean length of hospital stay (6.3 days [standard deviation 27.9] vs. 3.7 days [5.7];  = 0.31).

Conclusion: When compared to DPPSs, LAMSs are a safe, feasible, and effective modality for the treatment of pancreatic pseudocysts and are associated with a higher rate of clinical success, shorter procedure time, less need for percutaneous interventions, and a lower overall rate of adverse events.
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http://dx.doi.org/10.1055/a-0759-1353DOI Listing
November 2019

[Endoscopic submucosal dissection for mucosal low-risk early gastric cancer - a retrospective, unicentric study].

Z Gastroenterol 2018 Nov 12;56(11):1343-1353. Epub 2018 Nov 12.

Institut für Pathologie Süd, Städtisches Klinikum München GmbH, Deutschland.

Background:  Endoscopic submucosal dissection (ESD) is the standard-procedure in Asia for the treatment of early gastric cancer (EGC) within defined criteria. In Europe, this technique is being used more and more frequently. In the context of risk constellations (submucosal invasion, lymphangioinvasion, poorly differentiated carcinoma), the occurrence of lymph node metastases is possible. We defined a low-risk group (differentiated, mucosal EGC without ulceration and vascular infiltration, size independent) to investigate the endoscopic outcome and the long-term course of this special group with excellent prognosis.

Patients And Methods:  Patients with untreated low-risk EGC were included in this retrospective evaluation. Patient data (age, gender distribution), carcinoma parameters (number, size, location, Paris-Classification), histological parameters, resection data (including en bloc resection, R-status), follow-up (including local recurrence, survival) and complication data were evaluated.

Results:  In 55 patients, ESD was used to remove 61 low-risk EGC. In 93.4 %, the En-bloc resection succeeded, in 91.8 % of cases, an R0 status was documented. In 8 cases (13.1 %), intervention-dependent complications occurred: 5 delayed bleeding (8.2 %), two microperforations (3.3 %, no surgery required) and one non-ST-elevated myocardial infarciation (1.6 %). During the follow-up (mean: 54.3 months) there were 4 cases (6.6 %) of local recurrences, of which at least 2 could be successfully treated endoscopically. The other 2 patients died after repeated endoscopy before the first control. Overall, 4 patients (7.8 %) died during the follow up, none of them tumor-associated. In 9 patients (16.4 %) syn- or metachronous lesions were detected, all of which could be treated endoscopically. Lymphnode metastases did not occur.

Conclusion:  In the low-risk group that we defined, a high rate of en bloc and R0 resections were achieved with ESD; the detected local recurrences could be treated endoscopically. Metastases were not detected, no tumor-associated patient deaths occured. ESD is, therefore, recommended for this group as a standard therapy. The study provides no data on the endoscopic and clinical follow up in the presence of risk factors of both mucosal and other EGCs from the so-called Expanded Group (including lymphangio-invasion, submucosal invasive EGC, poorly differentiated G3 carcinomas).
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http://dx.doi.org/10.1055/a-0729-3061DOI Listing
November 2018

Comparison of cap-assisted endoscopy vs. side-viewing endoscopy for examination of the major duodenal papilla: a randomized, controlled, noninferiority crossover study.

Endoscopy 2019 05 10;51(5):419-426. Epub 2018 Sep 10.

Internal Medicine Department, Klinik Bad Aibling, Bad Aibling, Germany.

BACKGROUND : Use of a side-viewing endoscope is currently mandatory to examine the major duodenal papilla; however, previous studies have used cap-assisted endoscopy for complete examination of the papilla. The aim of this study was to compare cap-assisted endoscopy with side-viewing endoscopy for examination of the major duodenal papilla. METHODS : This was a prospective, randomized, blinded, controlled, noninferiority crossover study. Patients were randomized to undergo either side-viewing endoscopy followed by cap-assisted endoscopy or cap-assisted endoscopy followed by side-viewing endoscope. Photographs of the major duodenal papilla were digitally edited to mask the cap area before they were evaluated by three blinded external examiners. Our primary end point was complete visualization of the major duodenal papilla. Secondary end points were the ability to examine the mucosal pattern, the overview of the periampullary region, overall satisfaction, and time to locate the papilla. RESULTS : 62 patients completed the study. Complete visualization of the major duodenal papilla was achieved in 60 examinations by side-viewing endoscopy and in 59 by cap-assisted endoscopy (97 % vs. 95 %). The difference between the two examinations was 1.6 % with a two-sided 95 % confidence interval of -4.0 % to 7.3 %, which did not exceed the noninferiority margin of 8 %. Cap-assisted endoscopy achieved better scores regarding the examination of mucosal pattern and overall satisfaction, whereas side-viewing endoscopy had a better overview score ( < 0.001,  = 0.004, and  < 0.001, respectively). There was no relevant difference in the median times to locate the major duodenal papilla. CONCLUSION : Cap-assisted endoscopy and side-viewing endoscopy had similar success rates for complete visualization of the major duodenal papilla. Cap-assisted endoscopy is superior to side-viewing endoscopy regarding the mucosal pattern and overall satisfaction. Side-viewing endoscopy gives a better overview of the periampullary region.
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http://dx.doi.org/10.1055/a-0662-5445DOI Listing
May 2019

Endoscopic ultrasound-guided entero-enterostomy for the treatment of afferent loop syndrome: a multicenter experience.

Endoscopy 2018 09 2;50(9):891-895. Epub 2018 Mar 2.

Division of Gastroenterology and Hepatology, Johns Hopkins Hospital, Baltimore, Maryland, United States.

Background: Afferent loop syndrome (ALS) is traditionally managed surgically and, more recently, endoscopically. The role of endoscopic ultrasound-guided entero-enterostomy (EUS-EE) has not been well described. The aim of this study was to assess the technical and clinical success and safety of EUS-EE.

Methods: This was a multicenter, retrospective series at six centers in patients with ALS treated by EUS-EE. Data on patients treated with enteroscopy-assisted luminal stenting (EALS) at a single center were also collected.

Results: 18 patients (mean age 64.2 years, 72 % post-pancreaticoduodenectomy, 10 female) underwent EUS-EE. The most common symptoms were vomiting (27.8 %) and jaundice (33.3 %). Clinical success included resolution of symptoms in 88.9 % and improvement to allow hospital discharge in 11.1 %. Technical success was achieved in 100 % of cases, with a mean procedure time of 29.7 minutes. The most common procedure was a gastro-jejunostomy (72.2 %). Three adverse events (16.7 %) occurred (two mild, one moderate). When compared with data on EALS, patients treated with EUS-EE needed fewer re-interventions (16.6 % vs. 76.5 %;  < 0.001).

Conclusion: EUS-EE seems to be safe and effective in the treatment of ALS. Indirect comparison with EALS suggested that EUS-EE is associated with a reduced need for re-intervention.
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http://dx.doi.org/10.1055/s-0044-102254DOI Listing
September 2018

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

Gut 2019 03 3;68(3):445-452. Epub 2018 Jan 3.

Gastroenterologie, Kreiskrankenhaus Dormagen, Dormagen, Germany.

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.
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http://dx.doi.org/10.1136/gutjnl-2015-311037DOI Listing
March 2019

[Cost assessment for endoscopic procedures in the German diagnosis-related-group (DRG) system - 5 year cost data analysis of the German Society of Gastroenterology project].

Z Gastroenterol 2017 Oct 8;55(10):1038-1051. Epub 2017 Sep 8.

Klinik und Poliklinik für Innere Medizin A, Universitätsmedizin Greifswald.

 In the German hospital reimbursement system (G-DRG) endoscopic procedures are listed in cost center 8. For reimbursement between hospital departments and external providers outdated or incomplete catalogues (e. g. DKG-NT, GOÄ) have remained in use. We have assessed the cost for endoscopic procedures in the G-DRG-system.  To assess the cost of endoscopic procedures 74 hospitals, annual providers of cost-data to the Institute for the Hospital Remuneration System (InEK) made their data (2011 - 2015; § 21 KHEntgG) available to the German-Society-of-Gastroenterology (DGVS) in anonymized form (4873 809 case-data-sets). Using cases with exactly one endoscopic procedure (n = 274 186) average costs over 5 years were calculated for 46 endoscopic procedure-tiers.  Robust mean endoscopy costs ranged from 230.56 € for gastroscopy (144 666 cases), 276.23 € (n = 32 294) for a simple colonoscopy, to 844.07 € (n = 10 150) for ERCP with papillotomy and plastic stent insertion and 1602.37 € (n = 967) for ERCP with a self-expanding metal stent. Higher costs, specifically for complex procedures, were identified for University Hospitals.  For the first time this catalogue for endoscopic procedure-tiers, based on § 21 KHEntgG data-sets from 74 InEK-calculating hospitals, permits a realistic assessment of endoscopy costs in German hospitals. The higher costs in university hospitals are likely due to referral bias for complex cases and emergency interventions. For 46 endoscopic procedure-tiers an objective cost-allocation within the G-DRG system is now possible. By international comparison the costs of endoscopic procedures in Germany are low, due to either greater efficiency, lower personnel allocation or incomplete documentation of the real expenses.
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http://dx.doi.org/10.1055/s-0043-118350DOI Listing
October 2017

Cap Assisted Upper Endoscopy for Examination of the Major Duodenal Papilla: A Randomized, Blinded, Controlled Crossover Study (CAPPA Study).

Am J Gastroenterol 2017 05 14;112(5):725-733. Epub 2017 Mar 14.

II. Medizinische Klinik und Poliklinik, Klinikum rechts der Isar der Technischen Universität Mìnchen, Munich, Germany.

Objective: Examination of major duodenal papilla (MDP) by standard forward-viewing esophagogastroduodenoscopy (S-EGD) is limited. Cap assisted esophagogastroduodenoscopy (CA-EGD) utilizes a cap fitted to the tip of the endoscope that can depress the mucosal folds and thus might improve visualization of MDP. The aim of this study was to compare CA-EGD to S-EGD for complete examination of the MDP.

Methods: Prospective, randomized, blinded, controlled crossover study. Subjects scheduled for elective EGD were randomized to undergo S-EGD (group A) or CA-EGD (group B) before undergoing a second examination by the alternate method. Images of the MDP were evaluated by three blinded multicenter-experts. Our primary outcome measure was complete examination of the papilla. Secondary outcome measures were duration and overall diagnostic yield.

Results: A total of 101 patients were randomized and completed the study. Complete examination of MDP was achieved in 98 patients using CA-EGD compared to 24 patients using S-EGD (97 vs. 24%, P<0.001). Median duration from intubation of the esophagus until localization of the MDP was shorter with CA-EGD (46. vs. 96 s., P<0.001). In group A, 11 extra lesions and 12 additional incidental findings were detected by secondary CA-EGD, whereas neither were detected by secondary S-EGD in group B (22 vs. 0% and 24 vs. 0%, P<0.001 and P<0.001).

Conclusion: CA-EGD enabled complete examination of MDP in almost all cases compared to a low success rate of S-EGD. CA-EGD detected a significant amount of lesions and incidental findings when added to S-EGD. CA-EGD is a safe and effective method for examination of MDP.
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http://dx.doi.org/10.1038/ajg.2017.47DOI Listing
May 2017

EUS-guided gallbladder drainage in patients with acute cholecystitis and high surgical risk using an electrocautery-enhanced lumen-apposing metal stent device.

Gastrointest Endosc 2017 Oct 1;86(4):636-643. Epub 2017 Mar 1.

Department of Surgical Gastroenterology, L Aarhus University Hospital, Aarhus, Denmark.

Background And Aims: In high-risk surgical patients, the treatment of choice of acute cholecystitis is percutaneous transhepatic gallbladder drainage (PTGBD). Recently, a novel endoscopic device containing a lumen-apposing metal stent with an electrocautery (ECE-LAMS) on the tip has been developed.

Methods: High-risk surgical patients with acute cholecystitis who underwent EUS-guided gallbladder drainage (EUS-GBD) with the novel device were retrospectively retrieved from 7 tertiary care referral centers. Main endpoints were technical and clinical success rates, rate of procedural adverse events, and short- and long-term adverse events.

Results: Seventy-five patients (mean age, 75 ± 11 years; 36 men) underwent EUS-GBD. The procedure was technically and clinically successful in 98.7% and 95.9% of cases, respectively. Three patients without resolution of cholecystitis died, and 2 patients had procedure-related adverse events: 1 perforation requiring surgery and 1 major bleeding resolved conservatively. The mean follow-up for the entire cohort was 201 ± 226 days. Seven patients (9.6%) died within the first 30 days; 50 patients (71.4%) were alive at the last date of follow-up. Short- and long-term adverse events occurred in 6 patients: 3 had recurrent cholecystitis, 2 had migration of the stent, and 1 developed Bouveret syndrome, all managed nonsurgically. Overall, 8 adverse events (10.7%) occurred in the entire cohort of patients.

Conclusions: The novel ECE-LAMS for high-risk surgical patients with acute cholecystitis is safe, with a high technical and clinical success rate. Future multicenter studies comparing EUS-GBD versus PTGBD are warranted to determine which procedure is safer and clinically more effective for patients with high surgical risk acute cholecystitis.
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http://dx.doi.org/10.1016/j.gie.2017.02.027DOI Listing
October 2017

EUS-guided choledochoduodenostomy for malignant distal biliary obstruction using a lumen-apposing fully covered metal stent after failed ERCP.

Surg Endosc 2016 11 11;30(11):5002-5008. Epub 2016 Mar 11.

Digestive Endoscopy Unit, Catholic University, Rome, Italy.

Background: A novel lumen-apposing, self-expanding metal stent to perform EUS-guided drainage procedures has been recently developed. The aim of this study was to analyze the safety, technical and clinical effectiveness of this device for EUS-guided choledochoduodenostomy (EUS-CD) with palliative intent.

Methods: Retrospective analysis of all consecutive patients with unresectable malignant distal bile duct obstruction who, between March 2012 and September 2014, underwent EUS-CD using the study devices (AXIOS™ and Hot AXIOS™, Xlumena Inc., Mountain View, CA, USA) after unsuccessful ERCP in seven European centers was carried out.

Results: Fifty-seven patients (M/F 31/26; median age 73) underwent EUS-CD using the AXIOS™ stent or the Hot AXIOS™ delivery system. ERCP failure was due to duodenal obstruction in 41 patients (71.9 %) and to inability to cannulate the papilla in the remaining 16 patients (28.1 %). The procedure was technically successful in 56/57 patients (98.2 %), with a mean procedural time of 22.4 min (range 11-65). Clinical success was achieved in 54 of these 56 patients (96.4 %; 94.7 % of the entire cohort). Overall major procedural complication rate was 7 % (two duodenal perforations, one bleeding and one transient cholangitis). During follow-up, 5 out of 54 (9.3 %) patients with clinica success required re-intervention for stent migration in one case and a sump syndrome with transient increase in serum bilirubin concentrations with sludge in the distal duct reservoir in the remaining four patients.

Conclusions: Our study shows that EUS-CD using the AXIOS™ and the Hot AXIOS™ devices is a safe procedure, with high technical and clinical success rates.
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http://dx.doi.org/10.1007/s00464-016-4845-6DOI Listing
November 2016

EUS-guided drainage of pancreatic fluid collections using a novel lumen-apposing metal stent on an electrocautery-enhanced delivery system: a large retrospective study (with video).

Gastrointest Endosc 2015 Dec 23;82(6):1039-46. Epub 2015 May 23.

Digestive Endoscopy Unit, Catholic University, Rome, Italy.

Background And Aims: A lumen-apposing, self-expanding metal stent incorporated in an electrocautery-enhanced delivery system for EUS-guided drainage of pancreatic fluid collections (PFCs) recently has become available. The aim of this study was to analyze the safety and clinical effectiveness of this newly developed device in this clinical setting.

Methods: This was a retrospective analysis of all consecutive patients with PFCs who underwent EUS-guided drainage using the study device in 13 European centers.

Results: Ninety-three patients with PFCs (80% with complex collections) underwent drainage using the study device. Penetration of the PFC was accomplished directly with the study device in 74.2% of patients, and successful stent placement was accomplished in all but 1 patient, mostly without fluoroscopic assistance. Direct endoscopic necrosectomy (DEN) was carried out in 31 of 52 cases (59.6%) of walled-off necrosis and in 2 of 4 cases (50%) of acute peripancreatic fluid collection. Complete resolution of the PFC was obtained in 86 cases (92.5%), with no recurrence during follow-up. Treatment failure occurred in 6 patients because of persistent infection requiring surgery (n = 3), perforation and massive bleeding caused by the nasocystic drainage catheter (NCDC) (n = 2), and the need for a larger opening to extract large necrotic tissue pieces (n = 1). Major adverse events occurred in 5 patients (perforation and massive bleeding caused by the NCDC in 2 patients, 1 pneumoperitoneum and 1 stent dislodgement during DEN, and 1 postdrainage infection) and were mostly not related to the drainage procedure.

Conclusions: EUS-guided drainage with the electrocautery-enhanced delivery system is a safe, easy to perform, and a highly effective minimally invasive treatment modality for PFCs.
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http://dx.doi.org/10.1016/j.gie.2015.04.006DOI Listing
December 2015

Endoscopic ultrasound-guided transesophageal cholangiodrainage and consecutive endoscopic transhepatic Wallstent insertion into a jejunal stenosis.

Scand J Gastroenterol 2007 Mar;42(3):412-5

Department of Internal Medicine III, Municipal Hospital, Gera, Germany.

In cases where the papilla of Vater is unreachable because of pyloric/duodenal stenosis, or a catheter cannot be introduced into the papilla, or with recurrent tumor growth, or after previous gastrointestinal surgery, percutaneous transhepatic cholangiodrainage (PTCD) is considered to be the therapeutic alternative in cholestasis. The purpose of this report was to demonstrate that endoscopic ultrasound (EUS)-guided transesophageal cholangiodrainage is a feasible alternative in patients who decline to undergo PTCD. A 67-year-old female patient with recurrent tumor growth at the hepaticojejunostomy 17 months after a formerly resected cholangiocarcinoma (pT3, pN0 (0/2), M0, G2, R0; extended right hemihepatectomy), cholangitis, and peritoneal carcinomatosis underwent an EUS-guided transesophageal procedure to obtain cholangiodrainage by (i) puncture of a branch of the biliary tree at the left hepatic site, (ii) insertion of a guide wire into the bile duct and the anastomosed jejunum using the rendezvous technique with endoscopic retrograde cholangiopancreatography (ERCP)/conventional endoscopy, (iii) transesophagohepatic placement of an 8.5-Fr. double pigtail catheter, and (iv) transhepatic placement of a Wallstent through the jejunal stenosis, resulting in complete alleviation of the biliary and jejunal obstruction. There were no severe complications such as perforation or bleeding and no stent occlusion within the patient's lifetime of more than 3 months. Death was related to progressive tumor growth. EUS-guided transesophageal cholangiodrainage, here described in combination with Wallstent placement, is a reasonable, feasible, and encouraging treatment alternative in selected patients where conventional ERCP or PTCD is not an option.
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http://dx.doi.org/10.1080/00365520600881136DOI Listing
March 2007
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