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Objectives: Peristomal leakage, infection, and persisting fistula after tube removal are rare, but well-known complications in long-term percutaneous endoscopic gastrostomies (PEG). A standard treatment procedure is missing. This case series describes a procedure of tube removal, tailored antibiotic therapy and endoscopic closure with a gastropexy device after mechanical de-epithelialization of the fistulous tract., Case Presentation: Three patients with infected long-standing PEG (4 to 21 years) were included. The tubes were removed endoscopically and tailored antimicrobial therapy was administered over 10 to 14 days. The persisting fistula was de-epithelialized mechanically and sutured under endoscopic control with a dedicated gastropexy device 11 to 25 days thereafter. A new PEG tube was placed in the same session on a different site. After 30 days the fistula had healed completely, and the PEG worked well in all subjects., Conclusions: Endoscopic sealing of a persisting fistula with a dedicated gastropexy device after thorough de-epithelialization is a promising technique that needs confirmation by larger studies., Competing Interests: The authors declare that they have no conflict of interest., (Thieme. All rights reserved.)

Background  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 For reimbursement between hospital departments and external providers outdated or incomplete catalogues (e. g. DKG-NT, GOÄ) have remained in use.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. Methods  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. Results  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. Discussion  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., Competing Interests: Interessenkonflikt: M. Rathmayer, W. Heinlein, C. Reiß, M. Wilke haben als Berater bei der Durchführung der Kostenstudie und deren Auswertung ein Beratungshonorar von der Deutschen Gesellschaft für Gastroenterologie, Verdauungs- und Stoffwechselerkrankungen e. V. erhalten., (© Georg Thieme Verlag KG Stuttgart · New York.)

Competing Interests: Disclosure The authors report no conflicts of interest in this work.

Background and Aim: Due to limited acceptance of colonoscopy as diagnostic and screening test alternatives are warranted. Colon capsule endoscopy (CCE) has been shown to be a possible filter test, but because of logistical issues a second bowel preparation is usually required, if consecutive colonoscopy is needed. We therefore evaluated the feasibility of a single bowel preparation for both overnight CCE and (therapeutical) colonoscopy thereafter., Methods: Patients from two university hospitals referred to undergo colonoscopy were prospectively included in a dual centre feasibility study. A polyethylene glycol (PEG) based bowel preparation-schedule with ingestion of a colon capsule endoscopy (CCE) at 10pm and subsequent colonoscopy at about 12am on the next day was investigated. The first generation PillCam colon capsule was used with 4 different preparation protocols containing several prokinetics in different compositions (i. e. metoclopramide, erythromycin, sennosoides). The main endpoint was the proportion of patients who completed both CCE and colonoscopy; secondary endpoints were capsule transit times, amount of colon seen on CCE, bowel cleanliness, sensitivity and specifity of CCE and patients' acceptance., Results: 50 patients between 18 and 75 years were included. The sequence of overnight colon capsule endoscopy and colonoscopy was successfully completed in all but one (one refused colonoscopy). The capsule was excreted during recording time in 86 % of examinations, visualization of the complete colon was possible in 60 %, but adequate colon preparation was achieved in only 45 % irrespective of the regimen used. The preparation regimen consisting of a PEG-solution, erythromycin as prokinetic drug followed by PEG-solution as boost showed the largest proportion of adequate preparations. Overall sensitivity and specificity of CCE for polyps of any size were 65 % and 76 %, respectively. 26 of 30 patients (86.7 %) returned the subjective assessment questionnaire. 23 patients (88 %) reported mild to no discomfort or embarrassment during CCE, whereas 15 patients (58 %) did during the preparation procedure. Drinking the purgative solution was the most inconvenient step in 84 % of cases, drinking the boosts during CCE the second inconvenient step (60 %)., Conclusion: Overnight CCE-procedure followed by direct capsule-reading is feasible and safe and might avoid repetitive bowel preparation for subsequent colonoscopy. The bowel preparation needs to be improved., (© Georg Thieme Verlag KG Stuttgart · New York.)

Background and Aim: The prevalence of cervical heterotopic gastric mucosa (HGM) of the proximal oesophagus differs widely between studies, perhaps due to examination conditions during endoscopy. In this study we aimed to determine whether narrow band imaging (NBI) or high definition (HD) imaging improves detection of HGM. Possible factors of influence for HGM detection, in particular setting (position, timing, in-/out-patient), examination time and sedation parameters, were analysed., Methods: Retrospective analysis of 641 consecutive patients who underwent an oesophagogastroduodenoscopy (EGD) by the same, substantially experienced endoscopist between June 2011 and August 2013. The type of endoscope was randomly assigned to patients., Results: A total of 85 patients showed HGM with an overall prevalence of 13.3 %. The detection rate in the HD-NBI group was 18/127 (14.2 %) and in the HD white light (HDWL) group, 15/104 (14.4 %, p = 0.957). The detection rate between standard definition white light (SDWL) endoscopy (52/410, 12.7 %) and HD endoscopy did not differ significantly (33/231, 14.3 %, p = 0.566). Setting, sedation dosage and examination times were equally distributed between study groups. The indication of dysphagia (11.8 % vs. 2.4 % with p = 0.000, respectively) and dyspepsia (19.1 % vs. 10.8 %, p = 0.047, respectively) occurred significantly more often in HGM patients than in the control group. There was no difference in the detection rate depending on HGM size., Conclusions: The prevalence of HGM in the upper EGD is high and does not differ significantly between the study groups of SDWL, HDWL and HD-NBI under equivalent conditions., (© Georg Thieme Verlag KG Stuttgart · New York.)

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., (© Georg Thieme Verlag KG Stuttgart · New York.)