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Fremdkorper im oberen Gastrointestinal(GI)-Trakt stellen ein relevantes medizinisches Problem dar und sind fur etwa 5% der Notfallendoskopien verantwortlich. Die endoskopische Entfernung ist die Methode der Wahl und gelingt in 99% der Falle, wobei jedoch nicht alle Fremdkorper im oberen GI-Trakt endoskopisch entfernt werden mussen, da die Mehrzahl der Fremdkorper spontan abgeht. Bei Fremdkorpern im Osophagus mit Obstruktion, die in mehr als 75% der Falle vorliegt, ist oft schnelles Handeln erforderlich, da die Komplikationsrate mit der Verweildauer steigt. Bei der endoskopischen Entfernung ist v. a. der Erfindungsreichtum des Untersuchers gefragt.

Background: Percutaneous endoscopic gastrostomy (PEG) is considered the preferred route for long-term enteral feeding. The aim of this study was to determine predictors of an increased mortality risk after PEG insertion. Methods: A retrospective study was conducted during a 13-year period in the gastroenterology department of Erlangen University Hospital. The authors completed a questionnaire with details of demographic data, diagnosis, indication for PEG, type of tube, and cause of death. Patients were contacted regularly at scheduled appointments. Results: In total, 787 patients (574 male [72.9%]) underwent PEG placement by the pull technique. The main underlying disease was malignant (75.6%). By the end of the study period, 614 patients had died. The average survival time was 720 days. The 30-, 60-, 90-day and 1-, 3-, and 5-year mortality rates amounted to 6.5%, 9.8%, 13%, 32.1%, 59.3%, and 69.8%, respectively. Predictive factors of increased 30-day mortality were higher age, lower body mass index (BMI), and the presence of diabetes mellitus. The presence of all 3 variables served as an indicator to detect high-risk patients, with a sensitivity of 0.80 and a specificity of 0.64. Conclusion: Mortality predictors for patients after PEG insertion are higher age, lower BMI, and the presence of diabetes mellitus. To avoid unnecessary and dangerous examinations in high-risk patients, the above-mentioned predictive factors of mortality should be checked before PEG placement.

Lymphoid hyperplasia of the intestine has been associated with multiple diseases and symptoms. This study was undertaken to analyze the number and topographical distribution of the lymphoid follicles. A total of 302 adult consecutive patients were enrolled when they underwent elective colonoscopy. Standardized pictures from terminal ileum and colon were taken using video colonoscopes. In each picture, the number, size, and mucosal elevation of lymphoid follicles were analyzed in relation to histological and immunological findings and medical history. Lymphoid hyperplasia was found to be most extensive in the terminal ileum and cecum. Patients with untreated gastrointestinally mediated allergy (GMA) showed the highest number of lymphoid follicles per visible field in the terminal ileum ( P < 0.001) and cecum ( P = 0.003) vs. the control group. Patients with infectious colitis also showed a high number of lymphoid follicles per endoscopic visible field in the transverse colon ( P = 0.020). The presence of lymphoid hyperplasia is a frequent finding during colonoscopy. It may indicate an enhanced immunological mucosal response to antigenic stimulation such as GMA or infection.

OBJECTIVE Peptic ulcers are the leading cause of upper gastrointestinal (GI) bleeding. The aim of this study was the evaluation of the recent clinical practice in drug therapy and endoscopic treatment of ulcer bleedings in Germany and to compare the results with the medical standard. METHODS A structured questionnaire (cross-sectional study) was sent to 1371 German hospitals that provide an emergency service for upper GI bleeding. The project was designed similar to a nationwide inquiry in France in 2001. Forty-four questions concerning the following topics were asked: hospital organisation, organisation of emergency endoscopy service, endoscopic and drug therapy of ulcer bleeding, endoscopic treatment of variceal bleeding. Return of the questionnaires was closed in August 2004. RESULTS Response rate was 675 / 1371 (49 %). Mean hospitals size was < 200 beds, 49 % (n = 325) had basic care level. 92 % provided a 24-hour endoscopy service, specialized nurses were available in 75 %. Fiberscopes were used only in 15 %. A mean of 10 +/- 12 (range: 0 - 160) bleeding cases/month were treated, 6 +/- 6 cases per month (60 %) were ulcer bleedings. Endoscopy was performed in 72 % immediately after stabilization but in all cases within 24 hours. The Forrest classification was used in 99 % whereas prognostic scores were applied only in 3 %. Forrest Ia,/Ib/IIa/IIb/IIc/III ulcers were indications for endoscopic therapy in 99 %/ 99 %/ 90 %/ 58 %/ 4 %/ 2 % respectively. Favoured initial treatment was injection (diluted epinephrine, mean volume 17 +/- 13 mL/lesion) followed by clipping. In re-bleedings, 93 % tried endoscopic treatment again. Scheduled re-endoscopy was performed in 63 %. PPI were used in 99.6 %, 85 % administered standard dose twice daily. PPI administration was changed from intravenous to oral with the end of fasting in nearly all hospitals. PPI administration schemes can be improved. Indications for Helicobacter pylori eradication followed rational principles. CONCLUSION Medical and endoscopic treatment of bleeding ulcers reached a high standard, although some therapeutic strategies leave room for improvement. Bigger hospitals tend to be closer to the medical standard.

BACKGROUND: Since the first presentation of the compactEASIE in 1997, this training model has become established for nearly all interventional techniques in upper gastrointestinal endoscopy including ERCP. So far, training using double-balloon enteroscopy (DBE) for ERCP has not become established. AIMS: This paper presents a special organ preparation for the compactEASIE model which for the first time allows simulation of ERCP in patients who have had prior abdominal surgery. Two abdominal organ packages from freshly slaughtered pigs were used to create a postsurgical anatomic situation. RESULTS: A life-like training model was established for ERCP training in a postsurgical anatomic situation. A Roux-en-Y anastomosis was created such that the papilla was located around 100 cm beyond the pylorus. The duodenum was closed shortly above the pig papilla at the level of the pylorus. The papilla was successfully reached by DBE after 40 minutes. The papilla was cannulated and regular contrasting of the biliary system using fluoroscopy was achieved. Sphincterotomy, stent placement and exchange, and needle-knife sphincterotomy over a 7-Fr stent were conducted successfully. CONCLUSION: Modified organ preparations allow the simulation of and training in ERCP in postsurgical anatomic situations in training models using animal parts.

Background. The objective benefit of a training using the compact Erlangen Active Simulator for Interventional Endoscopy-simulator was demonstrated in two prospective educational trials (New York, France). The present study analysed whether endoscopic novices are able to reach a comparable level of endoscopic skills as in the above-described projects. Methods. Twenty-seven endoscopic novices (medical students, first year residents) were enrolled in this prospective, randomised trial. The compact Erlangen Active Simulator for Interventional Endoscopy-simulator with an upper GI-organ package and blood perfusion system was used as a training tool. Basic evaluation of endoscopic skills was performed after a practical and theoretical course in diagnostic upper GI endoscopy followed by a stratified randomisation according to the rating in endoscopic skills into intensive (n = 14) and control group (n = 13). The intensive group was trained 12 times every second week over 7 months in 4 endoscopic disciplines (manual skills, injection therapy, haemoclip, band ligation) by skilled endoscopist (three trainees/simulator). Assessment was performed (single steps/overall) using an analogue scale from 1 to 10 (1 = worst, 10 = optimal performance) by expert tutors. The control group was not trained. Blinded final evaluation of all participants was performed in January 2003. Results. We observed in all techniques applied a significant improvement of endoscopic skills and of the performance time in the intensive group compared to the control group (p < 0.001). The comparison with the previous projects showed that the intensively trained novices achieved comparable levels of performance to the GI fellows in the New York and France Project (at least 80% of the median score in three out of four techniques). Conclusion. Endoscopic novices acquired notable skills in interventional endoscopy in the simulator by an intensive, periodical training using the compactEASIE ® .

BACKGROUND AND STUDY AIMS Peptic ulcers are the most frequent cause of gastrointestinal bleeding. The use of hemoclips has become established as an effective form of treatment in addition to injection therapy. However, hemoclips have not previously been compared with injection therapy in an experimental setting using objective parameters. MATERIALS AND METHODS In a prospective, randomized, and controlled trial, the disposable Resolution hemoclip device (Boston Scientific, n = 40) was compared with conventional injection therapy (n = 40) in an experimental setting, using the compactEASIE simulator equipped with an upper gastrointestinal organ package to simulate bleeding. Four investigators with different levels of endoscopic experience participated in the study. On a randomized basis, each investigator treated 20 bleeding sites either by applying one clip (n = 10) or by carrying out high-volume four-quadrant injection (4 x 10 ml saline) of a spurting vessel. The efficacy of the hemostasis was assessed by continuous measurement of pressure within the afferent vessel before and after clip application or injection therapy and calculating the relative reduction in the vessel's diameter with each treatment method. The system pressure was recorded 1 min before and 1 min after treatment. The ease of application of each method was rated by the endoscopist and by the assisting nurse using a visual analogue scale (0 - 100, with 100 being best). RESULTS All of the 40 hemoclipping and injection treatments were carried out successfully. Both methods led to a significant increase in peak pressure (Resolution clip 71.8 +/- 66.8 mm Hg, P < 0.001; injection 71.9 +/- 53.8 mm Hg, P < 0.001), representing a significant relative reduction in the vessel diameter. There were no significant differences in peak pressure between the two treatments ( P = 0.995). The mean increase in pressure during the first minute after the intervention (clip 49.3 +/- 67.0 mm Hg vs. injection 19.9 +/- 41.6 mm Hg) was significantly greater with the hemoclipping procedure ( P = 0.021). More experienced investigators achieved a greater increase in system pressure, but the difference was not significant. The assessments of the ease of application by the assistants (84 +/- 13) and endoscopists (86 +/- 16) did not show any significant differences ( P = 0.402) for the clipping device. CONCLUSIONS No significant differences between the two treatment methods were detected with regard to the immediate efficacy of hemostasis. However, long-term hemostasis was better with hemoclipping. The endoscopist's level of experience also appears to play a role, particularly when hemoclips are used.

BACKGROUND AND STUDY AIMS Hemoclip therapy is a well-established procedure in the treatment of gastrointestinal bleeding. Although new products are provided periodically by the industry, comparative investigations are lacking. We compared two different hemoclip devices in an experimental setting, assessing them using objective hemostatic parameters. MATERIALS AND METHODS We compared two disposable clip devices (Olympus HX-200L-135 (n = 40) vs. Wilson-Cook Tri-Clip (n = 40)) in an experimental setting using the compact Erlangen Active Simulator for Interventional Endoscopy (compactEASIE) training model equipped with an upper gastrointestinal-organ package for bleeding simulation. This was a randomized, prospective, controlled trial. Four investigators with different levels of endoscopic experience applied ten hemoclip devices of each type to the spurting vessels, the clips allocated using a randomized list for each investigator. The efficacy of hemostasis was determined by continuous measurement of the pressure within the afferent vessel before and after clip application and calculation of the relative reduction of vessel diameter by the clip device. The system pressure was recorded over the period from 1 minute before to 1 minute after clip application. A secondary end point was a subjective assessment of the whole clip application procedure by the endoscopist and the assisting nurse, using a visual analog scale (0 - 100, with 100 representing the best experience). RESULTS A total of 39/40 clips of each type were applied successfully. Both clip devices led to a significant increase in system pressure, representing significant relative reduction of vessel diameter (Olympus 5.4 +/- 7.5 %, p < 0.001; Cook 4.9 +/- 8.0 %, p < 0.001). Overall, there was no significant difference between the two devices ( P = 0.756). However, the investigator with the least experience in endoscopy (< 100 procedures) produced significantly inferior results compared with the other three investigators, who had performed between 2000 and 6000 procedures each ( P < 0.05). We found no evidence of a learning curve from the intra-observer results. The devices received good, but not significantly different, overall ratings by the endoscopists (Olympus 69 +/- 24 vs. Wilson-Cook 65 +/- 16) and by the assisting nurses (Olympus 77 +/- 9 vs. Wilson-Cook 70 +/- 22). CONCLUSIONS Using an established cadaveric training model, no significant difference was found between the two types of hemoclip devices with respect to their "hemostatic efficacy". However, the experience of the endoscopist appears to play a major role in successful clip application. The use of a feedback mechanism in emergency endoscopy training, using continuous intravessel pressure monitoring, may substantially enhance the efficacy of training, resulting in a similar improvement in clinical results.

Bereits in den 1970er Jahren wurden Hamoclips als Zubehor fur die flexible gastroenterologische Endoskopie entwickelt. Kommerziell war der Hamoclip (HX-600 und HX-200, Olympus Endotherapie, Hamburg

AIM: To compare the new Olympus V-scope (VS) to conventional endoscopic retrograde cholangiopancreaticography (ERCP). METHODS: Forty-nine patients with previous endoscopic papillotomy who were admitted for interventional ERCP for one of several reasons were included in this single-centre, prospective randomized study. Consecutive patients were randomized to either the VS group or to the conventional ERCP group. ERCP-naive patients who had not undergone papillotomy were excluded. The main study parameters were interventional examination time, X-ray time and dose, and premedication dose (all given below as the median, range) and were investigated in addition to each patient’s clinical outcome and complications. Subjective scores to assess each procedure were also provided by the physicians and endoscopy assistants who carried out the procedures. A statistical analysis was carried out using the Wilcoxon rank-sum test. RESULTS: Twenty-five patients with 50 interventions were examined with the VS ERCP technique, and 24 patients with 47 interventions were examined using the conventional ERCP technique. There were no significant differences between the two groups regarding the age, sex, indications, degree of ERCP difficulty, or interventions performed. The main study parameters in the VS group showed a nonsignificant trend towards a shorter interventional examination time (29 min, 5-50 min vs 31 min, 7-90 min, P = 0.28), shorter X-ray time (5.8 min, 0.6-14.1 min vs 6.1 min, 1.6-18.8 min, P = 0.48), and lower X-ray dose (1351 cGy/m2, 159-5039 cGy/m2 vs 1296 cGy/m2, 202.2-6421 cGy/m2, P = 0.34). A nonsignificant trend towards fewer adverse events occurred in the VS group as compared with the conventional ERCP group (cholangitis: 12% vs 16%, P = 0.12; pain: 4% vs 12.5%, P = 0.33; post-ERCP pancreatitis: 4% vs 12.5%, P = 0.14). In addition, there were no statistically significant differences in assessment by the physicians and endoscopy assistants using subjective questionnaires. CONCLUSION: ERCP using the short-guidewire V-system did not significantly improve ERCP performance or patient outcomes, but it may reduce and simplify the ERCP procedure in difficult settings.

Endoscopic access to strictured biliodigestive anastomoses often is difficult and may require percutaneous transhepatic biliary drainage or reoperation. Push- or push-and-pull enteroscopy was used to diagnose disease and treat 24 postsurgical patients with suspected strictured biliodigestive anastomosis. Endoscopic retrograde cholangiography and biliary interventional procedures were used. Endoscopic accessibility, diagnosis of disease, therapeutic success, and complication rates were investigated at a single tertiary university gastroeneterology center. Push enteroscopy reached biliary enteroanastomoses in 5 of the 24 patients (20.8%), whereas push-and-pull enteroscopy found choledocho- or hepaticojejunostomies in 17 of the remaining 19 postsurgical patients (89.4%). In all, successful enteroscopic intervention was achieved for 21 of the 24 patients (87.5%), whereas only 3 patients had to undergo percutaneous cholangiodrainage (12.5%). Cicatricially changed biliodigestive anastomoses were found in 14 of 21 patients (66.6%) including a mucosal type stricture in 7 patients (50%), an intramural type stricture in 5 patients (35.7%), and a ductal type stricture in 2 patients (14.2%). The remaining seven patients (33.3%) were normal. Enteroscopic interventions at strictured biliodigestive anastomosis included ostium incision for 8 (57.1%) and endoprosthesis insertion for 13 (92.8%) of the 14 patients, with prompt resolution of cholestasis and cholangitis. The major complications for the 24 patients involving 68 double-balloon enteroscopy (DBE) examinations comprised 2 perforations (8.3% per patient), 1 mild peritonitis (4.1%), and 1 cholangitis (4.1%), whereas minor complications were experienced by up to 20.8% of the patients. Modern interventional enteroscopy yields a high rate of successful interventions for strictured biliodigestive anastomosis, requires ostium incision for mucosal and intramural types of strictures, and helps to reduce percutaneous approaches.

Einleitung: Die Entwicklung der Endoskopischen Submukosa Dissektion (ESD) in Japan erlaubt enbloc Resektion auch groser Fruhneoplasien. Nach Etablierung gab es auch Fallberichte, die streng submukose Raumforderungen mittels ESD entfernten. Im folgenden beschreiben wir die Entfernung eines submukosen GIST des Magens bei einem 71-jahrigen Patienten mit einem neuartigen Kombimesser fur die ESD. Kasuistik: Im Oktober 2007 wurde im Rahmen einer diagnostischen OGD wegen Ubelkeit ein ca. 15mm messende submukose Raumforderung an der Hinterwand im distalen Magencorpus bei einem 71-jahrigen Patienten zufallig entdeckt. Die Endosongraphie zeigte einen von der Submukosa ausgehenden homogene echoarme Raumforderung. Differentialdiagnostisch kam am ehesten ein GIST oder ein Leiomyom in Betracht. Nach Besprechung der Therapieoptionen mit dem Patienten wurde die Entfernung mittels ESD vereinbart. 12/07 wurde die submukose RF mit einem neuen Kombiinstrument zur ESD (Endo FK/FS, Kachu Technology, Sudkorea) entfernt, das aus einer Injektionsnadel und einem Flex-knife besteht. Beides kann wechselseitig ausgefahren werden und zur Injektion bzw. Dissektion genutzt werden, so dass zeitraubende Instrumentenwechsel entfallen. Im vorliegenden Fall konnte die submukose Raumforderung in einer Sitzung von ca. 90 Minuten komplett entfernt werden. Histologisch handelte es sich um einen GIST (CD117+, CD34+) mit niedrigem Proliferationsindex (2–3%). Zusammen mit der Grose handelte es sich um eine Niedrigrisiko-Konstellation, die keine weitere Nachbehandlung erforderte. Die Endosonographische Kontrolle nach 3 Monaten zeigte eine normale Wandschichtung ohne Rezidivverdacht. Schlussfolgerung: Die ESD stellt auch fur submukose Raumforderungen einen interessanten und auch komplikationsarmen Therapieansatz dar, der die en bloc Resektion dieser Tumoren erlaubt. Hilfreich sind hier neue Kombiinstrumente wie das verwendete Endo FK/FS Dissektionsmesser (Kachu Technology), die zeitraubende Instrumentenwechsel auf ein Minimum reduzieren konnen.

Die Interventionsmoglichkeit mit der APC stellt eine wichtige Therapieoption in der Endoskopie bei Blutungen/Tumoren dar. Diese Pilotstudie evaluierte, ob mit einem kostengunstigen, aber umfassenden Hochfrequenzchirurgiegerat der Serie Arc – plus effektiv und nebenwirkungsarm endoskopisch therapiert werden konnte. Es wurden 40 Patienten mit Blutungen (n=18), Tumorstenosen (n=13), nicht – resektablen colorektalen Adenomen (n=9) mit APC durch den Arc – plus Generator (Fa. BOWA – electronic GmbH) behandelt. Der Arc – plus Generator zeigte bei einem Sondenabstand von 0.2–2mm zur Lasion eine gute Anwendbarkeit mit hervorragenden Zundeffekten, auch im Niedrig – Energiebereich (1–5–20 Watt). Eine effektive Blutstillung konnte bei Angiodysplasien/Tumorblutungen mit einer Energie (Median, Range) von 32 (5–60 Watt) und einer Flussrate von 0.45 (0.2–0.8 l/min) erreicht werden. Zur Tumordestruktion bei Stenosen wurde eine Energie von 36 (1–60 Watt) bei einer Flussrate von 0.5 (0.3–0.7 l/min) verwandt, zur Koagulation von colorektalen Adenomen 27 (1–40 Watt) bzw. 0.4 (0.3–0.5 l/min). Abgesehen von Meteorismus und Gasakkumulation (3/22 Patienten, 13.6%), fehlendem Zundeffekt bei 1 von 40 Patienten (2.5%) und Einknicken der 1.5mm Sonde bei der Doppelballon – Enteroskopie (2 von 4 Patienten, 50%) fanden sich keine relevanten Nebenwirkungen/technische Schwierigkeiten. Der neue Arc – plus – Hochfrequenzgenerator erbrachte eine effektive Rate der Blutstillung bei Angiodysplasien und blutenden bzw. stenosierenden Tumoren. Fur den Anwender ergaben sich bei stabilen Abstandsverhaltnissen zwischen Sonde und Lasion besonders auch im Niedrig – Energiebereich von 1–5–20 Watt gute Zund- und Koagulationseffekte sowie keine Perforationen.

Background and Study Aims: The Erlangen Active Simulator for Interventional Endoscopy (EASIE) was introduced in 1997 as a training model for interventional endoscop y. Objective evidence of the benefits of training with this model has not previously been published. As part of two long-term projects, the benefits of a 1-day training course with the “compactEASIE” simulator were evaluated. Materials and Methods: Fourteen American and 18 French gastroenterology fellows were enrolled. These fellows were participants in the intensive groups performing training in endoscopic hemostasis, with a total number of 28 fellows in New York and 36 in France. Gastrointestinal endoscopy faculty members in New York and France evaluated and timed the fellows in four disciplines to establish baseline skills (manual skills; injection and coagulation; Hemoclip application; and variceal ligation) with the compactEASIE simulator. The trainees were reevaluated after an intensive 1-day course (with two or three fellows and one instructor per station), also including preparation and assistance for each procedure. The assessment (overall and parts) was done by expert tutors using an ordinal scale ranging from 1 to 10 (1 = poorest, 10 = best), recording also mistakes and performance time. The compactEASIE simulator, equipped with an upper gastrointestinal organ packag e and an artificial blood perfusion system, was used as the training tool. Results: A highly significant improvement (P£ 0.001) was observed in the performance of all endoscopic techniques. A significant reduction in performance time was also observed with three of the four endoscopic techniques. Successful hemostasis was significantly impro ved in two out of three techniques. Conclusions: A 1-day training course on endoscopic hemostasis using the compactEASIE simulator is capable of improving the performance of hemostasis procedures. Long-ter m effects of repeated training sessions are currently subject of collaborative studies in New York and France.