Backgrounds and Aims: A typical capsule endoscopy (CE) case generates tens of thousands of images, with abnormalities often confined to a just few frames. Omni Mode is a novel EndoCapsule software algorithm (Olympus, Tokyo, Japan) that proposes to intelligently remove duplicate images while maintaining accuracy in lesion detection. Methods: This prospective multicenter study took place across 9 European centers. Consecutive, unselected CE cases were read conventionally in normal mode, with every captured frame reviewed. Cases were subsequently anonymized and randomly allocated to another center where they were read using Omni Mode. Detected lesions and reading times were recorded, with findings compared between both viewing modes. The clinical significance of lesions was described according to the P classification (P0, P1, and P2). Where a discrepancy in lesion detection in either mode was found, expert blinded review at a consensus meeting was undertaken. Results: The patient population undergoing CE had a mean age of 49.5 years (range, 18-91), with the investigation of anemia or GI bleeding accounting for 71.8% of cases. The average small-bowel transit time was 4 hours, 26 minutes. The mean reading time in normal mode was 42.5 minutes. The use of Omni Mode was significantly faster (P < .0001), with an average time saving of 24.6 minutes (95% confidence interval, 22.8-26.9). The 2127 lesions were identified and classified according to the P classification as P0 (1234), P1 (656), and P2 (237). Lesions were identified using both reading modes in 40% (n = 936), and 1186 lesions were identified by either normal or Omni Mode alone. Normal mode interpretation was associated with 647 lesions being missed, giving an accuracy of .70. Omni Mode interpretation led to 539 lesions being missed, with an accuracy of .75. There was no significant difference in clinical conclusions made between either reading mode. Conclusions: This study shows that CE reading times can be reduced by an average of 40%, without any reduction in clinical accuracy.

Bestimmung von Effektivität und Risiken bei systematischer Anwendung der Inversion im Coecum. Vergleich zwischen Endoskopen.

Capsule endoscopy (CE) has become a first-line noninvasive tool for visualisation of the small bowel (SB) and is being increasingly used for investigation of the colon. The European Society of Gastrointestinal Endoscopy (ESGE) guidelines have specified requirements for the clinical applications of CE. However, there are no standardized recommendations yet for CE training courses in Europe. The following suggestions in this curriculum are based on the experience of European CE training courses directors. It is suggested that 12 hours be dedicated for either a small bowel capsule endoscopy (SBCE) or a colon capsule endoscopy (CCE) course with 4 hours for an introductory CCE course delivered in conjunction with SBCE courses. SBCE courses should include state-of-the-art lectures on indications, contraindications, complications, patient management and hardware and software use. Procedural issues require approximately 2 hours. For CCE courses 2.5 hours for theoretical lessons and 3.5 hours for procedural issued are considered appropriate. Hands-on training on reading and interpretation of CE cases using a personal computer (PC) for 1 or 2 delegates is recommended for both SBCE and CCE courses. A total of 6 hours hands-on session- time should be allocated. Cases in a SBCE course should cover SB bleeding, inflammatory bowel diseases (IBD), tumors and variants of normal and cases with various types of polyps covered in CCE courses. Standardization of the description of findings and generation of high-quality reports should be essential parts of the training. Courses should be followed by an assessment of trainees' skills in order to certify readers' competency.

Small bowel capsule endoscopy (SBCE) has become a first line diagnostic tool. Several training courses with a similar format have been established in Europe; however, data on learning curve and training in SBCE remain sparse.Between 2008 and 2011, different basic SBCE training courses were organized internationally in UK (n=2), Italy (n=2), Germany (n=2), Finland (n=1), and nationally in Germany (n=10), applying similar 8-hour curricula with 50% lectures and 50% hands-on training. The Given PillCam System was used in 12 courses, the Olympus EndoCapsule system in 5, respectively. A simple evaluation tool for capsule endoscopy training (ET-CET) was developed using 10 short SBCE videos including relevant lesions and normal or irrelevant findings. For each video, delegates were required to record a diagnosis (achievable total score from 0 to 10) and the clinical relevance (achievable total score 0 to 10). ET-CET was performed at baseline before the course and repeated, with videos in altered order, after the course.Two hundred ninety-four delegates (79.3% physicians, 16.3% nurses, 4.4% others) were included for baseline analysis, 268 completed the final evaluation. Forty percent had no previous experience in SBCE, 33% had performed 10 or less procedures. Median scores for correct diagnosis improved from 4.0 (IQR 3) to 7.0 (IQR 3) during the courses (P<0.001, Wilcoxon), and for correct classification of relevance of the lesions from 5.0 (IQR 3) to 7.0 (IQR 3) (P<0.001), respectively. Improvement was not dependent on experience, profession, SBCE system, or course setting. Previous experience in SBCE was associated with higher baseline scores for correct diagnosis (P<0.001; Kruskal-Wallis). Additionally, independent nonparametric partial correlation with experience in gastroscopy (rho 0.33) and colonoscopy (rho 0.27) was observed (P<0.001).A simple ET-CET demonstrated significant improvement of diagnostic skills on completion of formal basic SBCE courses with hands-on training, regardless of preexisting experience, profession, and course setting. Baseline scores for correct diagnoses show a plateau after interpretation of 25 SBCE before courses, supporting this number as a compromise for credentialing. Experience in flexible endoscopy may be useful before attending an SBCE course.

INTRODUCTION:Endoscopic stenting (ES) is a minimally invasive alternative to surgical gastroenterostomy (GE) for palliation of malignant gastroduodenal obstructions. This consecutive, retrospective analysis compares the clinical outcome of all patients undergoing ES or GE in the same period.METHODS:ES was performed at the Endoscopy Department, University Hospital Mannheim or at the Interdisciplinary Endoscopy Department, University Hospital Hamburg-Eppendorf. GE was performed at the Surgical Department, University Hospital Mannheim. All palliative ES or GE on patients with malignant gastroduodenal obstruction without earlier gastric resections between January 2001 and April 2007 were evaluated. Main outcome measurements were ability of solid food intake (gastric outlet obstruction score), persistence of nausea and vomiting (gut function score), length of hospital stay, morbidity, mortality and re-interventions.RESULTS:A total of 44 ES and 43 GE were performed. Nausea and vomiting--measured by means of the gut function score--persisted in significantly more patients in the GE group than in those who underwent stent placement (p = 0.0102). The gastric outlet obstruction score at discharge from the hospital revealed no significant difference in the ability of solid food intake between the groups. The hospital stay was significantly longer in the GE group (p = 0.0003). There was no significant difference in mortality and the rates of complications and re-interventions.CONCLUSION:In this study, ES is a generally equivalent--and in several points superior--alternative to GE for palliation of malignant gastroduodenal obstruction. ES seems to be the less invasive alternative for symptomatic patients. GE has good results in patients with longer survival and can be practiced within abdominal explorations.

Die ersten Bilder aus dem Dünndarm, vor 10 Jahren mit der drahtlosen Videokapsel gefilmt und aus dem Inneren des Körpers gefunkt, lösten wahre Begeisterung aus. Diese Begeisterung war besonders groß, wenn gar die lange vergebens gesuchte Quelle einer obskuren Blutung identifiziert werden konnte. Heute ist aus der Begeisterung eine nützliche, aber zeitaufwändige Routine-Methode geworden. Die spannungsvolle Erwartung der Anfangszeit, in der wir wie gebannt die Videos betrachtet haben (selbst wenn Details nicht so genau zu erkennen waren), ist einer routinierten Diagnostik gewichen. Heute werden andere Fragen gestellt, z.B. ob die Bildqualität mittlerweile denn auch dem hohen Standard der modernen Videoendoskope entspricht, wer das Ganze bezahlt, ob diese Kapsel-Untersuchung durch ausreichend gut geplante, prospektive – möglichst randomisierte undmeta-analysierte – Studien validiert wurde –, und ob die Qualität gesichert ist. Es reicht nicht mehr aus, dass diese Untersuchung Arzt und Patient begeistert, sondern sie muss auch einen klinischen „Impact“ besitzen und letztlich das „Outcome“ des Patienten günstig beeinflussen – nach Indikationen getrennt versteht sich, sowie unter Berücksichtigung möglicher prädiktiver Faktoren. Das Maß an Qualitätssicherung, wie sie für die Vorsorgekoloskopie vorbildlich etabliert wurde, ist sicher bei der Kapselendoskopie noch nicht erreicht. Es bleibt aber zu hoffen, dass die indikationsbezogene Koloskopie nicht irgendwann derart hinterfragt wird, wie es bei dem Einsatz der Kapselendoskopie der Fall ist. Nachdem nun auch technische Nachfragen zum Kapselendoskopie-System zunächst einmal mit einer Bearbeitungsnummer beantwortet werden und das Interesse sich etwas in Richtung BallonEnteroskopie und Spirale verlagert hat, sehnt sich so mancher Kollege den Pioniergeist der Anfangszeit der Kapselendoskopie zurück. Und schon taucht er wieder auf – der alte Pioniergeist: beim Thema „Ösophaguskapsel“ (=hier wird es vermutlich demnächst auch erst mal dabei bleiben) – und beim Thema Kolonkapsel. Hierbei keimt die Hoffnung auf, durch technische Weiterentwicklungen und Training in der Auswertung die Ergebnisse vergleichender Studien über die Zeit zu verbessern und mögliche Indikationen klarer zu definieren. Über allen Bemühungen hängt jedoch das Damokles-Schwert des Kostendruckes. So ist in Deutschland keine Kapselendoskopie zum Preis einer Koloskopie zu erhalten – schon aufgrund des Preises der Kapsel. Die Hoffnung besteht aber weiterhin, die Auswertezeit der Kapselendoskopie durch optimierte, automatische Befundungs-Algorithmen ähnlich einem „Langzeit-EKG“ verkürzen zu können. Der Traum von der steuerbaren Kapsel mit multiplen Diagnostikund Therapieoptionen erscheint uns in der Realität wieder ein Stück näher gekommen zu sein – ein solches Systemmüsste sich aber dem Vergleich mit den bereits etablierten Enteroskopie-Systemen stellen. Dieses Heft von Endo heute widmet sich schwerpunktmäßig der Kapselendoskopie. Basierend auf dem Kapsel Update 2010 anlässlich der diesjährigen Jahrestagung der DGE-BV in Hannover, präsentieren die Autoren sowohl die aktuelle Evidenz zu sinnvoller Vorbereitung und Vordiagnostik bei der Dünndarmkapsel, zur mittleren GIBlutung und zum Morbus Crohn, wie auch dem Thema „Kapselendoskopie und Dünndarmtumoren“. Ferner wird der aktuelle Stand zur Ösophagusund zur Kolonkapsel präsentiert und aktuelle Entwicklungen der Kapsel-Forschung angesprochen. Die Mischung aus evidenzund qualitätsgesichertem Einsatz in der gastroenterologischen Routinediagnostik mit einem Quantum Experimentierfreude macht das Thema Kapselendoskopie auch weiterhin spannend.

Identification of dysplasia in inflammatory bowel disease represents a major challenge for both clinicians and pathologists. Clear diagnosis of dysplasia in inflammatory bowel disease is sometimes not possible with biopsies remaining "indefinite for dysplasia." Recent studies have identified molecular alterations in colitis-associated cancers, including increased protein levels of alpha-methylacyl coenzyme A racemase, p53, p16 and bcl-2. In order to analyze the potential diagnostic use of these parameters in biopsies from inflammatory bowel disease, a tissue microarray was manufactured from colons of 54 patients with inflammatory bowel disease composed of 622 samples with normal mucosa, 78 samples with inflammatory activity, 6 samples with low-grade dysplasia, 12 samples with high-grade dysplasia, and 66 samples with carcinoma. In addition, 69 colonoscopic biopsies from 36 patients with inflammatory bowel disease (28 low-grade dysplasia, 8 high-grade dysplasia, and 33 indefinite for dysplasia) were included in this study. Immunohistochemistry for alpha-methylacyl coenzyme A racemase, p53, p16 and bcl-2 was performed on both tissue microarray and biopsies. p53 and alpha-methylacyl coenzyme A racemase showed the most discriminating results, being positive in most cancers (77.3% and 80.3%) and dysplasias (94.4% and 94.4%) but only rarely in nonneoplastic epithelium (1.6% and 9.4%; P < .001). Through combining the best discriminators, p53 and alpha-methylacyl coenzyme A racemase, a stronger distinction between neoplastic tissues was possible. Of all neoplastic lesions, 75.8% showed a coexpression of alpha-methylacyl coenzyme A racemase and p53, whereas this was found in only 4 of 700 nonneoplastic samples (0.6%). alpha-methylacyl coenzyme A racemase/p53 coexpression was also found in 10 of 33 indefinite for dysplasia biopsies (30.3 %), suggesting a possible neoplastic transformation in these cases. Progression to dysplasia or carcinoma was observed in 3 of 10 p53/alpha-methylacyl coenzyme A racemase-positive, indefinite-for-dysplasia cases, including 1 of 7 cases without and 2 of 3 cases with p53 mutation. It is concluded that combined alpha-methylacyl coenzyme A racemase/p53 analysis may represent a helpful tool to confirm dysplasia in inflammatory bowel disease.

Traditionally abdominal abscesses have been treated with either surgical or radiologically guided percutaneous drainage. Surgical drainage procedures may be associated with considerable morbidity and mortality, and serious complications may also arise from percutaneous drainage. Endoscopic ultrasound (EUS)-guided drainage of well-demarcated abdominal abscesses, with adjunctive endoscopic debridement in the presence of solid necrotic debris, has been shown to be feasible and safe. This multicenter review summarizes the current status of the EUS-guided approach, describes the available and emerging techniques, and highlights the indications, limitations, and safety issues.

BACKGROUND AND STUDY AIMS:Magnetic resonance cholangiopancreatography (MRCP) is a less-invasive alternative to endoscopic retrograde cholangiopancreatography (ERCP) for the diagnosis of primary sclerosing cholangitis (PSC). This study evaluated the diagnostic accuracy of MRCP in PSC compared with ERCP, and assessed the diagnostic accuracy of different T2w sequences.PATIENTS AND METHODS:95 patients (69 PSC, 26 controls) were evaluated using both ERCP and MRCP. Exclusion criteria included secondary sclerosing cholangitis and contraindications to MRCP. The diagnosis of PSC was confirmed in 69 patients based on ERCP as the reference gold standard. MRCP was performed using a 1.5 Tesla MR unit, using breath hold, coronal and transverse half-Fourier acquisition single-shot turbo spin-echo (HASTE), coronal-oblique, fat-suppressed half-Fourier rapid acquisition with relaxation enhancement (RARE), and coronal-oblique, fat-suppressed, multisection, thin-section HASTE (TS-HASTE) sequences. The MRCP morphological criteria of PSC were evaluated and compared with ERCP.RESULTS:The sensitivity, specificity, and diagnostic accuracy were 86%, 77%, and 83%, respectively, using the MRCP-RARE sequence, and increased further to 93%, 77%, and 88%, respectively, by the inclusion of follow-up MRCP in 52 patients, performed at 6-12-month intervals. HASTE and TS-HASTE sequences showed significantly lower diagnostic accuracy but provided additional morphologic information.CONCLUSIONS:MRCP can diagnose PSC but has difficulties in early PSC and in cirrhosis, and in the differentiation of cholangiocarcinoma, Caroli's disease, and secondary sclerosing cholangitis. A positive MRCP would negate some diagnostic ERCP studies but a negative MRCP would not obviate the need for ERCP.

Background & Aims: The aim of this study was to compare magnified still images obtained with high-resolution white light endoscopy, indigo carmine chromoendoscopy, acetic acid chromoendoscopy, and narrow-band imaging to determine the best technique for use in Barrett’s esophagus. Methods: We obtained magnified images from 22 areas with the 4 aforementioned techniques. Seven endoscopists with no specific expertise in Barrett’s esophagus or advanced imaging techniques and 5 international experts in thisfield evaluated these 22 areas for overall image quality, mucosal image quality, and vascular image quality. In addition, the regularity of mucosal and vascular patterns and the presence of abnormal blood vessels were evaluated, and this was correlated with histology. Results: The interobserver agreement for the 3 features of mucosal morphology with white light images ranged from 0.51 (95% confidence interval [CI]: 0.46‐0.55) to 0.53 (95% CI: 0.50‐0.57) for all observers, from 0.43 (95% CI: 0.33‐0.54) to 0.53 (95% CI: 0.41‐0.64) for experts, and from 0.51 (95% CI: 0.15‐0.33) to 0.64 (95% CI: 0.58‐0.70) for nonexperts. The interobserver agreement in these groups did not improve by adding one of the enhancement techniques. The yield for identifying early neoplasia with white light images was 86% for all observers, 90% for experts, and 84% for nonexperts. The addition of enhancement techniques did not improve the yield neoplasia. Conclusions: The addition of indigo carmine chromoendoscopy, acetic acid chromoendoscopy, or narrow-band imaging to white light images did not improve interobserver agreement or yield identifying early neoplasia in Barrett’s esophagus. C hromoendoscopy is a technique in which staining agents are sprayed on the mucosal surface of the gastrointestinal tract to enhance the endoscopic evaluation of the mucosa. This enables endoscopic detection of surface patterns or functional characteristics that may predict the presence of early neoplasia, lesions that may be difficult to detect with standard endoscopy only. Chromoendoscopy is usually combined with magnifying endoscopy for best results. In Barrett’s esophagus (BE), the typically used contrast enhancement agents are indigo carmine and acetic acid. Indigo carmine enhances the mucosal surface by pooling in the grooves between the mucosal villi, thus enabling the visualization of the pattern formed by mucosal folds and pits. Acetic acid achieves the same goal by means of reversible denaturation of superficial mucosal proteins. Both agents have been reported to recognize typical arrangements of the mucosal pit patterns that may corre

BACKGROUND & AIMSThe aim of this study was to compare magnified still images obtained with high-resolution white light endoscopy, indigo carmine chromoendoscopy, acetic acid chromoendoscopy, and narrow-band imaging to determine the best technique for use in Barrett's esophagus.METHODSWe obtained magnified images from 22 areas with the 4 aforementioned techniques. Seven endoscopists with no specific expertise in Barrett's esophagus or advanced imaging techniques and 5 international experts in this field evaluated these 22 areas for overall image quality, mucosal image quality, and vascular image quality. In addition, the regularity of mucosal and vascular patterns and the presence of abnormal blood vessels were evaluated, and this was correlated with histology.RESULTSThe interobserver agreement for the 3 features of mucosal morphology with white light images ranged from kappa = 0.51 (95% confidence interval [CI]: 0.46-0.55) to kappa = 0.53 (95% CI: 0.50-0.57) for all observers, from kappa = 0.43 (95% CI: 0.33-0.54) to kappa = 0.53 (95% CI: 0.41-0.64) for experts, and from kappa = 0.51 (95% CI: 0.15-0.33) to kappa = 0.64 (95% CI: 0.58-0.70) for nonexperts. The interobserver agreement in these groups did not improve by adding one of the enhancement techniques. The yield for identifying early neoplasia with white light images was 86% for all observers, 90% for experts, and 84% for nonexperts. The addition of enhancement techniques did not improve the yield neoplasia.CONCLUSIONSThe addition of indigo carmine chromoendoscopy, acetic acid chromoendoscopy, or narrow-band imaging to white light images did not improve interobserver agreement or yield identifying early neoplasia in Barrett's esophagus.

Background: N-butyl-2-cyanoacrylate has been successfully used for the treatment of bleeding from gastric fundal varices (FV). However, significant rebleeding rates and serious complications including embolism have been reported.Objective: Our purpose was to analyze the safety and efficacy of N-butyl-2-cyanoacrylate for FV bleeding by using 2 standardized injection technique and regimen.Design: Retrospective.Setting: Two tertiary referral centers.Patients: A total of 131 patients (9.1 men/40 women) with FV underwent obliteration with N-butyl-2-cyanoacrylate by a standardized technique and regimen.Interventions: (1) Dilution of 0.5 mL of N-butyl-2-cyanoacrylate with 0.8 mL of Lipiodol, (2) limiting the volume of mixture to 1.0 mL per injection to minimize the risk of embolism, (3) repeating intravariceal injections of 1.0 mL each until hemostasis was achieved, (4) obliteration of all tributaries of the FV, (5) repeat endoscopy 4 days after the initial treatment to confirm complete obliteration of all visible varices and repeat N-butyl-2-cyanoacrylate injection if necessary to accomplish complete obliteration.Main Outcome Measurements: Immediate hemostasis rate, early rebleeding rate, bleeding-related mortality race, procedure-related complications, long-term cumulative rebleeding-free rate, and cumulative survival rate.Results: Initial hemostasis and variceal obliteration were achieved in all patients. The mean number of sessions was 1 (range 1-3). The mean total volume of glue mixture used was 4.0 mL, (range 1-13 mL). There was no occurrence of early FV rebleeding, procedure-related complications, or bleeding-related death. The cumulative rebleeding-free rate at 1, 3, and 5 years was 94.5%, 89.3%, and 82.9%, respectively.Conclusion: Obliteration of bleeding FV with N-butyl-2-cyanoacrylate is safe and effective with use of a standardized injection technique and regimen.

Background: EUS-guided pancreatic pseudocyst and abscess drainage has become more popular and is used in many tertiary referral centers as a first line therapy instead of surgery. Drainage under EUS guidance is much more safer than non EUS-guided method. However, EUS scopes and puncture sets have to be improved. One major problem is the tangential axis of the puncture tract due to the oblique viewing optics of the EUS scope. This makes recannulation of the cyst very difficult. Aim: We describe our experience of an ongoing study in using a prototype forward viewing linear echoendoscope combined with a one-step simultaneous double-wire technique, which enables a simultaneous placement of 2 guidewires into the cyst after intial puncture.