[Intrajejunal levodopa in Parkinson's disease: Optimization of PEG application]. / Intrajejunale L-Dopa-Applikation bei der Parkinson-Krankheit: Optimierung der PEG-Anlage.

The various forms of Percutaneous Endoscopic Gastrostomy (PEG) are highly relevant in neurology, as pump-administered intrajejunal levodopa application is one of the indispensable forms of therapy in advanced Parkinson's disease. Optimal PEG placement and follow-up are therefore significant for the success of the therapy. However, the standard intrajejunal administration of levodopa gel via a JET-PEG, i. e. a PEG with an internal catheter inserted into the jejunum, is not without problems for various reasons. In particular, the considerable cumulative complication rates demand a reconsideration of the situation. The very limited absorption area of the drug in the region of the flexura duodenojejunalis must also be taken into account. Causes of complications are predominantly a non-optimal application technique of PEG and internal catheter as well as the frequent lack of an adequate follow-up. In this paper, the details of a modified and optimized application technique compared to the conventional techniques are presented. These new methods have proved their usefulness in clinical applications for years, and additionally a new application form, the Hybrid-PEG, is presented. However, many of the details derived from anatomical/physiological, surgical and endoscopic aspects must be strictly observed during the application in order to reduce or avoid minor and major complications. In particular, problems are caused by local infections in the area of the insertion point of the PEG including peritonitis, leaks and buried bumper syndrome (BBS). The relatively frequent dislocations of the internal catheter also prove to be particularly troublesome. These can ultimately be avoided by clip fixation of the catheter tip down in the jejunum. In particular, the use of the newly developed Hybrid-PEG, a combination of endoscopically controlled gastropexy with three sutures and subsequent central thread-pull-through of the PEG tube, can significantly reduce the complication rate and thus achieve a decisive improvement for patients. The aspects discussed here are highly relevant for all those involved in the therapy of advanced Parkinson's disease. Trustful interdisciplinary collaboration between neurology and endoscopy/surgery/gastroenterology is a prerequisite for good clinical outcomes.

Development and evaluation of artificial organ models for ERCP training in patients with surgically altered anatomies.

Endoscopy training models (ETM) using artificial organs are practical, hygienic and comfortable for trainees. However, few models exist for training endoscopic retrograde cholangiopancreatography (ERCP) in patients with surgically altered anatomy. This training is necessary as the number of bariatric surgeries performed worldwide increases. ETM with human-like anatomy were developed to represent the postoperative anatomy after Billroth II (BII) reconstruction for a standard duodenoscope and the situs of a long-limbed Roux-en-Y (RY) for device-assisted enteroscopy (DAE). In three independent workshops, the models were evaluated by international ERCP experts. In RY model, a simulation for small bowel behavior in endoscopy was created. Thirty-three experts rated the ETM in ERCP expert courses. The BII model was evaluated as suitable for training (school grades 1.36), with a haptic and visual impression rating of 1.73. The RY model was rated 1.50 for training suitability and 2.06 for overall impression. Animal tissue-free ETMs for ERCP in surgically altered anatomy were successfully created. Evaluation by experienced endoscopists indicated that the models are suitable for hands-on ERCP training, including device-assisted endoscopy. It is expected that patient care will improve with appropriate training in advanced procedures.

Endoscopic Treatment of T1 Colorectal Cancer.

Commonly accepted criteria for curative resection of T1 colorectal cancer include R0 resection with horizontal and vertical clear margins (R0), absence of lympho-vascular or vessel infiltration (L0, V0), a low to moderate histological grading (G1/2), low tumor cell budding, and limited (<1000 µm) infiltration into the submucosa. However, submucosal infiltration depth in the absence of other high-risk features has recently been questioned as a high-risk situation for lymph-node metastasis. Consequently, endoscopic resection techniques should focus on the acquisition of qualitatively and quantitively sufficient submucosal tissue. Here, we summarize the current literature on lymph-node metastasis risk after endoscopic resection of T1 colorectal cancer. Moreover, we discuss different endoscopic resection techniques with respect to the quality of the resected specimen.

Endoscopic submucosal resection: a technique using novel devices for incision and resection of neoplastic lesions.

BACKGROUND: Endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are established techniques for treatment of superficial gastrointestinal neoplasia. Limitations of EMR are low en bloc resection rates for larger lesions, resulting in frequent recurrences. Major disadvantages of ESD are technical difficulty and long procedure times. We evaluated technical feasibility and safety of newly designed devices for en bloc resection of lesions measuring 20-40 mm in a technique called endoscopic submucosal resection (ESR). METHODS: This case series included 93 lesions from different locations (11 stomach, 25 colon, 57 rectum) with a median size of 29 mm (range 10-70). ESR was performed using two novel instruments for circumferential mucosal incision and deep submucosal resection, respectively. RESULTS: Resection by ESR was feasible in all cases. En bloc and R0 rates were insufficient when ESR was attempted without prior circumferential mucosal incision, but were 70 % and 63 %, respectively, when mucosal incision was done before application of the submucosal resection device. We observed three complications (two delayed bleedings, one microperforation) but no cases of emergency surgery or 30-day mortality. CONCLUSIONS: Results demonstrated feasibility and excellent safety of ESR using two novel devices for en bloc resection of early gastrointestinal neoplasia. The technique offered relative technical ease and high efficacy.

[Interprofessional knowledge and skills training of the insertion technique for the PEG placement on simulators - development and testing of a national curriculum for physicians and nurses]. / Interprofessionelles Wissens- und Skillstraining der PEG-Anlage an Simulatoren ­ Entwicklung und Testung eines nationalen Curriculums für Ärzte und spezialisierte Pflegende.

INTRODUCTION: Expert opinion within the field of gastroenterology mandates a national training curriculum to be completed prior to performing a percutaneous endoscopic gastrostomy (PEG).The goal of the present study is both the development and evaluation of such a curriculum, thus aiming to provide physicians and nurses with the necessary knowledge and skills to safely perform the PEG procedure. METHODS: Testing was performed using a non-randomized, interventional pilot study on simulators. This included a: (1) preparatory, (2) theoretical, and (3) practical phase. Following the theoretical phase, cognitive skills were assessed with a knowledge test. During the practical phase, each participant's puncture procedure was recorded with a multi-channel video, and sensorimotor skills were evaluated with an assessment instrument (AS-PEG). Finally, participant satisfaction was evaluated using a questionnaire. RESULTS: Seven physicians and 17 nurses completed all phases and final examinations, as defined in the curriculum. An average of 70.3 ±â€Š3.7 (61-75) of 76 points and 37.1 ±â€Š2.1 (32-40) of 42 points were achieved in the knowledge and acquired sensorimotor skills tests, respectively. Overall, the evaluation revealed a high level of satisfaction among the participants with respect to content, achievement of learning objectives, and acquired practical skills. CONCLUSION: Dissemination of the curriculum is deemed useful and necessary to provide the theoretical and practical knowledge for physicians and nurses through a structured inter-professional knowledge and skills-training format and to offer nurses a legally secure framework.

Development and Pilot Validation of an Instrument Assessing Sensorimotor Skills for Percutaneous Gastral Puncture.

INTRODUCTION: The acquisition of sensorimotor skills, so-called "technical skills", plays an essential part in the professional and continuing educational training of medical and nursing staff. Facilities turn to simulator training to promote the safe and accurate performance of endoscopic examinations. Thus, this study aimed to develop and pilot-test a corresponding assessment instrument to monitor necessary sensorimotor or "technical" skills of the examiner for a safe percutaneous endoscopic gastrostomy (AS-PEG). MATERIALS AND METHODS: Instrument development and pilot validation involved four stages: identification of potential items and initial draft of the AS-PEG; expert panel with 11 experts (content validity index [CVI] calculated); empirical validation using a quasi-experimental intervention on simulators; revision of the pilot AS-PEG taking expert assessment, and empirical testing into consideration. RESULTS: The initial instrument yielded 13 categories and 44 items describing the PEG procedure. Experts rated 30 out of 44 items (68%) extremely or very important for the safety of the puncture of the stomach. Initial item-CVIs ranged from 0.00 to 1.00; scale-CVI was 0.61. Twenty-four trainees (7 physicians, 17 nurses) participated in the pilot simulation study. On average, 8:25 min were required for PEG placement (min-max 5:59-13:38 min, SD = 1:43). The revised AS-PEG version was reduced to 14 items with a range of the item CVI from 0.8 to 1.0, and a scale-CVI of 0.90. CONCLUSION: The AS-PEG instrument facilitates the evaluation of sensorimotor skills during percutaneous gastric puncture procedures within the context of PEG placement, across professions and without relating to the number of procedures previously performed. The instrument is economical and shows satisfying content validity.

[Comparison of safety insertion techniques of percutaneous endoscopic gastrostomy in nurses and physicians - a non-randomized interventional pilot study on a simulation model]. / Vergleich der Sicherheit der perkutan gastralen Punktion im Rahmen der PEG-Anlage zwischen Ärzten und spezialisierten Pflegenden ­ eine nicht randomisierte, interventionelle Pilotstudie an Simulatoren.

Percutaneous endoscopic gastrostomy (PEG) insertion represents a standardized procedure for enteral nutrition in patients with long-term eating difficulties for various reasons. In a clinical setting, delegation of stomach puncture and placement of a PEG tube, within the context of percutaneous endoscopic gastrostomy amongst nurses, occurs. In Germany, there are no studies yet showing the differences between physicians and nurses regarding the safety of percutaneous stomach puncture.In a non-randomized quasi-experimental interventional study on a simulation model, the safety of stomach puncture within the context of percutaneous endoscopic gastrostomy between physicians and nurses with special training was compared. Technical skills were recorded with video cameras and provided the basis for the following analysis. The study contained: (1) a theoretical preparation phase, (2) training on simulation model and a repeated practice of the skills, and (3) stomach puncture on the simulation model. The actions were recorded with a multichannel video technique. As part of the concept, nurses and physicians were trained together in theory and practice. The analysis was conducted with the newly designed Assessment Instrument Percutaneous Endoscopic Gastrostomy (AS-PEG). Seven physicians and 17 nurses took part in the pilot study. On average, the physicians reached a score of 36.4 ±â€Š2.2 (33 - 39) and nurses 37.4 ±â€Š2 (32 - 40), while the maximum score was 42. The evaluation of technical skills on the recorded videos by means of Assessment Instrument Percutaneous Endoscopic Gastrostomy (AS-PEG) showed no tendency to significant differences between physicians and nurses after theoretical and practical training. The study contributes a first objective evaluation of technical skills on stomach puncture within the context of percutaneous endoscopic gastrostomy with the newly designed AS-PEG.