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EUROPEAN HOSPITAL Vol 23 Issue 5/14 NEWS & ULTRASOUND Gastrointestinal medicine and surgery ‘Gastrointestinal medicine and sur- gery without interdisciplinary work- ing would be inconceivable,’ Prof. Galle emphasised. ‘We specialists in internal medicine are closely networked with surgeons and other specialists. In the case of stomach cancer, for example, if a patient is diagnosed via endoscopy the endoscopist carries out the biopsy, the pathologist makes the histo- logical diagnosis, the surgeon oper- ates on the patient and, before this, the radiologist would have been consulted to assess the poten- tial extent of the disease in any other areas away from the stomach. Gastrointestinal medicine and sur- gery are prime examples for a real interdisciplinary way of working – in daily clinical practice.’ Surgeons, he pointed out, expect real-time, good quality imaging to help procedures. ‘We also expect high quality support from patholo- gists. They have to make frozen sections during surgical procedures, have to attend clinical-pathological meetings and also need to provide information regarding the aggres- siveness of tumours.’ Personalised medicine ‘The development of personalised, molecular-genetically based diagno- sis will lead to treatment in the next step. In this context, RAS oncologi- cal diagnosis for colorectal cancer plays the most important part. If a mutation in the RAS gene is pre- sent, the use of biologically active substances, so-called antibody ther- apies, will be different to cases where the mutation is not present. Furthermore, we can learn from other diseases, in haematology for instance. With liquid tumours there is no limit to the availability of sample material. In gastrointestinal medicine this is much more diffi- cult – sometimes we have no tissue available at all. Therefore we work in all possible manners and, in the case of liver cancer for instance, utilise personal- ised diagnosis and treatment.’ Health insurers’ negativity ‘During the initial phase it is an additional service provided that is not billed separately. ‘The flat rates per case system works with full settlements, mean- ing that when a new method of treatment becomes available there will initially be no allowance for it in the reimbursement system. ‘We do indeed have initial prob- lems with most of the new or experimental procedures.’ Quality assurance – compli- ance entails lots of work ‘Initially, more quality also means more work. However, quality also can help to relieve strain. A quality- based approach can, for instance, ensure that junior doctors work in the safest possible way. ‘Quality assurance is basically an investment. We have to improve our documentation and develop more standard operating procedures (SOPs). These provide guidelines and are therefore indispensable. ‘Personally, I would even say there are only two things that should be important in medicine regarding billing: Indication and quality. The first question is whether a treatment is necessary and whether it can be specifically developed – and, if so, whether it is of good quality. Once these two simple questions have been answered, everything else is of lesser importance. This is why we included quality assurance measures in the whole series of events at our congresses, ranging from topics such as gall stones to stomach cancer, to do this subject justice.’ Guidelines and recommendations ‘The aims of guidelines developed through the DGVS (German Society of Gastrointestinal Diseases and Nutrition) and (American Board of Medical Specialties) are to achieve consistent diagnosis and treat- ment strategies for certain diseases. Guidelines provide a helpful frame- work for orientation – the reason why the DGVS has been developing guidelines for many years on topics such as stomach cancer, hepatitis B, pancreatitis, obstipation, diverticula etcetera. ‘On the DGVS board, our col- league’s responsibility is to ensure that certain guidelines are followed and updated. In some areas this is particularly difficult because things are very fast-moving. Hepatitis C, for instance, is characterised by incred- ible dynamics. Every few months we have to deal with new substances, and regular guidelines would not keep up with things here. In these situations we try to give updated recommendations several times a year, which are published in the Journal of Gastroenterology. ‘Medicine is characterised by fast progress and large amounts of new information that affect diagnosis and treatment. This means we also generate high costs. There will never be guidelines for all diseases, especially not current ones. ‘Currently this can be seen in the case of Ebola. There are experi- mental drugs that have not been licensed yet and therefore they should not really be used. ‘Ultimately, this is about an ethi- cal consensus rather than a scientif- ic issue. According to the WHO, the current, threatening constellation justifies over-riding the established, normally required multi-stage test- ing procedure. This is understand- able. If the need is this extensive, we should be able to compromise. We medics are well aware of this – take the example of the classic tri- age, which is the answer to ethical conflicts of this kind.’ A genuine interdisciplinary way for specialists to work At the close of the Gastrointestinal Medicine and Surgery meeting in Leipzig, Professor Peter R Galle, Congress President of the German Society for Gastroenterology, Digestive and Metabolic Diseases, spoke with of European Hospital about today’s emphasis on interdisciplinary exchange and the need to augment cooperation even further A specialist in Internal Medicine and Gastroenterology, Professor Peter R Galle has directed the Medical Clinic and Polyclinic at the Johannes Gutenberg University of Mainz since 1998. He has also served on the supervisory board and board of directors at the same University Hospital. A graduate from Marburg University and the Free University of Berlin, he wrote his doctorate in 1985, followed by his habilitation on the ‘Replication of Hepatitis B viruses in vitro’ in 1993. A little revolution in sonography Shear wave elastography detects more than liver disease Until recently liver biopsies were performed to stage hepatic fibro- sis in order to identify the suit- able therapy. ‘Since any interven- tion in the human body is asso- ciated with risks – haemorrhage and infection for example – we have long been looking for an alternative method to determine liver tissue elasticity. Today shear wave elastography is exactly such a method,’ says Professor Christoph F Dietrich MD, Medical Director of Clinic II at Caritas Hospital in Bad Mergentheim, Germany. Shear wave technology uses not only the b-mode image, which is based on information provided by the longitudinal ultrasound waves as they travel through the tissue with a speed of around 1.560 metres per second, but also at the transverse shear waves. The propagation of the shear waves in the tissue corre- lates to tissue elasticity: wave veloc- ity is proportional to tissue elastic- ity. Consequently, the propagation velocity in fibrotic tissue is higher than in healthy liver parenchyma. Currently, there are four different elastography procedures. Fibroscan, also called elastometry, is the most widely used proce- dure, although it does not gen- erate a typical ultrasound image. Acoustic Radiation Force Impulse Imaging (ARFI) provides a conven- tional ultrasound image. Shear wave elastography, introduced in 2009 by SuperSonic’s Aixplorer system, is the most recent and most innovative type of elastography. ‘The first two procedures have been comprehensively evaluated in the research literature. The third type, however, is based on shear waves and has the advantage of offering a high processing speed due to superfast processors. Consequently, the results are potentially better in 2D and 3D ultrasound,’ says Dietrich, who is using and researching this method in his hospital in Bad Mergentheim. ‘Unlike the competing procedure, the compressional elastography, which measures tissue elas- ticity based on the pressure applied via the transducer, the results generat- ed by the Aixplorer show a comparability of about 90 percent as soon as identical parameters are being compared,’ he adds. Professor Dietrich believes the Aixplorer is a little revolution in sonography. While it might still be in its ini- tial stages, it does show enormous potential as a non-invasive imaging method that can provide informa- tion on several other tissue char- acteristics. Moreover initial results Results are potentially better in 2-D and 3-D ultrasound Normal liver parenchyma in shear wave ultrasound (Aixplorer/SuperSonic) 6

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