Average Insertion Depth Research Articles

Determining the Mouth-to-Microphone Distance in Rigid Laryngoscopy: A Simple Solution Based on the Newly Measured Values of the Depth of Endoscope Insertion into the Mouth.

Mouth-to-microphone (MTM) distance is important when measuring the sound of voice. However, determining the MTM distance for laryngoscope-mounted microphones during laryngoscopic examinations is cumbersome. We introduce a novel solution for such cases, using the depth of insertion of the laryngoscope into the mouth DI as a reference distance. We measured the average insertion depth, DI, in 60 adult women and 60 adult men for rigid laryngoscopes with 70° and 90° view. We found the DI for the 70°/90° laryngoscope to be 9.7 ± 0.9/9.4 ± 0.6 cm in men, 8.9 ± 0.9/8.7 ± 0.7 cm in women, and 9.3 ± 0.9/9.0 ± 0.7 cm in all adults. Using these values, we show that, for microphones fixed at 15-40 cm from the tip of the laryngoscope, the final MTM distances are between 5 and 35 cm from the lips, and the standard uncertainties of these distances are between 16% and 2.5%. Our solution allows laryngologists and laryngoscope manufacturers to set and estimate the MTM distance for any rigid laryngeal endoscope with a microphone attached with reasonable accuracy, avoiding the need to measure this distance in vivo in routine practice.

Pre-clinical evaluation of the new veress needle+ mechanism on thiel-embalmed bodies: a controlled crossover study - Experimental research.

Eighteen participants (novices, intermediates, and experts) performed in total of 248 insertions in a systematic way on Thiel-embalmed bodies with wide and small bore versions of the conventional VN (VNc) and the VN+. Insertion depth was measured by recording the graduations on the needle under direct laparoscopic vision. Participants graded the bodies and the procedures as lifelike. Overall, a significant reduction (P<0.001) in average insertion depth was found for the VN+ compared to the VNc of 26.0 SD16 mm versus 46.2 SD15mm. The insertion depth difference in the novice group was higher compared to the intermediates and experts (P<0.001). The average insertion depth for both needle types was less (P<0.001) for female participants compared to male. This study indicated that the VN+ significantly reduced the insertion depth in all tested conditions. Whether the difference between female and male performance can be linked to differences in muscle control or arm mass should be further investigated. Useful technical information was gathered from this study to further improve the VN+.

Downward viewing common-path optical coherence tomography guided hydro-dissection needle for DALK.

Deep anterior lamellar keratoplasty (DALK) is a partial-thickness cornea transplant procedure in which only the recipient's stroma is replaced, leaving the host's Descemet's membrane (DM) and endothelium intact. This highly challenging "Big Bubble" procedure requires micron accuracy to insert a hydro-dissection needle as close as possible to the DM. Here, we report the design and evaluation of a downward viewing common-path optical coherence tomography (OCT) guided hydro-dissection needle for DALK. This design offers the flexibility of using different insertion angles and needle sizes. With the fiber situated outside the needle and eye, the needle can use its' full lumen for a smoother air/fluid injection and image quality is improved. The common-path OCT probe uses a bare optical fiber with its tip cleaved at the right angle for both reference and sample arm which is encapsulated in a 25-gauge stainless still tube. The fiber was set up vertically with a half-ball epoxy lens at the end to provide an A-scan with an 11-degree downward field of view. The hydro dissection needle was set up at 70 degrees from vertical and the relative position between the fiber end and the needle tip remained constant during the insertion. The fiber and needle were aligned by a customized needle driver to allow the needle tip and tissue underneath to both be imaged within the same A-scan. Fresh porcine eyes (N = 5) were used for the studies. The needle tip position, the stroma, and DM were successfully identified from the A-scan during the whole insertion process. The results showed the downward viewing OCT distal sensor can accurately guide the needle insertion for DALK and improved the average insertion depth compared to freehand insertion.

Estimating the Insertion Depth of a Peripherally Inserted Central Catheter in Newborns Using Weight and Gestational Age Measurements.

The objective of this study was to estimate the peripherally inserted central catheter (PICC) insertion depth in newborns. We retrospectively reviewed the records of 790 neonates who underwent PICC insertion for intravenous injections administered for 6 days or more following neonatal intensive care unit admission at our institution between January 2011 and October 2015. We analyzed patients' electronic medical records and chest standard radiographs. PICC insertion depths were calculated using the following equation: Insertion depth = Section + (β1 × Body weight). The predicted equation was checked for accuracy using Bland-Altman plots. Of 835 included neonates, 790 (94.6%) had properly positioned PICCs. Forty-three of 45 unsuitable patients (5.4%) had catheters inserted into the cephalic veins. Of the 790 patients with correctly inserted catheter tips, regression equations and standard errors were calculated for the average insertion depth and timing of PICC insertion. The catheter depth increased with every 100 g of weight gain and week of gestational age. More than 90% of the 4 vessels incorporating PICCs were included within the standard deviation of ±2.0, indicating high predictive validity. This study established a standard for accurately measuring PICC insertion depths.

Non-anesthetist-administered moderate sedation with midazolam and fentanyl for outpatient MRI-aided hybrid intracavitary and interstitial brachytherapy in cervix cancer: a single-institution experience.

PurposeThe aim of the study was to determine the feasibility of interstitial brachytherapy under non-anesthetist-administered moderate sedation, to identify factors influencing the insertion, and the total procedural time.Material and methodsA total of 47 insertions with hybrid intracavitary and interstitial applicators were performed in 23 patients from March 2017 to March 2020. Moderate sedation was achieved with intravenous midazolam and fentanyl administered by non-anesthetist. Insertion time and procedural time was recorded. Univariate and multivariate analysis were performed to evaluate the impact of different factors on insertion and procedural time.ResultsA total of 238 needles (range, 2-8 per insertion) were implanted, with an average insertion depth of 30 mm (range, 20-40 mm). The mean doses for midazolam and fentanyl were 3 mg (standard deviation [SD] = 1) and 53.3 mcg (SD = 23.9) per insertion, respectively. The median insertion time was 30 minutes (interquartile range [IQR] = 22-40), and the median total procedural time was 4.3 hours (IQR = 3.6-5.2). First time insertion, insertions performed before 2019, and higher midazolam dose were associated with significantly longer insertion time, whereas longer insertion time, MRI-based planning, and insertions performed before 2019 were associated with significantly longer total procedural time.ConclusionsOutpatient interstitial brachytherapy with non-anesthetist-administered sedation is achievable and well-tolerated. This method may significantly lessen the burden on hospital resources and has the potential to be cost-effective.

First Experience With a New Thin Lateral Wall Electrode in Human Temporal Bones.

A modern cochlear implant electrode array design must combine: improved surgical ease of use, structure preservation, particularly important for pediatric application, stable position within the cochlea over time, and a meaningful balance between hearing preservation against addressing sufficient cochlear tissue to support electrical-only hearing. The aim of this study was to investigate a new lateral wall electrode array design from Advanced Bionics on human temporal bones (TBs). Ten fresh-frozen TBs were implanted with the SlimJ electrode array via the round window. The electrode array is 23 mm long, with a cross-section varying from 0.25 × 0.55 mm at the most apical contact to 0.6 × 0.8 mm at the proximal marker contact. To assess location of the electrode array, the TBs were postoperatively scanned using cone beam computed tomography, and histology was performed to assess intracochlear trauma (Grades 0-4). All electrode arrays were considered easy to insert. The average insertion depth was 432 degrees measured from the round window with a range from 411 to 450 degrees azimuth. Nine out of 10 electrode arrays were inserted fully (<0.5 mm out of the cochlea), one electrode array was left 1.5 mm out of the cochlea. No translocations were observed in all 10 cochleae, slight touching of the basilar membrane at the distal portion of the array was observed in 50% of the cases. The results from the new thin lateral wall electrode array from Advanced Bionics provided consistent scala tympani locations. No translocations were observed and almost all electrode arrays were fully inserted. These results are promising and the new electrode array will be further studied in clinical practice investigating hearing preservation capabilities and speech performance.

Comparison of Insertion Depth and Hearing Preservation Results between HiFocus 1j and HiFocus Mid-Scala Electrodes in Pediatric Population

Abstract Background Various electrodes are available with a range of features and designs to fulfil anatomical and geometrical variations of the cochlea. The HiFocus 1j (1j) electrode developed by Advanced Bionics LLC is a lateral wall electrode designed to cover up to 1.5 turns or approximately 540° of the cochlea. The HiFocus Mid-Scala (HFms) was recently introduced and designed for structure preservation with a target insertion depth of 420°. Objective To evaluate the average insertion depth and variation, and to assess the potential for hearing preservation with 1j and HFms electrodes in children. Method A group of prelingually deafened children with regular anatomy who received the HiRes90K implant (either 1j or HFms electrode) underwent a plain radiography investigation shortly after the surgery to determine the angular insertion depth. The median age in each group was 3.6 years (1j) and 4.3 years (HFms). The amount of residual hearing was measured through audiometry prior surgery and then monitored at device activation and 1,3, 6, and 12 months later. Results Seventeen subjects were included for calculation of insertion depth. The median insertion depth and the variation for the 1j electrode was higher than for the HFms electrode (1j 476°; 443°–540°, HFms 413°; 390°–468°). Only eleven subjects were assessed for hearing preservation. Complete hearing preservation was achieved in seven subjects (five HFms and two 1j) and partial loss was observed in two subjects (one HFms and one 1j). Conclusion Both 1j and HFms electrodes are suitable for young children. Their flexible design allows round window insertions. The HFms group showed higher rates of hearing preservation (HP) than the 1j group.

PWE-149 5 Years of A DGH Delivered Regional Double Balloon Enteroscopy (DBE) Service

<h3>Introduction</h3> Double Balloon Enteroscopy (DBE) allows visualisation and interventional therapy throughout the small bowel. It was commenced in South Tyneside District Hospital (STDH) in January 2010 to complement the existing capsule endoscopy service. <h3>Methods</h3> Records were examined retrospectively for all DBEs at STDH between 1/1/2010 &amp; 31/12/2015 to determine the indication, route &amp; depth of insertion, findings &amp; therapies performed &amp; the complications. <h3>Results</h3> 92 procedures were performed from 172 referrals: (47%) via oral route, (52%) via anal route and (1%) via ileostomy. Procedures were done under conscious sedation or propofol, with GA for planned therapeutic cases. The average depth of insertion for the oral route was 174 cm &amp; 96 cm for the anal route. The overall average insertion time was 71 minutes. (61%) had tattoo applied. The indications were to evaluate suspected or confirmed Crohn’s disease (38%), obscure mid gastrointestinal (GI) bleeding (28%), suspected malignancy or abnormal imaging (20%), detect polyps in suspected or confirmed polyposis syndrome (7%) and refractory coeliac (1%). 25% of patients had more than one indication for DBE. DBE findings: 50% had normal examinations, 11% Crohn’s disease, 16% non-specific inflammation, 10% polyps, 4% tumours and 1% coeliac disease. Other diagnoses included small bowel angioectasia and radiation enteritis. The overall diagnostic yield was 50%. The diagnostic yield for suspected Crohn’s disease was 29%, evaluation of obscure mid GI bleeding was 31%, suspected polyps was 40%, refractory Coeliac was 100% and the evaluation of malignancy and abnormal imaging was 11%. 95% of patients who had a normal DBE had prior abnormalities in their imaging. Limitations: 10 procedures were incomplete due to equipment failure (5), persistent looping (4) &amp; inability to pass strictures (1). 1 was abandoned due to poor bowel preparation. Therapy was performed in 13 (14%) procedures: 3 dilatation of strictures, 5 had Argon Plasma Coagulation, 4 polypectomies and 1 had a bleeding ulcer clipped. No complications were recorded at DBE for any patients <h3>Conclusion</h3> Our DBE service is safe and complements other imaging modality. Our overall diagnostic yield is 50%. Our main indication for DBE is to evaluate suspected Crohn’s (38%) rather than for obscure GI bleeding as in the literature.¹ Even with stringent case selection the diagnostic yield for DBE was lower than the preceding VCE. <h3>Reference</h3> 1 Seong Ran, <i>et al</i>. Changes over time in indications, diagnostic yield, and clinical effects of double-balloon enteroscopy. <i>Clin Gastroenterol Hepatol</i> 2012;<b>10</b>(10):1152–1156. <h3>Disclosure of Interest</h3> None Declared

Deep enteroscopy with a conventional colonoscope: initial multicenter study by using a through-the-scope balloon catheter system

The advent of capsule endoscopy has revolutionized evaluation of the small bowel. Capsule endoscopy has become the criterion standard as the initial examination to diagnose small-bowel abnormalities, but does not allow for tissue sampling or therapeutic intervention. Deep enteroscopy can be performed by using a balloon-assisted device or a spiral overtube for both diagnostic and therapeutic interventions of the small bowel. Deep enteroscopy is time-consuming and requires special endoscopes and accessories to perform the examination. We studied a novel through-the-scope balloon catheter system used for deep enteroscopy that uses a conventional colonoscope and standard accessories. We performed a 9-center, retrospective study using a novel TTS balloon system for small-bowel evaluation. The new through-the-scope device is an on-demand balloon catheter that is inserted through the instrument channel of a standard colonoscope and enables deep advancement into the small bowel in either the anterograde or retrograde approach. It consists of a balloon inflation/deflation system and a single-use balloon catheter designed for anchoring in the small bowel. The balloon is inflated to an anchoring pressure in the small intestine, and a repetitive push-pull technique is performed, with the endoscope sliding over the guiding catheter to the inflated balloon. The catheter may be removed and reinserted to allow for therapeutic intervention while maintaining the endoscope position. A total of 98 patients were included; 52% were male, and the mean age was 55 years old (range 15-94 years). Indications included abdominal pain, iron-deficiency anemia, occult GI bleeding, diarrhea, abnormal capsule endoscopy, weight loss, protein losing enteropathy, retained foreign body, altered anatomy ERCP, and small-bowel strictures. Anterograde enteroscopy was performed in 65 patients. The average depth of insertion was 158 cm (range 50-350 cm) from the pylorus. Retrograde enteroscopy was performed in 33 cases. The average depth of insertion was 89 cm (range 20-150 cm) beyond the ileocecal valve. Overall, diagnostic yield was 44%. Theaverage advancement time for the anterograde and retrograde enteroscopy cases was 15.5 minutes. Therewere no procedural adverse outcomes reported in the 98 cases. The TTS advancing balloon is a safe and effective way to perform deep enteroscopy by using aconventional colonoscope without the need for an overtube. Procedure time is shorter than that of other formsof deep enteroscopy. Diagnostic yield and depth of insertion are on par with other forms of deep enteroscopy. This is the largest reported study using this novel technology to diagnose and treat small-bowel disease.

Use of the New NaviAid Enteroscopy System for Treatment of Bleeding Terminal Ileal Hamartoma

Introduction: Recent balloon-assisted enteroscopy modalities have been successful in diagnostic and therapeutic interventions in the small bowel, in both anterograde and retrograde manner. However, they each have their unique platforms and cannot be used between different scope systems. The NaviAid enteroscopy is a new system which utilizes a through-the-scope balloon catheter as an anchor for advancement into the small bowel, and can be used through the biopsy channel of various scope systems. Case Report: We report a unique case of a 36-year-old female who presented with melena and symptomatic anemia, requiring blood transfusions. She underwent a non-diagnostic upper endoscopy; however, on colonoscopy exam, she had altered blood in the ileo-cecal valve. Terminal ileal intubation showed a bleeding distant polypoid lesion that could not be reached with the colonoscope. Biopsies showed a hamartamatous lesion. Video capsule endoscopy did not show any other lesions in the entire small bowel. A NaviAid-assisted retrograde enteroscopy was successful in reaching the lesion in the terminal ileum, which was successfully resected endoscopically. The path report showed an isolated hamartomatous polyp with negative margins and no signs of malignancy. She recovered uneventfully without any recurrence of bleeding or anemia. Discussion: The NaviAid balloon-assisted enteroscopy is a safe and effective single-operator system for performing deep enteroscopy using a conventional colonoscope. It eliminates the need of an overtube or special scope platforms. Recent studies have shown an overall diagnostic yield of 45%, with average depth of insertion of 89 cm when used in a retrograde manner. Our case demonstrates its successful clinical utility in complete endoscopic resection of bleeding distant small bowel lesion.

Deep Enteroscopy with a Conventional Colonoscope: Initial Multicenter Study Using the NaviAid Balloon System

Purpose: Capsule endoscopy has revolutionized evaluation of the small bowel. Deep enteroscopy with single or double techniques allows for diagnostic and therapeutic intervention. Deep enteroscopy can be time consuming, but also requires special scopes and accessories to fit down the working channel. The NaviAid system enables the endoscopist to perform deep enteroscopy with the conventional colonoscope and use standard accessories. Methods: We performed a nine center retrospective study using the NaviAid balloon system for small bowel evaluation. The NaviAidTM AB device (SMART Medical Systems Ltd., Ra'anana, Israel) is an ondemand balloon catheter that is inserted through the instrument channel of a standard colonoscope and enables it to advance deep into the small bowel in either anterograde or retrograde approach. It consists of a balloon inflation/deflation system and a single-use balloon catheter, designed for anchoring in the small bowel. The balloon is inflated to anchor in the intestine and a repetitive push-pull technique is performed, with the endoscope sliding over the guiding catheter to the balloon inflated in the distal small bowel. The catheter may be removed to allow for therapeutic intervention while maintaining scope position. The balloon catheter can then be reinserted for further advancement. Results: A total of 98 patients were included; 52% were male, mean age 55 years old (range 15-94). Indications included abdominal pain, anemia, occult gastrointestinal bleed, diarrhea, abnormal capsule endoscopy, weight loss, protein losing enteropathy, retained foreign body, altered anatomy ERCP, and small bowel strictures. Anterograde enteroscopy was performed in 54 patients. The average depth of insertion (DOI) was 156 cm (range 50-350 cm). The average procedural time for the anterograde enteroscopy cases was 15.5 min. Retrograde enteroscopy was performed in 33 cases. The average DOI was 89 cm (range 20-150 cm) beyond the ileocecal valve. Overall, diagnostic yield was 45%. There were no procedural complications reported in the 98 cases. Conclusion: The NaviAidTM advancing balloon is a safe and effective way to perform deep enteroscopy using a conventional colonoscope without the need of an overtube. Procedure time is shorter than other forms of deep enteroscopy. Diagnostic yield and depth of insertion are on par with other forms of deep enteroscopy. This is the largest reported study using this novel technology to diagnose and treat small bowel disease.

Depth of Central Venous Catheterization by Intracardiac ECG in Adults

BackgroundCentral venous catheterization is done frequently in cardiac surgery and intensive care settings. Faulty positioning of the catheter can cause many complications.ObjectivesThe aim of our study was to study the average depth of insertion and formulate a general guideline through the right internal jugular vein (IJV).Patients and MethodsThe right IJV was cannulated over a period of four months and catheter tip positioning was guided by means of an intracardiac electrocardiogram (ECG). Insertion depth was registered at the position of maximum P wave amplitude and the catheter was fixed after withdrawing 2 cm. Pearson’s correlation coefficient was calculated to categorize any relationship between plots of distance versus patient’s height, and regression lines and equations were also calculated. Bland-Altman analysis of data was done to compare the old formulae with our derived formulae.ResultsA total of 155 adult patients were studied. Distances measured were found to be highly correlated with a patient’s height, followed by body surface area (BSA) and weight. For right IJV cannulation in valvular surgeries in adults, the depth of insertion (cm) was (height in cm / 15) + 2 ± 1.58 (SD) and in non-valvular surgeries in adults, it was (height in cm/15) + 1.4 ± 1.47 (SD). The bias was very small when the new formulae were compared to the existing formulae.ConclusionsThe devised formulae predicted the required depth of catheters thereby reducing the possibility of complications and need for radiographic confirmation.

Validity of insertion depth measurement in double-balloon endoscopy

In double-balloon enteroscopy (DBE) the use of a reliable and practical method to calculate the insertion depth of the endoscope could help to improve diagnosis accuracy and optimize the effort and cost of the technique. The objectives of this work were to compare and evaluate two methods of estimating the insertion depth and to obtain a descriptive model capable of representing the exploration dynamics and efficiency in terms of advanced distance and time. Oral DBE was performed in 25 pigs. Insertion depth was calculated during the procedure by: 1) estimation of time and distance for each push and pull cycle during progression; and 2) estimation of distance during withdrawal. At the maximum insertion depth a tattoo was placed, and the observed measures for the two methods were compared with the distance between the pylorus and the mark after euthanasia and necropsy of the animals 1 week after DBE. The average insertion depth during progression, withdrawal, and after necropsy was 324.92 cm, 317.23 cm, and 342.05 cm, respectively (P Anova = 0.72). The Pearson correlation coefficient (r > 0.85; P < 0.001) and paired Brand - Altman plots demonstrated high agreement between progression and necropsy (0.03 % difference) and between withdrawal and necropsy (6.9 % difference). The exploration dynamics and efficiency in terms of advanced distance per cycle and time fitted to potential and logarithmic regression models, respectively. Measurement of insertion depth in vivo was validated in the porcine model during progression and withdrawal. Estimation during progression was more accurate and allowed exploration dynamics and efficiency to be plotted, which might be used as approximate reference values for humans.

PMO-208 Double balloon enteroscopy in a district general hospital: the experience so far

IntroductionDouble Balloon Enteroscopy (DBE) is widely used in clinical practice worldwide and can be used to explore the small bowel in an antegrade or retrograde approach. A DBE service at...

Atrial Fibrillation Complicating Left Pneumothorax After Malpositioning of a Double-Lumen Tube

A 66-year-old woman (weight 133.3 lbs, height 158 cm) was scheduled for atrial septal defect (ASD) repair through a thoracotomy. Preoperative chest radiography was normal, and an electrocardiogram showed an incomplete right bundle-branch block. Transesophageal echocardiography revealed moderate right atrium and ventricle dilation, a pulmonary arterial pressure of 52 mmHg, and an ASD-associated left-to-right shunt. In the operating room, her blood pressure was 125/75 mmHg, her heart rate was 94 beats/min, and the SpO2 was 97% on room air. The patient was intubated with a 35F left-sided double-lumen tube (DLT) under direct laryngoscopy to a depth of 31 cm at the incisors. The DLT placement was checked by auscultation. During manual ventilation, increased airway resistance was noted, and no breath sounds were heard over either lung fields. The tube was pulled back 2 cm, and bilateral breath sounds were again documented. The end-tidal carbon dioxide waveform was present on the monitor. At that time, rapid-rate atrial fibrillation of 130 beats/min occurred with a blood pressure of 63/40 mmHg. Phenylephrine boluses were given to maintain hemodynamic stability. Correct positioning of the DLT was confirmed by fiberoptic bronchoscopy. Meanwhile, SpO2 remained within the normal range. Soon thereafter, a median sternotomy was performed instead of a thoracotomy, and a left pneumothorax was diagnosed and released by pleural opening. This was followed by rapid conversion of the atrial fibrillation into sinus rhythm and restoration of normal blood pressure. During one-lung ventilation, barotrauma from excessive tidal volume and high airway pressure may occur if a left-sided DLT is positioned distally such that the entire tidal volume is directed to only one lobe.1Silvalingam P. Tio R. Tension pneumothorax, pneumomediastinum, pneumoperitoneum, and subcutaneous emphysema in a 15-year-old Chinese girl after a double-lumen tube intubation and one-lung ventilation.J Cardiothorac Vasc Anesth. 1999; 13: 312-315Abstract Full Text PDF PubMed Scopus (34) Google Scholar, 2Malik S. Shapiro W.A. Jablons D. et al.Contralateral tension pneumothorax during one-lung ventilation for lobectomy: Diagnosis aided by fiberoptic bronchoscopy.Anesth Analg. 2002; 95: 570-572PubMed Google Scholar In our patient, high peak airway pressure may have been generated during manual ventilation to check the DLT position, which was placed too distal. The average depth of insertion for patients 170 cm tall was 29 cm, and for each 10-cm increase or decrease in height, the average placement depth was increased or decreased 1 cm.3Brodsky J.B. Benumof J.L. Ehrenwerth J. et al.Depth of placement of left double-lumen endobronchial tubes.Anesth Analg. 1991; 73: 570-572Crossref PubMed Scopus (95) Google Scholar A pneumothorax presents as increased airway pressure, decreased tidal volume, decreased SpO, and hypotension. Sudden-onset atrial fibrillation may occur for a variety of reasons during anesthesia. Our patient developed rapid-rate atrial fibrillation with hypotension, probably as a complication of the pneumothorax, which was diagnosed only after sternotomy. Had we initiated one-lung ventilation, cardiovascular collapse would have developed. Previous reports showed that a pneumothorax may be associated with numerous electrocardiographic changes.4Price J.W. Novel electrocardiographic changes associated with iatrogenic pneumothorax.Am J Crit Care. 2006; 15: 415-419PubMed Google Scholar, 5Strizik B. Forman R. New ECG changes associated with a tension pneumothorax.Chest. 1999; 115: 1742-1744Crossref PubMed Scopus (37) Google Scholar The sudden rise in intrathoracic pressure and rotation around the longitudinal axis of the heart has been suggested as a cause of these changes. A proposed mechanism for PR-segment changes is atrial ischemia caused by compression of air on the collapsed lung and subsequently on the heart. In our patient, a shift in heart position secondary to the pneumothorax in addition to the atrial enlargement may have predisposed to this mechanical irritation and subsequent atrial fibrillation. In conclusion, we report a case of atrial fibrillation complicating a left pneumothorax that was caused by barotrauma after malpositioning of a DLT in the presence of an ASD. Atrial fibrillation was reverted by releasing the pneumothorax. The diagnosis of a pneumothorax should be considered during DLT insertion whenever a patient develops cardiovascular instability.

Spiral enteroscopy: A preliminary experience in Asian population

In spite of recent developments in the field of enteroscopy the small bowel remains the challenging organ to access. The spiral enteroscopy is a novel technique using a special over-tube (Endo-Ease Discovery SB) system for deep intubation of the small bowel. The aim of the present study was to evaluate the efficacy of spiral enteroscopy with an Olympus enteroscope (SIF Q 180) in an Asian subset of patients. Between January and March 2010, 11 patients underwent spiral enteroscopies. The indication for the procedure was obscure gastrointestinal bleeding in five patients, Crohn's disease in two, malabsorbtion syndrome in two, Peutz-Jeghers syndrome in one and Osler Weber Rendu disease in one patient. Eleven patients (five male and six female) mean age 41.6 years (range 21-62 years) underwent spiral enteroscopy. Spiral enteroscopy advancement was successful in all patients. The average depth of insertion was 249 cm (range 120-400 cm) past the ligament of Treitz, and the average time for the procedure was 27.8 min (range 20-32 min). The findings included ulcers (n = 3), polyps (n = 1), arteriovenous malformation (n = 2), ulcer with stricture (n = 1), and lymphangiectasia (n = 1). No major complications were observed. In conclusion, our initial experience with spiral enteroscopy shows that it is easy to perform, takes less time than balloon assisted enteroscopy and is relatively safe.

Spiral Enteroscopy Is Safe and Effective for an Elderly United States Population of Patients With Numerous Comorbidities

Preliminary studies performed outside of the United States demonstrated that spiral enteroscopy is safe and effective when performed in young, healthy patients. However, spiral enteroscopy has not been evaluated in a US population of patients with numerous comorbidities. We evaluated the feasibility, efficacy, and safety of spiral enteroscopy in a US population of older patients with multiple comorbidities and a high prevalence of pathologic findings. We performed a prospective case series of 61 patients with clinical indications for deep enteroscopy conducted at 2 US academic tertiary referral centers. Patients underwent deep enteroscopy with the spiral Endo-Ease Discovery SB overtube. Insertion depth, procedure time, diagnostic findings, therapeutic maneuvers, sedation type, and complications were recorded. Spiral enteroscopy was attempted in 61 patients (mean age, 65.4 +/- 12.4 years); 52% were rated by American Society of Anesthesiologists guidelines as class 3 (n = 30) or 4 (n = 2). The procedure was successfully completed in 56 of 61 patients (92%). Average insertion depth was 217.4 +/- 79 cm beyond the ligament of Treitz. The total mean procedure time was 41 +/- 15 minutes (diagnostic time, 36 +/- 12 minutes; therapy time, 5 +/- 9 minutes). Positive findings were noted in 36 cases (59%), with therapeutic maneuvers performed in 30 cases (49%). A total of 41 cases (67%) were performed under conscious sedation; fluoroscopy was not used in any case. Four mild complications occurred, and there were no perforations. Spiral enteroscopy is technically feasible and safe in an elderly US population of patients with numerous comorbidities.

The clinical utility of single-balloon enteroscopy: a single-center experience of 172 procedures

Single-balloon enteroscopy (SBE) is a novel endoscopic technique designed to evaluate and treat small-bowel disease. Although there is substantial literature addressing double-balloon enteroscopy and its impact on the diagnosis and management of small-bowel disease, there are limited data available on the clinical utility of SBE. To evaluate the clinical utility and diagnostic impact of SBE in a large cohort of patients at a single tertiary center. Single-center, retrospective study. Digestive Disease Institute, Cleveland Clinic, Cleveland, Ohio. A total of 161 patients were referred for SBE from January 2006 to August 2008. Demographic, clinical, procedural, and outcome data were collected and analyzed. A total of 161 patients underwent a total of 172 procedures. Antegrade and retrograde approaches were used in 83% and 17% of subjects, respectively. The average insertion depth using the antegrade approach was 132 cm beyond the ligament of Treitz (range 20-400 cm). The average insertion depth using the retrograde approach was 73 cm above the ileocecal valve (range 10-160 cm). The average procedure time was 40 minutes overall, 38 minutes (range 12-90) antegrade and 48 minutes (range 28-89) retrograde. Fluoroscopy was used in 20 cases (12%). Diagnostic yield was 58% (99/172); 42% (72/172) were therapeutic cases. There were no significant complications. Single-center, retrospective study. SBE demonstrated a high diagnostic yield and frequently provided useful therapeutic intervention. It seems to be a safe and effective method for performing deep enteroscopy.

Experience of Double Balloon Enteroscopy (DBE) at a Tertiary Care Hospital: A Two Year Analysis

Purpose: DBE has opened a new frontier in the diagnosis and treatment of small bowel pathology. Studies have revealed technical difficulties that may be encountered with this procedure, in particular, difficult terminal ileal intubation. This study is aimed at assessing the utility, yield, and safety of DBE in a large U.S. referral center. Methods: This was a retrospective study of all DBEs performed at our endoscopy center between 11/2006 and 2/2009 by one experienced endoscopist with assistance from gastroenterology fellows. All procedures were performed using the Fujinon EN-450T5 double balloon enteroscope (Fujinon Inc, Saitama City, Japan). Data on patient characteristics (prior abdominal surgery), indication, route, depth of insertion (beyond the pylorus/ileocecal valve), time of procedure, CO2 use, findings, interventions, and complications was collected. Results: A total of 169 DBEs (121 per oral and 48 per anal) were performed on 152 patients. The most common indication for oral and anal DBE was abnormal video capsule endoscopy (44% oral, 40% anal). Abnormalities were found in 56% of DBEs resulting in change in patient management in 35% of cases. Average depth of insertion was 210 cm on oral route and 90 cm on anal route. Average time of procedure was 63 min on oral route and 64 min on anal route. Unlike prior studies, history of abdominal surgery did not impact the depth of insertion or time of procedure. The depth of insertion and time with and without surgery for oral DBE was 206 cm vs. 213 cm and 67 min vs. 58 min, respectively (P>0.05). The depth of insertion and time with and without surgery for anal DBE was 89 cm vs. 91 cm and 65 min vs. 63 min, respectively (P>0.05). There were no complications recorded in our series. Conclusion: DBE remains a challenging yet promising procedure to unlock the pathology of the small bowel. Abnormalities were found in a majority of patients undergoing DBE with a resultant change of management in a large proportion of those patients.

Low-cost flexible sigmoidoscopy screening: a community demonstration and education project.

The purpose of this project was to demonstrate that a low-cost, community-based screening and education approach (for both patients and physicians), as has been used with mammography, can be successful with flexible sigmoidoscopy. One hundred appointments over four days were made available via a targeted mailing to 12,000 health-interested community members if they were asymptomatic, 50 years old or older, and had never before been screened by flexible sigmoidoscopy. The cost for the procedure was set at $50. Professional education was accomplished by having local physicians interested in gaining greater experience with flexible sigmoidoscopy provide the screenings under supervision. All 100 patient appointments and seven physician-training slots were quickly filled. Ninety-five procedures were performed by seven local physicians, averaging 10 minutes per procedure, with an average insertion depth of 31 cm and a 4.2% premalignant-polyp detection rate. The patients were also given education and counseling about colorectal cancer screening and prevention, and were evaluated by pre- and post-testing, and satisfaction questionnaires. The patients demonstrated markedly significant knowledge gains about colorectal cancer prevention and early detection, with 99% agreeable to having the procedure repeated in the future. This project demonstrated a high level of both public and professional willingness to participate in a flexible sigmoidoscopy screening program. The project method is presented in detail to encourage future such programs.