Tip Of Endoscope Research Articles

Endoscopic hematoma evacuation in patients with spontaneous supratentorial intracerebral hemorrhage

BackgroundSurgical evacuation of spontaneous supratentorial intracerebral hemorrhage (ICH) is controversial because the traditional surgical approach sometimes causes further brain injury. The introduction of the neuroendoscope has brought with it the new idea of minimal invasiveness, which may improve the surgical results of ICH. MethodsTwenty-one patients with spontaneous supratentorial ICH underwent endoscopic hematoma evacuation between December 2010 and January 2012. Safe entry points could be Kocher's, Keen's, or Frazier's point, depending on the locations of the hemorrhages. The surgical steps were as follows: (1) cortical incision and dilation of the channel; (2) introduction of the transparent sheath; (3) gushing out of the hematoma under high intracranial pressure; (4) changing the angle of the transparent sheath, endoscope, and suction tip to remove residual hematoma; and (5) paving a layer of hemostatic agents after hematoma removal. ResultsThe median operative time was 120 minutes (range: 90–190 minutes), and the median blood loss was 160 mL (range: 50–300 mL). The median duration of intensive care unit stay was 6 days (range: 2–18 days). The median hematoma evacuation ratio was 90% (range: 60–99%). Two patients had rebleeding events, and the mortality rate was 9.5% (n = 2/21). The median Glasgow Coma Scale score improved from 8 to 11 within 1 week after surgery, and the median Glasgow Outcome Scale score was 3 after 6 months and 12 months follow-up. ConclusionWith the introduction of the minimally invasive techniques and the evolution of the neuroendoscope and hemostatic agents, the median operative time and blood loss have been significantly decreased. Although the hematoma evacuation rates were similar between the endoscope (90%) and craniotomy (85%) groups, the median intensive care unit stay was decreased from 11 days to 6 days due to reduced surgical invasiveness. This represents an important advancement in treating spontaneous supratentorial ICH, and provides a measured preview of the promising results that can be expected in the future.

Endoscopic closure of tracheoesophageal fistulas with the over-the-scope clip system.

Management of Tracheoesophageal Fistulas (TEFs) is associated with high morbidity and mortality and remains an interdisciplinary challenge. We describe the first two cases of successful endoscopic closure of TEFs due to tracheostomy tube and thoracic hydatid cysts surgery, using the Over-The-Scope Clip (OTSC) system. The OTSC system is composed of an application cap, which is mounted onto the distal tip of the endoscope and a connected releasing mechanism, installed on the handle of the scope. The rotation of the handle allows the release of the clip by a two tube sliding mechanism. Atraumatic version of OTSCs with medium sized caps, twin graspers and anchor were used in these cases. Both fistulae were successfully sealed with one clip. No complication was observed that could be ascribed to the clip itself or to the technique. One patient died because of pneumonia and septicemia after 1 week, but the symptoms of other patient were immediately improved. A thoracic radiography taken after 1 month showed that the clip is in place. Although prospective comparative clinical studies are needed to work out the drawbacks of the new OTSC device, it might be considered as a valid alternative to operation in TEFs.

Cap-assisted argon plasma coagulation

Cap-assisted argon plasma coagulation is carried out with a clear cap over the tip of the endoscope. The catheter is then positioned within the cap in such a manner that the tip of the catheter is kept at a reproducible distance from the mucosa (Fig. 1). This obviates the possibility of direct mucosal contact and the resulting direct thermal injury. It also allows for a very precise delivery of current to the target tissues by maintaining the position of the endoscope tip and catheter tip relative to the intended treatment area, maintaining luminal patency, and controlling the local gas dynamics of the argon. This technique does not appear to be widely used and has not been described in the medical literature, to our knowledge, but we suspect that some endoscopists may find it helpful. Video 1 (available online at www. giejournal.org) demonstrates this technique by use of a single-use, soft, straight cap (Olympus, Tokyo, Japan) to ablate radiation proctopathy in a symptomatic 68year-old man.

Temperature Changes Associated with Middle Ear Endoscopy in a Human Temporal Bone Model

Objectives: Endoscopic ear surgery is rapidly gaining popularity as a minimally invasive approach to address chronic ear disease. However, little is known about the potentially damaging temperature increases associated with endoscopy in the middle ear. Specifically, neither temperature change nor heat distribution associated with the endoscope has been quantified. In this study, we aim to measure temperature changes throughout the middle ear during rigid endoscopy in a human temporal bone model. Methods: Fresh human temporal bones were maintained at physiologic temperature during middle ear endoscopy with a 3-mm 0° Hopkins rod. Temperature changes were measured as a function of the distance between the endoscope tip and the round window membrane. Thermal gradient was determined by infrared imaging. Control studies conducted at room temperature were also performed. Results: An endoscope with a xenon or light-emitting diode light source on maximal power induced a rapid temperature elevation up to 46°C within 0.5-1 mm of the tip of the endoscope within 30-124 seconds. Elevated temperatures occurred at distances up to 8mm from the endoscope tip. Temperatures rapidly returned to baseline within 20-88 seconds after turning off the light source. Conclusions: Our findings have direct implications for endoscopic ear surgery and affirm the importance of avoiding excessive temperature elevation. We recommend employing submaximal light intensity and repositioning the endoscope frequently to provide rapid cooling. Ongoing studies use an animal model to explore the in vivo effects of prolonged middle ear endoscopy and evaluate for potential threshold shifts in auditory brainstem responses.

A new device for simultaneous manipulation of an endoscope and a treatment device during procedures: an ex vivo animal study.

Endoscopists must maneuver both endoscope and treatment device during procedures, requiring them to release their hand from the scope to manipulate the treatment device. Aiming to improve this situation, we developed a new device called the Thumb Drive. The Thumb Drive comprises a controller and catheter. After attaching the controller to the endoscope's grip, the catheter is inserted into the forceps channel. The treatment device is then inserted into the Thumb Drive and fixed with its tip protruding from the endoscope tip. A single endoscopist resected 10 lesions in a porcine stomach by endoscopic submucosal dissection (ESD) using the Thumb Drive. All lesions were resected en bloc using this new device without any perforations. The mean incision, dissection, and operative times were 97.2 ± 48.7 seconds, 121.6 ± 53.6 seconds, and 218.8 ± 67.8 seconds, respectively. The Thumb Drive enables the endoscopist to manipulate the treatment device with the thumb while handling the endoscope with the right hand during ESD. Its utility should be examined in in vivo studies as a next step.

Insulating and cooling effects of nasal endoscope sheaths and irrigation.

Heat generated at the tips of nasal endoscopes have been shown to reach temperatures high enough to cause thermal tissue injury. Endoscope sheaths have the potential to minimize the risk of thermal tissue injury. The purpose of this study was to assess the abilities of plastic and metal endoscope sheaths and sheath irrigation to insulate against dangerous scope tip temperatures. A 4-mm 0-degree rigid nasal endoscope was used with light-emitting diode (LED) and xenon light sources (400-W LED, 300-W, and 175-W xenon) to assess scope tip temperature before and after endoscope sheath placement. Temperatures were assessed again after placement of each sheath, both before and after active saline irrigation. Scope tip temperature was measured using a noncontact infrared thermometer. The unsheathed rigid scope tip reached a maximal temperature after 10minutes at 100% light source intensity. The 400-W LED and 300-W xenon sources generated potentially dangerous scope tip temperatures exceeding 42°C, whereas the 175-W xenon source never generated a maximal temperature over 32.6°C. After placement of plastic and metal sheaths, mean scope tip temperatures were decreased by 2°C (4.8%) and 2.2°C (5.5%), respectively. After active saline irrigation, mean scope tip temperatures were decreased by 5.1°C (12.6%) and 5.2°C (12.8%), respectively. With modern light sources, nasal endoscopes have the potential to reach temperatures that may cause thermal tissue injury. Endoscope sheaths lead to decreases in scope temperatures, and the effect is greater with active irrigation. In addition to improving visualization, endoscope sheaths may decrease the risk of thermal tissue injury.

Ultrahigh sensitivity endoscopic camera using a new CMOS image sensor: providing with clear images under low illumination in addition to fluorescent images.

We developed a new ultrahigh-sensitive CMOS camera using a specific sensor that has a wide range of spectral sensitivity characteristics. The objective of this study is to present our updated endoscopic technology that has successfully integrated two innovative functions; ultrasensitive imaging as well as advanced fluorescent viewing. Two different experiments were conducted. One was carried out to evaluate the function of the ultrahigh-sensitive camera. The other was to test the availability of the newly developed sensor and its performance as a fluorescence endoscope. In both studies, the distance from the endoscopic tip to the target was varied and those endoscopic images in each setting were taken for further comparison. In the first experiment, the 3-CCD camera failed to display the clear images under low illumination, and the target was hardly seen. In contrast, the CMOS camera was able to display the targets regardless of the camera-target distance under low illumination. Under high illumination, imaging quality given by both cameras was quite alike. In the second experiment as a fluorescence endoscope, the CMOS camera was capable of clearly showing the fluorescent-activated organs. The ultrahigh sensitivity CMOS HD endoscopic camera is expected to provide us with clear images under low illumination in addition to the fluorescent images under high illumination in the field of laparoscopic surgery.

PWE-039 Buried Treasure: Developing An Accurate, Low Cost Assessment Of Flexible Sigmoidoscopy Completion Using A Hand-held Metal Detector

IntroductionFlexible sigmoidoscopy (FS) is a validated screening test to reduce the incidence of colorectal cancer. Bowel Scope screening is due to be implemented in the UK by 2016. There is...

Endocuff-assisted colonoscopy: a new accessory to improve adenoma detection rate? Technical aspects and first clinical experiences

The Endocuff is a new colonoscopy accessory that has been designed to improve both the adenoma detection rate and endoscope tip control. A total of 50 Endocuff-assisted colonoscopies were analyzed retrospectively with regard to safety, procedural success, and complications. The cecal intubation rate was 98 %, and the mean intubation time was 6.0 minutes (95 % confidence interval 5.3 - 6.6 minutes). The ileal intubation rate was 76 %. In 30 % of patients, the Endocuff caused small, superficial, "scratch-like" mucosal lesions. In all other patients, no Endocuff-associated complications were observed. A total of 36 adenomas were detected in 50 patients. The adenoma detection rate was 34 %. Endocuff-assisted colonoscopy showed good procedural success rates in terms of cecal intubation rate and time, and a promising adenoma detection rate. Endocuff seems to improve endoscope tip control, especially during polypectomy. Endocuff may be a useful device for colorectal adenoma screening, and should be investigated in larger trials.

Endoscopic approaches to enteral feeding and nutrition core curriculum

Endoscopic approaches to enteral feeding and nutrition core curriculum

Thermal effects of endoscopy in a human temporal bone model: Implications for endoscopic ear surgery

Although the theoretical risk of elevated temperatures during endoscopic ear surgery has been reported previously, neither temperature change nor heat distribution associated with the endoscope has been quantified. In this study, we measure temperature changes during rigid middle ear endoscopy in a human temporal bone model and investigate whether suction can act as a significant cooling mechanism. Human temporal bone model of endoscopic middle ear surgery. Fresh human temporal bones were maintained at body temperature (∼ 36°C). Temperature fluctuations were measured as a function of 1) distance between the tip of a 3-mm 0° Hopkins rod and round window membrane, and 2) intensity of the light source. Infrared imaging determined the thermal gradient. For suction, a 20-Fr suction catheter was utilized. We found: 1) an endoscope maximally powered by a xenon or light-emitting diode light source resulted in a rapid temperature elevation up to 46°C within 0.5 to 1 mm from the tip of the endoscope within 30 to 124 seconds, 2) elevated temperatures occurred up to 8 mm from the endoscope tip; and 3) temperature decreased rapidly within 20 to 88 seconds of turning off the light source or applying suction. Our findings have direct implications for avoiding excessive temperature elevation in endoscopic ear surgery. We recommend: 1) using submaximal light intensity, 2) frequent repositioning of the endoscope, and 3) removing the endoscope to allow tissue cooling. Use of suction provides rapid cooling of the middle ear space and may be incorporated in the design of new instrumentation for prolonged dissection.

Intuitive user interfaces increase efficiency in endoscope tip control

Flexible endoscopes are increasingly used to perform advanced intraluminal and transluminal interventions. These complex interventions demand accurate and efficient control, however, current endoscopes lack intuitiveness and ergonomic control of the endoscope tip. Alternative handheld controllers can improve intuitiveness and ergonomics, though previous studies are inconclusive concerning their effect on the efficiency of endoscope manipulation. The aim of this study is to determine the efficiency of a robotic system with intuitive user interface in controlling the tip of the flexible endoscope. We compared the efficiency of time and tip trajectory when steering the endoscope tip using the conventional steering wheels and a robotic platform with three different user interfaces: a touchpad in combination with a position control algorithm, a joystick combined with linear rate control, and a joystick combined with non-linear rate control. Fourteen participants, without a medical background, used all four interfaces. They performed both large navigational and fine targeting tasks in a simulated environment which allowed objective cross-subject comparison. Afterward, the participants were asked to select their preferred steering method. Participants were significantly faster in steering the endoscope tip when using robotic steering compared to using the conventional steering method. Between the robotic interfaces, using the touchpad was significantly faster compared to the joystick with linear rate control. Use of the joystick with non-linear rate control led to a shorter tip trajectory compared to the touchpad. The majority of participants preferred the joystick with non-linear rate control over the other steering methods. This work shows that intuitive user interfaces can improve the efficiency of endoscope tip steering.

In vivo histologically equivalent evaluation of gastric mucosal topologic morphology in dogs by using confocal endomicroscopy.

BackgroundConfocal endomicroscopy (CEM) is an endoscopic technology permitting in vivo cellular and subcellular imaging. CEM aids real‐time clinical assessment and diagnosis of various gastrointestinal diseases in people. CEM allows in vivo characterization of small intestinal mucosal morphology in dogs.ObjectiveTo determine the feasibility of CEM to evaluate gastric mucosal morphology in dogs and to characterize the appearance in healthy dogs.AnimalsFourteen clinically healthy research colony dogs.MethodsExperimental study. Under general anesthesia, dogs underwent standard endoscopic evaluation and CEM of the gastric mucosa. In the initial 6 dogs, fluorescent contrast was provided with the fluorophore acriflavine (0.05% solution), applied topically. Subsequently, 8 dogs were assessed using a combination of fluorescein (10% solution, 15 mg/kg IV), followed by acriflavine administered topically. For each fluorophore, a minimum of 5 sites were assessed.ResultsConfocal endomicroscopy provided high quality in vivo histologically equivalent images of the gastric mucosa, but reduced flexibility of the endoscope tip limited imaging of the cranial stomach in some dogs. Intravenous administration of fluorescein allowed assessment of cellular cytoplasmic and microvasculature features. Topical application of acriflavine preferentially stained cellular nucleic acids, allowing additional evaluation of nuclear morphology. Identification of Helicobacter‐like organisms was possible in 13 dogs.Conclusion and Clinical ImportanceConfocal endomicroscopy provides in vivo images allowing assessment of gastric mucosal morphology during endoscopy, potentially permitting real‐time diagnosis of gastrointestinal disease.

Ligation-assisted endoscopic enucleation for treatment of esophageal subepithelial lesions originating from the muscularis propria: a preliminary study

An innovative ligation-assisted endoscopic enucleation (EE-L) technique was developed for the diagnosis and treatment of esophageal subepithelial lesions (smaller than 12 mm) originating from muscularis propria by combining endoscopic band ligation and endoscopic enucleation techniques. The aim of the study was to evaluate efficacy and safety of EE-L technique in the treatment of esophageal subepithelial lesions (smaller than 12 mm) originating from muscularis propria. Forty-seven esophageal subepithelial lesions (smaller than 12 mm) originating from the muscularis propria in 44 patients were treated with EE-L between September 2010 and September 2012. The lesion was first aspirated into the transparent cap attached to the tip of endoscope. The elastic band was then released around its base. The purpose of ligation was to force the lesion to assume a polypoid form with a pseudostalk. Endoscopic enucleation was then performed until the tumor was completely enucleated from muscularis propria using a hook knife and forceps. All tumors (median diameter: 8.2 ± 2.3 mm, range: 4-12 mm) were enucleated completely. Histopathology identified 45 tumors (95.7%) as leiomyoma, 2 (4.3%) tumors as gastrointestinal stromal tumor with very low risk. The mean time of the EE-L procedure was 12.5 ± 4.6 minutes (range: 6-23 minutes). Two patients experienced self-limiting, non-life-threatening hemorrhage after EE-L. No perforation and massive hemorrhage requiring further endoscopic or surgical intervention occurred. There were no recurrences during the 6-24 months follow-up period. EE-L offers the option of localized treatment of small esophageal muscularis propria tumors (smaller than 12 mm) with relatively few complications and low mortality, and provides the advantage of allowing a histopathological diagnosis. All the resected lesions in this study had a benign pathology.

Malignant cell contamination may lead to false-positive findings at endosonographic fine needle aspiration for tumor staging

Endoscopic ultrasound-guided fine needle aspiration (EUS-FNA) of lymph nodes is used for staging of gastrointestinal malignancies. False-positive rates of 5 % - 7 % are not well understood. Elements of EUS examinations that contribute to false-positive cytological findings were investigated. 13 patients undergoing EUS staging of gastrointestinal luminal malignancy were consecutively enrolled together with 3 patients with extraluminal tumors (pancreas, lung) defined as controls. After EUS, cellular debris and fluid were collected from the FNA needle catheter, instrument channel, and endoscope tip for cytologic and histologic investigation. 6 of 13 patients (46 %) had malignant cells contaminating the FNA needle catheter, instrument channel, or endoscope tip. Malignant cells were present in the instrument channel in 5 cases (38 %), exterior tip of echoendoscope in 4 (31 %) and needle catheter in 2 (15 %). Echoendoscopes used for FNA in patients with luminal tumors are at risk for malignant cell contamination of the instrument channel, FNA needle catheter, and echoendoscope tip. FNA needle contamination can contribute to false-positive findings.

Rectal Retroflexion during Colonoscopy: A Bridge over Troubled Water

Rectal Retroflexion during Colonoscopy: A Bridge over Troubled Water

Radiofrecuencia para esófago de Barrett: Revisión de la literatura

Radiofrequency ablation (RFA) is a first-line endoscopic therapy for Barrett's esophagus (Be) with high-grade dysplasia and intramucosal carcinoma with high eradication rates, low recurrence at 5 years (< 10%) and low rate complications. Long-term results are unknown, but 5 years trials reports a success rate > 90% overall. Patients with Be without dysplasia or mild dysplasia would have no indication today for RFA according to international guidelines, however it is likely that the appearance of biomarkers for progression to cancer, more experience and proper identification of factors of progression to dysplasia, some of these patients may benefit with RFA, the clinical reality is that in some countries and endoscopic centers RFA is performed with relative frequency in patients without dysplasia.Primary circumferential ablation is performed using a bipolar electrode based on a pneumatic balloon, while the secondary residual eB treatment is performed using a bipolar electrode mounted on a hinged platform on the endoscope tip. studies suggest that this ablation technique is highly effective in the removal of the mucosa and dysplasia in Barrett associated, and minimizes the disadvantages of known photodynamic therapy and argon plasma, such as esophageal stenosis and eB subescamosos foci (“subepithelial or buried Barrett”).There is experience of more than 5 years in some countries, while in Mexico a few months and little experience is the reality.

Transnasal Endoscope Locked in a Bent Position Causing Difficult Withdrawal

We report a rare but severe complication of routine transnasal esophagogastroduodenoscopy (EGD). The tip of a transnasal endoscope was locked in a bent position. Since the bent tip was unable to be returned to a neutral position, the snare from another endoscope inserted transorally was used to straighten it, which allowed the transnasal endoscope to be withdrawn with only mild injury to the gastric mucosa. Endoscopists should be aware of this complication and how to manage it.

A non-invasive navigation system for retargeting gastroscopic lesions

Biopsy is a traditional endoscopic surveillance of premalignant gastric lesions, and endoscopic tattooing is used for marking the biopsy's location. However, the tattooing has several disadvantages. For example, the procedure is an invasive operation and may not be durable due to the diffusion. Moreover, it is procedurally cumbersome with an associated risk of technical failure. In this study, a computer aided endoscopic navigation system (CAEN system) was developed for a non-invasive biopsy procedure. The CAEN system consists of a new, designed six degree of freedom (6-DOF) tracking endoscope device and a computer simulated work station. During the procedure, the endoscopist uses the tip of the tracking endoscope to touch the lesion. Then, the lesion's location is recorded in the work station, which then guides the endoscopist in retargeting the lesions in the follow-ups. The clinical experimental results demonstrate that the accuracy at the angularis is 5.2 ± 2.8 mm, at the antral lesser curvature is 7.2 ± 2.0 mm, at the antral greater curvature is 6.3 ± 3.1 mm, at the antral posterior wall is 8.2 ± 1.6 mm, and at the antral anterior wall is 7.9 ± 1.3 mm. The mean accuracy is 7.5 mm, and the P-value is 0.023, which is likely suitable for clinical practice. Furthermore, the proposed CAEN system requires less procedural time than the tattooing.

Novel treatment options for perforations of the upper gastrointestinal tract: endoscopic vacuum therapy and over-the-scope clips.

Endoscopic management of leakages and perforations of the upper gastrointestinal tract has gained great importance as it avoids the morbidity and mortality of surgical intervention. In the past years, covered self-expanding metal stents were the mainstay of endoscopic therapy. However, two new techniques are now available that enlarge the possibilities of defect closure: endoscopic vacuum therapy (EVT), and over-the-scope clip (OTSC). EVT is performed by mounting a polyurethane sponge on a gastric tube and placing it into the leakage. Continuous suction is applied via the tube resulting in effective drainage of the cavity and the induction of wound healing, comparable to the application of vacuum therapy in cutaneous wounds. The system is changed every 3-5 d. The overall success rate of EVT in the literature ranges from 84% to 100%, with a mean of 90%; only few complications have been reported. OTSCs are loaded on a transparent cap which is mounted on the tip of a standard endoscope. By bringing the edges of the perforation into the cap, by suction or by dedicated devices, such as anchor or twin grasper, the OTSC can be placed to close the perforation. For acute endoscopy associated perforations, the mean success rate is 90% (range: 70%-100%). For other types of perforations (postoperative, other chronic leaks and fistulas) success rates are somewhat lower (68%, and 59%, respectively). Only few complications have been reported. Although first reports are promising, further studies are needed to define the exact role of EVT and OTSC in treatment algorithms of upper gastrointestinal perforations.