Endoscopic Era Research Articles

Indications for the osteoplastic flap in the endoscopic era

To review and highlight recent articles on the osteoplastic flap over the last 12 months. Although advances in endoscopic sinus surgery have permitted rhinologists to manage a wide range of frontal sinus disease, recent retrospective studies have examined specific indications for the osteoplastic flap in this endoscopic era. Whether it will be inflammatory, anatomical or sinonasal tumor considerations, the osteoplastic flap remains an important surgical technique when endoscopic approaches are limited. The osteoplastic flap will remain an important tool in the armamentarium of the endoscopic surgeon to provide comprehensive management of the frontal sinus.

The Microscope in Transsphenoidal Surgery during the Endoscopic Era: A Step Backward to Run Forward

The Microscope in Transsphenoidal Surgery during the Endoscopic Era: A Step Backward to Run Forward

Management of Benign Ureteral Strictures in the Endoscopic Era

During the past decade, endoscopic management has emerged as the first-line treatment of benign ureteral strictures. We reviewed our experience with the management of benign ureteral strictures to determine the success rate of endoscopic surgery in a contemporary series and assessed the viability of surgical reimplantation in the modern era. We identified 75 patients with a diagnosis of ureteral stricture between 2000 and 2005 via electronic medical records search and excluded those with completely obliterated, external compressive, malignant, or ureteroenteric strictures, ureteropelvic junction obstruction, and those with follow-up less than 2 months. Thirty-four patients who were treated endoscopically (balloon dilation and/or holmium laser endoureterotomy) were identified. Mean stricture length in each patient was 1.6 +/- 1 cm (range 0.5-4 cm), and the mean number of procedures per patient was 1.7 +/- 0.8. Endoscopic success was achieved in 29 (85%), while 5 (15%) patients experienced endoscopic management failure and ultimately needed ureteral reimplantation. When comparing the endoscopically treated and reimplant groups, there was no significant difference in mean stricture length (1.38 +/- 1.13 vs 2 +/- 1.1 cm, P = 0.14), yet mean number of procedures performed (1.41 +/- 0.85 vs 3.6 +/- 1.5; P = 0.002) reached statistical significance. There were no clinical or radiographic signs of obstruction in 100% of patients who received endoscopic therapy only and 100% of patients who needed open surgical management at a mean follow-up of 25.2 +/- 19.3 and 7.7 +/- 3.2 months, respectively. Endoscopic surgery is clearly a successful primary treatment modality in the management of benign ureteral strictures with minimal morbidity. In the modern era of endoscopic surgery, however, ureteral reimplantation remains a viable option in treating the small subset of patients with benign ureteral strictures for whom endoscopic management fails.

Laparoscopic biliary tract injury prevention: zero tolerance, error free performance

Laparoscopic cholecystectomy is the gold standard procedure for initiation of a surgeon to the field of therapeutic endosurgery. It is an index operation for the training and evaluation of endoscopic surgeons. It is an index of endosurgeon’s social prestige and social perception of endoscopic surgery as well. Cholecystectomy, performed first by Carl Langenbuch in Europe and then by Justus Ohage in America, has been an index of innovations in surgical approaches as well. Piloted from the open era to the endoscopic era by Eric Muhe, laparoscopic cholecystectomy remains an index for the reporting of new endosurgical approaches, whether transgastric, transvaginal, or transumbilical. Irrespective of the approach, biliary tract injuries continue to haunt the endosurgeon even after eclipse of the learning (proficiency) curve [1]. Professional, social, and ethical costs associated with biliary tract injury have raised concerns across professional bodies such as the Society of American Gastrointestinal and Endoscopic Surgeons and the American Hepato-Pancreatic-Biliary Association, leading to introspection [1]. Patient-reported outcomes, the cornerstone of any new procedure [2], necessitated further analysis of possible contributory factors. Delineation of the proper biliary anatomy in all patients, use of Strasberg’s critical view of safety, and anatomic dissection have continued to be emphasized [1]. A reduction in the potential for cognitive error by ‘‘believing the seen and visible’’ and not trying to visualize a formed belief is important [3]. Concepts of ‘‘systems based approach’’ and ‘‘readbacks’’ have become mandatory to the practice of safe surgery [3, 4]. This error reduction model approach has proven itself in the airline, shipping and nuclear industries. The fact that injuries still are a problem is apparent by the advocacy of intraoperative cholangiography to avoid missing the injuries [1]. Biliary tract injuries remain an index of adverse outcomes in laparoscopic cholecystectomy. Technical considerations, including the necessity of energized dissection (ED) and the possible risk of instrument malfunction, have been accepted as necessary evils [1, 5]. Universal reliance on ED in laparoscopic surgery has blunted the distinction between dissection and hemostasis. This tantamounts to acceptance of collateral damage [6] despite the higher potential for thermal spread and heat absorbance in laparoscopic surgery even with the latest ED devices [7]. With evolution of laparoscopic skills, the distinction between anatomic dissection and non-ED hemostasis has been established. Now ED is not required in the index endoscopic surgery (i.e., laparoscopic cholecystectomy) [7]. However, delineation of biliary anatomy may be a concern in cases with severe and extensive inflammation. Hopes were raised by beautiful delineation of the biliary anatomy in difficult circumstances by autofluorescence of bile used in an animal model [8]. Three years of scientific pursuit since then, have demonstrated its application in human beings now [9]. Fluorescent intravenous cholangiography using easily available and safety proven indocyanine green is a definite B. B. Agarwal K. C. Mahajan Sir Ganga Ram Hospital, New Delhi 110060, India

Medical and surgical treatment of nasal polyps in endoscopic era

1952年，在骆兆平翻译的《耳鼻咽喉科学》一书中，对鼻息肉的治疗是这样介绍的：“息肉若已产生梗阻，宜割去。……局部麻醉可用蘸有麻药及肾上素的卷棉子放在息肉蒂部，然后用鼻圈套器之铉圈将息肉套住，徐徐向上移动至蒂部，轻轻将铉收紧，息肉就落下。”1978年，在《耳鼻咽喉科学》编写组编著的《耳鼻咽喉科学·鼻科学》中，也介绍了在局麻下，应用圈套器摘除鼻息肉的方法。但是，在这两本书中，都没有提到鼻息肉的药物治疗。20世纪80年代，鼻内镜手术从欧洲兴起，从此，我们进入了内镜时代。

Paranasal sinus mucoceles with skull-base and/or orbital erosion: Is the endoscopic approach sufficient?

The objective of this study was to review the management of paranasal sinus mucoceles with skull-base and/or orbital erosion in the endoscopic era. A retrospective data analysis. A chart review was performed on 57 patients treated from January 2001 to March 2007. The average age at the time of presentation was 50.6 years with a 1:1 male: female ratio. The most common site was the frontal sinus (54.4%), followed by frontoethmoid (29.8%) and sphenoid (8.8%). Areas of erosion included skull base (40.4%), orbit (50.9%), and both orbit and skull base (8.8%). Endoscopic drainage using image guidance was used in all 57 patients without complications. Fifty-six cases (98.2%) had a functionally patent mucocele opening with a median follow-up of 15 months. The endoscopic approach can be safely used for the management of mucoceles with skull-base and/or orbital erosion. Open adjunct approaches can be avoided in most cases.

Comprehensive Management of Failed Frontal Sinus Obliteration

Treatment of patients with failed frontal sinus (FS) obliteration (FSO) remains an important challenge in the endoscopic era. Advances in endoscopic techniques have facilitated the application of minimally invasive approaches for clinical scenarios that previously required open procedures. A retrospective chart review of patients presenting with failed FSO from January 1, 2001 to June 30, 2007 was performed. Seventeen patients (mean age, 52.8 years; 10 men and 7 women) presented at an average of 9.7 years from initial FSO. The most common primary presenting symptoms included headache (41.2%) and forehead swelling (23.5%). Seven patients had prior craniotomies and 10 patients had prior endoscopic sinus surgery. All patients underwent surgical exploration; revision procedures were required in 5 patients. Definitive procedures included endoscopic frontal sinusotomy (EFS; 10 patients), endoscopic frontal drill-out (3 patients), revision osteoplastic frontal sinusotomy with obliteration reversal (2 patients), and repeat FSO (2 patients). One patient required revision EFS twice. Initial intraoperative findings included mucocele (13 cases), bone wax (3 cases), fibrous tissue (2 cases), and polypoid mucosa (1 case). All patients had resolution or improvement of their primary presenting signs/symptoms. All FSO reversal patients achieved functional FS patency documented by endoscopy and/or CT scan with mean follow-up of 9.5 months (range, 1.5-30.8 months). Operative exploration should be considered in all patients with persistent or recurrent symptoms and/or signs of failed FSO. In most instances, repeat FSO can be avoided, and a minimally invasive endoscopic strategy can be used successfully.

Functional dyspepsia: the past, the present and the Rome III classification

The author summarizes the historical development of our knowledge about functional dyspepsia and overviews the so-called "road to Rome" process. Between 1988 and 2006, expert committees developed using the Delphi method subsequent classifications of functional gastrointestinal disorders (Rome I-III). The Rome III classification reassessed the diagnostic criteria for functional dyspepsia and distinguished new subgroups as the postprandial distress and epigastric pain syndrome. The rationale for the proposed new classification was based on the inadequacy of prior approaches such as the predominant symptom, the results of factor analyses in tertiary care and in the general population, clinical experience and new observations in the peer-reviewed literature. Epidemiologic data suggest that dyspeptic symptoms date back to the 1730s and their prevalence increased markedly subsequently, remaining the commonest diagnosis even in the endoscopic era. The current worldwide prevalence of functional dyspepsia is 7-45%, with large geographic variations. The role of Helicobacter pylori and Salmonella infection as etiologic factors is discussed. Amongst the pathophysiological features, the recent data on the role of phenotypic changes of acid secretion, alterations of fundic accommodation and antro-duodenal motility and gastric emptying, gastric hypersensitivity and hormonal disturbances are presented, but all these abnormalities are present only in a small part of the patients. The possible role of the polymorphism of alpha-adrenoceptor gene was also raised. The treatment of functional dyspepsia led to equivocal results and the high rate of placebo response makes difficult any interpretation. According to the recent meta-analyses, proton pump inhibitors and H 2 -histamine receptor blockers are superior to placebo. In spite of good results, cisapride was withdrawn in 2004. Eradication of Helicobacter pylori can induce sustained remission in a small but significant minority of patients. However, it might prevent further development of peptic ulcer and gastric carcinoma and from public health view, eradication of the infection must be performed by using a test-and-treat or test-and-scope strategy and the benefits and risks of this approach must be discussed with the patient. Each of the above treatments achieves transient symptomatic improvement only and follow-up of dyspeptic patients for 5-7 years showed the benign, but recurrent nature of the disease in 50% of the cases. The aim of the Rome III classification is the identification of pathophysiological changes associated with the new subgroups of functional dyspepsia which will permit their targeted pharmacologic treatment leading to better and cost-efficient results.

New Staging System for Sinonasal Inverted Papilloma in the Endoscopic Era

Advanced endoscopic techniques have emerged as the preferred treatment modality for sinonasal inverted papilloma (IP); however, a staging system that provides prognostic information has not yet been developed. This study aims to develop a clinically relevant staging system for IP managed with the endoscopic approach as the primary surgical modality. A systematic review of the English-language literature (1985-2006) and a single institution's experience. From the literature, 445 patients with IP treated by endoscopic resection were identified in 14 reports. Only patients with known IP sites and outcomes were included. Patients were categorized into three groups on the basis of recurrence rates (RR): group A (IP confined to the nasal cavity, ethmoid sinus, and medial maxillary sinus), 3.0% RR (n = 234); group B (IP with lateral maxillary sinus, sphenoid sinus, or frontal sinus involvement), 19.8% RR (n = 177); and group C (IP with extrasinus extension), 35.3% RR (n = 34). Pearson's chi-square test showed statistically significant differences for all pair-wise comparisons between groups (P < .05). Mean follow-up was 39.8 months. This new staging system for IP provides information about prognosis (as operationally defined by RR) for IP managed by advanced endoscopic techniques. In contrast, other staging systems for IP reflect surgeon's judgment rather than outcomes data. This new classification for IP provides important objective data for preoperative planning and patient counseling.

Colonoscopy: The Dominant and Preferred Colorectal Cancer Screening Strategy in the United States

Colonoscopy: The Dominant and Preferred Colorectal Cancer Screening Strategy in the United States

Comparison of Open versus Endoscopic Resection of Inverted Papilloma

Lateral rhinotomy with medial maxillectomy has served as the standard for surgical management of inverted papilloma (IP) in the pre-endoscopic era; since the late 1980s, endoscopic techniques have emerged as the minimally invasive alternative. The objective of this study was twofold: (1) to compare operative parameters, complications, and recurrence rates and (2) predictive factors for recurrence for open versus endoscopic cases of IP resection. Retrospective data analysis was performed on 68 patients with histopathologically confirmed IP treated at a tertiary care medical center from January 1983 to May 2005. Parameters for comparison included operative time (OT), estimated blood loss (EBL), length of hospital stay (HS), complications, and recurrence rate. Predictive factors for recurrence including open versus endoscopic cases, primary versus secondary IP, and tumor by Krouse stage were analyzed. The average age at time of presentation was 57.4 years with a male/female ratio of 2.2:1. Forty-nine patients underwent endoscopic resection, 13 patients underwent open resection, and 6 patients underwent limited open resection. Average OT and EBL were statistically similar for the three groups, whereas the average HS was statistically shorter (p = 0.002) for the endoscopic group. Biopsy-proven recurrence was noted in 11 (22%) endoscopic cases, 5 (39%) open cases, and 3 (50%) limited open cases. After reresection, all patients were free of disease. Mean follow-up was 16 months, 56 months, and 69 months for the endoscopic, open, and limited open groups, respectively. Analysis of predictive factors indicated that the surgical approach and primary versus secondary IP, regardless of approach, did not statistically impact recurrence rate. Chi-square analysis illustrated that patients with advanced-stage IP had a higher risk of recurrence (p = 0.002), regardless of surgical technique. In this series, endoscopic resection of IP was associated with shorter HS and equivalent EBL and OT compared with the open groups. The overall recurrence rate was lower in the endoscopic group with acceptable morbidity compared with the open and limited open groups. Thus, the endoscopic approach may serve as a superior alternative to the open approaches for successful extirpation of IP.

Frontal Sinus Obliteration

Osteoplastic frontal sinusotomy with obliteration was popularized by Goodale and Montgomery in the 1950s and has been considered the gold standard procedure for the surgical management of frontal sinus disease for many years. However, with advancements in functional endoscopic sinus surgery since the mid 1980s, the role of this operation has been questioned. Goodale and Montgomery in 1958 and Hardy and Montgomery in their subsequent review article describe the results of osteoplastic frontal sinusotomy with fat obliteration in 250 patients. Abnormalities included chronic frontal rhinosinusitis, frontal sinus mucocele, frontal sinus fractures, and complicated acute frontal rhinosinusitis. Patients were evaluated clinically using plain radiography and early-generation computed tomography. In the last 20 years numerous articles have been written about the endoscopic management of frontal sinus disease. Technology and instrumentation have advanced to the point that the frontal sinus can be accessed successfully and with minimal morbidity via transnasal endoscopic approaches. The purpose of this article is to examine the role of osteoplastic frontal sinusotomy with obliteration as the treatment of frontal sinus abnormality in an age of minimally invasive functional endoscopic sinus surgery. The pros and cons of this procedure will be presented, and reasonable indications will be outlined. A comprehensive description of anatomy is beyond the scope of this article. However, a brief review of frontal sinus anatomy is useful to understand the anatomic effects of inflammatory disease processes and the importance of appropriate choice of surgical approach to the frontal sinus. Unfortunately, the term nasofrontal duct continues to appear in the literature when in fact no such duct exists anatomically. Early anatomists recognized this long before the endoscopic era. The drainage from the frontal sinus is variable and at times difficult to ascertain, even with mutliplanar imaging, but most simplistically can be thought of in terms of the “frontal sinus outflow tract” (FSOT). The FSOT resembles an hourglass on sagittal view and includes the frontal sinus infundibulum, frontal sinus ostium, and frontal recess. Each of these areas can be affected by the varied pneumatization patterns of the ethmoid sinus, and each, if compromised, can lead to obstruction of outflow from the frontal sinus and secondary inflammatory disease. For example, an osteoma in the frontal sinus infundibulum may eventually obstruct outflow from the frontal sinus. The patient may develop a mucocele, mucopyocele, acute frontal rhinosinusitis with osteomyelitis (Pott puffy tumor), or chronic frontal rhinosinusitis. A large obstructing agger nasi cell or type I/II frontal cell can lead to the same scenarios by obstructing the frontal recess. In each of these clinical situations, however, the problem is not with the frontal sinus primarily but with obstruction of drainage within the FSOT.

Indications for the Caldwell-Luc approach in the endoscopic era

Caldwell and Luc described the Caldwell-Luc operation more than 100 years ago as the surgical treatment for maxillary sinus disease. During the last decades less radical interventions using endoscopic approach have mainly replaced the classical procedures done for chronic and recurrent maxillary sinusitis. Between 1991 and 2002, 62 patients had the Caldwell-Luc approach for different indications. Twenty (32%) patients had chronic sinusitis, 16 (26%) patients had inverted papilloma, 9 (15%) patients had suffered from nasal polyposis, 4 patients (6%) had dentigerous cyst, 4 (6%) patients had fungal ball, and 9 (15%) patients were operated for other indications. The use of this surgical approach is rational in cases of fungal disease and in endoscopic medial maxillectomy for treating inverted papilloma. In all other cases, the preferred approach should now be endoscopic.

X-Rays in the evaluation of adenoid hypertrophy: It's role in the endoscopic era.

To evaluate the reliability of X-rays in the diagnosis of adenoid hypertrophy and to validate this with flexible nasopharyngoscopy which is the existing gold standard. Lateral radiograph of the neck and a flexible nasopharyngeal endoscopy was done to evaluate adenoid enlargement in children aged 3-12 years who were included in a S week randomized double-blind placebo controlled study for the effect of beclomethasone in adenoid hypertrophy. These were graded independently by both the co-investigor and investigator X-ray and nasal endoscopy for reevaluation of adenoid size was done at the completion of the study. Variables of both the procedures were scored at the beginning and end of the study. The agreement between the two groups was assessed using weighted kappa statistic. There were 26 patients in the study, 17 of them had complete correlation between the X-ray and endoscopy findings. The agreement between these findings was statistically significant (p<01) with the weighted kappa 0.51. This study shows that lateral X-rays of the neck, besides being a noninvasive procedure, still remains a very reliable and valid diagnostic test in the evaluation of hypertrophied adenoids.

Angular dermoid cysts in the endoscopic era: retrospective analysis of aesthetic results using the direct, classic method.

The concept of the endoscopic approach was recently introduced for the removal of angular dermoid cysts. Therefore, it was considered necessary to evaluate the conventional direct incisional approach for angular dermoid cyst excision, with respect to long-term aesthetic results and complications. The need to change from the direct excisional technique to the endoscopic approach in hair-bearing areas was investigated. During a 25-year period, 95 children were surgically treated by a single surgeon (H.G.T.) for removal of angular dermoid cysts. Only 22 patients (23 percent) were available for reassessment. The follow-up periods after the excisional procedure were 1 to 12 years. Assessments were performed by a 15-member team of assessors, who scored the aesthetic results of the scars with comparative slides. In addition, a questionnaire was mailed to each family, to document the family members' perceptions of the aesthetic appearance of the scar. Twenty-eight families (29 percent) responded. The complications were determined through the medical records department. For 19 of 22 patients (86 percent), the scar was scored by 85 percent of the assessors as excellent or good. No assessor stated that a scar was unacceptable. In the family questionnaires, 26 of 28 families (93 percent) reported an excellent scar and two (7 percent) reported a fair scar. No family stated that the scar was unacceptable. The operative notes for the 95 patients revealed that only two cysts had ruptured during the surgical procedure (2 percent) and only one infection had occurred (1 percent). No other major complications were reported. It is concluded that the direct method for dermoid cyst excision is an excellent approach, with a low complication rate and a very high aesthetic success rate, when performed through a supra-eyebrow or infra-eyebrow incision.

Wireless capsule endoscopy

Wireless capsule endoscopy (WCE, also referred to in this issue as video capsule endoscopy and capsule endoscopy), using the M2A Capsule Endoscope, (Given Imaging Ltd., Yoqneam, Israel), closes the endoscopic gap between push enteroscopy and ileal intubation at colonoscopy and enables physicians to directly view the entire small intestine. WCE is performed most often in patients with obscure gastrointestinal bleeding. Other indications include chronic diarrhea, unexplained abdominal pain, weight loss, and iron deficiency anemia; it is also used to determine the extent of Crohn’s and celiac diseases. I welcomed the opportunity to edit this issue of the Gastrointestinal Endoscopy Clinics of North America. It was not only an exciting labor of love but also a unique opportunity to review the experiences of the esteemed authors with the M2A Capsule Endoscope. This is the initial comprehensive source of this new technology. WCE signals the beginning of a new endoscopic era that is filled with adventures as well as trepidation as we expand our knowledge base. Technological advances have resulted in improvement of our diagnostic armamentarium and, as expected, improved our diagnostic yield. New manifestations of old diseases as well as new diseases are being recognized; we are also seeing earlier stages of diseases. This raises the challenge of diagnosis and the therapeutic questions of which cases to treat and how to treat them. In addition, the natural history of these previously undescribed early lesions is unclear. We are sharpening our interpretative skills, and although the impulse is to run blindly ahead, we are straddled by caution.

Current state of ergonomics of operating rooms of Dutch hospitals in the endoscopic era

Laparoscopic procedures are mostly performed in operating rooms which have been designed for conventional surgery. The ergonomic layout of these operating rooms is not suited for endoscopic surgery. This study reports on the current state of ergonomics of Dutch operating rooms for laparoscopic surgery. Number of trolleys, presence of ceiling‐mounted booms, and number, positioning and size of monitors were recorded. The floor surface of operating rooms and lowest and highest positions of operating tables were documented. Positioning of the surgical team and monitors during laparoscopic surgery were assessed. Twenty‐nine hospitals participated in this study. The average number of trolleys per hospital was 2.4. The mean height of the center of the monitors was 163 cm. Average floor surface of operating rooms was 37.45 m2. Only one of the 29 hospitals had a ceiling‐mounted boom. The height of operating tables varied between 725 and 1215 mm. The floor space of current operating rooms is too small to allow use of space occupying technological systems. Less than 4% of operating rooms are equipped with permanent monitors mounted on booms. Operating tables cannot be lowered to a position which allows an ergonomic posture of the surgical team.

Comparison of endonasal endoscopic surgery and sublabial microsurgery for prolactinomas

BACKGROUND Endonasal endoscopy is a promising minimally invasive surgery for the treatment of pituitary adenomas; it is also a good alternative to traditional sublabial microsurgery. In this study, we compared endoscopic surgery with microsurgery and evaluated both for their safety and effectiveness. We chose prolactinomas for study because their hormone and symptomatic changes facilitated the comparison. METHODS During the past five years, 44 randomized prolactinoma patients underwent pituitary adenomectomy. Group A (22 patients) underwent endonasal endoscopic surgery for prolactinomas. Group B (22 patients) underwent sublabial transsphenoidal microsurgery for prolactinomas. RESULTS In groups A and B, patients with prolactinoma exhibited significantly reduced postoperative prolactin levels, return of menstrual cycle, and relief of galactorrhea, (Wilcoxon signed rank test) ( p < 0.001). But there were no statistically significant differences in the effectiveness of the procedures used in group A and group B. Visual improvement in cases of macroadenoma was satisfactory in both groups. Hospital stay in group A ranged from 2–5 days, with a mean of 3.2 days. Hospital stay in group B ranged from 4–8 days with a mean of 5.3 days. The hospital stay for group A patients was shorter (2.1 days) than for group B (Student t test, p < 0.05). The operative time was shorter by 1 hour in Group A (mean: 1.7 hours vs. mean: 2.7 hours, p < 0.05). There were fewer complications in group A (4.5%) than in group B (27%), p < 0.05. CONCLUSIONS The endoscopic era of pituitary surgery may be coming. Endonasal endoscopic surgery may have the same effectiveness as traditional microsurgery. However, endoscopic surgery may shorten hospital stay and operative time, and lead to fewer complications. It seems to be a good minimally invasive surgical technique for prolactinomas.

The Caldwell-Luc Procedure — is it Still Indicated in this Endoscopic Sinus Surgery Era?

The Caldwell-Luc Procedure — is it Still Indicated in this Endoscopic Sinus Surgery Era?