Endoscopic Laser Ablation Research Articles

Laser ablation of posterior nasal nerves for rhinitis.

Posterior nasal nerve (PNN) surgery, Radiofrequency (RF), and cryoablation have been described as alternative treatments for allergic and vasomotor rhinitis. We hypothesize that endoscopic (diode) laser ablation (ELA) is effective and less invasive than previously described methods. An IRB approved prospective study was performed. Thirty-two patients with chronic rhinitis and nasal congestion resistant to medical management were recruited. Total Nasal Symptom Score (TNSS) measurements were used to assess symptom severity and treatment outcomes. ELA was performed bilaterally in the clinic with a 940nm diode laser with CW 5W output, under topical/local anesthesia in 21 patients, while the remaining 11 were treated under sedation in the operating room. The 400-micron uninitiated diode laser fiber tip with a malleable protective shaft was specially designed for PNN ablation. The fiber was pre-shaped according to the intranasal anatomy and endoscopically advanced toward the posterior middle meatus. Patients were followed up for the first 90days after treatment. ELA was successfully completed in 97% of patients. No crusting, epistaxis, or other complications were observed. One patient could not be treated in the office due to limited endoscopic access. TNSS was reduced significantly after30 and 90days (mean±SD: 6.0±0.7 prior to ablation, 2.3±0.4 at 90days, p<.001). Rhinitis and congestion scores decreased at 30 and 90days after treatment compared to the baseline (p<.001). ELA of the PNN region is safe and well tolerated both in the office and ambulatory settings. Symptom scores were significantly decreased after 30 and 90days. This new minimally invasive method appears to be a promising treatment method.

Conservative Management of Upper Tract Urothelial Carcinoma with Endoscopic Thulium Laser Ablation

Purpose: The gold standard treatment for upper tract urothelial carcinoma (UTUC) is radical nephroureterectomy. The combination of ureterorenoscopy and laser ablation has recently become more accepted. This study aims at investigating the risk factors of tumor recurrence associated with the thulium laser ablation of UTUC and reporting its clinical outcomes with subgroup analyses. Materials and Methods: Patients who underwent endoscopic thulium laser ablation of UTUC as the primary treatment from June 2012 to November 2018 were reviewed retrospectively. Sixty-eight patients were enrolled, of whom 34 had complete data for analysis after applying the exclusion criteria. Bivariate analysis was performed to compare patients with and without recurrence. Multivariable Cox regression models were applied. Kaplan–Meier survival estimates were presented, and three tumor characteristics were used for subgroup analyses. Results: Fifteen patients (44%) had local tumor recurrence. Four patients (12%) had cancer-specific death. In bivariate analysis, statistical significance was noted for age, tumor grade, and tumor size (P = 0.018, 0.047, and 0.014, respectively). In multivariate analysis, statistical significance was noted for age and tumor size (P = 0.017 and 0.042, respectively). In the Kaplan–Meier estimates for subgroup analysis, statistical significance was noted only in the tumor size and tumor grade group (P = 0.0275). The study limitations included the retrospective design and small sample size. Conclusion: Tumor size and tumor grade are influential recurrence factors. The tumor stage did not show statistical significance in recurrence analysis. In subgroup analyses, tumor size was more influential than tumor grade with respect to the prognosis of local recurrence.

Outcome of twin pregnancy with two live fetuses at 11-13 weeks' gestation.

To report and compare pregnancy outcome in dichorionic (DC), monochorionic diamniotic (MCDA) and monochorionic monoamniotic (MCMA) twin pregnancies with two live fetuses at 11-13 weeks' gestation and to examine the impact of endoscopic laser surgery for severe twin-twin transfusion syndrome (TTTS) and/or selective fetal growth restriction (sFGR) on the outcome of MCDA twins. This was a retrospective analysis of prospectively collected data on twin pregnancies undergoing routine ultrasound examination at 11-13 weeks' gestation between 2002 and 2019. In pregnancies with no major abnormalities, we compared overall survival, fetal loss at < 24 weeks' gestation, perinatal death at ≥ 24 weeks, delivery at < 37 and < 32 weeks, and birth weight < 5th percentile between DC, MCDA and MCMA twins. The study population of 6225 twin pregnancies with two live fetuses at 11-13 weeks' gestation with no major abnormalities included 4896 (78.7%) DC, 1274 (20.5%) MCDA and 55 (0.9%) MCMA twins. In DC twins, the rate of loss at < 24 weeks' gestation in all fetuses was 2.3%; this rate was higher in MCDA twins (7.7%; relative risk (RR), 3.258; 95% CI, 2.706-3.923) and more so in MCMA twins (21.8%; RR, 9.289; 95% CI, 6.377-13.530). In DC twins, the rate of perinatal death at ≥ 24 weeks in all twins that were alive at 24 weeks was 1.0%; this rate was higher in MCDA twins (2.5%; RR, 2.456; 95% CI, 1.779-3.389) and more so in MCMA twins (9.3%; RR, 9.130; 95% CI, 4.584-18.184). In DC twins, the rate of preterm birth at < 37 weeks' gestation in pregnancies with at least one liveborn twin was 48.6%; this rate was higher in MCDA twins (88.5%; RR, 1.824; 95% CI, 1.760-1.890) and more so in MCMA twins (100%; RR, 2.060; 95% CI, 2.000-2.121). In DC twins, the rate of preterm birth at < 32 weeks was 7.4%; this rate was higher in MCDA twins (14.2%; RR, 1.920; 95% CI, 1.616-2.281) and more so in MCMA twins (26.8%; RR, 3.637; 95% CI, 2.172-6.089). In DC twin pregnancies with at least one liveborn twin, the rate of a small-for-gestational-age neonate among all liveborn twins was 31.2% and in MCDA twins this rate was higher (37.8%; RR, 1.209; 95% CI, 1.138-1.284); in MCMA twins, the rate was not significantly different (33.3%; RR, 1.067; 95% CI, 0.783-1.455). Kaplan-Meier analysis showed a significant difference in survival in MCDA and MCMA twins, compared to DC twins, for both the interval of 12 to < 24 weeks' gestation (log-rank test, P < 0.0001 for both) and that of ≥ 24 to 38 weeks (log-rank test, P < 0.0001 for both). Endoscopic laser ablation of intertwin communicating placental vessels was carried out in 127 (10.0%) MCDA twin pregnancies for TTTS and/or sFGR and, in 111 of these, surgery was performed at < 24 weeks; both fetuses survived in 62 (55.9%) cases, one fetus survived in 25 (22.5%) cases and there were no survivors in 24 (21.6%) cases. On the extreme assumption that, had laser surgery not been carried out in these cases, all fetuses would have died, the total fetal loss rate at < 24 weeks' gestation in MCDA twins would have been 13.5%. The rates of fetal loss at < 24 weeks' gestation, perinatal death at ≥ 24 weeks and preterm birth are higher in MCDA and more so in MCMA twins than in DC twins. In MCDA twins, the rate of fetal loss may have been reduced by endoscopic laser surgery in those that developed early TTTS and/or sFGR. These data would be useful in counseling parents as to the likely outcome of their pregnancy and in defining strategies for surveillance and interventions in the management of the different types of twin pregnancy. Copyright © 2019 ISUOG. Published by John Wiley & Sons Ltd.

2855 To Determine the Clinical Profile of Patients With Esophageal Cancers

INTRODUCTION: Cancer of the esophagus ranks twelfth among the major cancers in the number of new cases diagnosed and seventh in the number of cancer death. Its high mortality rate makes it a major concern. Numerous approaches have been described for resection of esophagus. Combined modality therapy including radiotherapy and chemotherapy has raised hope for improvement of survival with promising preliminary data.Finally, for palliation of dysphagia in those patients with advanced disease,various newer therapeutic options have been introduced like endoscopic stenting and laser ablation. Thus this study elaborates view of current literature pertaining to the disease and concludes by comparing the results of the present study with the former national and international scenario. METHODS: The one year cross sectional study was conducted at tertiary care hospital. All the patients either gender who were diagnosed as esophageal cancer were included in the study. These patients were allowed to undergo necessary investigations and treatment while the subjects excluded from study were patients who were lost to follow up and the non cooperative patients who not interested to participate in the study while the frequency / percentages (%) and means ± SD computed for study variables. RESULTS: During one year study period total fifty patients with esophageal carcinoma were explored and studied. the frequency for male and female population was 32 (64%) and 18 (36%) with mean ± sd for age of male and female individuals was 54.47 ± 5.87 and 51.75 ± 7.72 respectively. Gender male 32 (64%) and female 18 (36%), type of lesion exophytic 05 (10%), infiltrative 10 (20%), ulcerative 35 (70%), location upper third 05 (10%), middle third 30 (60%) and lower third 15 (30%). Histological type squamous cell carcinoma 36 (72%) and adenocarcinoma 14 (28%). CONCLUSION: Carcinoma esophagus is one of the most common gastrointestinal tract malignancies. It was the second most common gastrointestinal cancer in our hospital, second only to carcinoma stomach, constituting 6.2% of all malignancies. Squamous cell carcinomas accounts for the vast majority of cancers arising in high- incidence areas throughout the world.Seventy two percent of our patients had squamous cell cancer while twenty eight percent had adenocarcinoma. This reflects the difference in epidemiology and the fact that adenocarcinoma is not rising in incidence in less well- developed nations like ours compared to the West.

Thulium-Holmium:YAG Duo Laser in Conservative Upper Tract Urothelial Cancer Treatment: 13 Years Experience from a Tertiary National Referral Center.

Introduction and Objectives: To evaluate ablative safety and efficacy of thulium-holmium:YAG (TL-HL:YAG) duo laser in renal conserving retrograde intrarenal surgery (RC-RIRS) in upper tract urothelial carcinoma (UTUC). Materials and Methods: A retrospective study was performed on 178 consecutive patients referred for consideration of RC-RIRS UTUC-eLA (endoscopic laser ablation) in a tertiary center (January 2005 to December 2018). Key data were recorded using a standardized study proforma. Results: After endodiagnostic procedure, 42 declined rigorous endosurveillance protocol and went elsewhere for alternative treatment, leaving 136 patients, of whom 35 patients dropped out (25.7%) after undergoing primary radical nephroureterectomy (RNU) (unsuitable for renal preservation). This was left with 101 candidates who continued UTUC conservative management (intention-to-treat [ITT] population). Mean follow-up (FU) for these 101 patients was 28.7 months. At last FU (range 3-144 months), 70 patients (69.3%) were recurrence free, 22 (21.8%) had endoscopically treated recurrences, and a further 9 (8.9%) had undergone RNU. In the ITT population, kidney-preserving rate was 91%, whereas in imperative indications, it was 87.5%. Clavien-Dindo grade I complications only (self-limiting hematuria) were reported in 10%. Conclusions: Over a 13-year period, RC-RIRS UTUC treatment with the TL-HL:YAG duo laser was safe and oncologically noninferior to alternative combination laser energy technologies used for this indication.

1131-P: Endoscopic Duodenal Submucosal Laser Ablation for the Treatment of Type 2 Diabetes Mellitus: Results of First-in-Human Pilot Study

The duodenum has recently emerged as a key regulator in glucose metabolism via modulation of a complex network of neural and hormonal signals in response to ingested food. DiaGone™ is an endoscopic device which utilizes precisely controlled laser technology to target the duodenal submucosal neural plexi with the aim of improving glucose control by modulating the gastrointestinal neurohumoral axis. Nine subjects (5 males) with obesity (BMI 34.0 ± 4.6 kg/m2) and type 2 diabetes mellitus (T2DM) insufficiently controlled on metformin were included in this first-in-human trial in order to assess the efficacy and safety of DiaGone™. Subjects were instructed to continue with regular diet 24h after the procedure and metformin dose was not changed during the study period. Biochemical and anthropometric parameters were assessed at baseline and 3 and 6 months after the procedure and continuous glucose monitoring (CGM) and a standard liquid meal test were performed at baseline and 3 months after the procedure. DiaGone™ significantly decreased HbA1C from 78.3 ± 13.3 mmol/mol at baseline to 64.9 ± 6.4 mmol/mol and 64.8 ± 7.1 mmol/mol at 3 and 6 months, respectively (p&amp;lt;0.01). Similarly, a decrease in fasting glucose levels was noted (12.4 ± 3.5 vs. 9.5 ± 2.0 vs. 9.7 ± 2.7 mmol/l, p&amp;lt;0.01) with no significant changes in fasting insulin levels. Glucose AUC during the 150 min meal test 3 months after the procedure showed a reduction of 20% from baseline (43,435 vs. 34,096, p&amp;lt;0.01). No significant changes were observed in AUC for insulin. No adverse events related to the procedure or significant changes in weight were reported throughout the 6-month period. In conclusion, these pilot results suggest that endoscopic duodenal submucosal laser ablation using the DiaGone™ device is associated with improvements in both baseline and postprandial glycemia as well as HbA1C with no significant changes in insulin levels or body weight while having a favorable safety and tolerability profile. Disclosure M. Mraz: None. I. Marcovitch: Employee; Self; Digma Medical. I. Lankova: None. H. Kratochvilova: None. A. Cinkajzlova: None. M. Benes: None. J. Korner: Board Member; Self; Digma Medical. Stock/Shareholder; Self; Digma Medical. Z. Vlasakova: None. J. Spicak: None. T. Pelikanova: None. M. Haluzik: None. Funding MH CZ - DRO; Institute for Clinical and Experimental Medicine (IN00023001); RVO (VFN64165)

Therapeutic effects of endoscopic ultrasound-guided holmium laser ablation for pancreatic primary implantation carcinoma in nude mice

Objective To explore the effectiveness of endoscopic ultrasound(EUS)-guided holmium laser ablation for primary pancreatic implantation tumor in nude mice. Methods Pancreatic cancer cell line SW1990 were implanted into 20 4-6-week-old male balb/c nude mice to establish primary pancreatic implantation tumor in situ models. Then the nude mice were randomly divided into two groups, the treatment group(n=10) and the control group(n=10). The treatment group underwent EUS-guided holmium laser ablation in the pancreatic tumor. And no interventions were given to the control group. The volume of tumors of the two groups were measured under EUS at time points of 7 d, 14 d and 28 d after ablation. The activities, appetites and psychosis of all nude mice were evaluated in the meantime. At 28 d after ablation, lesions of pancreas were dissected and sliced for H&E staining. Results There were no complications in the treatment group, and all nude mice could tolerate the procedure. The mental state, activities and appetites of nude mice in the experimental group were better than those in the control group. Tumors of the control group enlarged. There was significant difference in the tumor size between the two groups at 28 d after ablation. HE staining showed coagulation necrosis in the ablation area. Conclusion EUS-guided holmium laser, producing coagulative necrosis in the ablation area, is effective for primary pancreatic implantation carcinoma in nude mice for about 28 days. Key words: Ultrasonography; Laser therapy, Holmium; Disease modelsl; Rats, nude

Feasibility of single position endoscopic laser balloon ablation for atrial fibrillation: The open 8 approach.

Ablation without shaft repositioning may make the endoscopic laser ablation system (EAS) more like a single shot approach. We tested the feasibility of wide circumferential ablation (WCA; no carina ablation and no shaft repositioning) in an "open 8" pattern for pulmonary vein isolation (PVI). Forty-eight patients (n = 48, age 64.6 ± 12 years) with paroxysmal and persistent atrial fibrillation (AF) were referred to our center for PVI with the EAS. WCA for the lateral and septal pulmonary veins was attempted in all patients. If not feasible, individual full circular isolation of each pulmonary vein (iPVI) was performed. Additional lesions were applied if acute complete electrical isolation was not achieved on the first encirclement. Any documented episode of AF after a 1-month blanking period was registered as a recurrence. Bilateral WCA was feasible in 21 out of 48 patients (43.8%). Additional lesions for complete electrical isolation after the first-pass ablation were less in WCA compared with iPVI (P = 0.02). WCA was accomplished faster, with less applied energy at both lateral (P < 0.01) and septal side (P < 0.01). The mean follow-up of the patient population was 232 ± 150 days. AF recurrence occurred later in patients treated with WCA (315 ± 124 vs 110 ± 88 days, P = 0.008). WCA with the EAS is safe, at least moderately feasible and highly effective, if achieved. Compared with iPVI it may be less time consuming, results in less energy application, and suppresses AF more effectively.

Treatment of congenital distal ureteral orifice stenosis by endoscopic laser ablation in dogs: 16 cases (2010-2014).

OBJECTIVE To determine characteristics of and outcomes for dogs with congenital distal ureteral orifice stenosis (CDUOS) treated by cystoscopic-guided laser ablation (CLA). DESIGN Retrospective case series. ANIMALS 16 client-owned dogs with CDUOS treated by CLA at 2 veterinary hospitals between 2010 and 2014. PROCEDURES Medical records were reviewed and data collected regarding clinical findings, imaging results, surgery characteristics, treatment, and outcome. Follow-up information was collected from dog owners and referring veterinarians via standardized interview. RESULTS Dogs included 10 males and 6 females; median age was 11.5 months (range, 4 to 112 months). Labrador Retriever (n = 6; 3 males) was the most common breed. Intramural ectopic ureteral openings were identified at the site of stenosis in 15 dogs (18/20 stenotic ureteral openings). Treatment with CLA to enlarge and relocate the stenotic opening was successful in all dogs. Median duration of anesthesia and hospitalization was 105 minutes and 24 hours, respectively. No complications were noted. Fourteen dogs remained alive (2 lost to follow-up) during a median follow-up period of 14.5 months. Owners of 11 of 13 dogs reported improvement in their dog's quality of life after CLA. The treated ureteral orifice remained patent in the 2 dogs that were reimaged. CONCLUSIONS AND CLINICAL RELEVANCE CDUOS should be considered as a differential diagnosis for dogs with idiopathic distal ureteral obstruction, particularly young male Labrador Retrievers, and was most often associated with an intramural ectopic ureter in this study. Treatment with CLA was safe and effective for opening the ureteral orifice.

Endoscopic laser ablation of ureteral endometriosis

A 37-year-old female with a known history of endometriosis presented with progressive dysmenorrhea and dyspareunia, and complaints of hematuria. After cystoscopy and bilateral retrograde pyelography was performed, distal stenosis in the right ureter without ureteral obstruction and renal impairment was diagnosed. Abdominal hysterectomy and excision of peritoneal endometriotic lesions on the surface of the right ureter and bladder wall was done preserving the ovaries. The intrinsic endometriotic lesion in the right ureter was detected ureteroscopically and histologically and treated successfully by holmium laser ablation avoiding ureteral resection and re-implantation.

Ex vivo feasibility study of endoscopic intraductal laser ablation of the breast.

To determine the feasibility and safety of breast endoscopic thulium laser ablation for treatment of intraductal neoplasia. Ductoscopy is a minimally invasive endoscopic approach of the milk ducts of the breast via the nipple. Besides diagnosis in women with pathologic nipple discharge (PND), it allows non-invasive removal of intraductal lesions with a stalk like papillomas. Removal, however, is often incomplete and flat lesions cannot be targeted. We therefore developed laser ductoscopy. Dosimetry of laser ductoscopy was assessed in thirteen mastectomy specimens, applying power settings of 1-5 W with 100-1000 ms pulsed exposure to a 375-μm outer diameter thulium fiber laser. Subsequently histology was obtained from the breast tissue that was treated with the Thulium laser. Endoscopic view was maintained during ductoscopic laser ablation at 1-3 W. Increasing power to 4-5 W caused impaired vision due to shrinkage of the main duct around the ductoscope tip. Histology revealed localized ablation of the duct wall. We show for the first time that laser ductoscopy is technically feasible. The Thulium laser enables a superficial intraductal ablation and is a useful tool for intraductal interventions. An in vivo prospective study is needed to further demonstrate its potential. Lasers Surg. Med. 50:137-142, 2018. © 2017 Wiley Periodicals, Inc.

Effects of Nd:YAG laser for the controlled and localized treatment of early gastrointestinal tumors: Preliminary in vivo study.

Endoscopic submucosal dissection (ESD) is a minimally invasive technique allowing for the removal of early gastrointestinal (GI) tumors, widely considered as a valid alternative to conventional surgery. However, ESD is technically demanding, and potentially severe complications, such as bleeding and perforation, may occur. Energy-based techniques (e.g., radiofrequency ablation) might offer a potential alternative to ESD. However, their use mandates the ability to predict the damage induced and to identify a "signature" of the complete ablation, without the need for a physical specimen. Ideally, an energy-based procedure should be tunable in order to limit the ablation to the superficial layers, namely mucosa (M) and submucosa (SM), without injuring the muscularis propria (MP), thereby minimizing GI perforation. This experimental study aims to investigate thermal damage induced by Nd:YAG laser on the gastric wall, at different laser settings such as power (P) and time (t). Laser ablation was performed on the stomach wall of 6 Wistar rats. Two powers (2.5W and 1.0W) and 3 exposure times (12s, 6s and 2s) were tested, for a total of 30 ablations. Histological analysis allowed to assess thermal damage, in terms of damage depth (DD) and identification of involved layers. The ratio (R) between DD and the total depth (TD) of target layers (M+SM) was used as an index to evaluate the effectiveness of laser settings. At P=2.5W, MP was damaged (R>1) in the majority of cases (11/15). At P=1.0W, MP was preserved in all tests (R<;1), and rarely (4/15) did the damage reach the whole SM (R=1). Histopathological analysis evidenced that tissue damage was strongly related to the variable tissue thickness. These preliminary results seem to support the fact that endoscopic tunable laser ablation is feasible with a consistent damage/power correlation. Further tests are required to optimize the settings for applications on early GI tumors.

Can ultrasound be helpful in selecting optimal management methods for pregnancies complicated by placental non-trophpblastic tumors?

Placental chorioangioma is the most common subtype of non-trophoblastic placental tumors. Other subtypes are very rare and usually associated with an uneventful course of pregnancy. Most chorioangiomas are small and of no clinical significance. Giant chorioangiomas may be associated with serious fetal and maternal complications. So far, no established ultrasound guidelines are available for the management of placental non-trophoblastic tumors. This may be attributed to the rarity of the disease entity and its different clinical features and complications. In this article, the role of ultrasound findings such as the tumor’s size, vascularity, feeding vessels, amniotic fluid and location of the placenta in the diagnosis, treatment and follow up of these tumors is presented relying on up-todate literature review. Conservative management with serial ultrasound examinations can be an adequate method for monitoring small uncomplicated tumors. Ultrasound-guided procedures such as amnioreduction and cordocentesis can be used for amelioration of complications. Chorioangioma-specific treatment is reserved for complicated cases in the second trimester of pregnancy when prematurity is a matter of concern. Endoscopic laser ablation is indicated when the feeding vessel is superficial and small. Interstitial laser ablation is helpful when the placenta is located in the anterior uterine wall. Ligation of the feeding vessels is preferred when they are large. Alcohol injection should be performed away from the vasculature to prevent toxicity. Microcoils should be inserted as near as possible to the tumor to prevent collateral formation. Ultrasound is also a method of choice for monitoring the effectiveness of these procedures.

An unusual clinical course of congenital subglottic stenosis – case report

Aim: To report an unusual clinical course of an infant with congenital laryngeal stridor. Indications for endoscopic examination of airways in such cases have also been discussed. Case report: A full-term male newborn was admitted to the Department of Paediatrics because of the symptoms of acute scrotum as well as because of breathing difficulties and severe hypoxemia. Soon after surgery the child was extubated but breathing difficulties persisted. A loud inspiratory stridor together with rapid respiratory deterioration occurred. The infant was intubated and underwent mechanical ventilation again. In the following period several trials of extubation were repeatedly unsuccessful despite favourable weaning parameters. Just few hours after each trial of extubation symptoms of acute laryngotracheobronchitis were apparent. Because of extubation failure, tube dependency and persistent atypical symptoms of croup unresponsive to standard pharmacotherapy, endoscopic assessment was performed at the age of one month. Concentric central membranous subglottic stenosis was visualized. While preparing for the endoscopic laser ablation treatment, stridor was getting less pronounced. Two weeks later patient underwent endoscopy again and significant regression of subglottic membrane narrowing was documented. Planned laser intervention was canceled. At the age of four months stridor disappeared. Conclusion: Laryngomalacia is the most common cause of congenital laryngeal stridor and endoscopic evaluation is usually not indicated in such cases. However, there are other causes of congenital stridor which are not so common, including congenital subglotttic stenosis. In this case an unusual spontaneous regression of congenital membranous subglottic stenosis was reported.

Endoscopic laser ablation of clival chordoma with magnetic resonance-guided laser induced thermal therapy

Abstract Background Chordomas are rare malignant tumors that are difficult to treat and have high recurrence rates despite aggressive therapy. Objectives We present the first case of a patient with a clival chordoma in which complete tumor ablation was achieved using Magnetic Resonance guided Laser Induced Thermal Therapy (LITT) delivered via an endoscopic endonasal approach. We analyzed the safety and feasibility of this approach and quantified the response of this pathology to thermal energy. This novel technique is intended to provide chordoma patients with an alternative to surgery and radiotherapy. Methods A 54 year-old female with a newly diagnosed clival chordoma elected MRI- guided LITT. She underwent placement of the laser catheter into the chordoma via an endoscopic endonasal approach. With real-time MR thermometry monitoring, laser-generated thermal energy was delivered to the tumor. We defined several parameters to quantify the thermal ablation response: the thermal damage ratio and the thermal ablation constant. Results Post procedure contrast-enhanced MRI demonstrated a complete thermal ablation of the mass. The patient tolerated the procedure well and is being followed with serial imaging. The tumor continues to regress beyond 4 months. Additionally, chordoma cells seem to be sensitive to LITT, as indicated by a complete ablation in less than 60 s. Conclusion The endoscopic endonasal approach to MRI-guided laser ablation is both technically feasible and safe. As a result, this therapy may be a useful alternative in hard-to-reach chordomas, or in recurrent cases that have failed other conventional treatment modalities.

Mucosa-sparing, KTP Laser Coagulation of Submucosal Telangiectatic Vessels in Patients With Radiation-induced Cystitis: A Novel Approach

This study aimed evaluate the safety and feasibility of endoscopic potassium titanyl phosphate (KTP) laser application in the management of patients with radiation-induced hemorrhagic cystitis (RHC). We retrospectively reviewed the records of 20 patients with RHC who underwent endoscopic KTP laser ablation of telangiectatic bladder vessels between October 2005 and January 2013. After initial cystoscopy, KTP laser was used to ablate the submucosal vasculature while preserving the overlying mucosa. The surgical outcome was evaluated by duration of hematuria-free interval, number of episodes of hematuria, and number of required medical and/or surgical interventions after initial treatment. Overall, 20 patients underwent 26 sessions of KTP laser ablation of bladder vessels. The procedure was able to stop bleeding 92% of the time and the average hematuria-free interval after ablation was 11.8 months, with a range of 1-37 months. In 13 patients (65%) hematuria resolved after 1 session of KTP laser treatment, whereas 5 patients (25%) required multiple sessions. Two patients (10%) with severe hematuria continued to have bleeding after laser treatment, which necessitated proximal diversion of urine with percutaneous nephrostomy tubes to control bleeding. This study suggests that KTP laser, with its unique photoselectivity property, is a safe, effective, and durable treatment with minimal side effects for ablation of submucosal bladder vessels in patients with RHC.

Maternal and fetal safety of fluid-restrictive general anesthesia for endoscopic fetal surgery in monochorionic twin gestations

Study ObjectiveTo review our experience with general anesthesia in endoscopic fetal surgery for twin-to-twin transfusion syndrome (TTTS), and to compare fetomaternal outcome before and after protocol implementation. DesignRetrospective impact study. SettingUniversity-affiliated medical center. MeasurementsData from 85 consecutive patients who underwent endoscopic laser ablation of placenta vessels for severe TTTS were studied. Outcomes were compared in patients before (2000–2007) and after (2008–2012) a change to strict intraoperative intravenous (IV) fluid and liberal vasopressor management. Perioperative parameters (IV fluid administration, vasopressor use, maternal hemoglobin [Hb] concentration); maternal complication rate (respiratory, hemorrhagic); pregnancy outcome; and fetal and neonatal survival were recorded. Main ResultsPatients in the early group (2000–2007; n = 55) received 1634 ± 949 mL of crystalloid fluid intraoperatively, compared with 485 ± 238 mL (P < 0.001; Student’s t test) given to the late group (2008–2012; n = 30). Maternal pulmonary edema and any respiratory distress were seen in 5.5% and 12.7% of patients in the early group, respectively, and in none of the late group patients (P < 0.05; Chi-square analysis). ConclusionsA significant risk of maternal respiratory complications exists after general anesthesia for endoscopic fetal surgery. Judicious fluid management significantly decreases this risk.

Flexible Carbon Dioxide Laser-Assisted Endoscopic Marsupialization and Ablation of a Laryngeal Saccular Cyst in a Neonate

To report the occurrence of a neonate with a lateral saccular cyst that was successfully managed by flexible, carbon dioxide laser-assisted endoscopic marsupialization and ablation. A full-term, 14-day-old girl presented to the clinic for progressively worsening stridor since birth. On fiber optic laryngoscopy, she was found to have a large, right saccular cyst obstructing the laryngeal inlet. The patient was admitted and underwent microlaryngeal endoscopic CO2 laser marsupialization and ablation of the saccular cyst. She was observed overnight and was discharged without complication the next day. At that time, stridor was no longer present and she remained symptom free at both her 2-week and 3-month follow-up. The congenital saccular cyst is a rare, abnormal dilation of the laryngeal saccule that is known to be a cause of airway obstruction. A variety of contrasting treatment strategies for laryngeal saccular cysts in children have been reported in the literature. Determining the definitive treatment modality thus remains a challenge that is compounded further by the rarity of the lesion. We introduce a new surgical technique that employs a 30-degree angled telescope with a flexible laser fiber system that provides excellent visualization of saccular cysts, in particular, lateral lesions that are less visible using line-of-sight technology.

Contralateral renal cell carcinoma ureteric metastases can arise on tyrosine kinase adjuvant therapy and be effectively treated by endoscopic laser excision and ablation.

Renal cell carcinoma (RCC) uncommonly metastasizes to the ureter and rarely to the contralateral ureter. We describe the presentation of 2 successive contralateral ureteric metastases from RCC in our institution. The first represents the only reported metachronous ureteric deposit on adjuvant sorafenib after laparoscopic radical nephrectomy for RCC. The other presented with a synchronous lesion after radiological work-up. Both lesions were treated with endoscopic excision and laser ablation with preservation of the renal unit and no local recurrence. We report these cases and discuss the literature.

Tracheal Metastasis From Melanoma Detected With 18F-FDG PET/CT

A 58-year-old man with a history of stage IIIB melanoma of the right arm initially treated 4 years prior presented with new onset cough and hemoptysis. Bronchial washings were positive for melanoma. The PET/CT study showed a hypermetabolic nodule in the posterior mid-trachea. These findings indicate metastatic melanoma to the trachea. No other metastatic foci were evident. This allowed for endoscopic laser ablation of the metastatic focus.