Endoscopic Surgery Research Articles

The Role of Spinal Anaesthesia with and without Intrathecal Opioid Coadministration in Improving Oncologic Outcomes after Endoscopic Transurethral Cancer Surgery

Spinal anaesthesia (SA) (compared to general) improves postoperative oncologic outcomes in transurethral resection of the bladder tumour (TURBT) for non-muscle invasive bladder cancer (NMIBC). Intrathecal coadministration of opioids does not affect NK cells function, and improves postoperative opioid sparing as well. There are no comparative data on oncologic outcomes of SA with/without intrathecal opioid in TURBT, which is the aim of our study. Seventy ASA I-III patients with NMIBC, aged ≥ 43 (range 43-90), who underwent one or more TURBT under SA were examined retrospectively. Of them, 36 received levobupivacaine 15 mg (L group) and 34 levobupivacaine 12.5 mg + fentanyl 12.5 mcg (LF group) intrathecally. All patients received scheduled Paracetamol 1.0 g/6 h, optional NSAIDs and as needed Tramadol as well. Data regarding demographics, ASA and CCI scores, analgesics consumption, urethrotomies, tumour-related factors (size, number, grade, stage, prior disease-recurrence, adjuvant therapy), tumour risk (low, intermediate, high), oncologic outcomes (recurrence rate/free time after TURB during the regular cystoscopy every 3 months/first year, every six months thereafter) were explored as well. LF patients were older, with less analgesics consumption and with a tendency towards longer recurrence-free time compared to L patients (p=0.074). The recurrence at three months along with prior and new disease-recurrences comprise our minority (n=27) with aggressive course of the disease. Among the rest the majority, LF subgroup (n=19) had lower recurrence rate than L subgroup (n=24) (p=0.03). As part of multimodal analgesic strategy, SA with intrathecal opioid coadministration may play a significant complementary role regarding oncologic outcomes after TURBT for NMIBC.

Indications and technique for transoral thyroid gland and parathyroid gland surgery

The conventional Kocher collar incision is the standard access to the thyroid and parathyroid glands. Although the incision length has been significantly shortened in recent years with this approach, there is increasing interest among patients in asurgical technique without visible scars in the décolleté. Transoral endoscopic thyroid gland surgery via the vestibular approach (TOETVA) is amodern technique that can be learned relatively quickly and leaves no visible scars because it is carried out exclusively through anatural orifice (natural orifice transluminal endoscopic surgery, NOTES). For retrieval of larger specimens, the transoral approach can be combined with aretroauricular access and thus covers alarger range of indications. The indications must be strictly followed, analogous to conventional surgery. Once the transoral access has been established, the operation is carried out as in open surgery but strictly from cranial to caudal. The classical complications are comparable to the results of conventional surgery. Specific complications include perioral, mandibular or cervical dysesthesia and hypesthesia.

Near-infrared fluorescence clip guided robot-assisted minimally invasive esophagectomy for esophagogastric junction cancer: a case report

BackgroundAlthough treatment strategy differs between countries, surgery remain the mainstay of treatment for localized esophagogastric junction cancer. Tumor proximal margin is one of the critical factors to achieve curative resection during esophagogastric junction cancer surgery. Thus, an accurate preoperative marking of the tumor is essential, however, accuracy of conventional methods was highly dependent upon endoscopists skills. Here, we present a case of a patient with locally advanced Siewert type II esophagogastric junction cancer treated by robot-assisted minimally invasive esophagectomy utilizing near-infrared fluorescence clip as a novel marking method.Case presentationA male patient in his 70 s was diagnosed as having cT3N1M1 esophagogastric junction cancer and was treated by immunochemotherapy followed by surgery. Near-infrared fluorescence marking clips were placed 2 cm above the tumor proximal end under endoscopy prior to surgery. Location of the clips were confirmed by fluorescence imaging during robotic surgery, and the esophagus was dissected by a surgical stapler without intraoperative endoscopy. Histopathologically, the tumor was diagnosed as ypT2N0M0, with negative margins.ConclusionsNear-infrared fluorescence clip may enable easy, safe, and an accurate preoperative marking, and may be considered during endoscopic surgeries.

Preoperative definition and new concept design of 3D printed buttress model to seal skull base after endoscopic endonasal surgery

PurposeThis study aims to integrate design methods and additive manufacturing with the use of a thermoplastic elastomer certified for medical use and reverse engineering towards a new concept of a customized buttress model with optimized features for the reconstruction of the osteo-dural opening after endoscopic endonasal transtuberculum-transplanum approach.Design/methodology/approachAdditive manufacturing allows making of cost-effective and useable devices with tailored properties for biomedical applications. The endoscopic endonasal approach to the suprasellar area enables the management of different intradural tumours, and the craniectomy at the skull base is generally wide and irregular. Defining an optimal strategy for osteodural defect closure at the preoperative stage represents a significant challenge.FindingsUsing the results obtained from a computed tomography analysis, skull base defects were designed to plan the surgical approach. Several concepts of customized buttress models were first built up, initially focusing on thin, flexible edges characterized by different thicknesses. Finite element analyses and design optimization allowed us to achieve the optimal design solution with improved compliance/flexibility for easy intranasal manoeuvrability, maintaining an adequate mechanical stability. As the thickness of the edges decreased, an increase of strain energy values was found (i.e. 1.2 mJ – Model A, 1.7 mJ – Model B, 2.3 mJ – Model C, 4.3 mJ – Model D). However, a further optimization (Model E) led to a significant increase of the compliance (strain energy of 14.1 mJ).Originality/valueThe results obtained from clinical evaluations demonstrated the feasibility of the proposed technical solutions, improving surgery effectiveness.

Tumor versus bland thrombus: diffuse large B-cell lymphoma presenting as cavernous sinus and left superior ophthalmic vein thrombosis.

A 66-year-old female with a history of sinusitis presented with persistent diplopia and worsening eyelid swelling. Examination revealed bilateral vision loss, cranial nerve palsies, left-sided chemosis, proptosis, and edema. Initial imaging showed sphenoid sinus opacification, bilateral ethmoid disease, lack of filling of bilateral cavernous sinuses, and partial thrombosis of the left superior ophthalmic vein. The sinus findings were evaluated with endoscopic sinus surgery, which was unremarkable. Subsequent orbital imaging suggested the lesions were in keeping with tumor thrombus as opposed to bland thrombus. CT scans revealed a large mass in the right axilla, which was biopsied and confirmed the diagnosis of diffuse large B-cell lymphoma (DLBCL). The patient was treated with anticoagulation, steroids, and chemotherapy resulting in marked improvement. Our report highlights a rare case of tumor thrombus from DLBCL causing bilateral cavernous sinus thrombosis and, to the best of our knowledge, the first documented case of superior ophthalmic vein thrombosis from tumor thrombus.

Practice guidelines on endoscopic surgery for qualified surgeons by the Endoscopic Surgical Skill Qualification System: Pancreas.

Practice guidelines on endoscopic surgery for qualified surgeons by the Endoscopic Surgical Skill Qualification System: Pancreas.

Feasibility Study of Endoscopic Surgery for Spontaneous Intracerebral Hemorrhage with Large Hematoma: a Comparison with Craniotomy Using Propensity Score Matching Analysis.

Spontaneous intracerebral hemorrhage (ICH) with large hematomas is commonly treated with craniotomy combined with decompressive craniectomy, procedures that involve huge trauma and require subsequent cranioplasty. Recently, endoscopic surgery has shown significant promise in treating ICH, but its feasibility for large hematomas remains uncertain. Therefore, this study aims to compare endoscopic surgery with craniotomy and to evaluate the efficacy and safety of endoscopic surgery in treating large hematomas ICH. A retrospective analysis was conducted on the clinical data from patients with spontaneous supratentorial ICH and hematoma volumes exceeding 50 mL who underwent either endoscopic surgery or craniotomy. Propensity score matching analysis was employed to reduce selection bias. The efficacy and safety of endoscopic surgery were evaluated by analyzing blood loss, postoperative edema, mortality rate, complications, and the Glasgow Outcome Scale (GOS) at 6-month follow-up. A total of 113 cases that met the criteria were collected, with 65 in the endoscopic surgery group and 48 in the craniotomy group. After propensity score matching, each group contained 34 cases. The mean hematoma volume was 64.84 ± 11.02 mL in the endoscopy group and 66.57 ± 12.77 mL in the craniotomy group (p = 0.554). Hematoma evacuation rates were 93.27% in the endoscopy group and 89.34% in the craniotomy group (p = 0.141). The endoscopy group exhibited lower blood loss, shorter surgical time, and reduced postoperative edema volume at 24 h compared to the craniotomy group. The rate of pulmonary infection was slightly lower in the endoscopy group compared to the craniotomy group (70.59% vs. 91.18%, p = 0.031), but there were no statistically significant differences in overall complications and mortality rate between the two groups. GOS scores were similar in both groups at the 6-month follow-up. Endoscopic surgery is safe and feasible for treating spontaneous supratentorial ICH with large hematomas, demonstrating efficacy similar to that of craniotomy with decompressive craniectomy.

Prospective comparative analysis of three types of decompressive surgery for lumbar central stenosis: conventional, full-endoscopic, and biportal endoscopic laminectomy

Conventional open laminectomy has long been considered one of the important surgical options for lumbar central stenosis owing to its positive outcomes. However, newer approaches have emerged as alternatives, including full-endoscopic and biportal endoscopic laminectomy. Therefore, a comparison of the outcomes that are associated with each of these surgical methods is warranted. This prospective multicenter trial, initiated in February 2019, compared the outcomes of three lumbar central stenosis surgical approaches: open laminectomy (OPEN), uniportal endoscopy (UNIPORT), and biportal endoscopy (BIPORT). Among 115 participants from seven centers, one-year follow-ups assessed laboratory, radiological, and clinical outcomes. Despite all groups showing adequate decompression and clinical improvement, the OPEN group exhibited less improvement in Visual analog scale (VAS) for back pain scores (p < 0.05) and significant postoperative increases in most laboratory markers. Furthermore, the OPEN group experienced a significant decrease in multifidus muscle cross-sectional area compared to endoscopic groups (p < 0.001). Each surgical techniques produced similar clinical outcomes and dural space expansion. However, endoscopic surgery was associated with better muscle preservation and better relief of back pain. Endoscopic surgery is a reasonable alternative to conventional laminectomy for treating lumbar central stenosis.This trial was registered on CRIS (Clinical Research Information Service, KCT0004355).

Open Versus Endoscopic Approach for Thoracic Disk Herniations: Equivalent Short-Term Outcomes With Significantly Different Costs.

Open thoracic diskectomy often requires significant bone resection and fusion, whereas an endoscopic thoracic diskectomy offers a less invasive alternative. Therefore, we sought to compare one-level open vs endoscopic thoracic diskectomy regarding (1) perioperative outcomes, (2) neurological recovery, and (3) total cost. A single-center, retrospective, cohort study using prospectively collected data of patients undergoing one-level thoracic diskectomy was undertaken from 2018 to 2023. The primary exposure variable was open vs endoscopic. The primary outcome was perioperative outcomes and neurological recovery. Secondary outcomes were total cost of care. Multivariable regression analysis controlled for age, body mass index, sex, symptom onset, disk characteristics, operative time, and length of stay. Of 29 patients undergoing thoracic diskectomy, 17 were open and 12 were endoscopic. Preoperative demographics, symptoms, and radiographic findings were comparable between the cohorts. Perioperatively, open surgery had significantly higher mean length of stay (4.9 ± 1.5 vs 0.0 ± 0.0 days, P < .001), median (IQR) longer operative time (342.8 [68.4] vs 141.5 [36] minutes, P < .001), and more blood loss (350 [390] vs 6.5 [20] mL; P < .001). 16 (94%) open patients required fusion vs 0 endoscopic (P < .001). Postoperative opioid use (P = .119), readmission (P = .665), reoperation (P = .553), and rate of neurological improvement (P > .999) were similar between the 2 groups. Financially, open surgical median costs were 7x higher than endoscopic ($59 792 [$16 118] vs $8128 [$1848]; P < .001), driven by length of stay (β = $2261/night, P < .001), open surgery (β = $24 106, P < .001), and number of pedicle screws (β = $1829/screw, P = .002) on multivariable analysis. On sensitivity analysis, open surgery was never cost-efficient against endoscopic surgery and excess endoscopic revision rates of 86% above open revision rates were required for break-even costs between the surgical approaches. Endoscopic thoracic diskectomy was associated with decreased length of stay, operative time, blood loss, and total cost compared with the open approach, with similar neurological outcomes. These findings may help patients and surgeons seek endoscopic approach as a less morbid and less costly alternative.

Outcomes of Endoscopic Sinus Surgery in Treating Paranasal Sinus Mucoceles with Orbital Complications

Outcomes of Endoscopic Sinus Surgery in Treating Paranasal Sinus Mucoceles with Orbital Complications

Maxillary Antrostomy Versus Complete Sinus Surgery for Odontogenic Sinusitis With Frontal Sinus Extension.

Endoscopic sinus surgery (ESS) is often necessary when managing odontogenic sinusitis (ODS), but ESS extent for ODS with extramaxillary sinus involvement has been incompletely studied. This study compared outcomes after wide maxillary antrostomy (MA) alone versus complete ESS for ODS with frontal sinus involvement. A multicenter prospective cohort study was conducted on patients with uncomplicated ODS (no extrasinus spread) who underwent ESS when computed tomography demonstrated maxillary, anterior ethmoid (AE), and frontal sinus opacification. Multiple preoperative and postoperative variables were recorded, including 22-item sinonasal outcome tests (SNOT-22) and endoscopic findings. Ultimate SNOT-22 and endoscopic resolution, and time to SNOT-22 and endoscopic resolution were compared between patients who underwent MA alone versus "complete" ESS (maxillary, ethmoid, frontal; not sphenoid). Of 70 patients, mean age was 59.2 years, and 55.7% were male. Thirty-five underwent MA alone, and 35 had complete ESS. At first postoperative visits (mean 9.3 days), AE sinus purulence was more likely resolved after complete ESS compared with MA (97.1% vs. 71.4%, p = 0.006). However, time to resolution of AE purulence was comparable by 6 weeks postoperatively (p = 0.158). There were no significant differences in times to foul smell resolution and achieving ≥9 point SNOT-22 reduction (p > 0.05). For ODS with frontal sinus involvement, MA alone and complete ESS both resulted in rapid and long-term symptomatic resolution. While ultimate resolution of sinus purulence was equivalent between surgery groups, complete ESS did lead to faster resolution of frontoethmoidal purulence in a significant number of cases. 2 Laryngoscope, 2024.

Factors Contributing to the Recurrence of Chronic Rhinosinusitis With Nasal Polyps After Endoscopic Sinus Surgery: A Systematic Review.

Chronic rhinosinusitis with nasal polyposis (CRSwNP) occurs due to the inflammation of sinonasal tissue. Cases of CRSwNP more commonly demand revision endoscopic sinus surgery (ESS) as compared to patients without polyposis. The recurrence rate varies widely depending on various factors, such as the extent of surgery, patient compliance with postoperative care, and the severity of the underlying disease. Studies conducted on chronic rhinosinusitis (CRS) patients showing recurrence or relapse of nasal polyps post endoscopic sinus surgery were included. We used the modified Newcastle-Ottawa scale (NOS) for cross-sectional studies and cohort studies. Only 15 articles met our inclusion and exclusion criteria after the full-text screening. The studies enrolled participants between 2009 and 2022, including 2,515 ESS patients. The mean age of the included subjects ranged between 37.1 and 57.57 years. In conclusion, CRSwNP is a chronic inflammatory disease that can impose a significant burden on patients, healthcare systems, and society. Asthma, aspirin intolerance, peripheral eosinophilia, interleukin-5 (IL-5) expression, T2 profile, and intense sinus opacification have been noted to be independent predictors of the condition in different studies. Recurrent polyposis in CRS signals a more aggressive disease course, requiring close follow-up and revision surgeries in the long run.

Tualang Honey-impregnated Nasal Pack in Endoscopic Sinus Surgery Reduces Post-operative Inflammation and Bacterial Growth

Tualang Honey-impregnated Nasal Pack in Endoscopic Sinus Surgery Reduces Post-operative Inflammation and Bacterial Growth

The Impact of Surgical Telementoring on Reducing the Complication Rate in Endoscopic Endonasal Surgery of the Skull Base.

Pituitary adenomas represent the most common pituitary disorder, with an estimated prevalence as high as 20%, and they can manifest with hormone hypersecretion or deficiency, neurological symptoms from mass effect, or incidental findings on imaging. Transsphenoidal surgery, performed either microscopically or endoscopically, allows for a better extent of resection while minimising the associated risk in comparison to the transcranial approach. Endoscopy allows for better visualisation and improvement in tumour resection with an improved working angle and less nasal morbidity, making it likely to become the preferred surgical treatment for pituitary neoplasms. The learning curve can be aided by telementoring. We retrospectively analysed the clinical records of 94 patients who underwent an endoscopic endonasal resection of a pituitary neoplasm between the years 2011 and 2023 at Maribor University Medical Centre in Slovenia. Remote surgical telementoring over 3 years assisted with the learning curve. The proportion of complication-free patients significantly increased over the observed period (60% vs. 79%). A gradual but insignificant increase in the percentage of patients with improved endocrine function was observed. Patients' vision improved significantly over the observed period. By gaining experience, the extent of gross total tumour resection increased insignificantly (67% vs. 79%). Telementoring for the endoscopic endonasal approach to pituitary neoplasms enables low-volume centres to achieve efficiency, decreasing rates of postoperative complications and increasing the extent of tumour resection.

Brain Abscess Can Be a Catastrophic Complication Following Endoscopic Sinus Surgery: A Case Report

Brain Abscess Can Be a Catastrophic Complication Following Endoscopic Sinus Surgery: A Case Report

Comparison of Total Endoscopic Ear Surgery and Microscopic Postauricular Canal-Wall-Down Approach on Primary Acquired Cholesteatoma.

This study aimed to compare total endoscopic ear surgery (TEES) and microscopic postauricular canal-wall-down tympanomastoidectomy (CWD) in cholesteatoma surgery in our clinic. This study included 59 patients, of whom 30 and 29 were operated on with CWD in 2016-2018 and TEES in 2019-2021, respectively and compared regarding intraoperative findings, hearing outcomes, long-term outcomes, and recidivism rates between groups. This study excluded patients in stage IV according to the European Academy of Otology and Neurotology/Japan Otological Society Staging System on Middle Ear Cholesteatoma, aged < 18, with congenital cholesteatoma, who underwent revision surgery. Two patients in the TEES group had recidivism (6.9%), with recurrent disease observed in both patients and residual disease in none, whereas 3 patients in the CWD group had recidivism (10%), including recurrent disease in 2 and residual disease in 1 patient. Tympanic membrane perforation occurred in 2 (6.9%) and 1 (3.3%) patients in the TEES and CWD groups, respectively. The 2 groups revealed no significant difference in terms of recidivism and perforation rates (P=1.000, P = .612). The CWD group had a longer mean operation time (225.54 ± 47.86 minutes) than the TEES group (160.55 ± 24.98 minutes) (P < .001). The 2 groups demonstrated no significant difference regarding pre- and postoperative air-bone gap (ABG) and ABG gain (P = .105, P=.329, P=.82, respectively). Total endoscopic ear surgery provides similar results in terms of hearing, recidivism, and long-term outcomes with the microscopic CWD approach. However, the CWD approach is still important, especially in patients in advanced stages.

Carotid Plexus Sympathetic Nerves as a Landmark for the Abducens Nerve Within the Cavernous Sinus During Endoscopic Endonasal Surgery: Cadaveric Anatomic Study and Surgical Consideration.

The abducens nerve (CN VI) is vulnerable to injury during endoscopic endonasal transcavernous surgery. In this study, the authors aimed to develop the surgical anatomic landmark and explore the relationship between the sympathetic nerves (SNs) around the internal carotid artery (ICA) and CN VI within the cavernous sinus (CS). The relationship and patterns between the SNs and CN VI were investigated in 15 cadaveric specimens. The intraoperative examples of anatomic landmark were presented. There were SNs around the ICA running into the CN VI, classified into ascending SNs and accessory sympathetic branches. The ascending SNs were divided into 3 types: (1) Type I had a single ascending SN. There were 2 subtypes of Type I (Type IA [17/30, 56.7%] was defined as a single ascending branch that ran into the CN VI, and Type IB [4/30, 13.3%] was defined as a single ascending branch with a terminal bifurcation before merging into the CN VI or lateral CS wall), (2) Type II (7/30, 23.3%) was defined as 2 ascending branches that ran into the CN VI and the lateral CS wall, and (3) Type III (2/30, 6.7%) was defined as 3 ascending branches that ran into the CN VIs and the lateral wall of the CS. The accessory branches of the SNs were defined by sympathetic branches from the posterior genu or horizontal ICA and found in 6/30 sides (20%). The authors propose a classification of the relationship between paraclival ICA SNs and the CN VI within the CS, as approached during endoscopic endonasal surgery. The consistent relationship of the ascending SN and CN VI within the CS provides a reliable anatomic landmark during the endonasal approach to the CS.

Hypopituitarism, Diabetes Insipidus, and Syndrome of Inappropriate Antidiuretic Hormone Secretion after Pituitary Macroadenoma Surgery with Indocyanine Green Dye.

(1) Background: Pituitary adenomas are benign tumors comprising about 18% of all intracranial tumors, and they often require surgical intervention. Differentiating pituitary tissue from adenoma during surgery is crucial to minimize complications. We hypothesized that using ICG dye would reduce the hormonal complication rates. (2) Methods: A prospective randomized study (February 2019-October 2023) included 34 patients with non-functional macroadenomas of the pituitary gland randomly assigned to receive intraoperative ICG or be in the control group. All underwent endoscopic endonasal transsphenoidal surgery. Pituitary function was assessed preoperatively, immediately postoperatively, and 3-6 months postoperatively. Adenohypophysis function was evaluated with hormonal tests (Cosyntropin stimulation test, TSH, fT3, fT4, prolactin, IGF-1, FSH, LH, and testosterone in men) and neurohypophysis function with fluid balance, plasma and urine osmolality, and serum and urinary sodium. (3) Results: Of the 34 patients (23 men, 11 women; average age 60.9 years), 5.9% in the ICG group developed diabetes insipidus postoperatively, compared to 23.5% in the control group. Adenohypophysis function worsened in 52.9% of the ICG group and in 35.3% of the control group. (4) Conclusions: Our study did not confirm the benefits of using ICG in these surgeries. Further research with a larger sample is needed.

Residual Cyst Mimicking an Aggressive Neoplasm—A Life-Threatening Condition

Odontogenic cysts are frequently encountered in clinical practice. However, residual cysts, a specific type of inflammatory odontogenic cyst, are relatively rare. These cysts may slowly expand over time, damaging surrounding soft tissues and bone, typically without posing a threat to life. We report the case of a 67-year-old man with liver failure and a cystic tumor in his right maxilla that had invaded his oral cavity and cheek, causing nasal obstruction and severe bleeding following an incisional biopsy. A computed tomography (CT) scan of the mass was nonspecific, and an initial histopathological analysis of the tissues was inconclusive due to chronic inflammation and hemorrhagic alterations, complicating the diagnostic pathway. The suspicion of a potentially aggressive malignant neoplasm and the need for immediate intervention due to bleeding necessitated a tracheotomy, tumor removal, percutaneous endoscopic gastrostomy, and transfusions of red blood cells. A subsequent histopathological examination revealed features indicative of a residual cyst. The entire lesion was excised through functional endoscopic sinus surgery. The surgical treatment was performed safely and effectively. Follow-up CT confirmed complete removal of the lesion. This case highlights a rare yet possible complication of odontogenic cysts and underscores the necessity of early diagnosis and comprehensive prophylaxis to prevent severe complications.

EDS-FLU efficacy in patients with chronic rhinosinusitis with or without prior sinus surgery in ReOpen1 and ReOpen2 randomized controlled trials.

The inability of topical medications to reach sinus cavities is a potential reason for lack of efficacy in chronic rhinosinusitis (CRS). One purpose of endoscopic sinus surgery (ESS) is to enable delivery of medications into the sinus cavities. The exhalation delivery system with fluticasone (EDS-FLU; XHANCE) creates unique biomechanics that enable deposition of intranasal corticosteroid into sinuses and sinus drainage pathways but may have differing efficacy in operated versus unoperated sinuses. Two 24-week randomized trials (ReOpen1/2) evaluated EDS-FLU versus EDS-placebo in patients with CRS, stratified by surgical status. Surgery-naive (n=332) and prior-surgery (n=215) patient groups were analyzed as pooled data from ReOpen1/2. Outcome measures (least-squares mean change from baseline) included combined symptom score (CSS) and congestion score at weeks 4, 8, and 12 and average of percentages of opacified volume (APOV) of ethmoid/maxillary sinuses on CT and Sinonasal Outcome Test 22 (SNOT-22) total score at week 24. Baseline scores suggested moderate-severe disease: mean CSS=5.8; APOV=67.2%. EDS-FLU produced significant improvement versus placebo (p<0.05): CSS (surgery-naive, -0.68vs. -1.42; prior ESS, -0.70vs. -1.87); congestion (surgery-naive, -0.24vs. -0.59; prior ESS, -0.24vs. -0.69); and SNOT-22 (surgery-naive, -7.56vs. -18.30; prior ESS, -10.72vs. -18.74). Similar results were observed for APOV (p<0.05). No statistically significant difference was observed between surgery subgroups with either EDS-FLU dose. EDS-FLU improved symptoms, sinus opacification, and quality of life in patients with CRS with or without prior ESS, suggesting a role for EDS-FLU in both populations.