Endoscopic Techniques Research Articles

Optical enhancement mode 2 improves the detection rate of gastric neoplastic lesion in high-risk populations: A multicenter randomized controlled clinical study.

Detection of early neoplastic lesions is crucial for improving the survival rates of patients with gastric cancer. Optical enhancement mode 2 is a new image-enhanced endoscopic technique that offers bright images and can improve the visibility of neoplastic lesions. This study aimed to compare the detection of neoplastic lesions with optical enhancement mode 2 and white-light imaging (WLI) in a high-risk population. In this prospective multicenter randomized controlled trial, patients were randomly assigned to optical enhancement mode 2 or WLI groups. Detection of suspicious neoplastic lesions during the examinations was recorded, and pathological diagnoses served as the gold standard. A total of 1211 and 1219 individuals were included in the optical enhancement mode 2 and WLI groups, respectively. The detection rate of neoplastic lesions was significantly higher in the optical enhancement mode 2 group (5.1% vs. 1.9%; risk ratio, 2.656 [95% confidence interval, 1.630-4.330]; p<0.001). The detection rate of neoplastic lesions with an atrophic gastritis background was significantly higher in the optical enhancement mode 2 group (8.6% vs. 2.6%, p<0.001). The optical enhancementmode2 group also had a higher detection rate among endoscopists with different experiences. Optical enhancement mode 2 was more effective than WLI for detecting neoplastic lesions in the stomach, and can serve as a new method for screening early gastric cancer in clinical practice. United States National Library of Medicine (https://www. gov), ID: NCT040720521.

Management of colorectal neoplasia in IBD patients: current practice and future perspectives.

Inflammatory bowel disease (IBD) patients are at increased risk of developing colorectal neoplasia (CRN). In this review, we aim to provide an up-to-date overview and future perspectives on CRN management in IBD. Advances in endoscopic surveillance and resection techniques have resulted in a shift towards endoscopic management of neoplastic lesions in place of surgery. Endoscopic treatment is recommended for all CRN if complete resection is feasible. Standard (cold snare) polypectomy, endoscopic mucosal resection and endoscopic submucosal dissection should be performed depending on lesion complexity (size, delineation, morphology, surface architecture, submucosal fibrosis/invasion) to maximize the likelihood of complete resection. If complete resection is not feasible, surgical treatment options should be discussed by a multidisciplinary team. While (sub)total and proctocolectomy play an important role in management of endoscopically unresectable CRN, partial colectomy may be considered in a subgroup of patients in endoscopic remission with limited disease extent without other CRN risk factors. High synchronous and metachronous CRN rates warrant careful mucosal visualization with shortened intervals for at least 5 years after treatment of CRN.

Quality of Life in Patients Undergoing Endoscopic Thyroidectomy Versus Conventional Open Thyroidectomy: Interim Results From Randomized Trial.

We determined whether endoscopic thyroidectomy (ET) is associated with better health-related quality of life (QoL) compared with open thyroidectomy. We randomly assigned 28 patients aged older than 18 years, Bethesda IV or less on cytology and gland volume of <40 mL to undergo hemithyroidectomy through either open or endoscopic (axillo-breast approach/bilateral axillo-breast approach) technique. The primary outcome was QoL scores on the Short Form-36 and Thyroid-Specific Questionnaire at 2, 6, and 12 weeks postsurgery. Secondary outcomes were postoperative complications, hospital stay, and pain scores. The generic QoL scores based on Short Form-36 were statistically nonsignificant between the two groups. QoL scores based on Thyroid-Specific Questionnaire were statistically significant (P < 0.05) favoring open thyroidectomy in the following domains: (1) numbness at 2, 6, and 12 weeks (P = 0.04, 0.004, and 0.005, respectively), (2) shoulder impairment at 2 weeks (P = 0.017), and (3) favoring ET in cosmesis at 6 and 12 weeks (P = 0.037 and 0.02, respectively). ET has longer operative time (104.6 ± 25.4 vs 123 ± 8.9 min; P = 0.03), longer hospital stays (2.8 ± 0.4 vs 2.4 ± 0.5; P = 0.056) and higher pain scores at 2 and 6 weeks (P = 0.007 and 0.012, respectively) but decreased intraoperative bleeding (33.5 ± 6.4 vs 29.1 ± 3.7 mL; P = 0.037). ET has higher cosmetic satisfaction, increased numbness, and shoulder movement impairment during short-term postsurgery follow-up. Both techniques are similar in impacting general physical, mental, and social health-related QoL. (Clinical Trials Registry of India, Reg. No. CTRI/2020/07/026374).

Endoscopic resection in subepithelial lesions of the upper gastrointestinal tract; experience of a tertiary referral hospital in The Netherlands.

Objectives Histological confirmation of subepithelial lesions (SELs) in the upper gastrointestinal tract remains challenging. Endoscopic resection of SELs is increasingly used for its excellent diagnostic yield and opportunity to do away with continued surveillance. In this study, we aimed to evaluate the indications, success-rates and complications of different endoscopic resections techniques for SELs in a large, tertiary referral hospital in Rotterdam, The Netherlands. Methods Data between October 2013 and December 2021 were retrospectively collected and analyzed. Main outcomes are R0-resection rate, en bloc resection rate, recurrence rate and procedure-related adverse events (Clavien-Dindo). Secondary outcomes are procedure time, need for surgical intervention and clinical impact on patient management. Results A total of 58 patients were referred for endoscopic resection of upper gastro-intestinal SELs. The median diameter of lesions was 20 mm (range 7-100mm). Median follow-up time was 5 months (range 0.4-75.7). Forty-eight (83%) procedures were completed successfully leading to en bloc resection in 85% and R0-resection in 63%. Procedure-related adverse events occurred in 6 patients (13%). Severe complications (CD grade 3a) were seen in 3 patients. Local recurrence rate for (pre)malignant diagnosis was 2%. Additional surgical intervention was needed in 7 patients (15%). A total of 32 patients (67%) could be discharged from further surveillance after endoscopic resection. Conclusions Endoscopic resection is a safe and effective treatment for SELs and offers valuable information in undetermined SELs in which repeated sampling attempts have failed to provide adequate tissue for diagnosis.

Percutaneous Endoscopy and Image-guided Retrieval of Dropped Gallstones - A Case Series.

Recurrent abscesses can happen due to dropped gallstones (DGs) after laparoscopic cholecystectomy (LC). Recognition and appropriate percutaneous endoscopy and image-guided treatment options can decrease morbidity associated with this condition. We report a minimally invasive endoscopy and image-guided technique for retrieval of dropped gallstones in a series of 6 patients (M/F=3/3; median age: 75.5 years [68 to 82]) presenting with recurrent or chronic intra-abdominal abscesses secondary to dropped gallstones. Technical success was defined as the visualization and retrieval of all stones. DGs were identified on pre-procedure imaging. Number of abscesses recurrence was 12 (1/6), 1 (3/6), and 0 (2/6) with a median interval of 2 months (1 to 21) between cholecystectomy and abscess development. Percutaneous endoscopy and fluoroscopy guidance were utilized in all cases. Technical success was achieved in 4 patients (66%). The median procedure time was 65.8 minutes (39 to 136). The median fluoroscopy time and dose were 12.6 min (3.3 to 67) and 234 mGy (31 to 1457), respectively. There were no intraprocedure and postprocedure complications. No abscess recurrence was reported among successful procedures during a median follow-up of 193 days (51 to 308). Percutaneous image and endoscopy-guided lithotripsy/lithectomy are safe and effective. This technique is a suitable alternative to open surgery for dropped gallstones. Level 4, Case Series.

Endoscopic Transventricular Transaqueductal Excision of Fourth Ventricular Neurocysticercosis: 2-Dimensional Endoscopic Video: 2-Dimensional Operative Video.

Ventricular neurocysticercosis is a challenging disease that may cause obstructive hydrocephalus and require surgical intervention.1,2 Cysts of the lateral and third ventricle can be addressed by neuroendoscopy and removal of the cyst, when feasible. Surgical excision of cysts from the fourth ventricle can be achieved through endoscopic or microsurgical techniques, depending on the experience of the surgeon and characteristics of the cyst. Unresectable cysts causing hydrocephalus require cerebrospinal fluid diversion through a ventriculoperitoneal shunt.1-8 Medical therapy consisting of antiparasitic and anti-inflammatory agents should be limited to patients where surgery is a poor option or in cases, where there are residual cysts in the body. Medical therapy can cause an inflammatory response resulting in adherence of the cyst to the ventricular wall, which increases the surgical complication rate. Therefore, surgical cyst excision should always precede medical therapy.2 The endoscopic transventricular transaqueductal approach has been described in the literature as a safe route to resect nonadherent cysts when performed by an experienced neuroendoscopist.1-5 Although descriptions of the procedure exist in the literature, no video outlines its detailed operative steps and relevant anatomy. In this video, we present a case of a 42-year-old woman who presented with obstructive hydrocephalus caused by a third ventricular cestode that migrated into the fourth ventricle during her hospitalization. The patient underwent an endoscopic transventricular transaqueductal excision of a fourth ventricular cyst with complete neurological recovery and without requiring ventricular shunting. The patient consented to the procedure and to the publication of her video and images. Institutional Review Board review is not required for a single case report.

Unilateral biportal endoscopy via two different approaches for upper lumbar disc herniation: a technical note

BackgroundThe traditional surgical procedures for upper lumbar disc herniation (ULDH) usually lead to frequent complications. We aim to investigate the clinical efficacy of the unilateral biportal endoscopy (UBE) technique in treating upper lumbar disc herniation (ULDH).MethodsFrom January 2020 to December 2021, the clinical data of 28 patients with ULDH treated with the UBE technique were collected and analyzed for surgery time under UBE, postsurgical drainage, postsurgical hospital stay, and complications. The clinical efficacy was evaluated according to the modified MacNab score, Oswestry disability index (ODI), and visual analogue scale (VAS) of low back pain and lower limb pain before the surgery; one week, one month, and three months after the surgery; and at the last follow-up.ResultsAll patients underwent the UBE surgery successfully. The surgery time under UBE for non-fusion cases was 47.50 ± 11.84 min (monosegment) and 75.00 ± 20.66 min (two segments), while that for fusion cases was 77.50 ± 21.02 min. The postsurgical drainage for non-fusion cases was 25.00 ± 13.94 mL (monosegment) and 38.00 ± 11.83 mL (two segments), while that for fusion cases was 71.25 ± 31.72 mL. The postsurgical hospital stay was 8.28 ± 4.22 days. The follow-up time was 15.82 ± 4.54 months. The VAS score for each time period after the surgery was significantly lower (P < 0.05), while the ODI was significantly higher than that before the surgery (P < 0.05). According to the modified MacNab scoring standard, the ratio of excellent to good was 96.43% at the last follow-up. Two patients experienced transient numbness and pain in their lower limbs and no activity disorder after the surgery, and they recovered after conservative treatment.ConclusionsThe clinical effect of UBE technique in treating ULDH was reliable. According to the needs of the disease, the interlaminar approach or paraspinal approach of the UBE technique was selected. This technique took into account the effect of treatment, achieved the purpose of minimal invasiveness, and did not require special instruments. Therefore, it has the potential for clinical application.

Is endoscopic third ventriculostomy a viable treatment option for normal pressure hydrocephalus? A systematic review

Background: Endoscopic third ventriculostomy (ETV) is considered an alternative treatment for hydrocephalus and has become a standard of care for obstructive hydrocephalus. Recent studies have also explored its role in normal pressure hydrocephalus (NPH). We conducted a systematic review aiming to assess the outcomes of this minimally invasive endoscopic technique as a viable treatment option for NPH. Methods: A systematic literature search was performed using PubMed and Scopus databases, using iterations of search terms “Endoscopic third ventriculostomy,” “Idiopathic normal pressure hydrocephalus,” and “Normal pressure hydrocephalus.” To be eligible for inclusion in the review, articles had to report the usage of ETV as a primary treatment modality for NPH, report its outcomes, and be published in the English language. Results: Out of the 13 studies selected for qualitative synthesis, nine supported the use of ETV for NPH as an effective treatment option with improvement in the preoperative symptoms. Two studies favored shunt over ETV, stating that quality of life is better with VP shunt insertion. One study reported that ETV has higher perioperative mortality rates that outweigh its benefits. One study reported it to be an ineffective surgical option. Conclusion: The current review of evidence does not support the use of ETV for the treatment of NPH, except perhaps in a small subset of patients. These patients have a shorter duration of symptoms and a better preoperative neurological status. The lumbar infusion test and ventricular infusion test are modalities useful for selecting these candidates.

The transition of surgical simulation training and its learning curve: a bibliometric analysis from 2000 to 2023.

Proficient surgical skills are essential for surgeons, making surgical training an important part of surgical education. The development of technology promotes the diversification of surgical training types. This study analyzes the changes in surgical training patterns from the perspective of bibliometrics, and applies the learning curves as a measure to demonstrate their teaching ability. Related papers were searched in the Web of Science database using the following formula: TS=((training OR simulation) AND (learning curve) AND (surgical)). Two researchers browsed the papers to ensure that the topics of articles were focused on the impact of surgical simulation training on the learning curve. CiteSpace, VOSviewer and R packages were applied to analyze the publication trends, countries, authors, keywords and references of selected articles. Ultimately, 2461 documents were screened and analyzed. The USA is the most productive and influential country in this field. Surgical endoscopy and other interventional techniques publish the most articles, while surgical endoscopy and other interventional techniques is the most cited journal. Aggarwal Rajesh is the most productive and influential author. Keyword and reference analyses reveal that laparoscopic surgery, robotic surgery, virtue reality (VR) and artificial intelligence (AI) were the hotspots in the field. This study provided a global overview of the current state and future trend in the surgical education field. The study surmised the applicability of different surgical simulation types by comparing and analyzing the learning curves, which is helpful for the development of this field.

Advantages and caveats of endoscopic to the infratemporal fossa as isolated and combined techniques.

Identify the benefits and caveats of combining minimal access approaches to the infratemporal fossa (ITF), such as the endoscopic transnasal, endoscopic transorbital, endoscopic transoral, and endoscopic sublabial transmaxillary approaches to address extensive lesions not amenable to a single approach. The study provides anatomical metrics including area of exposure and degree of surgical freedom. Five human cadaveric specimens (10 sides) were dissected to expose and methodically analyze the anatomical intricacies of the ITF using the following minimal access approaches: endoscopic transnasal transpterygoid (EETA), endoscopic sublabial transmaxillary, endoscopic transorbital via infraorbital foramen, and endoscopic transoral techniques. Area of exposure at the pterygopalatine fossa and surgical freedom at the ITF were obtained for each approach. The endoscopic sublabial transmaxillary sinus and the combined approach afford a significantly greater exposure than an isolated EETA. The difference in exposure (mean) between the endoscopic sublabial transmaxillary and EETA was 1.62 ± 0.85 cm2 (p < 0.001), and the difference between the combined approach and EETA was 4.25 ± 0.85 cm2 (p < 0.001). Combining minimal access endoscopic approaches to the ITF can provide significantly greater exposure than an isolated EETA; thus, providing enhanced access to address lesions with extensive involvement of the ITF, especially those with superolateral and inferolateral extensions. In addition, some approaches may have an adjunctive role to the resection, such as the endoscopic transoral approach offering the potential for early control of the internal maxillary artery and its branches, some of which may be supplying the tumor in the ITF; or the endoscopic transorbital approach yielding a direct line of sight to the superior ITF and middle cranial fossa. NA.

Managing radiation safety and protection in gastroenterology in Japan: insights from the REX-GI study.

Fluoroscopy-guided gastrointestinal procedures, including gastrointestinal stenting, balloon-assisted endoscopy (BAE), endoscopic retrograde cholangiopancreatography (ERCP), and endoscopic ultrasound (EUS), are essential for diagnosis and treatment in gastroenterology. Such procedures involve radiation exposure that necessitates strict safety measures to protect patients, doctors, and medical staff. The April 2020 update to Japan's Ionizing Radiation Injury Prevention Regulations for occupational exposure reduced the lens exposure dose limit to approximately one-seventh of its previous level. This change highlights the need for improved safety protocols. Without adaptation, the sustainability of fluoroscopy-based endoscopic techniques could be at risk due to the potential to exceed these new limits. This review examines the current state of medical radiation exposure in the field of gastroenterology in Japan and discusses the findings of the REX-GI study.

EARLY PREDICTORS OF REMISSION IN ACROMEGALY PATIENTS AFTER PURE ENDOSCOPIC ENDONASAL TRANSSPHENOIDAL SURGERY

Surgery is the first line treatment in acromegaly but it takes months to confirm remission. It is crucial to determine remission early in order to inform the patient and plan further treatment options. We aimed to evaluate the predictors of remission at the early phase after endoscopic endonasal pituitary surgery in acromegaly patients. Methods: Fifty-four GH-adenoma patients operated via pure endoscopic endonasal approach were analysed in this observational study. We compared the basic clinical, radiological characteristics, and the preoperative and postoperative hormone levels in terms of remission according to current guidelines. Results: The surgical remission rate was 61.1%. When the patients were compared according to surgical remission, the age, gender, and immunohistochemical granulation type were non-significant, while diabetes mellitus was more common (55.6% vs 44.4%), the preoperative tumor volume (1.2  0.9 cm3 vs 4.1  4.2 cm3), postoperative GH and IGF-1 levels were higher in the non-remission group (p0.05). We defined a number of cut-off values of both GH and IGF-1 levels to predict remission at the postoperative phase. Age standardized regression analyses showed that postoperative day 1 (POD-1) GH levels (OR:8.9; 95%CI:1.99-40.0, p=0.004) and tumor volume (OR:3.14; 95%CI:1.09-9.0, p=0.034) were found to be significant independent predictors for remission. Conclusion: We demonstrated that tumor volume and POD1 GH levels are independent predictors of remission in acromegaly patients operated via pure endoscopic endonasal technique and may be used as an early marker of remission and this may lead to taking adjuvant medical therapies early into account to improve prognosis.

Comparative analysis of approaches to the Wharton's duct during surgery of the submandibular gland: A retrospective case-control study.

We investigated complications and recurrence rates after surgical techniques for sialolith removal with intact and resected Wharton's duct of the submandibular gland. The retrospective case-control analysis of a series analysed 271 surgical operations (2003-2022) for sialolithiasis performed at a hospital department of Otolaryngology-Head and Neck Surgery. The study compared two approaches: (1) pure endoscopic technique or pinpoint stone removal with Wharton's duct left intact and (2) transoral duct dissection or pinpoint stone removal technique, after which the duct was shortened. While choosing the surgical option, the size of the stone, the location of the stone, and the presence of multiple stones were taken into account. The rates of complications (lingual nerve paraesthesia, duct stenosis, drooling, and sialoadenitis), the incidence of foreign bodies, and the rate of recurrence during follow-up of ≥18 months were compared. 323 sialoliths were removed from 271 patients. Of these 323 calculi, 150 were removed by the first approach and 173 by the second approach. The calculi varied in diameter from 2 to 38 mm with an average diameter of 8.2 mm. For all 271 patients, the rate of recurrence was 4.8%, but 11 recurrent cases (8.7%) appeared after the first approach surgeries and 2 cases (1.4%) after the second approach surgeries (p = .03). Other variables did not show statistically significant differences. Surgical removal of the submandibular calculi, ending with shortening of Wharton's duct, reduces the recurrence rate for sialolithiasis but does not affect the rate of postsurgical complications.

Applying the Full Endoscopic Keyhole Technique to CPA Lesions: A Single-Center Study.

In recent years, endoscopy has become an increasingly common tool used during neurosurgical procedures. However, its application in treating cerebellopontine angle (CPA) lesions has not progressed as rapidly. In this study, the authors present their initial experience with surgically treating CPA lesions using a fully endoscopic keyhole retrosigmoid approach. They conducted a retrospective analysis of clinical data from patients who underwent endoscopic keyhole CPA surgery at their center between May 2017 and April 2022. They provide a comprehensive explanation of this method and an overview of the strategies that have been developed to achieve better clinical outcomes. The study included 107 patients, consisting of 10 cases of vestibular schwannoma, 21 cases of epidermoid cyst, 32 cases of trigeminal neuralgia, and 44 cases of hemifacial spasm. The authors analyzed the clinicodemographic details of the patients. Among the 31 tumor cases, gross total resection was achieved in 25 patients (80.6%), while near-total resection was performed in 6 patients (19.4%). In patients with trigeminal neuralgia, facial pain resolved in 31 out of 32 patients (96.9%). Similarly, facial convulsions disappeared or were relieved in all 44 patients (100%) with hemifacial spasms after the operation. Postoperative complications included facial nerve paresis (n=9, 8.4%), with improvement observed in 6 cases during follow-up, transient facial hypoesthesia (n=3, 2.8%), cerebrospinal fluid rhinorrhea (n=3, 2.8%), transient abducens paresis (n=1, 0.9%), and postoperative hemorrhage (n=1, 0.9%). Endoscopy provides improved deep illumination and, combined with close-up observation, enhances the visualization of structures within the CPA region. The fully endoscopic keyhole technique is a safe and effective method for managing CPA lesions.

MULTICENTER STUDY ON THE INCIDENCE AND TREATMENT OF MEDIASTINAL LEAKS AFTER ESOPHAGECTOMY (MUMELE 2)

BackgroundManagement of mediastinal anastomotic leaks (MALs) after Ivor Lewis esophagectomy includes conservative, endoscopic, or surgical management. Endoscopic vacuum therapy (EVAC) is becoming a routine approach for MALs, although the outcomes have not been defined. PurposeThis study describes the incidence, treatment, and outcomes of MALs in patients who underwent esophagectomy in three Italian high-volume centers that routinely use EVAC for MAL. MethodsPatients who underwent Ivor Lewis esophagectomy between September 2018 and March 2023 were included. ResultsA total of 681 patients underwent Ivor Lewis esophagectomy, of whom 88 had an MAL. MAL rates for open, minimally invasive, and robotic esophagectomy were 11.5%, 13.4%, and 14.8%, respectively. Global and specific 30- and 90-day mortality rates for MAL were 0.9% and 2.1% and 6.8% and 15.9%, respectively. Nonoperative management (NOM) as primary treatment was chosen for 62 patients. The most common NOM and OM was EVAC (62.9%) and anastomotic redo (53.8%), respectively. Diversion was the OM for seven patients, three of whom died. Primary treatment proved successful in 40 patients. Among them, EVAC alone was successful in 35.9% of patients. Globally, endoscopic treatment including EVAC was successful in 79% of NOM and 55.7% of MALs. NOM and OM were chosen as secondary treatment for 27 and 10 patients, respectively. Secondary treatment proved successful in 21 patients. ConclusionsThe incidence of MAL after Ivor Lewis esophagectomy is approximately 13%. Endoscopic techniques have a success rate of almost 80%, with EVAC representing a significant part of this treatment process.

Combined Endo-Laparoscopic Surgery (CELS) for the Management of Complex Colorectal Lesions

Detection of colon polyps is common and is expected in 20-30% of screening colonoscopies. As the number of colonoscopies performed increases, the detection of advanced and difficult to resect polyps will also rise. These polyps tend to be larger, greater than 2cm, have flat morphology, and are in difficult anatomic locations behind haustral folds or at sharp flexures of the colon. Advanced endoscopic techniques such as endoscopic mucosal resection (EMR) and endoscopic submucosal dissection (ESD) are useful to remove these polyps. However, many polyps remain unresectable with these techniques. Combined endoscopic laparoscopic surgery (CELS) has shown to be an effective technique to facilitate safe removal of complex polyps. CELS encompasses a variety of techniques including laparoscopic assisted ESD/EMR and laparo-endoscopic full thickness excisions (FLEX). Success rate of CELS ranges from 70-100%, with less than 5% conversion to colectomy. Perioperative outcomes boast shorter hospital length of stay, with low rates of serious post-op complications when compared to colectomy. Malignancy rate after CELS in appropriately selected patients is low, ranging from 1.6%-10% of cases. Polyp recurrence rate after CELS is also low, usually less than 10%. Use of CELS for early-stage cancers remains controversial but maybe adequate in appropriately selected patients. Further evaluation and long-term studies are needed to study its efficacy in cases of known cancer. The purpose of this review is to provide recommendations for use of CELS techniques, appropriate indications, describe technical tips, and review potential future applications.

Simultaneous versus staged bilateral carpal tunnel release via open and endoscopic surgeries: a retrospective propensity score-matched patient comorbidity analysis.

Carpal tunnel syndrome (CTS) presents bilaterally in nearly 60%-70% of affected patients. Bilateral carpal tunnel release (CTR) can be performed in a staged or simultaneous fashion. There remains a limited understanding of the optimal preoperative factors to use for patient selection when determining simultaneous versus staged bilateral CTR. Moreover, it is unclear how these factors influence postoperative outcomes. In this study, the authors aimed to identify and compare preoperative comorbidities and postoperative outcomes in patients who had undergone simultaneous versus staged open and endoscopic bilateral CTR. The authors performed a retrospective analysis of data collected from the TriNetX database. Patients with bilateral CTS who had been treated from February 1, 2002, to February 1, 2022, were dichotomized by their bilateral release approach: simultaneous or staged within 3 months. The resulting groups were analyzed separately by open versus endoscopic techniques. Next, cohorts were analyzed for preoperative comorbidities to identify possible factors for surgical determination. Then, they were propensity score matched on demographics and comorbidities. Postoperative outcomes within 6 months of surgery were measured with and without matching. After matching, 9286 and 3709 patients remained in the open and endoscopic groups, respectively. Those who had undergone staged surgeries via an open or endoscopic approach had more preoperative comorbidities. After matching, staged open release was associated with significantly higher rates of postprocedural care, hand/joint pain, limb pain, trigger finger, and upper respiratory tract infections. Simultaneous open release was associated with higher rates of emergency room visits. Staged endoscopic release was associated with significantly higher rates of postprocedural care, limb pain, and trigger finger. No significant outcomes were favored in the simultaneous endoscopic group. Before matching, patients who had undergone staged CTR had significantly higher rates of preoperative medical comorbidities compared with patients in the simultaneous CTR group. Moreover, staged CTR was significantly associated with higher rates of postoperative complications. After matching on demographics and comorbidities, staged CTR was still associated with higher rates of postoperative complications, suggesting that preoperative comorbidities do not influence postoperative outcome. Further prospective studies could be used to validate these results and provide new findings for the management and treatment of these groups.

Uniportal Dual Mode Dry-Saline Endoscopy for Lumbar Disc Herniation

Objective: Posterior dry medium endoscopic lumbar discectomy techniques have been successfully used to treat lumbar disc prolapse. A drawback of these techniques is repeated blood staining of the scope tip while working close to the surgical target. To address this drawback, we modified the design of the previous Arthrospine system and made it compatible for use in air and saline medium to treat lumbar, cervical, and thoracic disc prolapse. Herein, we describe the operative technique and results of lumbar discectomy in a dual (air/saline) medium using this system.Methods: Eighty patients underwent endoscopic discectomy using the Arthrospine Duo system for lumbar disc prolapse. The procedure was conducted through a muscle dilatation approach using 5-mm and 10-mm dilators. The Arthrospine Duo tube was passed over a 10-mm dilator, the working insert was adjusted over the tube in a press-fit manner, and endoscopic discectomy was performed using a 30° arthroscope and conventional microdiscectomy instruments in an air or saline medium.Results: As per the modified MacNab criteria, 80% (n=64) of patients had excellent, 12.5% (n=10) good, 6.25% (n=5) fair, and 1.25 patients (n=1) had poor results. The leg pain visual analogue scale improved from 7.87±0.68 to 1.3±0.67 at 2 years of follow-up. As complications, dural tears and transient paraesthesia occurred in 4 patients (5%) each, nerve root injury in 1 patient (1.25%), and superficial wound infection in 5 patients (6.25%).Conclusion: The uniportal Arthrospine Duo system can be used in air/saline medium and is an excellent minimally invasive option for lumbar discectomy.

Surgical Treatment of Lithiasis of the Main Pancreatic Duct: A Challenging Case and a Literature Review

Pancreaticolithiasis represents a rare phenomenon, being superimposed most of the time on a form of chronic pancreatitis of multifactorial etiology. Pancreaticolithiasis is a late complication of the phenomenon of chronic pancreatitis. The reverberant inflammatory process, followed by the fibrotic degeneration of the pancreatic parenchyma, and pancreatic fluid stasis at the ductal level are factors that contribute to the phenomenon of calcium precipitation. This article describes the case of a patient with a diagnosis of pancreaticolithiasis (Wirsung duct lithiasis), a phenomenon superimposed on chronic pancreatitis of ethanolic cause (Rosemont classification). It was decided to perform surgery via the classical approach with the perfection of corporeo-caudal pancreatectomy and preservation of the splenic vessels (Kimura procedure) with pancreatico-jejunal anastomosis on the Roux-en-Y loop. The aim of this study is to identify the best method of treatment for pancreaticolithiasis. To enhance the case and provide a basis for standardization, a literature review was carried out, which included a total of six articles. The results of this study highlight that, currently, the management of symptomatic pancreaticolithiasis encompasses medical therapy (enzyme replacement therapy), interventional therapy (ESWL (extracorporeal shock wave lithotripsy) ± ERCP (endoscopic retrograde cholangiopancreatography), ERCP + sphincterotomy + stent insertion, and POP (oral pancreatoscopy)), and surgical treatment. In conclusion, based on the analysis conducted in this study, the size of the calculi present determines which is the suitable therapeutic care. Unlike stones over 0.5 cm, when surgery is explicitly advised for therapeutic purposes in the absence of endoscopic techniques, stones under 0.5 cm should be treated using endoscopic procedures.

Endoscopic Repair of Refractory Tracheoesophageal Fistula with a Cardiac Septal Occluder Device in a 12 Years-Old Patient

Purpose: Esophageal atresia (EA) and tracheoesophageal fistula (TEF) are rare anomalies in neonates that must be surgically repaired by esophageal reconstruction with or without ligation of the fistula. Recurrent tracheoesophageal fistula (rTEF) occurs in 3-15% of primary surgical repairs in esophageal atresia; it is associated with recurrent hospital admissions and up to 27% short term mortality. Dependable reparation very often proves difficult by standard surgical techniques. Using oesophageal fully covered self-expandable metal stents in adult patients yields a &amp;lt;50% efficacy and other endoscopic techniques such as occlusion by clips or glue show no better results. A minimally invasive alternative is the use of vascular plug septal occluders. We report the efficacy of endoscopic placement of a cardiac septal occluder (CSO) in a paediatric patient. Clinical case: A 12-year-old female with recurrent (rTEF) and refractory tracheoesophageal fistula (refTEF) was subjected to an refTEF closure procedure via endoscopic placement of a cardiac septal occlusion device. Conclusion: Debate regarding the gold standard of rTEF treatment closure a hot debate but flexible endoscopy is an accepted alternative. This report describes the successful fixing of a refTEF using a cardiac septal occluder. After four weeks follow up, no re-incidence of the tracheoesophageal fistula was detected. The results advocate for the endoscopic closure of refractory tracheoesophageal fistula with cardiac occluders in children thus establishing a promising therapeutical alternative in refTEF in paediatric population patients.