Endoscopic Visualization Research Articles

2D versus 3D Endoscopy: Head-to-Head Comparison in a Simulated Model of Endoscopic Endonasal Dural Suturing.

Objective Endonasal dural suturing (EDS) has been reported to decrease the incidence of cerebrospinal fluid fistula. This technique requires handling of single-shaft instrumentation in the narrow endonasal corridor. It has been proposed that three-dimensional (3D) endoscopes were associated with improved depth perception. In this study, we sought to perform a comparison of two-dimensional (2D) versus 3D endoscopy by assessing surgical proficiency in a simulated model of EDS. Materials and Methods Twenty-six participants subdivided into groups based on previous endoscopic experience were asked to pass barbed sutures through preset targets with either 2D (Storz Hopkins II) or 3D (Storz TIPCAM) endoscopes on 3D-printed simulation model. Surgical precision and procedural time were measured. All participants completed a Likert scale questionnaire. Results Novice, intermediate, and expert groups took 11.0, 8.7, and 5.7 minutes with 2D endoscopy and 10.9, 9.0, and 7.6 minutes with 3D endoscopy, respectively. The average deviation for novice, intermediate, and expert groups (mm) was 5.5, 4.4, and 4.3 with 2D and 6.6, 4.6, and 3.0 with 3D, respectively. No significant difference in procedural time or accuracy was found in 2D versus 3D endoscopy. 2D endoscopic visualization was preferred by the majority of expert/intermediate participants, while 3D endoscopic visualization by the novice group. Conclusion In this pilot study, there was no statistical difference in procedural time or accuracy when utilizing 2D versus 3D endoscopes. While it is possible that widespread familiarity with 2D endoscopic equipment has biased this study, preliminary analysis suggests that 3D endoscopy offers no definitive advantage over 2D endoscopy in this simulated model of EDS.

Gross, computed tomographic, and endoscopic anatomy of the equine carpal extensor tendon sheaths.

(1) To describe the computed tomography (CT) and gross anatomy of the equine extensor carpi radialis sheath (ECRS) and common digital extensor sheath (CDETS); (2) to describe a single-portal endoscopic examination of the ECRS and CDETS. Ex vivo experimental. Thirty clinically normal cadaver thoracic equine limbs severed at the humeral diaphysis. Ten limbs underwent plain and intrathecal contrast CT examinations and gross dissection of the ECRS and CDETS. Single-portal endoscopic examination of ECRS and CDETS was attempted in 4 limbs and endoscopic examination was performed on 16 limbs. Endoscopic video recordings were reviewed by 3 observers for quality of visualization before dissection and examination for iatrogenic damage. Interobserver agreement for ECRS and CDETS visualization was determined with Fleiss' κ agreement. Extensor carpi radialis sheath and CDETS anatomy was consistent between gross dissection and CT examinations. The ECRS endoscopic portal was medial at the level of the intersection between the extensor carpi obliquus and extensor carpi radialis tendon. The CDETS endoscopic portal was lateral, 5cm proximal to the lateral styloid process of the ulna. The ECRS and CDETS were well visualized and interobserver agreement was substantial (κ=.73; P < .0001) and moderate (κ = .53; P < .0001), respectively. Computed tomography examinations provided useful anatomical information, consistent with gross dissection of the ECRS and CDETS. The described single-portal endoscopic techniques allowed consistent tenoscopic examination of the majority of the ECRS and CDETS. Awareness of the intrathecal anatomy of the ECRS and CDETS should facilitate the treatment of these tendon sheaths. The proposed portals provide good to excellent single-site endoscopic visualization of the majority of the ECRS and CDETS.

Ex vivo study: is it possible to overcome the blurriness caused by holmium laser fragmentation of kidney stones?

Better endoscopic vision is mandatory for successful ureteroscopic stone operations to achieve shorter operating time. However, an important impairing factor for a good endoscopic view is the cloudiness of vision which was formed during laser fragmentation. Holmium laser fragmentation of calcium oxalate stones produces calcium carbonate solubility of which is dependent on pH, citrate, and phosphate. In this ex vivo research, the solubility of calcium carbonate has been investigated in solutions composed of various concentrations of citrate and phosphate buffered at different pH levels after laser fragmentation of calcium oxalate stones. Calcium oxalate stones were placed into the laboratory tubes filled with various concentrations of citrate-phosphate buffers with different pH values. Laser energy in dusting mode was applied to the stones and spectrophotometric measurement for optical density (OD) was calculated for each buffered solution for clarity comparison. In the first phase, solutions composed of four different molar concentrations of citrate-phosphate buffer (0.2, 0.3, 0.4 and 0.5 molars) at various pH levels were used. Then, the next phase of the study was designed to compare solutions demonstrating the lowest OD values with an isotonic saline solution. The results were most convenient at 0.5 molarity (pH = 6) followed by 0.4 molarity (pH = 7) in the first phase (OD values of 0.054 and 0.065, respectively). In the next phase, OD values of both buffered solutions were significantly lower than those of isotonic saline solution (p = 0). Two specific buffers have provided better optic visibility values after laser fragmentation supporting their use as an irrigation solution for the favor of less cloudiness.

S3131 An Unusual Case of Postprandial Diarrhea: Gastrocolic Fistula from Gastric Band Erosion

Introduction: Bariatric surgery is increasingly performed nowadays. Gastroenterologists may encounter patients with its complications. Known complication of laparoscopic adjustable gastric banding (LAGB) include reflux, band slippage, erosion, pouch enlargement, and port breakage. We report a case with an unusual complication of LAGB. Case Description/Methods: A 45-year-old male with LAGB and atrial fibrillation presented with chronic diarrhea. Symptoms onset was 3 years ago after his partial small bowel resection when he presented with peritonitis. The patient reported loose stool within 15 minutes after each meal, abdominal pain, and 13-lbs weight loss. Physical exam was unremarkable. Laboratory data were within normal limits except mild anemia (Hgb of 12.9 g/dL) and mild renal impairment (Cr of 1.55 mg/dL). Upper GI study with small bowel follow through showed two separate channels arising from the proximal stomach with one connecting to the mid-transverse colon, suggesting a gastrocolic fistula (GCF) (figure 1A). CT scan of chest/abdomen/pelvis that was performed prior to barium studies was reviewed and demonstrated gastric erosion of the LAGB, with tethering of gastric cardia to the transverse colon with prolapse of the tubing into the distal transverse colon (figure 1B). Subsequent upper endoscopy showed an eroded gastric band in the gastric cardia and appeared to be extending through the gastric wall (figure 1C). Colonoscopy noted gastric band was entering transverse colon and extended distally (figure 1D). Surgical specimen of previous small bowel resection was reviewed and didn't show small bowel ischemia nor small bowel Crohn’s disease. The patient is currently evaluated by a bariatric surgeon for the definite treatment. Discussion: GCF is an uncommon manifestation of certain malignancies, pancreatitis, Crohn’s disease, peptic ulcer disease, and few cases related to other bariatric surgeries, usually with sleeve gastrectomy. LAGB related erosions of stomach, colon, and small bowel have been reported. To best of our knowledge, there are only 3 other cases of GCF related to LAGB. We report a rare complication of LAGB. Mechanism of GCF from LAGB is not fully understood, and is likely related to erosion of gastric wall from band pressure or foreign body reaction. Symptoms includes abdominal pain, weight loss, diarrhea, and sepsis. Diagnosis is made with upper GI series, contrast enhanced CT and endoscopic visualization. Surgery is the mainstay of treatment with removal of band and closure of fistula.Figure 1.: Endoscopic image of gastric ulcer in first case (A). Microscopic image H&E stained 400x of lymphoepithelial lesion with surrounding lymphocyte mucosal invasion (B). Endoscopic image of polypoid lesion in second case (C). Microscopic image H&E stained 200x of diffuse lymphocyte invasion into the lamina propria and muscularis mucosa (D).

Autonomous Hierarchical Surgical State Estimation During Robot-Assisted Surgery Through Deep Neural Networks

Many operations in robot-assisted surgery (RAS) can be viewed in a hierarchical manner. Each surgical task is represented by a superstate, which can be decomposed into finer-grained states. The estimation of these discrete states at different levels of temporal granularity provides a temporal perception of the current surgical scene during RAS, which is a crucial step towards many automated surgeon-assisting functionalities. We propose Hierarchical Estimation of Surgical States through Deep Neural Networks (HESS-DNN), a deep learning-based system that concurrently estimates the current super- and fine-grained states. HESS-DNN incorporates endoscopic vision, robot kinematics, and system events data from the da Vinci Xi surgical system. HESS-DNN is evaluated on a real-world robotic inguinal hernia repair surgery dataset: HERNIA-20, and achieves accurate state estimates of both surgical superstate and the corresponding fine-grained surgical state. We show that HESS-DNN improves state-of-the-art fine-grained state estimation across the entire HERNIA-20 RAS procedure through its hierarchical design. We also analyze the relative contributions of each input data type and HESS-DNN's design to surgical (super)state estimation accuracy.

S3177 Combination of Chemical Dissolution and Endoscopic Removal as an Alternative to Surgical Removal of Huge Phytobezoar

Introduction: Bezoars are the collection of undigested or slowly digested materials in the gastrointestinal tract. The phytobezoars are the most common type. Phytobezoars develop rapidly and usually present with gastric outlet obstruction symptoms. Here in, we report a case of giant phytobezoar which responded to chemical dissolution with carbonated fluids (Coca-cola) and cellulase which was later removed by endoscopic procedure. Case Description/Methods: A 65-year-old elderly male with a past medical history of arthritis presented with epigastric pain and vomiting for two months without any significant weight loss. He was found to have cholelithiasis and Cholecystitis on previous admission for similar complaints, for which he underwent laparoscopic cholecystectomy 1 month back. Persistent epigastric pain made us think of other possibilities. On further questioning, he said that he has been ingesting some herbs for arthritis. Subsequently, the patient underwent upper Gastrointestinal endoscopy, which revealed a stony hard, mobile, large bezoar of 9.0 × 10.0 cm. Endoscopic extraction was not possible due to hard consistency and huge size. Chemical dissolution with enzyme cellulase supplements and coca-cola drinks were advised to the patient. Two sequential endoscopies with an interval of 20 days demonstrated the reduced size of the bezoar, and it was successfully removed with the help of a polypectomy snare in piecemeal fashion. The patient remained symptoms free after the removal of the bezoar. Discussion: Gastric bezoars are indigestible foreign material and present with reduced gastric motility. Bezoars may be asymptomatic, but can cause serious complications. Diagnosis is made by imaging or by direct endoscopic visualization. Small soft bezoars can pass the intestinal tract and can be managed medically by inhibiting the gastric acid secretion or neutralizing secreted acid by administering the proteolytic enzymes, cellulase, carbonated fluids given orally or by gastric lavage followed by endoscopic fragmentation. However, large hard bezoars need aggressive surgical management. We treated the giant phytobezoar with chemical dissolution followed by endoscopic removal in piecemeal fashion. This approach has prevented the patient from going through the complications of surgical approach. We recommend that the chemical dissolution can be tried even in giant bezoars before considering a surgical approach. Ours is the first case that demonstrated the response of giant phytobezoar to chemical dissolution.

S3149 Plexiform Fibromyxoma: A Perplexing Condition of the Stomach

Introduction: Plexiform fibromyxoma (PF) is a rare, often benign tumor of mesenchymal origin typically found within the stomach. It features a plexiform cellular architecture of myofibroblasts encircled by a myxoid intercellular matrix with rich vasculature. Takahashi et. al described the first cases of known PF in 2007. It was officially recognized as a subtype of gastric mesenchymal neoplasm by the World Health Organization in 2010. Here, we present a case of PF detected during surveillance endoscopy. Case Description/Methods: 64-year-old male presented for esophagogastroduodenoscopy (EGD) with ablation of Barrett esophagus with low-grade dysplasia. He had undergone 4 previous EGDs remarkable for hyperplastic antral polyps which were removed. His most recent physical exam and labs were unremarkable. During the EGD, he was found to have antral erythema with no clear discernable lesions (figure 1). Biopsies of the region were obtained which stained negative for cytokeratin AE1/AE3, S100, CKIT/CD34 (in lesional cells), and DOG1 while positive for smooth muscle actin (SMA), consistent with PF. Discussion: The clinical presentation of PF is usually nonspecific. Commonly reported symptoms include abdominal pain, fullness, nausea, and vomiting, followed by complications of symptomatic anemia such as syncope. Reported size of PF lesions range from 0.8 - 17.0 cm. Immunohistochemically, the tumor cells are positive for SMA and vimentin, and can show focal or partial staining for CD10, desmin and caldesmon. The spindle cells are negative for DOG-1, C-KIT, epithelial membrane antigen (EMA), ALK, S-100 and CD34 with a low Ki-67 proliferation index. On CT or MRI imaging, PF appears as a solid, cystic, or solid/cystic mass with well-defined borders. Due to the increased vascularity of the tumor, CT with contrast may show mild enhancement of the solid portion during the arterial phase and strengthened progressive enhancement during the venous and delayed phases. Differential diagnoses for these tumors include gastrointestinal stromal tumors (GIST), leiomyoma, granular cell tumor, schwannoma, myxoma and angiomyxoma, gastric blastoma and malignant epithelioid tumor with GLI1 rearrangement. The current treatment of choice is surgical excision. Given the lack of clear lesion in our patient, further imaging will be obtained to attempt to determine margins. Increased awareness by endoscopists and pathologists of this condition is necessary for accurate diagnosis and management of this condition.Figure 1.: Endoscopic visualization of pre-pyloric ulcers.

TH21. CEREBROSPINAL FLUID PROTEOMICS TARGETED FOR CENTRAL NERVOUS SYSTEM PROCESSES IN BIPOLAR DISORDER

Primary central nervous system lymphoma (PCNSL) is a rare tumor with a poor prognosis. Early brain biopsy is essential to avoid a diagnostic delay. To date, reports of successful diagnosis for PCNSL of the corpus callosum by endoscopic biopsy are rare.Herein, we report the case of an elderly woman with PCNSL of the corpus callosum who initially presented with rapidly progressive dementia. The condition was finally diagnosed by microscopic biopsy after unsuccessful endoscopic biopsy. Moreover, the postoperative course was uneventful. She is currently receiving systemic chemotherapy.Early diagnosis and subsequent systemic chemotherapy with or without whole brain radiotherapy are critical for PCNSL. Endoscopic biopsy may be a diagnostic option for suspected PCNSL, although stereotactic needle biopsy is most commonly used.Utilizing neuronavigation and 5-aminolevulinic acid (ALA) fluorescence guidance could be helpful in identifying lesions insufficiently exposed by endoscopic visualization. However, cerebrospinal fluid (CSF) loss due to the endoscopic approach through the ventricle might be a cause of neuronavigation misregistration.

Feasibility study of endoscopic biliary drainage under direct peroral cholangioscopy by using an ultra-slim upper endoscope (with videos).

The therapeutic utility of peroral cholangioscopy (POC) is limited. Direct POC using an ultra‑slim upper endoscope expands the therapeutic indications because of its larger working channel, of up to 2.2 mm. We evaluated the feasibility of selective biliary drainage using a plastic stent under direct POC. From April 2015 to March 2019, biliary drainage under endoscopic visualization was performed in the same endoscopic session as direct POC without exchanging the duodenoscope. After guidewire insertion through the stricture or stone, a 5 Fr plastic stent and/or nasobiliary drainage catheter was used for biliary drainage. Selective biliary drainage under direct POC was performed in 32 patients, including 17 with difficult bile duct stones. Biliary drainage was performed with a plastic stent in 29 patients, nasobiliary drainage in one, and combined drainage in two patients. The technical success rate for biliary drainage placement under direct POC was 100 % (32/32). No significant procedure-related complications occurred. In conclusion, biliary drainage with a plastic stent or catheter under direct POC using an ultra-slim upper endoscope is feasible and may be useful for lesions obstructing the bile duct.

Early Outcome of Cold Knife Ablation and Diathermy Fulguration of Posterior Urethral Valve; A Comparative Study

Background: Posterior urethral valve (PUV) is the most common obstructive anomaly of the urethra. Urethral valves have a wide range of clinical and anatomical presentations and today most patients are diagnosed in the prenatal or early neonatal period. Cold knife and diathermy fulguration are two of the technique of PUV ablation.&#x0D; Objective: To find out early outcome of posterior urethral valve ablation between cold knife and diathermy fulguration.&#x0D; Methodology: This prospective comparative interventional study was conducted in the Department of Pediatric surgery in Dhaka Shishu Hospital (DSH), Dhaka. 54 patients with PUV, admitted for valve ablation during study period were included in this study. Patients were divided in to two group. Among them, 27 were in Group-A, whose PUV ablation were done by cold knife and 27 were in Group-B whose PUV ablation were done by diathermy fulguration. Successful ablation was confirmed under endoscopic vision as well as with the demonstration of good stream following supra pubic compression, at the end of the procedure. All patients were kept with 72 hours of urethral catheterization (All silicon self retaining Foley’s catheter according to body texture ) .Post PUV ablation pt. were given discharged with prophylactic antibiotics on 4th POD.&#x0D; Results: The mean age was found 18.37±16.13 months in cold knife ablation group and 12.70±11.03 months in diathermy fulguration group. Significant number (06/22.2%) of cases were associated with residual valve in diathermy fulguration group and non signicant number (301/3.7%) cases in cold knife ablation group . Significant number (04/14.8%) of cases were associated with post PUV ablation stricture urethra also in diathermy fulguration group and no stricture was found in cold knife ablation group . Significant hematuria. was present in 2(7.4%) in cold knife ablation group and 1(3.7%) in diathermy fulguration group.&#x0D; Conclusion: This study concludes that use of cold knife in case of ablation of PUV causes less post ablation obstruction (residual valve and stricture urethra) than using diathermy fulguration and can be regarded a safe and better option for PUV treatment.

V04-06 3D AUGMENTED REALITY ROBOT ASSISTED PARTIAL NEPHRECTOMY GUIDED BY INDOCYANINE GREEN: A STEP NEARER TO “AUTOMATIC” OVERLAPPING?

You have accessJournal of UrologyAdrenal & Renal Oncology I (Nephron Sparing Surgery) (V04)1 Sep 2021V04-06 3D AUGMENTED REALITY ROBOT ASSISTED PARTIAL NEPHRECTOMY GUIDED BY INDOCYANINE GREEN: A STEP NEARER TO “AUTOMATIC” OVERLAPPING? Francesco Porpiglia, Daniele Amparore, Federico Piramide, Enrico Checcucci, Paolo Verri, Gabriele Volpi, Sabrina De Cillis, Alberto Piana, Pietro Piazzolla, Andrea Bellin, Matteo Manfredi, Vezzetti Enrico, and Cristian Fiori Francesco PorpigliaFrancesco Porpiglia More articles by this author , Daniele AmparoreDaniele Amparore More articles by this author , Federico PiramideFederico Piramide More articles by this author , Enrico CheccucciEnrico Checcucci More articles by this author , Paolo VerriPaolo Verri More articles by this author , Gabriele VolpiGabriele Volpi More articles by this author , Sabrina De CillisSabrina De Cillis More articles by this author , Alberto PianaAlberto Piana More articles by this author , Pietro PiazzollaPietro Piazzolla More articles by this author , Andrea BellinAndrea Bellin More articles by this author , Matteo ManfrediMatteo Manfredi More articles by this author , Vezzetti EnricoVezzetti Enrico More articles by this author , and Cristian FioriCristian Fiori More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002000.06AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In the actual scenario of nephron sparing “precision” surgery, the availability of hyper-accuracy 3D models (HA3DTM) revealed to be useful thanks to their spatial visualization. In the last years, a step further was represented by the advent of Augmented Reality (AR) technology, in which the superimposition of 3D virtual images allowed an intraoperative surgical navigation. In this study, with the aim to automatize the 3D virtual and endoscopic images co-registration, we developed a dedicated software based on computer vision algorithms. METHODS: This is a feasibility study of our new dedicated software, named “IGNITE” (Indocyanine GreeN automatIc augmenTed rEality), able to automatically anchor the HA3DTM model with the endoscopic vision of the real organ. For this project we applied computer vision algorithms which need clear landmarks to correctly identify the target organ. In order to overcome the colors similarity of the operative field and to provide a more depictable shape for the software we decided to use indocyanine. In order to overcome the colors similarity of the operative field and to provide a more depictable shape for the software we decided to use indocyanine. In this way the kidney appears as a bright green organ surrounded by a dark operative field. We enrolled patients with renal mass scheduled for AR robot-assisted partial nephrectomy. All patients underwent a four-phase contrast-enhanced CT, in order to create the HA3D models, visualized as AR images inside the robotic console.Perioperative and postoperative data were collected and analyzed. RESULTS: Ten cases were enrolled in this pilot experience. Mean lesions size was 46.6 (+16.3) mm. Median PADUA score was 9 (IQR 8-10). Mean operative and ischemia time were 88.9 (+42.7) and 20.5 (3.5) min, respectively. In all the cases (even in completely endophytic or posterior tumors) the automatic tracking was successful without manual assistance by the operator, allowing to perform enucleoresection of the renal mass with no damages of the tumor’s pseudocapsule and avoiding positive surgical margins. Moreover, no intra- or postoperative complications (>2 according to Clavien- Dindo) were recorded. CONCLUSIONS: Present findings suggest that the new evolution of our AR platform based on computer vision algorithm allows an effective automatic AR RAPN. The automatic 3D model overlapping lead to a correct identification of the tumor, even in endophytic and posterior cases, without risk of complications or positive surgical margins. Source of Funding: N/a © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e292-e293 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Francesco Porpiglia More articles by this author Daniele Amparore More articles by this author Federico Piramide More articles by this author Enrico Checcucci More articles by this author Paolo Verri More articles by this author Gabriele Volpi More articles by this author Sabrina De Cillis More articles by this author Alberto Piana More articles by this author Pietro Piazzolla More articles by this author Andrea Bellin More articles by this author Matteo Manfredi More articles by this author Vezzetti Enrico More articles by this author Cristian Fiori More articles by this author Expand All Advertisement Loading ...

The Significance of Flat/Invisible Dysplasia and Nonconventional Dysplastic Subtypes in Inflammatory Bowel Disease: A Review of Their Morphologic, Clinicopathologic, and Molecular Characteristics.

Patients with inflammatory bowel disease are at significantly increased risk of dysplasia and colorectal cancer (CRC). The early detection, histologic grading, and removal of dysplasia plays a critical role in preventing the development of CRC. With advances in endoscopic visualization and resection techniques, colectomy is no longer recommended to manage dysplasia, unless surveillance colonoscopy detects flat/invisible dysplasia (either high-grade dysplasia or multifocal low-grade dysplasia) or an endoscopically unresectable lesion. Although there are numerous review articles and book chapters on the morphologic criteria of conventional (intestinal type) dysplasia, the most well-recognized form of dysplasia, at least 7 distinct nonconventional morphologic patterns of epithelial dysplasia have been recently described in inflammatory bowel disease. Most practicing pathologists are not familiar with these nonconventional subtypes and thus, may even overlook some of these dysplastic lesions as benign or reactive. However, the recognition of these subtypes is important, as some of them appear to have a high risk of developing advanced neoplasia (high-grade dysplasia or CRC) and often show molecular alterations characteristic of advanced neoplasia. This review briefly describes the morphologic criteria of conventional dysplasia but predominantly focuses on all 7 nonconventional subtypes as well as our understanding of their clinicopathologic and molecular features that can assist in their risk stratification.

Experimental investigation of 2-methyl furan as an additive with camphor blended gasoline blend for SI engines

The experimental investigation is performed on the MPFI spark-ignition engine fuelled by 20% camphor blended gasoline (CMO20) at various load conditions. In order to improve its performance characteristics, 2-methyl furan (2-MF) is added as an additive to the CMO20 blend in the proportions of 1%, 2%, and 3% by volume. In this study, the endoscopic combustion visualization technique is employed to compare and analyze the changes observed in the spatial flame characteristics between the test fuels. Also, the effect of 2-methyl furan as an additive with CMO20 blend on the engine combustion characteristics is studied. From the endoscopic results, it is found that the flame spread area with respect to different crank angle positions increases with2-MF concentration in the CMO20 during the early and middle stages of the combustion. The engine characteristics study results revealed that the CMO20 blend with 3% 2-MF gives a brake thermal efficiency (BTE) of 27.22% which is higher than sole gasoline and CMO20 blend whose values are 26.82% and 26.05%respectively at 8 kW load. It is observed that the early start of combustion and faster burn rate associated with 2-MF increased the cylinder pressure and heat release rates of the CMO20 blend. The CO and HC emission decreased by about 3.75% and 4.76% for 3% 2-methyl furan blended CMO20 blend when compared to sole gasoline and NOx emission slightly increased.

Single-Layer Fascia Patchwork Closure for the Extended Endoscopic Transsphenoidal Transtuberculum Transplanum Approach: Deep Suturing Technique and Preliminary Results

To describe a single-layer fascia patchwork closure (FPWC) without nasoseptal flap (NSF) and compare postoperative cerebrospinal fluid (CSF) leakage between FPWC using NSF and single-layer FPWC without NSF for the extended endoscopic transsphenoidal transtuberculum transplanum approach. Forty-five cases of suprasellar tumor in 42 patients were treated with extended endoscopic transsphenoidal removal, resulting in extensive, high-flow CSF leakage. Following the intradural procedure for treatment of various suprasellar tumors, fascia lata was inlaid subdurally on the cranial base defect and patch-sutured around its entire circumference under endoscope visualization, using an average of 17 stitches. Septal bone or hydroxyapatite plate was used for the hard support material against pulsatile intracranial pressure. NSF was added in the earlier 17 cases. Closure was completed without NSF in the more recent 28 cases when the Valsalva maneuver confirmed watertight closure. Two recent cases required NSF after Valsalva maneuver and were included in the FPWC+ NSF group. Postoperative CSF leakage did not occur in the FPWC+ NSF group but occurred in 2 patients in the single-layer FPWC group (7.1%) (P= 0.52). There was no significant difference in CSF leakage between single-layer FPWC and FPWC+ NSF. The mean suturing time for FPWC was 85.8 minutes, and the shortest was 39 minutes in a recent case (mean, 17 stitches; n= 35, video analysis). Single-layer FPWC may be a viable technical option for effective skull base reconstruction after the extended endoscopic transsphenoidal transtuberculum transplanum approach.

Current Helicobacter pylori Diagnostics.

The high prevalence of Helicobacter pylori and the variety of gastroduodenal diseases caused by this pathogen necessitate the use of only accurate methods both for the primary diagnosis and for monitoring the eradication effectiveness. There is a broad spectrum of diagnostic methods available for detecting H. pylori. All methods can be classified as invasive or non-invasive. The need for upper endoscopy, different clinical circumstances, sensitivity and specificity, and accessibility defines the method chosen. This article reviews the advantages and disadvantages of the current options and novel developments in diagnostic tests for H. pylori detection. The progress in endoscopic modalities has made it possible not only to diagnose precancerous lesions and early gastric cancer but also to predict H. pylori infection in real time. The contribution of novel endoscopic evaluation technologies in the diagnosis of H. pylori such as visual endoscopy using blue laser imaging (BLI), linked color imaging (LCI), and magnifying endoscopy is discussed. Recent studies have demonstrated the capability of artificial intelligence to predict H. pylori status based on endoscopic images. Non-invasive diagnostic tests such as the urea breathing test and stool antigen test are recommended for primary diagnosis of H. pylori infection. Serology can be used for initial screening and epidemiological studies. The histology showed its value in detecting H. pylori and provided more information about the degree of gastric mucosa inflammation and precancerous lesions. Molecular methods are mainly used in detecting antibiotic resistance of H. pylori. Cultures from gastric biopsies are the gold standard and recommended for antibiotic susceptibility tests.

O-024 Endoscopic management of the unexplained infertility, what does it add?

Abstract text Endoscopic management of the unexplained infertility, what does it add? Stephan Gordts stephan.gordts@lifeexpertcentre.be Unexplained infertility “strictu sensu” is not a diagnosis, but a description of a status where no causal factor is identified in a couple trying to conceive for at least one year. The more parameters are assessed, the more likely to identify an etiology, the less likely becomes “unexplained” infertility. Limiting the fertility exploration to indirect visualization techniques like ultrasound, HSG or HycoSy involves the risk of missing existing pathologies. Uterus Uterine volumetric abnormalities can be detected by indirect techniques, but information is lacking on the visualization of the endometrium in case of chronic endometritis and the presence of endometrial defects and hypervascularization areas as seen in patients with adenomyosis. Tubo-ovarian Even with the increased accuracy of indirect visualization techniques, lesions of minimal endometriosis and tubo-ovarian adhesions are not detected (Table). Tubal normality constitutes not only normal tubal patency but also normal tubal function. The importance of subtle tubal lesions is underestimated. Hydatid of Morgagni are detected in 38.1% in patients with infertility versus only in 16,7% in fertile women (Gupta et al. JMIG 2017).Removal of these lesions resulted in a spontaneous pregnancy rate of 58.7% versus 20.6 in the non-treated group (Rasheed et al. EJOG Repr. 2011). Endometriosis In a series of 107 patients with unexplained infertility and 3 failed IVF cycles (Agni Pantou et al. J. Clin. Med. 2019)laparoscopy revealed the presence of endometriosis in 57.97%, peri-adnexal adhesions in 23.3% and was normal in 18.69%. Also, in a group of patients with 3 failed IVF cycles and unexplained infertility (Xiaoming Yu et al.Medicine 2019) laparoscopy showed endometriosis in 57.7%, tubal abnormalities in 31.1% and adhesions in 33.3%. Laparoscopic correction of these pathologies did not only result in a spontaneous pregnancy rate of 35% but resulted also in a higher pregnancy rate after IVF compared to the non-treated control group. Unexplained infertility hides frequently undiagnosed endometriosis. Endometrial BCL6 levels, a proto-oncogene where overexpression is associated with increased cellular proliferation and progesterone resistance, are increased in patients with endometriosis. In case of elevated BCL6 in patients with unexplained infertility, laparoscopy confirmed the presence of endometriosis in 93.8% (Evans-Hoeker et al. 2016). Abnormal BCL6 expression in a population with unexplained infertility reduced the chance of having a successful IVF treatment in 74% of the population (Almquist et al. Fertil Steril 2017). Transvaginal Hydro Laparoscopy Direct endoscopic visualization remains important but due to the invasiveness, diagnostic standard laparoscopy is frequently postponed or omitted in the exploration of the infertile patient. The technique of transvaginal hydro-laparoscopy allows in a minimal invasive way the inspection of the pelvis. In a consecutive series of 2288 patients without obvious pelvic pathology, findings were normal in 49.3%, endometriosis was diagnosed in 15.9% and tubal pathology in 14.5% of the patients (Gordts et al. FVV 2021). The rate of failed access was 1% and the complication rate 0.74%. Causing a minimal ovarian trauma, treatment of these early endometriotic lesions resulted in a spontaneous pregnancy rate of 73.2%. Conclusion The inappropriate use of “unexplained infertility” by omitting the diagnostic endoscopy in the exploration of the infertile patient, can hide undiagnosed and treatable pathology, jeopardizing possibilities for patients for a spontaneous conception and can be responsible for reduced pregnancy rates after IVF.

Retrospective analysis of silicon intubation by Ritleng probe and Sutupak suture fixed in silicone tube in congenital nasolacrimal duct obstruction.

Purpose:The aim of this study was to perform a retrospective review of the outcome of silicon intubation using the Ritleng probe and a modified braided silk suture (Ethicon Sutupak) fixed in a silicone tube in children with congenital nasolacrimal duct obstruction (CNLDO).Methods:Records of all children between 1 and 12 years of age who underwent silicone tube intubation with the Ritleng probe and Ethicon Sutupak suture (2-0) fixed in silicone tube for CNLDO with a minimum of 1-year follow-up were identified. The hollow Ritleng probe was inserted via the canaliculus into the inferior meatus. The Sutupak thread-guide, attached to the silicone tube, was advanced through the probe lumen and retrieved using a hook under endoscopic visualization. The tube ends were tied to each other and tube removal was planned after 3 months. Absence of watering, discharge, and matted lashes after removal of silicone tube was defined as success.Results:One hundred and fifty-two eyes of 152 children with a mean age of 3.26 ± 2.3 years were included in the study. The procedure was successful in 145 eyes (95%) after removal of the silicone intubation with relief of symptoms observed in most patients by fifth-day follow-up (n = 120 eyes, 83%). The mean duration of follow-up was 3.48 ± 1.3 years. No other significant differences were observed between patients who did (n = 47) and did not (n = 105) have previous probing including success rates (95% vs. 96%, P = 0.89).Conclusion:Silicone intubation with Ritleng probe and Sutupak suture fixed in silicone tube was successful in resolution of symptoms of CNLDO in majority of patients. Using a low-cost suture did not affect success rates.

Gastroesophageal Stents for the Management of Post Sleeve Gastrectomy Leakage: Interventional Radiology Experience

Abstract Objective The aim of this study was to assess the efficacy and safety of retrievable, self-expandable gastroesophageal stents to manage gastric leaks post sleeve gastrectomy by interventional radiology (IR). Methods This is a retrospective study of patients with gastric leaks post sleeve gastrectomy who were managed with gastroesophageal stent placement. The diameters of the stents ranged from 23 to 30 mm and the lengths 12.5 to 24 cm. Results Thirty-one patients (mean age, 32.4 ± 7.97 years) were included in the study, and 46 stents were placed. The total average stenting time was 59.1 ± 35.5 days. Leakage resolved in 93.5% of the patients. Thirty-eight (82.6%) of the stents were retrieved by IR, and the remaining stents were retrieved under endoscopic visualization. Stricture occurred as a complication in four patients: three of which were treated with stenting (one by IR and two by endoscopy) and one required esophagoplasty. Six patients experienced stent migration, three of which underwent stent adjustment, while the remaining three underwent stent reinsertion Conclusion Gastroesophageal stent placement by IR for gastric leaks post sleeve gastrectomy is safe and effective in our study.

Combined microsurgical-endoscopic paramedian supracerebellar-infratentorial approach for resection of a pineal low-grade glioma.

The authors present the case of a 20-year-old male with a history of headaches and blurred vision found to have a pineal mass and chronic hydrocephalus. The patient initially underwent an endoscopic third ventriculostomy and pineal mass biopsy that revealed a low-grade neuroepithelial neoplasm. A microsurgery-endoscope–assisted paramedian supracerebellar-infratentorial approach was chosen and a gross-total resection was achieved. The patient’s postoperative and follow-up course has been unremarkable, with early postoperative imaging demonstrating no residual tumoral mass. The operative video highlights the advantages of endoscopic visualization for deep lesions in the pineal region and posterior third ventricle.The video can be found here: https://stream.cadmore.media/r10.3171/2021.4.FOCVID2119.

Accurate instance segmentation of surgical instruments in robotic surgery: model refinement and cross-dataset evaluation.

Automatic segmentation of surgical instruments in robot-assisted minimally invasive surgery plays a fundamental role in improving context awareness. In this work, we present an instance segmentation model based on refined Mask R-CNN for accurately segmenting the instruments as well as identifying their types. We re-formulate the instrument segmentation task as an instance segmentation task. Then we optimize the Mask R-CNN with anchor optimization and improved Region Proposal Network for instrument segmentation. Moreover, we perform cross-dataset evaluation with different sampling strategies. We evaluate our model on a public dataset of the MICCAI 2017 Endoscopic Vision Challenge with two segmentation tasks, and both achieve new state-of-the-art performance. Besides, cross-dataset training improved the performance on both segmentation tasks compared with those tested on the public dataset. Results demonstrate the effectiveness of the proposed instance segmentation network for surgical instruments segmentation. Cross-dataset evaluation shows our instance segmentation model presents certain cross-dataset generalization capability, and cross-dataset training can significantly improve the segmentation performance. Our empirical study also provides guidance on how to allocate the annotation cost for surgeons while labelling a new dataset in practice.