Fiberoptic Endoscopy Research Articles

Transmural gastric closure and NOTES – How far have we come?

The ability to perform secure closure of transmural gastric defects will represent a significant milestone in the evolution of therapeutic gastrointestinal endoscopy. In 1958, the flexible fiberoptic endoscope was introduced by Larry Curtiss and Basil Hirschowitz as a diagnostic modality. Over the ensuing decades, an interventional focus gradually took shape – initially for more invasive diagnostic techniques, such as biopsies and polypectomies, but later encompassing hemostasis, pancreaticobiliary procedures (i. e., endoscopic retrograde cholangiopancreatography and sphincterotomies), fine needle aspirations under endoscopic ultrasound guidance, and endoscopic mucosal resection and endoscopic submucosal dissection for resection of early-stage cancers. However, this growing interventional focus was mostly confined to the gastrointestinal lumen.

Ex Vivo Diagnosis of Lung Cancer Using a Raman Miniprobe

Lung cancer is the most common cause of cancer death. The conventional method of confirming the diagnosis is bronchoscopy, inspecting the airways of the patient with a fiber optic endoscope. A number of studies have shown that Raman spectroscopy can diagnose lung cancer in vitro. In this study, Raman spectra were obtained from ex vivo normal and malignant lung tissue using a minifiber optic Raman probe suitable for insertion into the working channel of a bronchoscope. Shifted subtracted Raman spectroscopy was used to reduce the fluorescence from the lung tissue. Using principal component analysis with a leave-one-out analysis, the tissues were classified accurately. This novel technique has the potential to obtain Raman spectra from tumors from patients with lung cancer in vivo.

The Value of Breast Ductoscopy in Radiologically Negative Spontaneous/Persistent Nipple Discharge

Breast ductoscope is a fiberoptic endoscope used for examining the distal breast ducts under direct vision in order to identify the source of pathologic nipple discharge. The purpose of this study was to investigate the reliability of intra-operative breast ductoscopy in patients with pathologic nipple discharge, which could not be identified by radiologic tests. Between April 2002 and March 2007, breast ductoscopy was performed in 34 patients who had pathologic nipple discharge with no radiologic evidence about the source. The procedures were carried out under general anesthesia and ductoscopic findings were as well as the histopathology of the specimens were recorded and documented. In 88%, (30 of 34) of the patients, endoscope was successfully introduced into the external orifice of the ducts at the nipple and proximal breast ducts were successfully visualized. Ductoscopy revealed intraductal lesions (i.e., ductal obstruction, intraductal papilloma, red patches, and erythematoid platter) in 20 patients (66%). Among the 20 patients with visible endoluminal pathology, nine had a papilloma and eight had signs of either acute inflammation (bleeding, erythema) or previous inflammation with healing (adhesions and blocked ducts). In two cases, invasive breast carcinoma was identified, one of which was ductal carcinoma in situ (DCIS) with minimal invasion. In both cases, there had been blocked ducts. In one case DCIS was identified. Breast ductoscopy is a reliable and easy-to-use method to demonstrate the source of pathologic nipple discharge in cases with bleeding and other intraductal lesions.

A contemporary review of voice and airway after laryngeal trauma in children

To discuss three cases of pediatric laryngeal trauma that highlight current techniques in diagnosis and treatment of the voice following laryngeal trauma. To examine the diagnostic utility of "chip tip" video laryngoscopy and to explore the current uses for open, endoscopic, or combined approaches within the context of these cases. Case series with review of contemporary techniques. A case series of three children who sustained laryngeal trauma is presented. Ages range from 6 weeks to 17 years. The diagnostic evaluation and treatment strategies are reviewed with a focus on contemporary techniques. A 15-year-old boy who sustained blunt neck trauma was diagnosed with a vocal fold avulsion on video laryngoscopy with digital image processing and a significant mucosal tear with exposure of the paraglottic space on direct laryngoscopy. Anatomical reapproximation required a combined open and endoscopic repair. A 17-year-old football player developed a glottic hematoma after blunt cervical trauma. This was managed conservatively with serial chip tip video laryngoscopy that provided high fidelity images and facilitated proper and timely diagnosis and treatment. A 6-week-old male suffered vocal fold avulsion from a traumatic intubation. Laryngofissure with reattachment of the vocal fold resolved his aspiration and reconstructed the laryngeal anatomy. Enhanced imaging via chip tip video laryngoscopy, compared to conventional fiberoptic endoscopy, might provide additional diagnostic information in pediatric patients with laryngeal trauma. Additionally, there could be a role for video strobolaryngoscopy in selected laryngeal trauma patients. Open, endoscopic, and combined approaches could be used to optimize voice and swallowing outcomes in pediatric laryngeal trauma.

Application of fibreoptic endoscope in evaluation of swallowing

To investigate the effect of fibreoptic endoscopic evaluation of swallowing (FEES) in the assessment of dysphagia. Fifty-two patients with neurogenic dysphagia underwent FEES and videofluoroscopy (VF) within a 2-day period. The results obtained were compared. FEES with all consistencies revealed premature leakage in 48.1%, pooling in 75.0%, penetration in 69.2%, and aspiration in 55.8%, silent aspiration in 28.8% of patients. VF revealed above items in 44.2%, 63.5%, 57.7%, 46.2%, 21.2%, respectively. The FEES was then measured against the VF for sensitivity, specificity, positive predictive value, and negative predictive value. FEES showed higher sensibility and negative coincidence rate of penetration (90.0%, 81.3%), aspiration (87.5%, 87.0%) and silent aspiration (90.9%, 97.3%). According to the severity, the dysphagia in patients was classified into no penetration, penetration, aspiration and silent aspiration. A weighted Kappa value of 0.713 signified "substantial" agreement between the two tests. FEES is an effective and valuable tool for evaluating oropharyngeal dysphagia, and is helpful in guiding the patients for diet and rehabilitation.

SH02 HAROLD H. HOPKINS – BROUGHT LIGHT TO DARKNESS

There is no doubt endoscopy and minimal invasive surgery has revolutionised the diagnostic and therapeutic approaches of a multitude of surgical disorders. Some of the most important milestones in the development of endoscopy and minimal invasive surgery have been attributed to the work of Harold H. Hopkins.Harold H. Hopkins, born on December 6, 1918, was a renowned physicist for his contribution in optical science. The first notable invention of Hopkins was the zoom lens. However, his first notable contribution to medicine started when he met Hugh Gainsborough, a gastroenterologist dissatisfied with the instruments for performing gastroscopy. The development of the ‘fiberscope’, consisting of a bundle of very fine glass fibres that eventuated as the flexible fiberoptic endoscopes in use today.In 1959, the invention of the “rod‐lens” system represented a significant development in endoscopy from the conventional lens system used at the time by using glass rods that occupy most of the telescope tube, hence reducing the glass/air interfaces. The result was brighter images and smaller diameter of the telescope. Nevertheless, it was not until 1965 when the idea was recognised by Professor George Berci, a young Australian surgeon at the time, who introduced the system to Karl Storz in Germany and manufactured the first prototype. The subsequent range of rigid endoscopes produced became worldwide standards for their excellent image quality.Hopkins died on October 22, 1994, but his legacy in development of optical systems revolutionised the development and application of endoscopy and minimal invasive surgery.

Autofluorescence Endoscopy

Autofluorescence endoscopy is a wide area imaging technique, with the ability to rapidly examine a large surface area of gastrointestinal mucosa to detect small areas of dysplasia or cancer. It has potential in diseases such as Barrett's esophagus, ulcerative colitis, and gastric cancer, in which large areas of mucosa may harbor areas of dysplasia or superficial cancer not visible on conventional or high-definition white-light endoscopy. Autofluorescence endoscopy technology has evolved from fiberoptic to video technology with a marked improvement in image quality. Although fiberoptic autofluorescence endoscopy seems to provide no advantage over conventional white-light imaging, videobased technology, especially if combined with narrow band imaging, offers great promise for enhancing endoscopic surveillance of Barrett's esophagus. However, for this technology to have future clinical applications, image quality still needs to be improved and the false positive rate needs to be decreased further. Autofluorescence technology detects indirect measures of dysplasia and carcinoma, and is nonspecific, so additional enhancements are clearly desirable.

Ian Gilmore: President of the Royal College of Physicians

Ian Gilmore: President of the Royal College of Physicians

Acoustic analysis of swallowing sounds: A new technique for assessing dysphagia

To perform acoustic analysis of swallowing sounds, using a microphone and a notebook computer system, in healthy subjects and patients with dysphagia affected by neurological diseases, testing the positive/negative predictive value of a pathological pattern of swallowing sounds for penetration/aspiration. Diagnostic test study, prospective, not blinded, with the penetration/aspiration evaluated by fibreoptic endoscopy of swallowing as criterion standard. Data from a previously recorded database of normal swallowing sounds for 60 healthy subjects according to gender, age, and bolus consistency was compared with those of 15 patients with dysphagia from a university hospital referral centre who were affected by various neurological diseases. Mean duration of the swallowing sounds and post-swallowing apnoea were recorded. Penetration/aspiration was verified by fibreoptic endoscopy of swallowing in all patients with dysphagia. The mean duration of swallowing sounds for a liquid bolus of 10 ml water was significantly different between patients with dysphagia and healthy patients. We also described patterns of swallowing sounds and tested the negative/positive predictive values of post-swallowing apnoea for penetration/aspiration verified by fibreoptic endoscopy of swallowing (sensitivity 0.67 (95% confidence interval 0.24-0.94); specificity 1.00 (95% confidence interval 0.56-1.00)). The proposed technique for recording and measuring swallowing sounds could be incorporated into the bedside evaluation, but it should not replace the use of more diagnostic and valuable measures.

How we do it: A combined method of traditional curette and power-assisted endoscopic adenoidectomy

Conclusion. After conventional curette adenoidectomy, a significant mass of residual adenoid tissue is observed in about 50% of the cases. The combined approach of conventional curette and endoscopic adenoidectomy with microdebrider assures a complete and accurate removal of the mass. It is an effective and safe method without significantly prolonging the operative time. Objectives. To describe the surgical technique of conventional curette adenoidectomy completed with the microdebrider under endoscopic vision in case of residual adenoid tissue. Patients and methods. This was a retrospective review of 143 consecutive patients (age range 2–16 years, mean 6.2) who underwent endoscopic adenoidectomy for adenoid hypertrophy at an academic hospital-based institution. A classic transoral curette adenoidectomy was performed initially. Then a rigid fibre-optic endoscope was used transnasally to assess the completeness of surgery. Residual adenoid tissue was removed using a microdebrider under endoscopic vision. Results. After conventional curette adenoidectomy 70 children (48.9%) underwent residual adenoid tissue transnasal removal. Mean curette adenoidectomy time with endoscopic visualization of the nasopharynx was 9.1 min and, in the case of completion with the microdebrider, 14.6 min. No significant intraoperative bleeding, postoperative haemorrhage or other complications have occurred. After a mean follow-up of 24.4 months, no patients have been readmitted for symptoms of adenoid regrowth.

An uncommon case of right-sided throat pain and swallow syncope

A 63-year-old man presented with recurrent syncopal attacks associated with swallowing and right-sided throat pain. Immediately after admission, he presented a 16-s asystolia. The patient's clinical history was unremarkable except for previous postimplant periodontitis. Several episodes of severe bradycardia and sinus pauses, always associated with painful deglutition, were recorded subsequently. X-ray orthopanthomography and magnetic resonance imaging of the neck confirmed several areas of periodontitis around the previous dental implants and right mastoid inflammation. A barium swallow and fibre-optic endoscopy also revealed a small sliding hiatus hernia and distal chronic oesophageal inflammation. Despite complete dental curettage, antibiotics and antigastro-oesophageal reflux therapy, only partial relief of the pain and incomplete resolution of the arrhythmic disorder were obtained after 3 weeks, and the patient underwent pacemaker implantation. At 1-month follow-up, however, he reported the complete relief of the throat pain; subsequent Holter monitoring showed normal sinus rhythm, without pacemaker-induced electrical activity.

O.435 CT face in the primary survey of polytrauma

Introduction: Laryngotracheal injuries are uncommon with an estimated incidence of 1‰ (1–6 patients per 15 000–42 500 trauma victims). They may be associated with fractures of the facial skeleton. Their symptoms are variable ranging from obvious airway obstruction to minor or almost missing symptoms. Early diagnosis and proper initial management may sometimes be difficult or delayed.Patients: Three patients with maxillofacial fractures and concomitant laryngotracheal injuries are presented. The diagnostic procedures used and the management of these injuries are reported.Discussion and Conclusion: Due to their low incidence and their hidden nature laryngotracheal injuries may pose diagnostic problems, especially in polytraumatized or intubated patients. Subcutaneous emphysema is the chief clinical sign. Fibreoptic endoscopy is the most important and informative diagnostic examination. Radiographic evaluation by CT scan provides additional information about the extent of the injury and the indication for surgery. A coordinated team approach is necessary for proper management of these injuries.

High-Speed Imaging Used to Detect Vocal Fold Paresis: A Case Report

High-speed imaging has been used to study vocal fold vibration and has been shown to provide additional information in aid of our understanding of pathologic vocal fold vibration. This is the first case report of vocal fold paresis diagnosed by high-speed imaging. An 18-year-old girl presented with intermittent voice loss that had been present for 4 years. The patient had been seen by other otolaryngologists and had been given proton pump inhibitors without any improvement in her voice. Her voice was diplophonic. The patient was examined by rigid stroboscopy and was found to have a predominantly open phase pattern but a normal vibratory pattern. High-speed photography showed a distinct vibratory frequency for each vocal fold, suggestive of a paresis pattern. Laryngeal electromyography confirmed the diagnosis of vocal fold paresis. A computed tomographic scan of the larynx and chest showed a thymoma. After thymectomy, the patient recovered full voice function. High-speed imaging is useful for the clinical evaluation of pathologic vocal fold vibration and can detect subtle features of paralysis that may not be detected on fiberoptic endoscopy and rigid stroboscopy. The additional information from high-speed imaging helped to make the diagnosis of vocal fold paresis in this patient.

Idiopathic Pneumatosis Coli Presenting as an Isolated Submucosal Mass Confirmed by Endoscopic Ultrasound

Purpose: Pneumatosis coli, also known as pneumatosis cystoides intestinalis (PCI), is a rare condition involving gas in the bowel wall. Primary, or idiopathic, PCI is an uncommon form, comprising 15% of all cases of PCI. We present a case where a patient with idiopathic, isolated PCI was misdiagnosed in the community and referred to our institution, where we made the diagnosis with endoscopic ultrasound. Methods: N/A Results: A 54 year-old Caucasian man underwent average-risk colon cancer screening colonoscopy at a community endoscopy center. Colonoscopy revealed a 10 mm submucosal lesion at the splenic flexure, and two much smaller similar-appearing lesions adjacent to it (see image). A few biopsies were taken with cold forceps. The remainder of the colon and distal terminal ileum appeared normal. Histologic analysis revealed benign mucosal tissue and mildly disordered glandular architecture. He was referred to our institution for evaluation with EUS for suspicion of lipoma versus submucosal nodules. The patient denied any GI or respiratory symptoms. His past medical history included hypertension and depression, for which he was taking antihypertensive and antidepressant medications. Two months later at our institution, the patient underwent a fiber-optic lower endoscopy to the transverse colon, which revealed a smooth, round, centimeter-sized submucosal lesion at the splenic flexure, with a few smaller similar-appearing lesions adjacent to it. These were soft when probed. EUS revealed anechoic areas in the submucosa with air shadows. A sclerotherapy needle was inserted into two of the masses, and air was aspirated from them. Conclusion: Idiopathic pneumatosis coli can present as an isolated lesion in an asymptomatic patient. Endoscopists should be aware of the typical features of pneumatosis coli to avoid misdiagnosis and unnecessary treatment. EUS can be a useful diagnostic tool in diagnosing pneumatosis coli.

Pharyngeal residue across the lifespan: a first look at what’s normal

Without good evidence, post-swallow pharyngeal residue is considered abnormal. Our aim was to document residue from normal food and fluid boluses in young and elderly healthy populations. Prospective, single-blind assessment of residue severity from Fibreoptic Endoscopic Evaluation of Swallowing. Tertiary specialist ENT teaching hospital. Fifty-one healthy participants; twenty-one aged <40 and thirty aged 65+. Each swallowed six representative boluses. Two teams independently rated pharyngeal residue severity at 11 anatomical sites. The mean residue scores were less than 1 when averaged across all boluses and anatomic sites. Differences due to age were slight. Our preliminary data indicate that substantial pharyngeal residue is not common in young or elderly, and probably indicates disordered swallowing.

Rhabdomyomatous well-differentiated liposarcoma arising in giant fibrovascular polyp of the esophagus

We report an example of an esophageal giant fibrovascular polyp harboring a well-differentiated liposarcoma with rhabdomyomatous differentiation in a 68 year-old man. Initial imaging studies including fiberoptic endoscopy and 2 computed tomographic examinations, and laparoscopic myotomy failed to demonstrate the polypoid intraluminal nature of the lesion. Thus, alternative diagnoses including a malignant neoplasm and achalasia were entertained. A third computed tomography with contrast showed a pedunculated mass. Surgical resection revealed a 15-cm smooth-surfaced club-shaped mass composed of a well-differentiated liposarcoma demonstrating myoglobin, muscle-specific actin, and myogenin-positive rhabdomyomatous differentiation. To date, no previously reported giant fibrovascular polyp case has described a liposarcoma with rhabdomyomatous change.

Maintenance of airway caliber in isolated airways by deep inspiration and tidal strains

Deep inspirations (DIs) are large periodic breathing maneuvers that regulate airway caliber and prevent airway obstruction in vivo. This study characterized the intrinsic response of the intact airway to DI, isolated from parenchymal attachments and other in vivo interactions. Porcine isolated bronchial segments were constricted with carbachol and subjected to transmural pressures of 5-10 cmH2O at 0.25 Hz (tidal breathing) interspersed with single DIs of amplitude 5-20 cmH2O, 5-30 cmH2O, or 5-40 cmH2O (6-s duration) or DI of amplitude 5-30 cmH2O (30-s duration). Tidal breathing was ceased after DI in a subset of airways and in control airways in which no DI was performed. Luminal cross-sectional area was measured using a fiber-optic endoscope. Bronchodilation by DI was amplitude dependent; 5-20 cmH2O DIs produced less dilation than 5-30 cmH2O and 5-40 cmH2O DIs (P=0.003 and 0.012, respectively). Effects of DI duration were not significant (P=0.182). Renarrowing after DI followed a monoexponential decay function to pre-DI airway caliber with time constants between 27.4+/-4.3 and 36.3+/-6.9 s. However, when tidal breathing was ceased after DI, further bronchoconstriction occurred within 30s. This response was identical in both the presence and absence of DI (P=0.919). We conclude that the normal bronchodilatory response to DI occurs as a result of the direct mechanical effects of DI on activated ASM in the airway wall. Further bronchoconstriction occurs by altering the airway wall stress following DI, demonstrating the importance of continual transient strains in maintaining airway caliber.

Fast handheld two-photon fluorescence microendoscope with a 475 μm × 475 μm field of view for in vivo imaging

A fast handheld two-photon fiber-optic fluorescence endoscope for three-dimensional (3D) in vivo cellular imaging is developed. The compact handheld probe of the two-photon endoscope can simply be placed into contact with the target tissue to reveal clear 3D surface and subsurface histological images without biopsy. The new system has, to the best of our knowledge, the largest field of view (FOV) of 475 microm x 475 microm and a 3D imaging volume larger than 475 microm x 475 microm x 250 microm. A real-time two-photon fluorescence image is displayed at 0.4 mm(2)/s. The lateral and axial resolutions of the two-photon fluorescence endoscope are better than 1 and 14.5 microm, respectively.

Automatic feature generation in endoscopic images

Fiber optic endoscopy is essential for minimally invasive surgery, but endoscopic images are very challenging for computer vision algorithms, since they contain many effects like tissue deformations, specular reflections, smoke, variable illumination and field of view. We developed a method to extract features from endoscopic images usable for scene analysis and classification. These features could be used with data from other sensors for workflow analysis and recognition. Evolutionary reinforcement learning that automatically computes good features, making it possible to classify endoscopic images into their respective surgical phases. It is especially designed to abstract the relevant information from the highly noisy images automatically. Automatic feature extraction was used to classify images from endoscopic cholecystectomies into their respective surgical phases. These automatically computed features perform better than some classical features from computer vision. The automated feature extraction process enables reasonable classification rates for complex and difficult images where no good features are known. We developed an automatic method that extracts features from images for use in classification. The method was applied to endoscopic images yielding promising results and demonstrating its feasibility under demanding conditions.

Obstruction of the Eustachian Tube Orifice and Pressure Changes in the Middle Ear: Are They Correlated?

We performed a cross-sectional study to investigate whether the obstruction of the eustachian tube orifice due to adenoid hyperplasia changes the pressures in the middle ear. Fifty consecutive children 2 to 12 years of age with nasal obstruction were examined from May to October 2005. Adenoid size and status of the eustachian tube orifice were assessed with nasal flexible fiberoptic endoscopy. Tympanometry was used to evaluate the middle ear. In children with occlusion of the eustachian tube orifice by adenoid tissue, 87% had abnormal pressure in the middle ear according to tympanograms. When orifices were not occluded, 86% of the tympanograms were normal (p < .001). Obstruction of the eustachian tube orifice by adenoid tissue was associated with tympanograms suggestive of abnormal pressure in the middle ear. Future studies with a larger sample size are necessary to clarify this association.