Flexible Endoscopy Research Articles

Adenoid ve Nazal Patolojilerin Pediatrik Epistaksisteki Etkileri

Aim: The aim of this study was to investigate the effects of adenoid and nasal pathologies in paediatric patients with recurrent epistaxis.Methods: A total of 100 (61 boys, 39 girls) individuals aged 2–17 years (mean age: 8.9 ± 3.6 years) were included in this study. Anterior rhinoscopy and flexible nasal endoscopy were used to examine all the patients. The epistaxis duration, treatment in active epistaxis by parents, medical history, medical treatment and interventions were recorded. The location of the epistaxis site, nasal mucosa type, the presence of nasal vestibulitis, nasal septum deviation location and type, adenoid size and the degree of inferior turbinate hypertrophy were recorded.Results: The deviation was present in 31 (62%) patients with recurrent epistaxis and in 14 (28%) patients without epistaxis. The presence of deviation was significantly higher in the epistaxis group than in the control group (p < 0.05). The nasal mucosa type was friable mucosa in 37 (74%) patients, vascularised mucosa in 11 (22%) patients and friable-vascularised mucosa in 2 (4%) patients in recurrent epistaxis group. A significant relationship was detected between nasal mucosa type and age, the presence of the deviation, deviation location, the Mladina type in epistaxis group (p < 0.05, p < 0.05, p < 0.05, p < 0.05).Conclusion: Nasal septum deviation, inferior turbinate hypertrophy and nasal mucosa type are associated with paediatric recurrent epistaxis.

Endoluminal Suture-technique for the Stomach Closure of an Experimental Model.

In the modern minimally invasive era, diagnostic and therapeutic endoscopic interventions are one of the most emerging fields. For the new operational techniques, it is a major aim to develop reliable instruments, such as suturing devices for flexible endoscopes. The aim of this study was to assess the feasibility of a safe and reproducible suturing technique with an endoluminal suturing device. The evaluation of the technique was performed in twenty explanted special prepared porcine stomachs. Three different techniques were compared, single stitches, figure-of-eight, or Z-pattern and running sutures in terms of suturing time and bursting pressure. After verification of the reliability of the method, a 3 cm long full thickness incision on the stomach was closed with the endoscopic suturing device in four surviving animals. In our ex vivo studies, we have shown that the figure of 8 or Z- technique is the most optimal for stomach closure without considerable time-cost, thus this technique was chosen as the standard method for the in vivo study. The endoscopic stomach wall suturing was successful in all four cases, the postoperative period was uneventful and ended on the tenth postoperative day with autopsy. With the applied suturing device, the endoscopic suturing of the stomach is safe and reproducible, thus a human application may also be justified.

Uroflowmetry is a viable surrogate for urethroscopy in evaluation of anatomical success following urethroplasty.

This study aimed to investigate the utility of uroflowmetry in predicting anatomical success following urethroplasty based on real-world clinical data. Data from 100 male patients who underwent urethroplasty for urethral strictures at our institute were analyzed. Postoperative anatomical success was determined as the passage of a 16.2 Fr flexible endoscope after approximately 4months following the procedure. Sensitivity and specificity of the maximal flow rate (Qmax ), average flow rate (Qave ), and Qmax - Qave for anatomical success were determined, along with receiver operating characteristic analysis. The optimal cutoff was set using Youden's index. Anatomical success was observed in 67%. Voided volumes in the success and failure groups were equivalent: 252 ± 121 versus 242 ± 91 ml, respectively. In 18 cases, voided volumes were <150 ml. Parameters of uroflowmetry were all significantly higher in the anatomical success group when compared to those in the failure group: the mean value of Qmax was 26.1 versus 15.0ml/s; Qave , 14.2 versus 9.1ml/s; and Qmax - Qave , 11.9 versus 5.9ml/s, respectively (p< 0.0001 for each parameter). The area under the curve was 0.8082 for Qmax , 0.7727 for Qave , and 0.8186 for Qmax - Qave . Optimal cutoff values for Qmax and Qmax - Qave were 20 and 6 ml/s, which predicted anatomical success with 86% and 87% positive predictive value, respectively. This analysis presents statistically valid cutoffs by which uroflowmetry can be used as a viable surrogate of anatomical success following urethroplasty in clinical practice.

Design and control of a new electrostrictive polymer based continuum actuator for endoscopic robot

Minimally Invasive Surgery (MIS) consists of the insertion of a flexible endoscope into the patient body through natural orifices. Over the past few decades, the growing interest in microelectromechanical systems (MEMS) has paved the way for ubiquitous miniaturized integrated sensors and actuators in medical endoscopy. Nowadays, recent advances in materials have opened a promising way to fulfill the surgical requirements and size constraint for the development of smart continuum structures. Among smart materials, electroactive polymers (EAPs) exhibit exceptionally large, fast, repeatable, and reversible motions while perfectly meeting the requirements of micro-integration. However the high applied voltage required for the actuation is not compatible with in vivo medical application. To overcome these issues, a multilayered concept has been proposed. In this work a relaxor ferroelectric electrostrictive polymer is studied for its large electromechanical strain. A wide range of parameters involved in the active material has led us to the development of a finite element model on Abaqus to guide the experimental development. Then, to control this smart endoscopic robot a kinematic and a dynamic models have been built. To test and validate these models a Co-simulation procedure has been developed. This procedure coupled Abaqus and Matlab-Simulink allowing testing proposed control algorithms.

Multicenter clinical trial for the resection of rectal polyps using a new laparoendoscopic hybrid transanal access device

IntroductionComplex polyps require the use of advanced endoscopic techniques or minimally invasive surgery for their approach. In rectal polyps it is of special relevance to reach a consensus on the best approach to avoid under- or overtreatment that increases unnecessary morbidity and mortality. MethodsWe describe a prospective, multicenter, pilot clinical trial with a first-in-human medical device. It is hypothesized that UNI-VEC® facilitates transanal laparoendoscopic surgery for the removal of early rectal tumors. The primary objective is to evaluate that it is safe and meets the established functional requirements. Secondary objectives are to evaluate results, complications and level of satisfaction. Results16 patients were recruited in 12 months with a minimum follow-up of 2 months. The mean size was 3.4 cm with the largest polyp being 6 cm. Regarding location, the mean was 6.6 cm from the anal margin. Endoscopic Mucosal Resection (EMR) (6.3%), Endoscopic Submucosal Dissection ESD (43.8%), REC (6.3%) and TAMIS (43.8%) were performed. The mean time was 73.25 min. The 56.3% used a 30° camera and 43.8% used the flexible endoscope as a viewing instrument. The 56.3% were benign lesions and 43.8% malignant. Complete resection is achieved in 87.5%. Regarding complications, mild bleeding (Clavien I) occurred in 25%, 6.3% and 21.4% at 24 h, 48 h and 7 days respectively. Continence was assessed according to the Wexner scale. At 7 days, 60% showed perfect continence, 26.7% mild FI and 13.3% moderate FI. At 30 days, 66.7% had perfect continence, 20% mild FI and 13.3% moderate FI. At 2 months, 4 patients were reviewed who at 30 days had a Wexner's degree higher than preoperative and perfect continence was demonstrated in 25% of the patients, 50% mild and 25% moderate. In no case did rectal perforation or major complications requiring urgent reintervention occur. As for the level of reproducibility, safety, level of satisfaction with the device and evaluation of the blister, the evaluation on a scale of 0–10 (9.43, 9.71, 9.29 and 9.50 respectively). All the investigators have previous experience with transanal devices. ConclusionsThe study demonstrates the efficacy and safety of UNI-VEC® for the treatment of rectal lesions. It will facilitate the implementation of hybrid procedures that seek to solve the limitations of pure endoscopic techniques by allowing the concomitant use of conventional laparoscopic and robotic instrumentation with the flexible endoscope.

Ensayo clínico multicéntrico para la resección de pólipos rectales mediante un nuevo dispositivo de acceso transanal híbrido laparoendoscópico

IntroductionComplex polyps require the use of advanced endoscopic techniques or minimally invasive surgery for their approach. In rectal polyps it is of special relevance to reach a consensus on the best approach to avoid under- or overtreatment that increases unnecessary morbidity and mortality. MethodsWe describe a prospective, multicenter, pilot clinical trial with a first-in-human medical device. It is hypothesized that UNI-VEC® facilitates transanal laparoendoscopic surgery for the removal of early rectal tumors. The primary objective is to evaluate that it is safe and meets the established functional requirements. Secondary objectives are to evaluate results, complications and level of satisfaction. ResultsSixteen patients were recruited in 12 months with a minimum follow-up of 2 months. The mean size was 3.4 cm with the largest polyp being 6 cm. Regarding location, the mean was 6.6 cm from the anal margin. Endoscopic mucosal resection (EMR) (6.3%), endoscopic submucosal dissection (ESD) (43.8%), REC (6.3%) and TAMIS (43.8%) were performed. The mean time was 73.25 min. The 56.3% used a 30° camera and 43.8% used the flexible endoscope as a viewing instrument. The 56.3% were benign lesions and 43.8% malignant. Complete resection is achieved in 87.5%. Regarding complications, mild bleeding (Clavien I) occurred in 25%, 6.3% and 21.4% at 24 h, 48 h and 7 days, respectively. Continence was assessed according to the Wexner scale. At 7 days, 60% showed perfect continence, 26.7% mild FI and 13.3% moderate FI. At 30 days, 66.7% had perfect continence, 20% mild FI and 13.3% moderate FI. At 2 months, 4 patients were reviewed who at 30 days had a Wexner's degree higher than preoperative and perfect continence was demonstrated in 25% of the patients, 50% mild and 25% moderate. In no case did rectal perforation or major complications requiring urgent reintervention occur. As for the level of reproducibility, safety, level of satisfaction with the device and evaluation of the blister, the evaluation on a scale of 0–10 (9.43, 9.71, 9.29 and 9.50, respectively). All the investigators have previous experience with transanal devices. ConclusionsThe study demonstrates the efficacy and safety of UNI-VEC® for the treatment of rectal lesions. It will facilitate the implementation of hybrid procedures that seek to solve the limitations of pure endoscopic techniques by allowing the concomitant use of conventional laparoscopic and robotic instrumentation with the flexible endoscope.

Airway Management in Adult Intensive Care Units: A Survey of Two Regions in China.

The critical medicine residency training in China started in 2020, but no investigation on the practice of tracheal intubation in ICUs in China has been conducted. A survey was sent to the adult ICUs in public hospitals in Shenzhen (SZ) city and Xinjiang (XJ) province using a WeChat miniprogram to be completed by intensive care physicians. It included questions on training on intubation, intubation procedures, and changes in the use of personal protective equipment due to COVID-19. We analyzed 301 valid questionnaires which were from 72 hospitals. A total of 37% of respondents had completed training in RSI (SZ, 40% vs. XJ, 30%; p = 0.066), and 50% had participated in a course on the emergency front of the neck airway (SZ, 47% vs. XJ, 54%; p = 0.256). Video laryngoscopy was preferred by 75% of respondents. Manual ventilation (56%) and noninvasive positive pressure ventilation (34%) were the first-line options for preoxygenation. For patients with a high risk of aspiration, nasogastric decompression (47%) and cricoid pressure (37%) were administered. Propofol (82%) and midazolam (70%) were the most commonly used induction agents. Only 19% of respondents routinely used neuromuscular blocking agents. For patients with difficult airways, a flexible endoscope was the most commonly used device by 76% of respondents. Most participants (77%) believed that the COVID-19 pandemic had significantly increased their awareness of the need for personal protective equipment during tracheal intubation. Our survey demonstrated that the ICU doctors in these areas lack adequate training in airway management.

O009 Keep The Chin Up: Evidence-based standardised care pathway for infants with Pierre Robin Sequence (PRS)

Abstract Background Management of upper airway obstruction in neonates with Pierre Robin Sequence (PRS) is challenging given difficulties in grading severity of disease, difficulties obtaining early polysomnography (PSG) and variable practices with no widely accepted standard protocol. We aimed to develop a standardised care pathway for infants with PRS. Methods Total 190 publications were identified of which 21 were reviewed in detail. Majority were review articles or retrospective studies. Consultation was obtained from the Complex Airway Team (multidisciplinary team of neonatologist, paediatric sleep specialist, otolaryngologist, plastic surgeon, clinical nurse specialist and speech pathologist), geneticists, audiologists, the consumer group “PRS Australia” and ANZ paediatric sleep physicians. Final recommendations were based on consensus and quality of the evidence. Results We developed a pathway outlining sequential interventions to manage OSA based on functional assessment by PSG (7-14 day of life) and structural assessment by flexible nasal endoscopy “FNE” (0-7 day of life). Conduct of bedside PSG in NICU instead of sleep lab enables innovative, timely, patient-centred and cost-effective service delivery. We standardised reporting of glossoptosis (Yellon classification), laryngomalacia (Olney et.al) and airway (Seattle DISE scoring) on FNE. Early multidisciplinary involvement, structured assessment of feeding, synchronous airway lesions and associated genetic syndromes is also considered. The pathway allows for standardised management and discharge planning with clearly defined multidisciplinary follow-ups. Intended outcome/impact This project is likely first in Australia to standardise care pathway for infants with PRS encompassing collaborative, innovative and structured care delivery principles. The project provides foundation for future clinical and research collaboration.

Cost comparison of oral, transnasal and magnet assisted capsule endoscopy in the examination of the upper gastrointestinal tract in patients with dyspepsia

IntroductionConventional oral upper gastrointestinal (GI) endoscopy can obe uncomfortable. By comparison, transnasal endoscopy (TNE) and magnet assisted capsule endoscopy (MACE) have superior tolerability. A cost comparison of competing upper GI...

Neuroendoscopic Surgery for Pediatric Intraventricular Tumors

Various tumors are found in ventricles and tissues surrounding the ventricles in children, adolescents, and young-adult patients. They cause cerebrospinal fluid pathway obstruction, resulting in hydrocephalus and isolated ventricles. In this paper we describe a neoplasm arising from the lateral and third ventricle. Intraventricular tumors are good candidates for neuroendoscopic surgery. Firstly, minimally invasive and established procedures, neuroendoscopic biopsy with flexible endoscopy or rigid endoscopy, are performed. These endoscopic biopsies can be performed concurrently with other procedures, such as third ventriculostomy or septostomy, to improve cerebrospinal fluid circulation. Neuroendoscopic biopsy for intraventricular tumor is associated with high diagnostic yield and relatively low incidence of morbidity and mortality, compared with open surgery. Endoscopic diagnostic procedure also can be applied in patients without ventricular dilatation, assisted by neuronavigation or echo-guided equipment. Secondly, neuroendoscopic cylinder surgery also makes it possible to remove intraventricular tumors with less damage. The two hands technique with rigid endoscopy helps debulking and hemostasis during tumor removal. Further developments in endoscopic equipment and training systems aimed at enhancing cooperation between the operator and assistant should be expected in the future. Neuroendoscopic resection appears to be a safe and reliable treatment option for patients with intraventricular tumors.

Diagnostic utility of endoscopic duodenal biopsies and histopathological finding in upper gastrointestinal diseases: A 2-year analysis

Background: Diseases of gastrointestinal (GI) tract present wit myriad signs and symptoms. Appropriate management of these diseases involves proper evaluation. Upper GI endoscopies are becoming increasingly popular because it helps in first localizing the lesion and then biopsy specimens can be obtained from affected area. Duodenal biopsy followed by histopathological examination may clinch the diagnosis in majority of the cases. Aims and Objectives: The aim of the study was to find out diagnostic utility of endoscopic duodenal biopsies and histopathological finding in the upper GI diseases. (1) To analyze duodenal endoscopic biopsy samples obtained from patients presenting with the upper GI symptoms. (2) To correlate endoscopic and histopathological findings in studied cases. Materials and Methods: A retrospective and prospective observational study was carried out at the private histopathology center over a period of 2 years. All the patients underwent upper GI endoscopy with duodenal biopsies using flexible endoscope. Histopathology of the samples obtained from endoscopic duodenal biopsies in patients presenting with the upper GI symptoms were analyzed. The endoscopic findings such as mass lesion or ulcerative lesion were correlated with histopathological findings. Results: Out of these 704 biopsies, 303 (43.04%) were esophageal biopsies, 220 [31.25%] were gastric, and 181 [25.71%] were duodenal biopsies. There were 129 (71.27%) males and 52 (28.73%) females with a M: F ratio of 2.5: 1. The mean age of the cases was found to be 54.7±12.32 years. Out of 181 biopsies which were performed in this study, 100 (55.25%) lesions were found to be having neoplastic etiology whereas 81 (44.75%) lesions were found to have non-neoplastic etiology. Among patients who were found to have duodenal growth on endoscopy well differentiated adenocarcinoma (15.47%) followed by moderately differentiated adenocarcinoma (6.63%) were the common pathologies. In cases of non-neoplastic etiology, non-specific duodenitis was most common pathology (17.13%). Conclusion: Endoscopic biopsy followed by histopathological examination is cornerstone of the management of patients presenting with intractable upper GI symptomatology.

PSAT281 Crico-tracheal Resection with End-to-End Anastomosis for Locally Advanced Thyroid Cancer: A Case Series of Early Postoperative Outcomes of a Low-Income Country from Latin America

Abstract Introduction Tracheal invasion is a poor prognostic factor in patients with aggressive thyroid cancer. Crico-tracheal resection and primary anastomosis (CTRA) is the preferred surgical technique. Appropriate resection can improve early postoperative outcomes and long-term oncological outcomes. A recent systematic review of eastern literature showed a moderate rate of postoperative complications. However, there is a paucity of data regarding early postoperative complications in Latin America. Therefore, the aim of this report is to describe the early postoperative outcomes of three patients with thyroid cancer invading the trachea who underwent CTRA in two tertiary referral centers (1 public and 1 private) in a low-income country. Clinical Cases There were 2 females (F1: 53 y, F2: 55 y) and 1 male (M1: 53 y) patients from Ecuador. Patient F1 had follicular variant of papillary thyroid cancer (PTC) and was operated on in the public center and patients F2 and M1 had classic variant of PTC. Neck CT and perioperative flexible endoscopy were performed for airway invasion assessment. All patients underwent total thyroidectomy with circumferential CTRA. Patient F1 had a right lobe thyroid tumor with intraluminal invasion of the 5th tracheal ring up to the cricoid cartilage, the recurrent laryngeal nerve (RLN) and common carotid artery, and bilateral central neck lymph node metastasis. She underwent bilateral central neck dissection, carotid shaving, and RLN resection. Patient F2 showed an enlarged, multinodular thyroid invading the 4th up to the 1st tracheal ring, without luminal compromise. There was no invasion to other structures. Patient M1 had a right lobe thyroid tumor, with intraluminal invasion of the 4th tracheal ring up to the cricoid cartilage and invasion of the RLN. He underwent RLN resection. Patient F1 and M1 were classified as Shin IV and patient F2, Shin III. Regarding the 30-day postoperative complications, patient F1 had tracheostomy infection on day 5, tracheal dehiscence and anastomotic dehiscence that caused massive bleeding, cardiorespiratory failure and death on day 8. Patient M1 only presented mild bleeding through the traqueostomy tube on day 1, non-compressive cervical hematoma on day 2, and was discharged on day 5. Patient F2 had no complications and was discharged on day 3. The last 2 patients were decanulated successfully at the 2-week follow-up and received adjuvant radioactive iodine. Conclusions CTRA seems to be a safe procedure with moderate postoperative complications, low mortality, and zero tracheotomy-dependency rates in patients operated in Ecuador. Our results are similar to those described in the international literature. Further studies are needed to confirm these results and draw robust conclusions. Presentation: Saturday, June 11, 2022 1:00 p.m. - 3:00 p.m.

A combined approach of robot-assisted laparoscopic pyeloplasty and flexible endoscopy to treat concomitant ureteropelvic junction obstruction and calyceal stones in children: Technical considerations and review of the literature.

The management of children with concomitant ureteropelvic junction (UPJ) obstruction and calyceal stones remains challenging. The various treatment options available for pediatric nephrolithiasis may require multiple sessions, and the techniques by themselves are not designed for simultaneous correction of UPJ obstruction. Recently, success in combining robot-assisted laparoscopic pyeloplasty (RALP) and flexible endoscopy has been reported by multi-institutional studies to treat children with concomitant UPJ obstruction and renal stones. Given the paucity of technical details of this novel approach in the existing literature, we herein report our techniques to treat two girls aged 6 and 10 years who had concomitant UPJ obstruction and multiple stones in mid- and lower poles calyces. Three robotic ports were used without any assistant ports. A flexible endoscope, either a cystoscope or a single-use ureteroscope, was introduced via the undocked epigastric port to perform nephroscopy and stones removal after the renal pelvis was opened. The rest of the RALP was completed in the usual manner. Technical modifications were employed to facilitate the flexible endoscope to examine the entire calyceal system. Both patients underwent successful surgical procedures by the combined approach without any intra- or post-operative complications. Three and 14 stones were removed from each of the patients respectively. Postoperative investigations demonstrated successful correction of UPJ obstruction and complete stone clearance in both patients. A combined approach of RALP and flexible endoscopy is a safe and effective technique to treat concurrent UPJ obstruction and calyceal stones in children.

Teaching endoscopic management of gastrointestinal hemorrhage using a modular simulation curriculum

BackgroundAs flexible endoscopy is increasingly adopted as a minimally invasive approach to surgical challenges, an efficient curriculum is needed to train surgeons in therapeutic endoscopy. We developed a simulation-based approach to teaching endoscopic management of gastrointestinal hemorrhage as part of a modular curriculum, complete with task performance pre- and post-testing. MethodsTwo sessions of our advanced flexible endoscopy course were taught using ex vivo porcine models to simulate active gastrointestinal hemorrhage and allow for training in hands-on endoscopic management. The module is composed of hands-on pretesting, didactics, mentored practice sessions, and postcourse assessments. Pre- and postcourse tests and surveys evaluated knowledge, confidence, and performance of participants and results were analyzed using the paired t test. ResultsSixteen practicing surgeons participated in the course. After course completion, overall knowledge-based assessments improved from 3.4 (±1.9) to 5.8 (±2.0) (P < .001). Although participants with glove sizes >7.0 and ≥2 years in practice had higher pretest evaluator scores (P = .045 and P = .020), all participants demonstrated overall improvement in endoscopic management of hemorrhage, with postcourse evaluator score increases from 20.9 (±1.6) to 23.6 (±2.0) (P = .001) and specific improvements in identification of target bleeding (P = .015), endoscopic clip setup (P < .001), and clip deployment (P = .002). Surveys also found increased confidence in competency after curriculum completion, 11.6 (±3.4)–23.0 (±5.5) (P < .001). ConclusionOur simulation-based approach to teaching the endoscopic management of gastrointestinal bleeding emphasizes hands-on pretesting and provides an effective training model to improve the knowledge, confidence, and technical performance of practicing surgeons.

Guideline Quick View: Flexible Endoscopes.

AORN JournalVolume 116, Issue 5 p. 476-483 Guideline Quick View Guideline Quick View: Flexible Endoscopes First published: 27 October 2022 https://doi.org/10.1002/aorn.13828Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onFacebookTwitterLinkedInRedditWechat Volume116, Issue5November 2022Pages 476-483 RelatedInformation

Clinical Issues-November 2022.

Reuse of single-use bronchoscopes Key words: single use, bronchoscope, contamination, time limit, instructions for use (IFU). Endoscope processing room workflow Key words: one-room design, decontamination sink, droplets, clean storage, transport. Simethicone use during endoscopy Key words: adenosine triphosphate (ATP) testing, defoaming agent, water bottle, borescope inspection, residue. Implementing borescope inspection of flexible endoscopes Key words: visual inspection, cleaning verification, high-risk endoscopes, competency verification, prepurchase evaluation.

Robotic-assisted vs non-robotic traction techniques in endoscopic submucosal dissection for malignant gastrointestinal lesions.

Endoscopic submucosal dissection is an effective approach with higher en bloc resection and complete resection rate for superficial gastrointestinal (GI) lesions. However, endoscopic submucosal dissection is technically challenging and associated with several adverse events, such as bleeding or perforations. The single channel flexible endoscope's intrinsic limitations in preserving visualization of the submucosal dissection plane as compared to laparoscopic surgery are the most common cause of complications during the endoscopic submucosal dissection technique. As a result, traction techniques were created as the endoscope's second helping hand in order to improve the effectiveness of the endoscopic submucosal dissection method. Trainees can master endoscopic submucosal dissection methods more quickly by using traction techniques. The anatomical location of the lesion plays a major role in determining which traction technique should be employed. An appealing way of traction is robot-assisted endoscopic submucosal dissection, and various types of endoscopic robots that allow bimanual operation are currently being developed. The advent of robot-assisted endoscopic technology ushers in a new era of endoscopic submucosal dissection, and with it come its own unique challenges that remain to be elucidated. Future research and development efforts are needed to focus on pathways and curriculums for trainees to master the currently available traction techniques and provide avenues for the development of newer traction modalities. In this article, we discuss evolution, characteristics, technological improvements and clinical comparisons of both robotic and non-robotic endoscopic traction techniques used in endoscopic submucosal dissection.

Lessons learned from early experience of per oral endoscopic myotomy in children

Background/AimsAchalasia cardia (AC) is rare in children, and the standard treatment is open or Laparoscopic Heller's myotomy with or without fundoplication if pneumatic dilatation has failed. Per oral endoscopic myotomy (POEM) is a novel technique for management of achalasia with good results in adults. We report POEM in four children and the outcome with special emphasis on the technique and management of intra-operative complications. MethodFour children aged 7–15 years presenting with progressive dysphagia, cough, night-time aspirations, and weight loss of six months to one year were investigated with upper GI contrast study, flexible endoscopy and biopsy, oesophageal manometry, and a diagnosis of Type 1 & 2 AC was made. An experienced adult endoscopist in collaboration with the paediatric surgical team performed POEM. ResultsPOEM was performed successfully using ERBE HYBRID knife setup and waterjet injection for the submucosal tunnelling. Operative time was 25–40 min (mean 31 min). The hospital stay was 3–8 days with last 3 patients discharged on day three. No major intraoperative or post-operative complications were seen. The Eckardt score changed from above 4 to 0 at one-month follow-up. All four are well at one year post-operatively and beyond. Two patients had subcutaneous emphysema post-operatively. One developed pneumoperitoneum intra-operatively. ConclusionPOEM was successfully performed with only minor adverse events in experienced hands. Anticipation and preparation for potential intraoperative complications and assigned responsibilities to each team helped the safe completion in the shortest time. Rectifying pneumoperitoneum concurrently without interruption of the operation exemplified teamwork. Level of EvidenceIII

Epidemiologic and Diagnostic Pattern of Thyroid Gland Cancer Patients in Douala and Yaounde: A Cross Sectional Study

Flexible endoscopy was used in examination cervix lesion the first was studied by Nishiyama et al was reported the used of endoscopy for diagnosing cervical neoplasms. The second study of K Uchita et al.

Epidemiologic and Diagnostic Pattern of Thyroid Gland Cancer Patients in Douala and Yaounde: A Cross Sectional Study

Flexible endoscopy was used in examination cervix lesion the first was studied by Nishiyama et al was reported the used of endoscopy for diagnosing cervical neoplasms. The second study of K Uchita et al.