High-definition Endoscopy Research Articles

High-definition endoscopy with digital chromoendoscopy for histologic prediction of distal colorectal polyps.

BackgroundDistal diminutive colorectal polyps are common and accurate endoscopic prediction of hyperplastic or adenomatous polyp histology could reduce procedural time, costs and potential risks associated with the resection. Within this study we assessed whether digital chromoendoscopy can accurately predict the histology of distal diminutive colorectal polyps according to the ASGE PIVI statement.MethodsIn this prospective cohort study, 224 consecutive patients undergoing screening or surveillance colonoscopy were included. Real time histology of 121 diminutive distal colorectal polyps was evaluated using high-definition endoscopy with digital chromoendoscopy and the accuracy of predicting histology with digital chromoendoscopy was assessed.ResultsThe overall accuracy of digital chromoendoscopy for prediction of adenomatous polyp histology was 90.1 %. Sensitivity, specificity, positive and negative predictive values were 93.3, 88.7, 88.7, and 93.2 %, respectively. In high-confidence predictions, the accuracy increased to 96.3 % while sensitivity, specificity, positive and negative predictive values were calculated as 98.1, 94.4, 94.5, and 98.1 %, respectively. Surveillance intervals with digital chromoendoscopy were correctly predicted with >90 % accuracy.ConclusionsHigh-definition endoscopy in combination with digital chromoendoscopy allowed real-time in vivo prediction of distal colorectal polyp histology and is accurate enough to leave distal colorectal polyps in place without resection or to resect and discard them without pathologic assessment. This approach has the potential to reduce costs and risks associated with the redundant removal of diminutive colorectal polyps.Trial registrationClinicalTrials NCT02217449.

Surveillance of duodenal adenomas in familial adenomatous polyposis patients: medical objectives and technical requirements.

Surveillance of duodenal adenomas in familial adenomatous polyposis patients: medical objectives and technical requirements.

Total Laparoscopic Hysterectomy With Percutaneous (Percuvance) Instruments: New Frontier of Minimally Invasive Gynecological Surgery

Study ObjectiveTo highlight the first case of laparoscopic hysterectomy performed with percutaneous instruments (The Percuvance System, Teleflex Incorporated, Wayne, PA). DesignThe basis of the system is a <3-mm diameter shaft that, when connected to an introducer tool tip, can be inserted percutaneously through the skin. The introducer tool tip can then be exchanged outside the body for a wide variety of 5-mm interchangeable surgical tool tips. The shaft is sufficiently strong to hold structures, and surgeons can use its interchangeable tool tips to grasp, cut, and manipulate tissue. We used a 3-dimensional high-definition 10-mm flexible tip endoscope (ENDOEYE FLEX 3D, Olympus Winter & IBE GMBH, Hamburg, Germany). BackgroundMinilaparoscopy is an attractive approach for hysterectomy due to advantages such as reduced morbidities and enhanced cosmesis. However, it has not been popularized because of the lack of suitable instruments and high technical demand. The Percuvance system represents a significant advance in minimally invasive surgery. SettingCatholic University of the Sacred Hearth, Rome, Italy. PatientA 53-year-old, multiparous patient with endometrial endometroid cancer grade 1, Fédération Internationale de Gynécologie et d'Obstétrique stage IA. The patient provided informed consent to use the images and video of the procedure. Institutional review board approval was not required. InterventionThe patient was hysteroscopically diagnosed with endometrial cancer after removal of an endometrial polyp adnexectomy. Once referred to our center, surgical staging was planned, including total hysterectomy and bilateral adnexectomy. Laparoscopy with 2 lateral percutaneous and 1 soprapubic 3-mm instruments was believed to be feasible to achieve these procedures. Main ResultsThe operation was performed successfully with no intraoperative or postoperative complications. Operative time was 80 minutes overall, and blood loss was 50 mL. The pathology report confirmed endometrial endometroid cancer grading 1, Fédération Internationale de Gynécologie et d'Obstétrique stage IA. The patient was discharged on day 1. After 2 months, no late complications or recurrence was detected. ConclusionPercutaneous total hysterectomy is technically feasible, and the use of this novel device permits surgeons to mantain a standard setting. Further studies are mandatory to define the benefits, advantages, and costs of this novel approach with respect to other minimally invasive approaches.

Accuracy of the newly introduced FUSE-system for assessment of disease activity in inflammatory bowel diseases (IBD) compared to high-definition endoscopy

Accuracy of the newly introduced FUSE-system for assessment of disease activity in inflammatory bowel diseases (IBD) compared to high-definition endoscopy

Initial Experience with High-Definition Camera-On-a-Chip Flexible Endoscopy for Intraventricular Neurosurgery

The usefulness of existing neuroendoscopes has been limited by either decreased range of motion or suboptimal image resolution. The flexible high-definition chip-camera endoscope has emerged as a potential solution to the shortcomings of available instruments by combining superior flexibility and image quality in order to better operate within spatially constrained intraventricular operations. Here we describe a 36-year-old woman who presented with hydrocephalus caused by an obstructive mass arising from the tectum. A high-definition camera-on-a-chip flexible neuroendoscope was used to sample the tectal mass after a traditional neuroendoscope was used to perform a third ventriculostomy. As demonstrated by this initial experience, the use of high-definition camera-on-a-chip flexible endoscopy may provide enhanced intraoperative visualization and application for intraventricular neurosurgery.

Role of Rhinopharyngoscopy in Diagnosis of Rhinopathies.

Rhinopathies, or diseases of the sinonasal cavity, are a heterogeneous group of disorders ranging from benign entities to malignant processes. Proper evaluation and treatment of rhinopathies are dependent on accurate visualization and characterization of the disease processes. Prior methods of evaluation of the sinonasal cavity were dependent largely on anterior rhinoscopy, which unfortunately provides poor visualization of the superior, posterior, and lateral extent of the sinonasal cavity. With the advent of high-definition flexible and rigid endoscopes, rhinopharyngoscopy has proven to be a critical component in the evaluation of the sinonasal cavity. Here, we discuss rhinopharyngoscopy with emphasis on technique and evaluation of common rhinopathies and future developments.

Endoscopic therapy in early adenocarcinomas (Barrett's cancer) of the esophagus.

The incidence of early esophageal adenocarcinoma has been increasing significantly in recent decades. Prognosis depends greatly on the choice of treatment. Early cancers can be treated by endoscopic resection, whereas advanced carcinomas have to be sent for surgery. Esophageal resection is associated with high perioperative mortality (1-5%) even in specialized centers. Early diagnosis enables curative endoscopic treatment option. Patients with gastrointestinal symptoms and a familial risk for esophageal cancer should undergo upper gastrointestinal endoscopy. High-definition endoscopes have been developed with technical add-on that helps endoscopists to find fine irregularities in the esophageal mucosa, but interpreting the findings remains challenging. In this review we discussed novel and old diagnostic procedures and their values, as well as our own recommendations and those of the authors discussed for the diagnosis and treatment of early Barrett's carcinoma. Endoscopic resection is the therapy of choice in early esophageal adenocarcinoma. It is mandatory to perform a subsequent ablation of all residual Barrett's mucosa to avoid metachronous lesions.

OC-028 High definition white light endoscopy (HDWLE) versus high definition with chromoendoscopy (HDCE) in the detection of dysplasia in long standing ulcerative colitis: a randomised controlled trial

<h3>Introduction</h3> Patients with ulcerative colitis (UC) have an increased risk for colorectal cancer. The yield of surveillance can be improved by addition of newer endoscopic methods like chromoendoscopy (CE)¹and HDWLE when compared to standard definition endoscopy.²There are no studies comparing HDCE and HDWLE. The aim of this trial is to compare the rate of detection of dysplasia in patients with long standing UC with HDWLE compared to HDCE. <h3>Method</h3> Parallel group randomised controlled trial (clinicaltrials.gov number NCT02138318) in which patients with long standing UC (&gt;10 years) requiring surveillance colonoscopy were randomised to either HDWLE or HDCE (with 0.2% indigo carmine spray). HD scopes (Olympus CF260L or 290L) and processors (Olympus Spectrum CV260 or Elite CV290) and HD monitors were used for all procedures. Time to reach caecum and withdrawal time was recorded. Presence of dysplasia was confirmed by two expert GI histopathologists. Data was analysed according to the number of patients who had dysplastic endoscopic lesions detected (per patient analysis) and also to the number of dysplastic lesions (per lesion analysis). <h3>Results</h3> In total 53 patients were randomised to HDWLE and 50 to the HDCE arm. Baseline characteristics including duration of disease, bowel preparation, endoscopists, concomitant PSC and previous dysplasia were similar in both arms. A total of 14 dysplastic lesions (1 with high grade and 13 with low grade dysplasia) were detected in 11 patients (22%) in the HDCE arm and 6 dysplastic lesions (all low grade dysplasia) in 5 patients (9.4%) in the HDWLE arm. HDCE was significantly better (p = 0.04) than HDWLE on a per patient basis for the detection of endoscopically visible dysplastic lesions. HDCE (0.26 ± 0.6) detected more dysplastic lesions per-patient than HDWLE (0.12 ± 0.4). Withdrawal time was significantly (p &lt; 0.001) higher in HDCE (21.2 ± 5.8 min) compared to HDWLE (13.6 ± 3.3 min). <h3>Conclusion</h3> HDCE significantly improves the detection of dysplastic lesions in patients undergoing surveillance endoscopy for UC and should be the procedure of choice in these patients. On average it increases procedure time by 8 min over HDWLE. <h3>Disclosure of interest</h3> None Declared. <h3>References</h3> Subramanian V, Mannath J, Ragunath K, Hawkey CJ. Meta-analysis: the diagnostic yield of chromoendoscopy for detecting dysplasia in patients with colonic inflammatory bowel disease. <i>Aliment Pharmacol Ther.</i>2011;33:304–312 Subramanian V, Ramappa V, Telakis E, <i>et.al</i>. High definition versus standard definition endoscopy for detection of dysplasia in colonic inflammatory bowel disease. <i>Inflamm Bowel Dis</i>. 2013;19:350–5

PWE-030 High definition (hd) endoscopy but not i-scan significantly increases the detection of markers of coeliac disease: a multicentre uk study: Abstract PWE-030 Table 1

<h3>Introduction</h3> Coeliac disease (CD) remains underdiagnosed. Many patients with CD have undergone a previous endoscopy where the opportunity to make a diagnosis was missed. Clinicians may rely on endoscopic markers of CD to guide biopsy but they lack sensitivity. A routine duodenal biopsy approach may solve this problem but it is expensive. Methods to improve the detection of CD at endoscopy to guide biopsy would seem advantageous. I-Scan, a digital enhancement technique, has shown promising results. However, only one, single centre study has been performed. This was an uncontrolled, unblinded trial in high prevalence population (35% CD). We aimed to assess the utility of I-Scan in a lower prevalence population in a randomised controlled trial <h3>Method</h3> Patients from 2 UK hospitals (Royal Hallamshire Hospital, Sheffield and St. Mary’s Hospital, London) were randomised into 2 groups: Group 1 standard HD white light endoscopy (WLE) and Group 2 WLE plus I-Scan. Patients were compared to a standard non-HD WLE control group, Group 3. All patients received at least 4 duodenal biopsies. Coeliac serology was performed concurrently. The presence of endoscopic markers of CD, scalloping, mosaic pattern, nodularity, loss of duodenal folds or increased vascularity was noted and compared to VA on histology as the gold standard <h3>Results</h3> 700 patients (63% female, mean age 51.7) were recruited (201 into Group 1, 199 in Group 2 and 300 into Group 3). In total 130 (18.5%) new diagnoses of CD were made (19 in Group 1, 22 in Group 2 and 89 in Group 3). In new CD cases, endoscopic markers of CD were seen in 80.5% in the HD groups compared to 41.6% in Group 3 (p &lt; 0.0001). In Group 2, I-Scan appeared to enhance changes in 18% of new CD cases. However there was no significant difference in sensitivity between Group 1 (89.5%) and Group 2 (72.7%) (p = 0.2). Full sensitivity and specificity analysis is shown in Table 1. The severity of VA was analysed for missed cases. There was no significant difference in the distribution of VA severity across the 3 groups (p = 0.6). The use of HD/I-Scan did not prevent total VA being missed <h3>Conclusion</h3> HD endoscopy significantly increases the detection of the endoscopic markers of CD (p &lt; 0.0001). However although I-scan appears to enhance the changes of villous atrophy it does not significantly increase the detection of markers (p = 0.2) <h3>Disclosure of interest</h3> None Declared.

PWE-184 Eosinophilic esophagitis; presentation, diagnosis and response to therapy in a tertiary referral centre in london

Introduction Eosinophilic esophagitis (EoE) is a chronic immune-mediated disorder characterised by an increased eosinophil infiltrate combined with typical symptoms of dysphagia/food bolus obstruction although those with refractory-reflux symptoms without inflammation are not commonly suspected. Recent guidance has improved clinical awareness, endoscopic vigilance and biopsy protocols. This study captures recent trends in endoscopy, histology and subsequent response to therapy of patients with EoE in a London tertiary referral centre. Method Between February 2013 and January 2015, reports were collected for all patients who underwent high definition endoscopy and biopsies at University College London Hospital. Patients with oesophageal cancer or surgery were excluded. Demographics, clinical characteristics, eosinophil concentration and response to therapy were collected for all those with >15 eosinophils/high power field (eos/hpf). Mann-Whitney and Kruskal-Wallis tests were used to analyse non-parametric variables. Results Of the 848 patients with dysphagia who had biopsies, 39 (4.6%) had >15 eos/hpf; however a total of 46 patients were found to have >15 eos/hpf (30M; mean age 39.5 ± 14.5 years). Patients with eosinophilia presented mostly with dysphagia (25; 54%) and food impaction (22; 48%) while another 7 (15%) also presented with refractory-reflux symptoms (only 2 with Grade A esophagitis but with >80 eos/hpf in the proximal oesophagus). 22% had a history of atopy/asthma. 26/46 (57%) exhibited EoE-specific endoscopic findings; corrugated rings (18), strictures (5), furrows (6) and Schatzki ring (4). 7/46 (17%) had esophagitis Grade A (4), B (2) and C (1) esophagitis. The remaining 13 (28%) had a normal endoscopy. There was no difference in the mean eos/hpf between patients with EoE-specific endoscopic changes (47 ± 24), esophagitis (46.5 ± 21.2) and normal endoscopy (47.5 ± 24.9) (p = 0.915). Furthermore the mean eos/hpf between those who presented with dysphagia, food bolus obstruction or refractory-reflux was similar (p = 0.804). 37 patients were treated with either proton pump inhibitors (PPI; 19) or topical steroids (18). Of the 26 patients whose outcomes were reported, 10 responded to steroids and 9 to PPIs. Response to PPIs was more likely in those with reflux-predominant symptoms vs. dysphagia (p = 0.027). The maximum number of eos/hpf did not predict response to therapy as a whole (p = 0.586) nor in those treated with steroids versus PPI (p = 0.188). Furthermore, there was no association of response to treatment when compared to age, endoscopic appearance or atopy (p = NS). Conclusion It is increasingly recognised that EoE does not only present with dysphagia. Therapy targeted towards the predominant symptom can improve outcome in patients with EoE. Disclosure of interest None Declared.

Advances in the Endoscopic Assessment of Inflammatory Bowel Diseases: Cooperation between Endoscopic and Pathologic Evaluations.

Endoscopic assessment has a crucial role in the management of inflammatory bowel disease (IBD). It is particularly useful for the assessment of IBD disease extension, severity, and neoplasia surveillance. Recent advances in endoscopic imaging techniques have been revolutionized over the past decades, progressing from conventional white light endoscopy to novel endoscopic techniques using molecular probes or electronic filter technologies. These new technologies allow for visualization of the mucosa in detail and monitor for inflammation/dysplasia at the cellular or sub-cellular level. These techniques may enable us to alter the IBD surveillance paradigm from four quadrant random biopsy to targeted biopsy and diagnosis. High definition endoscopy and dye-based chromoendoscopy can improve the detection rate of dysplasia and evaluate inflammatory changes with better visualization. Dye-less chromoendoscopy, including narrow band imaging, iScan, and autofluorescence imaging can also enhance surveillance in comparison to white light endoscopy with optical or electronic filter technologies. Moreover, confocal laser endomicroscopy or endocytoscopy have can achieve real-time histology evaluation in vivo and have greater accuracy in comparison with histology. These new technologies could be combined with standard endoscopy or further histologic confirmation in patients with IBD. This review offers an evidence-based overview of new endoscopic techniques in patients with IBD.

446 High Definition White Light Endoscopy (Hdwle) Versus High Definition With Chromoendoscopy (Hdce) in the Detection of Dysplasia in Long Standing Ulcerative Colitis: a Randomized Controlled Trial

Introduction Patients with ulcerative colitis (UC) have an increased risk for colorectal cancer. The yield of surveillance can be improved by addition of newer endoscopic methods like chromoendoscopy (CE) 1 and HDWLE when compared to standard definition endoscopy. 2 There are no studies comparing HDCE and HDWLE. The aim of this trial is to compare the rate of detection of dysplasia in patients with long standing UC with HDWLE compared to HDCE. Method Parallel group randomised controlled trial (clinicaltrials.gov number NCT02138318) in which patients with long standing UC (>10 years) requiring surveillance colonoscopy were randomised to either HDWLE or HDCE (with 0.2% indigo carmine spray). HD scopes (Olympus CF260L or 290L) and processors (Olympus Spectrum CV260 or Elite CV290) and HD monitors were used for all procedures. Time to reach caecum and withdrawal time was recorded. Presence of dysplasia was confirmed by two expert GI histopathologists. Data was analysed according to the number of patients who had dysplastic endoscopic lesions detected (per patient analysis) and also to the number of dysplastic lesions (per lesion analysis). Results In total 53 patients were randomised to HDWLE and 50 to the HDCE arm. Baseline characteristics including duration of disease, bowel preparation, endoscopists, concomitant PSC and previous dysplasia were similar in both arms. A total of 14 dysplastic lesions (1 with high grade and 13 with low grade dysplasia) were detected in 11 patients (22%) in the HDCE arm and 6 dysplastic lesions (all low grade dysplasia) in 5 patients (9.4%) in the HDWLE arm. HDCE was significantly better (p = 0.04) than HDWLE on a per patient basis for the detection of endoscopically visible dysplastic lesions. HDCE (0.26 ± 0.6) detected more dysplastic lesions per-patient than HDWLE (0.12 ± 0.4). Withdrawal time was significantly (p Conclusion HDCE significantly improves the detection of dysplastic lesions in patients undergoing surveillance endoscopy for UC and should be the procedure of choice in these patients. On average it increases procedure time by 8 min over HDWLE. Disclosure of interest None Declared. References Subramanian V, Mannath J, Ragunath K, Hawkey CJ. Meta-analysis: the diagnostic yield of chromoendoscopy for detecting dysplasia in patients with colonic inflammatory bowel disease. Aliment Pharmacol Ther. 2011;33:304–312 Subramanian V, Ramappa V, Telakis E, et.al . High definition versus standard definition endoscopy for detection of dysplasia in colonic inflammatory bowel disease. Inflamm Bowel Dis . 2013;19:350–5

Tu1750 High Definition (HD) Endoscopy but Not I-SCAN Significantly Increases the Detection of Markers of Celiac Disease: a Multicentre UK Study

Tu1750 High Definition (HD) Endoscopy but Not I-SCAN Significantly Increases the Detection of Markers of Celiac Disease: a Multicentre UK Study

Minimally invasive mitral valve surgery through right mini-thoracotomy: recommendations for good exposure, stable cardiopulmonary bypass, and secure myocardial protection.

An apparent advantage of minimally invasive mitral surgery through right mini-thoracotomy is cosmetic appearance. Possible advantages of this procedure are a shorter ventilation time, shorter hospital stay, and less blood transfusion. With regard to hard endpoints, such as operative mortality, freedom from reoperation, or cardiac death, this method is reportedly equivalent, but not superior, to the standard median sternotomy technique. However, perfusion-related complications (e.g., stroke, vascular damage, and limb ischemia) tend to occur more frequently in minimally invasive technique than with the standard technique. In addition, valve repair through a small thoracotomy is technically demanding. Therefore, screening out patients who are not appropriate for performing minimally invasive surgery is the first step. Vascular disease and inadequate anatomy can be evaluated with contrast-enhanced computed tomography. Peripheral cannulation should be carefully performed, using transesophageal echocardiography guidance. Preoperative detailed planning of the valve repair process is desirable because every step is time-consuming in minimally invasive surgery. Three-dimensional echocardiography is a powerful tool for this purpose. For satisfactory exposure and detailed observation of the valve, a special left atrial retractor and high-definition endoscope are useful. Valve repair can be performed in minimally invasive surgery as long as cardiopulmonary bypass is stable and bloodless exposure of the valve is obtained.

Advanced technology for the improvement of adenoma and polyp detection during colonoscopy.

Early detection and removal of adenomatous polyps reduces colorectal cancer death. However, many studies have reported that up to 20% of adenomas can be missed during colonoscopy. To improve visualization and reduce the blind spot of the colonic mucosa for an increase in the adenoma detection rate, many endoscopic techniques and technologies have been developed. The benefit of the high-definition endoscope for improving adenoma and polyp detection is marginal. Wide-angle colonoscope has failed to improve adenoma detection compared to standard colonoscopy. Although the cap-assisted colonoscope can reduce cecal intubation times, it does not seem to improve adenoma and polyp detection. The diagnostic accuracy of the colon capsule endoscope is low compared to the conventional colonoscope. Third Eye(®) retroscope(®) , which provides additional retrograde viewing, has revealed significant improvement in adenoma and polyp detection compared to standard colonoscopy. However, this device increases procedural times. Recently developed full-spectrum endoscopy colonoscope and extra-wide-angle-view colonoscope have demonstrated a significantly lower miss rate of polyps. However, clinical trials are mandatory to determine the efficacy of these novel technologies for cancer screening. In addition, education and training for these novel techniques and technologies should seriously be considered to improve adenoma and polyp detection.

Endoscopy-assisted interhemispheric transcallosal hemispherotomy: preliminary description of a novel technique.

Various hemispherotomy techniques have been developed to reduce complication rates and achieve the best possible seizure control. To present a novel and minimally invasive endoscopy-assisted approach to perform this procedure. Endoscopy-assisted interhemispheric transcallosal hemispherotomy was performed in 5 children (April 2013-June 2014). The procedure consisted of performing a small craniotomy (4 × 3 cm) just lateral to midline using a transverse skin incision. After dural opening, the surgery was performed with the assistance of a rigid high-definition endoscope, and bayoneted self-irrigating bipolar forceps and other standard endoscopic instruments. Steps included a complete corpus callosotomy followed by the disconnection of the hemisphere at the level of the basal nuclei and thalamus. The surgeries were performed in a dedicated operating room with intraoperative magnetic resonance imaging and neuronavigation. Intraoperative magnetic resonance imaging confirmed a total disconnection. The pathologies for which surgeries were performed included sequelae of middle a cerebral artery infarct (n = 2), Rasmussen syndrome (n = 1), and hemimegalencephaly (2). Four patients had an Engel class I and 1 patient had a class II outcome at a mean follow-up of 10.2 months (range, 3-14 months). The mean blood loss was 80 mL, and mean operating time was 220 minutes. There were no complications in this study. This study describes a pilot novel technique and the feasibility of performing a minimally invasive, endoscopy-assisted hemispherotomy.

Complicated Urinary Tract Infections: Highlights On Diagnosis And Minimally Invasive Treatment

Complicated urinary tract infection (UTI) has always been a challenging subject to diagnose and treat. New, less invasive, techniques have been introduced in the last decade with the development of the new generations of high definition endoscopes and the robotic platforms to treat the surgically correctable pathologies underlying UTIs. This review will discuss the different underlying pathological conditions for complicated UTI and their management.

Endoscopic epilepsy surgery: Emergence of a new procedure.

The use of minimally invasive endoscopic surgery is fast emerging in many subspecialties of neurosurgery as an effective alternative to the open procedures. The author describe a novel technique of using an endoscope for performing a corpus callosotomy and hemispherotomy. A description of endoscopic disconnection for a hypothalamic hamartoma (HH) and a review of the literature is also presented. Thirty four patients underwent endoscopic procedures between January 2010 and March 2015. These included endoscopic-assisted inter-hemispheric trans-callosal hemispherotomy (EH; n = 11), endoscopic-assisted corpus callosotomy with anterior/posterior commissurotomy (CCWC; n = 16), and endoscopic disconnection for HH (n = 7). EH and CCWC were performed with the use of a small craniotomy (4 cm × 3 cm). The surgeries were performed using a rigid high-definition endoscope, bayonetted self-irrigating bipolar forceps, and other standard endoscopic instruments along with the guidance of intra-operative magnetic resonance imaging and neuronavigation. HH disconnection was performed using endoscopic neuronavigation through a burr hole. Hemispherotomy: Sequelae of middle cerebral artery infarct (5), Rasmussen's syndrome (3), and hemimegalencephaly (3). Class I Engel (9) and class II (2), mean follow-up of 8.4 months, range: 3-18 months. Mean blood loss: 85 cc, mean operating time: 210 min. CCWC: All had a diagnosis of Lennox-Gastaut syndrome (LGS), with etiologies of hypoxic insult (10), lissencephaly (2), bilateral band heterotropia (2), microgyria and pachygyria (2). Mean follow-up: 18 ± 4.7 (16-27 months). Drop attacks stopped in all the patients. Seizure frequency and duration decreased >90% (11) and >50% (5). HH: Type II (2), Type III (2), Type IV (3). 5 had IA outcome. The article emphasizes the role of endoscopic procedures for epilepsy surgery and provides a review of literature. This experience may subserve to coin the term "endoscopic epilepsy surgery" for a fast emerging subspeciality in the field of epilepsy surgery.

A novel technique for peroral direct cholangioscopy.

Direct cholangioscopy has been possible since the 1970sbut the reliability of the intubation of the common bile duct (CBD) and second-order ducts has limited the applicability of the technique. One of the limitations to accessing the ducts is the acute angulation between the duodenum and the CBD. Various methods have been employed to access the ducts including mother-and-baby endoscopes and balloon assisted intubation. Mother-and-baby systems are expensive, require additional equipment, and provide poorer quality images than standard endoscopes. Balloon-assisted intubation carries a risk of damage to the CBD, and requires specialist equipment with an associated learning curve. Using this technique, we have successfully intubated second-order ducts and have been able to make reliable in vivo diagnosis using high definition endoscopes, remove difficult stones, and biopsy lesions under direct vision without complications. The advantages of our technique are its low cost, that no additional equipment is required, and that it has a short learning curve. More research is needed into the technique to determine its limits and the associated risks. We have developed a novel technique that involves the use of a standard stiff wire (SMGW, Marflow AG, Switzerland) bent to the angulation of the duodenum-CBD junction and passed through the working channel of a standard 5.6-mm Olympus nasendoscope. The technique begins after endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy with a nasendoscope passed orally into the duodenum with the tip directed at the sphincter of Oddi. A pre-bent stiff wire is passed through the working channel until the bend in the wire sits within the flexible portion of the endoscope. The nasendoscope is then railroaded over the pre-bent wire into the CBD by advancing the nasendoscope whilst holding the wire fixed. Once the flexible portion of the nasendoscope is completely within the CBD, the wire can be removed to allow full use of the working channel.

Multiple-Band Imaging Provides Better Value Than White-light Endoscopy in Detection of Dysplasia in Patients With Barrett's Esophagus

Surveillance of patients with Barrett's esophagus usually is performed with standard white-light endoscopy (SDWLE) and the collection of 4 biopsy specimens (every 1-2 cm of the metaplastic segment), based on Seattle protocol. New endoscopic techniques are used routinely, but have been validated based only on low-grade evidence. We aimed to validate the use of high-definition magnifying endoscopy with multiple-band imaging (HDMEMBI) with a targeted biopsy collection for the detection of dysplasia, using SDWLE with quadrant biopsy collection as the reference. In a cross-over study, patients with suspected or histologically verified BE (without known neoplasia) seen at a tertiary referral high-volume endoscopy center in Sweden, from November 2009 through November 2012, were assigned randomly to undergo HDMEMBI (n = 63) or SDWLE (n = 47) as the initial procedure, followed by the other procedure in 1 to 4 months. The primary end point was the total number of subjects found to have low-grade dysplasia or high-grade dysplasia (HGD) by each technique. Secondary end points included the number of biopsy specimens taken and the duration of each procedure. There was no significant difference between groups in diagnostic yield for low-grade dysplasia (14 in HDMEMBI vs. 13 in SDWLE) or HGD. Four HGDs were found: 3 using HDMEMBI and 1 using SDWLE. Significantly fewer biopsy specimens were collected during the HDMEMBI procedure (P < .001). The diagnostic yield for the detection of dysplasia per biopsy specimen collected therefore was significantly higher for HDMEMBI than SDWLE (0.25 vs. 0.07; P = .018). There was no significant difference in the duration of procedures. There is no significant difference in the detection of dysplastic lesions using HDMEMBI with targeted collection of biopsy specimens vs SDWLE with 4-quadrant biopsy specimen collection. However, HDMEMBI requires the collection of significantly fewer biopsy specimens, providing better value for health care providers. ClinicalTrials.gov number: NCT01694511.