Invasive Endoscopic Procedures Research Articles

Acute cholangitis: a state-of-the-art review.

Acute cholangitis is a potentially life-threatening bacterial infection of the intra and/or extrahepatic bile ducts. It remains the second and third cause of community-acquired and hospital-acquired bacteremia, respectively, and is associated with mortality rates of up to 15%, despite advances in broad-spectrum antimicrobial therapy and improved access to emergency biliary tract decompression procedures. Even though not much has changed in recent years in terms of diagnosis or treatment, new data have emerged regarding multidrug-resistant bacteria that serve as etiologic agents of cholangitis. Moreover, different approaches in antibiotic regimes depending on severity grading and bile sample cultures as well as novel minimally invasive endoscopic procedures that can help when consecrated treatments such as endoscopic retrograde cholangiopancreatography (ERCP) fail, cannot be performed, or are unavailable have been proposed. This state-of-the-art review aims to offer a complete and updated assessment of the epidemiology, novel diagnostic and therapeutic methods, complications, and prognostic variables of acute cholangitis. The authors will review the prognostic implications of unusual complications, the relevance of regular bile samples and antibiograms, and their new role in guiding antibiotic therapy and limiting antibiotic resistance to present an organized and comprehensive approach to the care of acute cholangitis.

Seven-Year Experience of Intramural Surgery in the Middle East: A Safety and Feasibility Analysis.

Background: Intramural surgery techniques, particularly esophageal peroral endoscopic myotomy (E-POEM), gastric peroral endoscopic myotomy (G-POEM), and peroral endoscopic myotomy for Zenker's (Z-POEM), have emerged as forefront minimally invasive endoscopic procedures. While several studies have reported on the outcomes in North America and Asia, evidence in the Middle East and North Africa remains limited. This study aims to evaluate the feasibility and safety of intramural surgery techniques within this region. Methods: This retrospective cohort study was conducted with approval from the institutional review board. All patients who underwent esophageal peroral endoscopic myotomy, gastric peroral endoscopic myotomy, and peroral endoscopic myotomy for Zenker's from January 2016 to August 2023 were included. Results: In total, 119 patients underwent intramural surgery procedures during this period. The esophageal peroral endoscopic myotomy group had 81 (68%) patients, the gastric peroral endoscopic myotomy had 34 (28.6%) patients, and the peroral endoscopic myotomy for Zenker's had 4 (3.4%) patients. The full cohort was 48.7% female, with a mean overall age of 40.5 years. The mean overall body mass index was 27.5 kg/m2. The chief complaint was dysphagia (n = 80, 67.2%). All cases were successfully completed endoscopically. During the first 30 days, the most common complications were nausea/vomiting requiring admission (n = 4, 4.76%) and pneumomediastinum (n = 2, 2.38%). At a follow-up of 19 months, there were four mortalities; the causes of death were cardiac arrest (three cases) and end-stage prostate cancer (one case). Conclusions: Intramural surgery techniques are safe and technically feasible with low complication rates. Our study suggests that clinical success in the Middle East and Northern Africa population is comparable to larger international series.

Diagnostic Accuracy of Ultrasound in Evaluation of Obstructive Jaundice with MRCP as a Gold Standard

Abstract Background MRCP has high sensitivity for CBD stones, strictures and malignancies in cases of obstructive jaundice especially cases with suspicion (clinical/CBD-IHBR dilatation on USG). As MRCP has more diagnostic accuracy compared to ultrasound in detecting the cause of obstruction in cases of obstructive jaundice, USG may be considered as an initial screening test and MRCP for definitive treatment planning. The limitation of the study is the small sample size. Objective To evaluate cross sectional retrospective study was done From June 2021 to June 2022 on 31 patients (17 females and 14 males) presenting with obstructive jaundice were referred from Internal Medicine, General Surgery and Clinical Oncology Department to Diagnostic Radiology Department in Ain Shams University hospitals, MRCP were done for all the patients and then Abdominal US examination were performed and then comparison between US & MRCP result were done. Results The US has sensitivity of 100.0%, specificity of 100.0% and accuracy of 100.0 % in detection of level of obstruction and also has sensitivity of 71.0% and accuracy of 71.0% in detecting cause of obstruction taking MRCP as a gold standard. Conclusion MRCP is an excellent tool for detecting the cause of obstructive jaundice, Use of MRCP could therefore spare the patients from invasive preoperative endoscopic procedures and it can also most likely reduce overall surgical costs. We propose MRCP as the method of choice for the diagnostic imaging of obstructive jaundice.

Highly functional duodenal stent with photosensitizers enables photodynamic therapy for metabolic syndrome treatment: Feasibility and safety study in a porcine model.

Duodenal mucosal resurfacing (DMR) by thermal ablation of the duodenal mucosa is a minimally invasive endoscopic procedure for controlling metabolic syndrome (MS). However, thermal energy can cause adverse effects due to deep mucosal injury, necessitating an additional mucosal lifting process, which complicate the procedures. Therefore, we aimed to develop a similar procedure using non-thermal photodynamic therapy (PDT) for DMR using a highly functional metal stent covered with photosensitizers (PSs) to minimize the potential risks of thermal ablation injury. We developed a novel PS stent enabling the controlled release of radical oxygen species with specific structures to prevent stent migration and duodenal stricture after ablation and performed an animal study (n = 8) to demonstrate the feasibility and safety of PDT for DMR. The stents were placed for 7 days to prevent duodenal strictures after PDT. To confirm PDT efficacy, we stained for gastric inhibitory polypeptide (GIP) and glucose transporter isoform 1. The PS stents were deployed, and PDT was applied without evidence of duodenal stricture, pancreatitis, or hemorrhage in any of the pigs. Microscopic evaluation indicated apoptosis of the mucosal cells in the irradiated duodenum on days 7 and 14, which recovered after day 28. Immunohistochemistry revealed suppressed GIP expression in the mucosal wall of the irradiated duodenum. Endoscopic PDT for DMR using PS stents could be applied safely in a porcine model and may result in decreased GIP secretion, which is a crucial mechanism in MS treatment. Further clinical studies are required to explore its safety and efficacy in patients with MS.

Closing the Gap: The Incidence of Complications in Minimally Invasive Tubular, Endoscopic, and Robotic-Assisted Transforaminal Lumbar Interbody Fusion Procedures

Background ContextThe aim of the current study was to compare the incidence of postoperative complications between MIS tubular, endoscopic and Robot-assisted TLIF techniques. MethodsConsecutive patients who underwent single or multi-level TLIF between 2020 and 2022. Pre-operative and post-operative patient reported outcomes (VAS Leg and ODI), demographic, and intra-operative variables were recorded. One way ANOVA with Bartlett’s equal-variance and Pearson chi-squared tests were used. ResultsThe current study included a total of 170 TLIF patients: 107 (63%) tubular, 42 (25%) endoscopic, and 21 (12%) robot-assisted. All three TLIF techniques had similar complication rates: tubular 6 (5.6%), endoscopic 2 (4.8%), and robot-assisted 1 (4.8%) all occurring within the first two weeks. Tubular TLIF reported the lowest incidence of new onset neurological symptoms, primarily radiculitis or numbness/tingling, at two weeks postoperatively (p<0.05) with 21 (20%) tubular, 17 (41%) endoscopic, and 9 (43%) robot-assisted patients. There were two revisions in the robot-assisted group, while tubular and endoscopic each had one within one year. There was no statistical difference in pre- or postoperative PROs between the TLIF groups. ConclusionsThe current study demonstrated that tubular, endoscopic, and robot-assisted TLIF procedures had similar complication rates. The tubular MIS TLIF reported less new neurological symptoms compared to endoscopic and robot-assisted TLIF procedures at two weeks postoperative, with all groups declining in symptom persistency at later time intervals. Average VAS scores continuously improved up to one year postoperatively amongst all groups.

Weight-Loss Endoscopy Trial: A Multicenter, Randomized, Controlled Trial Comparing Weight Loss in Endoscopically Implanted Duodenal-Jejunal Bypass Liners versus Intragastric Balloons versus a Sham Procedure.

Obesity is associated with reduced life expectancy and various comorbidities. Surgical interventions are effective but accompanied by the risk of serious complications. Less invasive endoscopic procedures mainly comprise the intragastric balloon (IB) and the duodenal-jejunal bypass liner (DJBL). A randomized, sham-controlled study comparing both procedures has not been undertaken so far. We performed a randomized, patient- and assessor-blinded, controlled trial comparing weight loss in IB versus DJBL versus a sham procedure (2:2:1 ratio). Patients with a BMI &gt;35 kg/m2 or &gt;30 with obesity-related comorbidities were included. The IB was removed after 6 months and the DJBL after 12 months. The main objective was successful weight loss (&gt;10% from baseline) 12 months after explantation of the devices. Secondary outcomes were changes in comorbidities, quality of life, and complications. Thirty-three patients were randomized. Recruitment has to be stopped suddenly in after the DJBL device lost its CE mark in Europe. In all, 11 patients received DJBL, 15 IB, and 7 were allocated to the sham group. Blinding was feasible in all patients. Weight decreased from baseline until explantation (DJBL: 129.4 ± 28.3 kg to 107.4 ± 16.7 kg; IB: 118.3 ± 22.8 kg to 107.4 ± 25.7 kg; sham: 134.6 ± 18.0 kg to 131.2 ± 14.3 kg), but patients regained weight almost to the baseline level 12 months after explantation. Only 1 patient in IB group reached the primary endpoint. Severe device-related complications were very rare. Endoscopic bariatric procedures failed to achieve effective weight loss 12 months after explantation of the devices. The results of this trial need to be interpreted with caution due to its early termination.

Retrospective Analysis of Rectal Endoscopic Submucosal Dissection at Ordensklinikum Linz and Kepler Universitätsklinikum Linz.

Background and study aim: Endoscopic submucosal dissection is a minimally invasive endoscopic procedure for the removal of neoplastic benign and early malignant lesions in the gastrointestinal tract. In this study, we analyse the success and safety of rectal ESD at Linz hospitals, focusing on a specific endoscopist. Additionally, we examine whether there is a learning curve regarding success parameters. Methods: This retrospective study included all 102 patients who underwent endoscopic submucosal dissection of the rectum by a defined endoscopist at Ordensklinikum Hospital and Kepler University Hospital between December 2010 and May 2021. With the collected data, a descriptive statistic was carried out and regression analyses were performed. Results: The en bloc resection rate was 78.4% and the rate of lesions removed in healthy tissue was 55.6%. The average procedure time was 179 min and the complication rate was 7.8%. In total, 26.4% of cases showed carcinoma; in 25.9% of these cases, an oncologically curative resection was achieved with ESD. Follow-up data were available for 61.1% of cases, with recurrence being diagnosed in 3.6% of cases. A learning curve was observed regarding the rate of lesions removed in healthy tissue and the procedure time, but not regarding the en bloc resection rate. Conclusions: Endoscopic submucosal dissection is a safe method for the removal of large rectal adenomas and early carcinomas. The en bloc resection rate of the analysed procedures is within the range of comparable European studies. The rate of lesions removed in healthy tissue is below the R0 resection rate of the comparative literature; however, a learning curve could be observed in this parameter.

Absence of a pancreatic microbiome in intraductal papillary mucinous neoplasm

ObjectiveThis study aims to validate the existence of a microbiome within intraductal papillary mucinous neoplasm (IPMN) that can be differentiated from the taxonomically diverse DNA background of next-generation sequencing procedures.DesignWe...

The Rising Importance of Minimally Invasive Spine Endoscopic Pain Procedures in Modern Pain Practice

The Rising Importance of Minimally Invasive Spine Endoscopic Pain Procedures in Modern Pain Practice

Extraction of terminal ileal lipomas to cecum can facilitate endoscopic resection: A case series with video.

Large ileal lipomas over 2 cm can cause symptoms, that may require a resection. Due to the narrow lumen and thin walls of the ileum, endoscopic treatments can have a high risk of adverse events and require technical expertise, thus surgical resection is currently the mainstay of treatment. To overcome the technical challenges, we developed a novel method to endoscopically resect terminal ileal lipomas. The technique involves extracting the lesion into the cecum, which creates sufficient space to maneuver, and a better field of view. The lipoma is resected with endoscopic mucosal resection or endoscopic submucosal dissection. The appearance of the lipoma protruding out of the ileocecal valve resembles that of a tongue sticking out of the mouth, thus we named this the "tongue out technique". To assess the technical feasibility of this method, we retrospectively analyzed seven cases of terminal ileal lipoma that were endoscopically resected using the "tongue out technique" at NTT Medical Center Tokyo between January 2017 and October 2023. Technical success was 100% and en bloc resection was achieved in all cases. The median size was 31 (14-55) mm. Three cases were resected with endoscopic mucosal resection while endoscopic submucosal dissection was performed on the other four cases. There was one case of delayed post-endoscopic mucosal resection bleeding, which was caused by clip dislodgement. There were no perforations. No recurrence of the lipoma or associated symptoms have been observed. This new technique can allow more ileal lipomas to be treated with minimally invasive and organ-preserving endoscopic procedures.

Semaglutide vs Endoscopic Sleeve Gastroplasty for Weight Loss

Obesity is a disease with a large socioeconomic burden. Endoscopic sleeve gastroplasty (ESG) is a minimally invasive endoscopic bariatric procedure with wide global adoption. More recently, new weight-loss medications, such as glucagon-like peptide-1 receptor agonists (eg, semaglutide), have attracted increased attention due to their efficacy. However, their cost-effectiveness over an extended period compared with ESG is a critical gap that needs to be better explored for informed health care decision-making. To assess the cost-effectiveness of semaglutide compared with ESG over 5 years for individuals with class II obesity. This economic evaluation study, conducted from September 1, 2022, to May 31, 2023, used a Markov cohort model to compare ESG and semaglutide, with a no-treatment baseline strategy. The study comprised adult patients in the US health care system with class II obesity (body mass index [BMI] of 35-39.9). The base case was a 45-year-old patient with class II obesity (BMI of 37). Patients undergoing ESG were subjected to risks of perioperative mortality and adverse events with resultant costs and decrement in quality of life. Strategies included treatment with semaglutide and ESG. Costs (2022 US dollars), quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratio (ICER) with a willingness-to-pay threshold of $100 000/QALY. A 5-year time horizon with a cycle length of 1 month with a 3% discount rate was used. Probabilities, costs, and quality-of-life estimates of the model were derived from published literature. One-way, 2-way, and probabilistic sensitivity analyses were also performed. The model found that ESG was more cost-effective than semaglutide over a 5-year time horizon, with an ICER of -$595 532/QALY. Endoscopic sleeve gastroplasty added 0.06 QALYs and reduced total cost by $33 583 relative to semaglutide. The results remained robust on 1-way and probabilistic sensitivity analyses. Endoscopic sleeve gastroplasty sustained greater weight loss over 5 years vs semaglutide (BMI of 31.7 vs 33.0). To achieve nondominance, the annual price of semaglutide, currently $13 618, would need to be $3591. This study suggests that ESG is cost saving compared with semaglutide in the treatment of class II obesity. On price threshold analyses, a 3-fold decrease in the price of semaglutide is needed to achieve nondominance.

Endoscopic submucosal dissection and endoscopic mucosal resection for esophageal and gastric lesions: A comparison of procedures

ObjectiveEsophageal and gastric lesions are effectively managed with minimally invasive upper endoscopic procedures such as endoscopic mucosa resection (EMR) and endoscopic submucosal dissection (ESD), offering patients alternatives to invasive interventions. While ESD is well established in Eastern Asia, its adoption in Denmark for superficial esophageal cancer is recent. This study presents real-world data on the feasibility, safety, and hospitalization duration associated with ESD and EMR for esophageal and gastric lesions. MethodsA retrospective analysis was conducted on patients who underwent ESD or EMR at a specialized center in Denmark from October 2016 to June 2022. Data on treatment, indication, lesion location, hospitalization duration, procedure duration, specimen size, complications, recurrence, and one-year overall survival were collected. Statistical comparisons utilized the Mann–Whitney U test, independent sample median test, and chi-squared test. ResultsThe study included 130 patients (144 procedures): 72 underwent ESD and 58 underwent EMR. Compared with EMR, ESD resulted in greater percentages of en bloc and R0 resections (98.8% vs. 64.1%, p < 0.001; and 83.9% vs. 23.8%, p < 0.001), greater complication rates (28.7% vs. 3.1%, p < 0.001) and longer procedure times (119.5 min vs. 37.0 min, p < 0.001). The ESD procedure time significantly decreased over time (p = 0.01). The local recurrence rates were 14.5% for ESD and 23.8% for EMR (p = 0.767). The one-year overall survival rates were similar between the groups (95.8% vs. 94.8%, p = 0.553). ConclusionBoth ESD and EMR are safe and viable for treating esophageal and gastric lesions. ESD offers advantages but requires more time and skill. These findings support the literature, emphasizing the importance of considering patient-specific factors and surgeon proficiency in selecting the appropriate procedure.

Capsule endoscopy and panendoscopy: A journey to the future of gastrointestinal endoscopy

In 2000, the small bowel capsule revolutionized the management of patients with small bowel disorders. Currently, the technological development achieved by the new models of double-headed endoscopic capsules, as miniaturized devices to evaluate the small bowel and colon [pan-intestinal capsule endoscopy (PCE)], makes this non-invasive procedure a disruptive concept for the management of patients with digestive disorders. This technology is expected to identify which patients will require conventional invasive endoscopic procedures (colonoscopy or balloon-assisted enteroscopy), based on the lesions detected by the capsule, i.e., those with an indication for biopsies or endoscopic treatment. The use of PCE in patients with inflammatory bowel diseases, namely Crohn’s disease, as well as in patients with iron deficiency anaemia and/or overt gastrointestinal (GI) bleeding, after a non-diagnostic upper endoscopy (esophagogastroduodenoscopy), enables an effective, safe and comfortable way to identify patients with relevant lesions, who should undergo subsequent invasive endoscopic procedures. The recent development of magnetically controlled capsule endoscopy to evaluate the upper GI tract, is a further step towards the possibility of an entirely non-invasive assessment of all the segments of the digestive tract, from mouth-to-anus, meeting the expectations of the early developers of capsule endoscopy.

Being a Female Gastroenterologist in Turkey.

Our aim is to examine the representation of woman gastroenterologists in both work and social life in Turkey and to elucidate the difficulties they encounter during their career pathways or while actively practicing their profession. A self-structured survey consisting of 25 questions was sent via email to all 152 female gastroenterologists. Survey results were received from 140 participants. Sixty percent of the woman gastroenterologists had marriage-career conflicts, and 74% of them stated that they could not manage work-life balance with their children. Among these woman gastroenterologists, 46.6% of them reported that they had faced carrier-related barriers and challenges while applying for an academic rise or expecting a promotion in their job, 58.5% were exposed to gender mobbing, and 35.6% were subjected to verbal or physical violence. On the other hand, woman gastroenterologists are found to be underrepresented in endoscopic interventions where only one-third of the participants perform invasive endoscopic procedures, and the percentage of those who perform advanced endoscopy such as endoscopic submucosal dissection and endoscopic mucosal resection remains even less as 8.9%. The number of women in leadership positions during their careers is found to be low, and only 2 women were selected as the president of the society since 1959, the establishment time of the Turkish Society of Gastroenterology. More effort is needed to keep a fair gender balance in Turkish gastroenterology society and to increase the women's representation in therapeutic endoscopy options and also in leadership positions.

Unveiling Insights: A Comprehensive Review of the Role of Medical Thoracoscopy in Pleural Effusion Assessment.

Pleural effusion, characterized by abnormal fluid accumulation in the pleural cavity, poses diagnostic and therapeutic challenges across various medical conditions. This comprehensive review explores the role of medical thoracoscopy in assessing pleural effusions, providing insights into its historical context, procedural intricacies, diagnostic performance, safety considerations, and clinical applications. Medical thoracoscopy, a minimally invasive endoscopic procedure, offers advantages such as high diagnostic yield, therapeutic interventions, real-time assessment, and a minimally invasive nature. The review critically analyzes the procedure's advantages and disadvantages, including technical expertise, risk of complications, resource intensity, and patient selection criteria. Comparative analyses with alternative diagnostic modalities highlight the unique benefits of medical thoracoscopy in specific clinical scenarios. The diagnostic yield of medical thoracoscopy is examined, considering sensitivity and specificity in various contexts. Patient selection criteria, complications, and safety measures are discussed, emphasizing the importance of careful consideration in integrating thoracoscopy into clinical practice. The review further explores its clinical applications, including differentiating exudative and transudative effusions, identifying specific etiologies, and its role in treatment planning. In conclusion, medical thoracoscopy emerges as a valuable tool in the comprehensive management of pleural effusions, offering a nuanced approach to diagnosis and treatment. The evolving landscape of diagnostic modalities underscores the continued significance of medical thoracoscopy and potential advancements in the field.

Single-centre endoscopic gastrostomy placement results: Experience and management of complications and side effects of nutritional products; review of 426 case presentations

Introduction: We aim to present the results, experience, and management of the complications and side effects of nutritional products in geriatric patients (age≥65 years) who underwent percutaneous endoscopic gastrostomy. Materials and Method: Between January 01, 2018, and 31 December 2021 we examined 426 patients from the endoscopy and intensive care units. We assessed their primary diseases, insertion indications, procedural complications (endoscopy unit, patient bedside, surgery-household), consultations in the clinic, and procedural morbidity and mortality. Results: Tubes were successfully placed in 426 patients but could not be inserted in 2 patients. The most common indication was cerebrovascular disease (45.3%) and the most common complication was catheter mobilization 16 (3.7%), primarily due to caregivers after discharge. In one patient, the tube passed through the transverse colon before reaching the stomach. This was noticed during colonoscopy and subsequently removed, after which the wound was closed primarily without any major complications. Wound infection resulting from leakage from the side of the tube, occurred in 12 patients (2.8%). Complications were more frequent in male patients aged &gt; 70 years. The most common side effects of nutritional products in these patients were intolerance and diarrhoea. Conclusion: Percutaneous endoscopic gastrostomy is safe and minimally invasive endoscopic procedure associated with low rate of morbidity. Clinicians can maximize outcomes and identify complications early by being aware of complications and utilizing preventive strategies. Furthermore, they need to be aware of the proper management of nutritional products’ side effects. Keywords: Aged; Endoscopy; Critical Care; Gastrostomy.

Endoscopic Revisional Gastroplasty After Bariatric Surgery with a Single-Channel Endoscope.

Less invasive endoscopic bariatric procedures are under development for the management of recurrence of obesity. The purpose of the current manuscript was to evaluate the safety of the endoscopic revisional gastroplasty (ERG) for patients with recurrence of weight gain following different bariatric procedures. This is a retrospective single-center study over 22 patients using the ERG between January 2020 to July 2022 at Bouchard Private Hospital (Marseille, France). The demographic data, past surgical history, obesity complications, time interval between the surgical and endoscopic procedures, and intra and postoperative parameters and outcomes were analyzed. A total of 22 patients underwent ERG: 19 female (86.4%) with a mean age of 34.2years and a mean BMI of 32.9kg/m2 (± 3.4). Average time between the revisional bariatric surgery and ERG was 14.4months (range 5-36). There were 14 cases of LSG (77.8%), 9 cases of RYGBP (19.4%), and 3 cases with previous gastric band. All procedures were completed by endoscopy with no complication and a mean length of hospital stay of 1.1days (± 0.9). The weight loss results at 1-year follow-up were available for 17 of the 22 patients: two patients were lost to follow-up (4%) and 3 patients had less than a 1-year follow-up from the ERG. The mean BMI, 1year after ERG, was 28.7kg/m2 (± 7.4); the mean BMI loss and %EWL were, respectively, 4.2kg/m2 (± 4.7) and 53.1% (± 17). Endoscopic revisional gastroplasty represents a safe minimal invasive approach that can be considered an effective and well-tolerated procedure for patients with previous bariatric surgery.

Minimally invasive endoscopic evacuation with the novel, portable Axonpen neuroendoscopic system for spontaneous intracerebral hemorrhage

Minimally invasive surgeries have shown potential to improve mortality and clinical outcomes of spontaneous intracerebral hemorrhage (ICH). The present study assessed the first-in-human outcomes of a novel, portable neuroendoscopic system for ICH evacuation at our single center. This neuroendoscopic system integrates real-time visualization into a handpiece which has controllable suction, irrigation, and coagulation to allow a neurosurgeon to conduct minimally invasive ICH evacuation independently with bimanual dexterity. Pre- and postoperative data of ten patients who had spontaneous basal ganglia hemorrhage (mean: 46.5 ± 12.2 mL) and underwent evacuation with the specified neuroendoscopic system were collected prospectively. The mean time to receive surgery was 12.1 ± 7.6 h. Mean operative time was 3.4 ± 0.9 h. The mean hematoma volume decreased to 6.0 ± 3.9 mL at postoperative 6 h, resulting in a mean volume reduction of 86.0 ± 11.2% (P = 0.005). The median length of intensive care unit stay was 3 days (IQR, 3–4 days). At discharge, the median Glasgow Coma Scale (GCS) score significantly improved to 11.5 (IQR, 11–15; P = 0.016), and the median modified Rankin Scale (mRS) score was 4 (IQR, 4–5). Six patients (60%) showed a favorable mRS score of ≤ 3 on their last return visit. Neither death nor rebleeding occurred during the follow-up periods. Integrated design of the innovative device is valuable to optimize minimally invasive endoscopic ICH evacuation procedure. Further studies are needed to clarify long-term benefits from such type of the innovative device to early intervention of ICH.

Abstract 17755: Post-Cardiac Injury Syndrome From Robotic Atrial Septal Defect Closure: A Case of Recurrent Pericarditis

Case Presentation: A 23-year-old female rugby player presented for recurrent chest pain. She has a history of atrial septal defect (ASD) repaired with robotic ASD closure. She developed acute pericarditis postoperatively and was treated with naproxen and colchicine inpatient. Her subsequent recurrences occurred with playing rugby and were treated with ibuprofen, colchicine, and prednisone. Electrocardiogram showed sinus bradycardia at 59 beats per minute but without ST segment changes. Cardiac magnetic resonance (CMR) imaging showed mild-to-moderate circumferential pericardial late gadolinium enhancement (LGE) without signal hyperintensity on T2 STIR imaging. She was diagnosed with chronic recurrent pericarditis secondary to post-cardiac injury syndrome (PCIS) and was started on rilonacept. On follow-up after 1 year, the patient remained symptom-free. She gradually increased her activity level to walking 3 miles per day and weaned down to rilonacept monotherapy. Repeat CMR showed mild pericardial LGE that was improved from before. Discussion: PCIS is a known cause of pericarditis due to local and systemic inflammatory responses to cardiothoracic surgery. Robotic ASD closure is a minimally invasive endoscopic procedure that has a favorable safety profile; PCIS is not a previously documented complication. Treatment of pericarditis secondary to PCIS includes NSAIDs plus 3 months of colchicine for acute pericarditis, NSAIDs plus 6 months of colchicine for a first recurrence, with corticosteroids or interleukin-1 inhibitors added for further recurrences. Incomplete treatment of acute pericarditis, as in this patient's case, is a risk factor for recurrent pericarditis. The risk of recurrences with physical activity is debated and current guidelines recommend restriction from physical activity until there is no evidence of active disease, though the data is not robust. In clinical practice, a gradual return-to-play program is frequently utilized.

Scar Formation after Unilateral Pectineal Suspension

UPS is a minimally invasive endoscopic procedure using a single Ethibond suture to attach the anterior cervix or vaginal vault unilaterally to the pectineal ligament (Figure 1a). The procedure allows anatomical prolapse correction by repositioning the uterus or vaginal vault to its original place within the pelvis [1]. The clinical image demonstrates the effective creation of supportive scar tissue during laparoscopic re-evaluation (Figure 1b). The fibrous scar formation has the capacity to stabilize the permanent result.