Median Procedure Time Research Articles

Sex identification in juvenile and adult Indonesian blue-tongued skinks (Tiliqua gigas) through cystoscopy and accuracy of contrast radiography.

To describe a nonsurgical endoscopic technique for sex identification in Indonesian blue-tongued skinks (Tiliqua gigas) and to assess accuracy of contrast radiography of the hemipenile/hemiclitoral pouches. 42 clinically healthy Indonesian blue-tongued skinks between 6 months and 3 years old and weighing between 22 and 550 g. Cystoscopy was performed under general anesthesia. Gonads were visualized through the transparency of the urinary bladder, and their gross morphology was described. Contrast was applied in the tail pouches before obtaining full-body radiographs. Two radiologists, blinded to the sex of the skink, evaluated the radiographs. Cystoscopy was achieved in all 42 skinks. Visualization of the gonads through the urinary bladder was possible in 41 (98%; 95% CI, 87% to 99%) of the skinks, with 18 of them identified as males and 23 identified as females. Median procedure time was 60 seconds (range, 25 to 180 seconds) and was not associated with procedure order (-0.69; 95% CI, -1.83 to 0.45) or with the weight (0.02 g; 95% CI, -0.07 to 1.0) or the identified sex (11.7; 95% CI, -15.07 to 38.45) of the skink. Radiographs had a sensitivity of 69.6% (95% CI, 47.1% to 86.8%) and a specificity of 75.0% (47.6% to 92.7%) to identify female skinks. All the skinks recovered uneventfully. Cystoscopic sex identification is feasible in Indonesian blue-tongued skinks of various age and size. Considering the difficulty in identifying their sex otherwise, this technique could provide a significant improvement in the veterinary care of this species. In this population, contrast radiographs showed limited accuracy for sex identification.

Beyond Anatomy: Use of Sinus Propagation Mapping to Identify the Slow Pathway for Cryoablation in Pediatric Patients.

Slow pathway modification via cryoablation is a common treatment of atrioventricular nodal re-entrant tachycardia (AVNRT) in pediatric patients. Sinus propagation mapping (SPM) is a tool that has been used to augment identification of the AVNRT slow pathway. We hypothesize that the use of SPM will decrease the total number of ablations performed and decrease the number of ablations until the slow pathway is successfully modified without a significant increase in procedure time. We conducted a retrospective review of patients who underwent cryoablation for AVNRT from August 2016 through March 2021. We excluded patients >21 years of age, those who underwent radiofrequency ablation; those with prior AVNRT ablation, additional pathways, or arrhythmias; and those with congenital heart disease. Out of 122 patients identified by the IMPACT database query, 103 met the inclusion criteria. Fifty-two patients (50.5%) had SPM completed during their procedures. The median number of ablations needed until successful slow pathway modification was two ablations in patients who underwent SPM and four ablations in the non-SPM group (P = .03). There was no significant difference in the total number of ablations between groups. The median total procedural time was longer in the SPM group (152 vs. 125 min; P = .01). SPM can be utilized to further improve the successful treatment of AVNRT with cryotherapy by lowering the number of ablations needed until successful slow pathway modification. However, the technique requires some additional time to collect sufficient data points to create the sinus map.

Efficacy and safety of pulmonary vein isolation with pulsed field ablation vs. novel cryoballoon ablation system for atrial fibrillation.

Pulsed-field ablation (PFA) has emerged as a novel treatment technology for patients with atrial fibrillation (AF). Cryoballoon (CB) is the most frequently used single shot technology. A direct comparison to a novel CB system is lacking. We aimed to compare pulmonary vein isolation (PVI) using PFA vs. a novel CB system regarding efficiency, safety, myocardial injury, and outcomes. One hundred and eighty-one consecutive patients underwent PVI and were included (age 64 ± 9.7 years, ejection fraction 0.58 ± 0.09, left atrial size 40 ± 6.4 mm, paroxysmal AF 64%). 106 patients (59%) underwent PFA (FARAPULSE, Boston Scientific) and 75 patients (41%) underwent CB ablation (PolarX, Boston Scientific). The median procedure time, left atrial dwell time and fluoroscopic time were similar between the PFA and the CB group with 55 [interquartile range (IQR) 43-64] min vs. 58 (IQR 48-69) min (P < 0.087), 38 (30-49) min vs. 37 (31-48) min, (P = 0.871), and 11 (IQR 9.3-14) min vs. 11 (IQR 8.7-16) min, (P < 0.81), respectively. Three procedural complications were observed in the PFA group (two tamponades, one temporary ST elevation) and three complications in the CB group (3× reversible phrenic nerve palsies). During the median follow-up of 404 days (IQR 208-560), AF recurrence was similar in the PFA group and the CB group with 24 vs. 30%, P = 0.406. Procedural characteristics were very similar between PFA and CB in regard to procedure duration fluoroscopy time and complications. Atrial fibrillation free survival did not differ between the PFA and CB groups.

Repeat pulmonary vein isolation and anterior line ablation using a novel point-by-point pulsed-field ablation system

BackgroundPulsed-field ablation (PFA) is a nonthermal energy source for ablation of cardiac arrhythmias. This study investigated the prospective outcomes of a novel PFA generator in conjunction with a commercially available, contact force-sensing, focal ablation catheter. ObjectiveThe purpose of this study was to assess the feasibility, safety, and lesion characteristics of point-by-point PFA in consecutive patients undergoing repeat ablation of atrial fibrillation (AF). MethodsThe study involved reisolation of pulmonary veins (PVs) with electrical reconnection and the creation of an anterior line (AL) in patients with anterior substrate or durable pulmonary vein isolation (PVI). ResultsIn 24 patients (46% female; mean age 67 ± 10 years; 67% persistent AF), successful reisolation of 27 of 27 reconnected PVs (100%) was performed. In 19 patients, AL ablation was performed, with bidirectional block in 16 (84%), median ablation time 26 [21, 33] minutes, and first-pass bidirectional block in 13 patients (68%). Acute AL reconduction occurred in 8 of 19 patients (42%). Among these 8 patients, a subsequent sustained block of the AL was achieved in 5 (63%). Ultra-high-density electroanatomic mapping revealed homogeneous but relatively large low-voltage areas in the ablated regions. Median procedural, left atrial dwell, and fluoroscopy times were 100 [90, 109] minutes, 83 [75, 98] minutes, and 10 [8, 13] minutes, respectively. No major or minor complications occurred. ConclusionThis study demonstrated feasibility, acute efficacy, and safety of point-by-point PFA for repeat PVI and AL ablation. Further studies are warranted to assess the long-term durability and comparison with established ablation methods.

The efficacy and safety of multi-loop traction device for gastric endoscopic submucosal dissection: a single center prospective pilot study

Although gastric endoscopic submucosal dissection (ESD) is widely used, the degree of difficulty varies greatly depending on the lesion. Since the multi-loop traction device (MLTD) has been suggested to shorten the procedure time in colorectal ESD, we examined the efficacy and safety of using the MLTD in gastric ESD. Thirty patients with gastric neoplasms were prospectively enrolled from February 2022 to December 2022, and the outcomes of ESD with the MLTD were evaluated. The primary outcomes were procedure time and dissection speed. The secondary outcomes were en bloc and R0 resection rates, MLTD attachment time, and complications of ESD with the MLTD. After excluding 1 patient, 29 patients (29 lesions) were treated by ESD with the MLTD. The median procedure time was 26 min (range, 9–210 min), and the median submucosal dissection speed was 39.9 mm2/min (12.4–102.7 mm2/min). The rate of en bloc resection was 100%, the median MLTD attachment time was 3 min (1–7 min), and none of the patients showed intraoperative or postoperative perforations. Thus, gastric ESD with the MLTD showed a favorable procedure time and dissection speed and an acceptable complication rate. Hence, the MLTD may be effective for gastric ESD.

Atrial fibrillation catheter ablation: electroporation against high-power short duration radiofrequency

Abstract Background Pulmonary vein isolation (PVI) is one of the cornerstones of rhythm-control therapy for symptomatic atrial fibrillation (AF) patients. The new ablation technologies of pulse field ablation (PFA) and high-power short-duration radiofrequency ablation (HPSD) with the new QDOT® catheter have been recently introduced in the EP lab. Aims To evaluate and compare the efficacy, and safety of single-shot PFA and HPSDRA for PVI in AF symptomatic patients. Methods Single centre, retrospective study of consecutive patients undergoing PVI with PFA or HPSD between May-December 2022. Data on demographic, procedural and clinical/ electrocardiographic recurrence (assessed after a 3-months blanking period) were analysed. Comparative analysis between both techniques was performed. Results One hundred and ten consecutive patients were included (63 ± 11 years, 75% men), with a mean CHA2DS2-VASc score of 2±1 points, median LVEF of 61% [IQR 57-62%] and a median left atrial volume index (by CT scan) of 56 mL/m2 [IQR 51-67 mL/m2]. 55% patients presented paroxysmal-AF and 19 patients (17%) performed a redo ablation. 47% (n=52) patients performed HPSD and 53% (n=58) PFA (all with CARTO®3D system v.7 and high-density mapping). In the HPSD: median RF ablation time was 792 sec [IQR 614-919sec], while in PFA was 90 sec [IQR 30-138 sec]. Median time of catheter inside the LA for PFA was 18 min [IQR 2-33 min]. Comparing HPSD and PFA (Fig 1): median procedure time was similar (91 min [IQR 71-107 min] vs 89 min [IQR 66-111 min], p=0.261), while median fluoroscopy time was lower with HPSD (5.4 min [IQR 3.1-6.8 min] vs 13.2 min [IQR 10.3-15.6 min], p&amp;lt;0.001); posterior wall isolation (PWI) was performed in 5 (10%) HPSD vs 21 (37%) PFA patients (p&amp;lt;0.001). All PFA patients undergoing PWI had first pass isolation, while only 40% of HPSD had first pass isolation. When performed PVI only, PFA presents a lower median procedure time than HPSD (76 min [IQR 62-93 min] vs 97 min [IQR 69-135 min], p=0.048). There was only one major complication, a cardiac tamponade with PFA, treated with pericardiocentesis. At 3 months of follow-up, 17% (n=10) patients had clinical or electrocardiographic AF recurrence: 7 PFA patients and 3 HPSD patients (p=0.127). Conclusions PFA and HPSD were both feasible and safe. When undergoing PVI-only, procedure time was lower with PFA. In patients undergoing PWI, PFA achieved higher first pass isolation. Although still in its early real-world evaluation, both techniques seem to be efficient, providing low AF recurrence during follow-up.

Left atrial posterior wall isolation using pulsed-field ablation: procedural characteristics, safety, myocardial injury and short-term outcomes

Abstract Background Pulsed-field ablation (PFA) has emerged as a novel treatment strategy for patients with atrial fibrillation (AF). Among targets beyond pulmonary vein isolation (PVI), ablation of the left atrial posterior wall (LAPW) has gained increased interest in patients with persistent AF. PFA offers a novel ablation technology possibly able to overcome the obstacles of incomplete isolation and concerns of damage to adjacent structures. Purpose To assess procedural characteristics, safety, myocardial injury and short-term outcomes of patients undergoing LAPW ablation in a clinical setting. Methods Consecutive patients undergoing PFA PVI with LAPW isolation were included. Using a multi-spline PFA catheter in a flower configuration, two anchor lesions per vein extending to the LAPW were deployed. Then, the wire was pulled back into the lumen, the PFA catheter and sheath were rotated along the entire LAPW in a flower configuration thereby creating overlapping lesions as assessed by a 3D-electro-anatomical mapping system. First-pass isolation was controlled using a multipolar mapping catheter. Complications were checked with an echocardiogram, high sensitivity cardiac troponin T was measured the next day and for recurrence detection a Holter ECG was performed during follow up. Results 25 patients with persistent AF undergoing PVI were included (age 69 ± 12 years, left atrial volume index 37 ml/m2). 17 patients underwent redo-PVI with LAPW and 8 patients first time PVI with LAPW ablation. The median number of applications to perform LAPW isolation using PFA was 24 (IQR 14-28). The median procedure time was 69 min (IQR 56-81). The median LA dwell time was 59 min (IQR 49-72). The median fluoroscopy time was 10 min (IQR 8-14). First-pass isolation was achieved in 24/25 cases (95%). There were no complications. High sensitivity cardiac troponin T level post-procedurally was 951 ng/L (IQR 717-1189). Median duration of follow-up were 95 days, (IQR 84-184), AF recurrence was observed in 2 patients (8%). Conclusion LAPW ablation with PFA appears safe and results in high acute isolation rates. The optimal technique to perform LAPW ablation using PFA needs to be defined. Data on long-term outcomes are missing.

Atrial fibrillation high power radiofrequency ablation: efficiency and safety

Abstract Introduction High power-ablation index (HP-AI) guided radiofrequency (RF) ablation of atrial fibrillation (AF) is increasingly being used as an alternative to conventional power (CP) ablation due to its better procedural performance and similar safety profile. Some evidence suggests that the lower RF time used in HP-AI may also have a protective effect in contact related complications. Despite this evidence, this strategy is still not widely used. Purpose Compare procedural efficiency and safety between HP-AI vs CP-AI-guided ablation in AF patients (pts). Methods Retrospective single-center study of consecutive pts submitted to AI-guided ablation, between 05/2018 and 10/2022. RF power and AI were 25W/500 and 45W/500 for the anterior wall and 20W/380 and 35W/380 for the posterior wall in CP-AI and HP-AI, respectively. Procedure related complications incidence were checked at 1 month. Results Of a total of 83 pts included in the study, mean age was 62±10y and 57.8% were males. HP-AI was performed in 61.4% (n=51). 39.2% had persistent AF (vs 25% in CP-AP, p=0.235). HP-AI was associated with significantly lower median procedure duration (150.0[140.0-180.0]min vs 192.0[180.0-235.0]min, p&amp;lt;0.001), fluoroscopy time (9.2[7.3-11.3]min vs 12.2[9.7-14.3]min, p=0.003) and RF time (26.3[20.4-28.4]min vs 34.3[30.1-39.6]min, p&amp;lt;0.001). These times were significantly reduced for both paroxysmal and persistent AF (figure 1). Electrical isolation of all the pulmonary veins was achieved in all patients. There were no early complications related to the procedure in either CP-AI or HP-AI groups. Conclusion HP-AI guided AF ablation significantly reduced procedure duration without impairing safety. It was also associated with lower RF application time, which may potentially lead to a reduction in procedure related complications. Data regarding long-term effectiveness will eventually support HP-AI as the best option for RF AF ablation.Comparison of median procedural times

Long- term results of interventional treatment of paravalvular leaks after prosthetic valve replacement with plug devices. Results from a prospective registry

Abstract Background Interventional closure of paravalvular leaks (PVL) after surgical valve replacement has developed to an attractive treatment option for patients at high operative risk. There is a lack of prospective data on long- term clinical outcome after percutaneous PVL closure. Methods We analysed data from a multicenter prospective registry on interventional PVL closure. Results 41 patients (10 women and 31 men) with symptomatic PVL were included in the plug registry at nine German hospitals from 2014 until 2020. In total 67 plug implantations were accomplished, 46.3% of procedures were performed for aortic PVLs and 53.7% were done for mitral PVLs. In 82% of patients PVL closure was performed once, in 16% of patients twice and 2,0% underwent three procedures. Mean age was 68.,7 ± 13.5 years. Indication was symptomatic heart failure with NYHA class ≥ II (63.4%), hemolysis (4.9%) or NYHA class ≥ II and hemolysis (31.7%). Mean log. Euro-Score I was 16.6 ± 11.6%. Aortic PVLs were treated using a retrograde transfemoral access (100%), mitral PVLs were treated using either a transseptal (96%) or transapical access (4%). For the first performed PVL closure the median procedural time was 100 minutes, fluoroscopy time was 31 minutes. Interventional closure of PVL was completely successful in 76%, partially successful in 10% and failed in 14%. Clinical improvement of at least one NYHA class was achieved in 56.4% and of two NYHA classes in 15.4% of patients after the procedure. In 7.3% hemolysis and transfusion dependence were successfully treated by plug implantation. Postprocedurally a severe aortic PVL was described in 4.2% (preprocedural in 41.7%) and a severe mitral PVL was seen in 8.3% (preprocedural in 47.6%). Interventional complications occurred in 21.9%. In-hospital mortality rate was 4.9%. A follow-up was performed after 30 days, 12 months, 3 and 5 years. Within a median time of 511 days (quartiles: 45;1136 days) 10 patients died. Mortality rates were 10.1% at one-year-, 18.5% at 3-year- and 32.5% at 5-year-follow-up. After one-year follow-up two reinterventions on the aortic valve (7.7%) were needed (one for PVL and one for treatment of an aortic stenosis), whereas two reinterventions (7.7%) were performed for mitral PVLs (1 percutaneous and 1 surgical PVL-closure). After 3-year follow-up one further percutaneous PVL closure (3.2%) was performed for an aortic and two further PVL closures (6.5%) for mitral PVLs (1 percutaneous, 1 surgical). After 5-year follow-up no PVL closure was necessary. The estimated rates for mortality and/or reintervention (either surgical or interventional) were 25.6% at one-year, 36.8% at 3 years and 45.1% at 5-year follow-up. Conclusion The multicenter plug-registry describes a high procedural success rate with clinical improvement in the majority of patients and acceptable long-term outcomes after percutaneous PVL closure.

Cone-beam computed tomography image-guided percutaneous microwave ablation for lung nodules in a hybrid operating room: an initial experience.

The experience of thermal ablation of lung lesions is limited, especially performing the procedure under localisation by cone-beam CT in the hybrid operation room (HOR). Here, we present the experience of microwave ablation (MWA) of lung nodules in the HOR. We reviewed patients who underwent image-guide percutaneous MWA for lung nodules in the HOR under general anaesthesia between July 2020 and July 2022. The workflow in the HOR including the pre-procedure preparation, anaesthesia consideration, operation methods, and postoperative care was clearly described. Forty lesions in 33 patients who underwent MWA under general anaesthesia (GA) in the HOR were analysed. Twenty-seven patients had a single pulmonary nodule, and the remaining six patients had multiple nodules. The median procedure time was 41.0 min, and the median ablation time per lesion was 6.75 min. The median global operation room time was 115.0 min. The median total dose area product was 14881 μGym2. The median ablation volume was 111.6 cm3. All patients were discharged from the hospital with a median postoperative stay of 1 day. Four patients had pneumothorax, two patients had pleural effusion during the first month of outpatient follow-up, and one patient reported intercostal neuralgia during the 3-month follow-up. Thermal ablation of pulmonary nodules under GA in the HOR can be performed safely and efficiently if we follow the workflow provided. The procedure provides an alternative to managing pulmonary nodules in patients. Thermal ablation of pulmonary nodules under GA in the HOR can be performed safely and efficiently if the provided workflow is followed. • We tested the feasibility of microwave ablation of lung lesions performed in a hybrid operating room. • To this end, we provide a description of microwave ablation of the lung under cone-beam CT localisation. • We describe a workflow by which ablation of the pulmonary nodule can be performed safely under general anaesthesia.

Feasibility and safety of 0.6% sodium alginate in endoscopic submucosal dissection for colorectal neoplastic lesion: A pilot study.

The usefulness of 0.6% sodium alginate (SA) as a submucosal (SM) injection solution for endoscopic SM dissection (ESD) has gained attention over the past few years. However, using ESD for colorectal neoplastic lesions is not explicitly researched as yet. Thus, we conducted this study to determine the feasibility and safety of 0.6% SA solution for colorectal ESD. In this single-center, retrospective pilot study, a total of 100 cases treated with ESD using 0.6% SA as a SM injection solution for colorectal neoplasia at our institute were retrospectively reviewed to clarify the clinical feasibility and safety of 0.6% SA. The primary endpoint was to evaluate the complication rate, and the secondary endpoint was to determine the procedure time and the amount of solution used. Intraoperative perforation was observed in 1 case (1.0%), 2 cases (2.0%) presented with postprocedural hemorrhage, and no lethal adverse events were observed. The median ESD procedure times were 39.5min (10-150), and the amount of solution used was less than 20mL in 67 cases (67.0%). En-bloc resection could be achieved in 97 cases (97.0%). Although six cases underwent subsequent surgery due to the deep SM invasion (>1000μm), there were no cases with nodal involvement, confirmed through histopathological evaluation. Our findings indicate that 0.6% SA can potentially ensure safe and secure ESD for colorectal neoplasia.

Duodenal neuroendocrine tumors: Short-term outcomes of endoscopic submucosal dissection performed in the Western setting.

Background and study aims Endoscopic resection (ER) is recommended for the management of duodenal neuroendocrine tumors (D-NETs) confined to the submucosal layer, without lymph node or distant metastasis. While this is accepted practice for lesions < 10 mm, consensus for larger lesions remains unclear. Although endoscopic submucosal dissection (ESD) has been proposed as the preferred ER technique for DNETs ≥10 mm, there are limited data on efficacy and safety, particularly in the Western setting. Patients and methods We performed a retrospective analysis of patients with D-NETs who underwent ESD between 2012 and 2022 in three tertiary referral centers in Australia, France, and Belgium. Results Fourteen patients with 15 D-NETs were evaluated. Median patient age was 64 years (interquartile range [IQR] 58-70 years). All D-NETs were confined to the duodenal bulb. Median D-NET size was 10 mm (IQR 7-12 mm) and specimen size was 15 mm (IQR 15-20 mm). Median procedure time was 60 minutes (IQR 25-90 minutes). The rate of en bloc resection was 100%. Intra-procedural perforation occurred in four patients (26.7%), with all closed endoscopically without long-term sequelae. There were no episodes of clinically significant bleeding. No local recurrence, lymph node or distant metastasis was observed at a median follow-up of 19.9 months (IQR 10.3-49.3 months). Conclusions In experienced hands, ESD for D-NETs can achieve a 100% en bloc resection rate. There were no cases of local recurrence or distant metastatic spread, indicating that ESD may be a viable option for patients with D-NETs 10 to 15 mm that are not surgical candidates.

Advanced Image-Guided Percutaneous Technique Versus Advanced Laparoscopic Surgical Technique for Peritoneal Dialysis Catheter Placement

Timely placement of a functional peritoneal dialysis (PD) catheter is crucial to long-term PD success. Advanced image-guided percutaneous and advanced laparoscopic techniques both represent best practice catheter placement options. Advanced image-guided percutaneous is a minimally invasive procedure that does not require general anesthesia. Retrospective cohort study comparing time from referral to procedure, complication rate, and 1-year catheter survival between placement techniques. Patients who had advanced laparoscopic or advanced image-guided percutaneous PD catheter placement from January 1, 2011 to December 31, 2013 in an integrated Northern California health care delivery system. PD catheter placement using advanced laparoscopic or advanced image-guided percutaneous techniques. One-year PD catheter survival; major, minor, and infectious complications; time from referral to PD catheter placement; and procedure time. Wilcoxon rank sum tests to compare referral and procedure times; χ2/Fisher exact tests to compare complications; and modified least-squares regression to compare adjusted 1-year catheter survival between PD placement techniques. We identified 191 and 238 PD catheters placed through advanced image-guided percutaneous and advanced laparoscopic techniques, respectively. Adjusted 1-year PD catheter survival was 80% (95% CI, 74%-87%) using advanced image-guided percutaneous technique vs 91% (87%-96%) using advanced laparoscopic technique (P=0.01). Major complications were<1% in both groups. Minor and infectious complications were 45.6% and 38.7% in advanced image-guided percutaneous and advanced laparoscopic techniques, respectively (P=0.01). Median days from referral to procedure were 12 and 33 for patients undergoing advanced image-guided percutaneous and advanced laparoscopic techniques, respectively (P<0.001). Median procedure time was 30 and 44.5 minutes for patients undergoing advanced image-guided percutaneous and advanced laparoscopic techniques, respectively (P<0.001). Retrospective study with practice preference influenced by timing, local expertise, and resources. Both advanced image-guided percutaneous and advanced laparoscopic techniques reported rare major complications and demonstrated excellent (advanced laparoscopic) and acceptable (advanced image-guided percutaneous) 1-year PD catheter survival. For patients referred for PD catheter placement at centers where advanced laparoscopic resources or expertise remain limited, the advanced image-guided percutaneous technique can provide a complementary and timely option to support the utilization of PD. Peritoneal dialysis is a preferred dialysis modality for many patients. However, the lack of available skilled surgeons can limit the placement of the peritoneal dialysis catheter in a timely manner. In the past decade, interventional radiology has developed expertise in placing peritoneal dialysis catheters. Using data from an integrated health care system, we compared the outcome of peritoneal dialysis catheters placed using laparoscopic surgery and interventional radiology techniques. Our results showed excellent 1-year patency of peritoneal dialysis catheters placed using laparoscopic surgery, whereas interventional radiology placement of catheters had lower but acceptable1-year patency survival, based on best practice guideline criteria. Hence, interventional radiology placement of peritoneal dialysis catheters may be a viable alternative when laparoscopic surgery is not available or feasible.

Feasibility of laparoscopic stapled partial cystectomy in canine cadavers.

To describe a technique for laparoscopic partial cystectomy and evaluate sealing of canine urinary bladder tissue with an endoscopic stapler. Prospective, cadaveric study. Eleven canine cadavers. Laparoscopic partial cystectomy was performed with an endoscopic gastrointestinal anastomosis (GIA) stapler. Leak testing and urodynamic evaluation was performed to measure intravesical pressure at initial leakage and catastrophic failure or the maximum pressure at which intravesical pressure plateaued. Surgical time, complications, and site of leakage were also recorded. Laparoscopic partial cystectomy was successfully performed in 10 of 11 cadavers. Median procedure time was 13.6 min (10.1-15.2 min). Median intravesical pressure at initial leakage was 31 mmHg (28-56 mmHg) with a median increase from initial pressure of 15 mmHg (11-37 mmHg). No catastrophic failure of the cystectomy site was observed during leak testing. Intravesical pressure plateaued at a median of 52 mmHg (39-73 mmHg), which was a median of 13 mmHg (8-23 mmHg) higher than intravesical pressure at initial leakage. The median total volume infused at the time of plateau of intravesical pressure was 89 mL (58-133 mL). Laparoscopic stapled partial cystectomy was feasible in canine cadavers. Endoscopic GIA staplers appear to seal the canine urinary bladder with minimal leakage. Use of an endoscopic GIA stapler may provide a minimally invasive option for partial cystectomy in dogs. Further evaluation for application to clinical cases is warranted.

Endoscopic Ultrasound-Guided Naso-gallbladder Drainage Using a Dedicated Catheter for Acute Cholecystitis After Transpapillary Metal Stent Placement for Malignant Biliary Obstruction.

Acute cholecystitis is a significant adverse event after self-expandable metal stent (SEMS) placement for malignant biliary obstruction (MBO); however, no appropriate treatment strategy has been established for its management. This study aimed to examine the feasibility and utility of endoscopic ultrasound-guided naso-gallbladder drainage (EUS-NGBD) for the management of acute cholecystitis occurring after SEMS placement. This retrospective study investigated consecutive patients with acute cholecystitis after SEMS placement for unresectable MBO, in whom EUS-NGBD was attempted. The study outcomes included technical success, clinical success, procedure time, adverse event, and cholecystitis recurrence, associated with the procedure. During the study period, EUS-NGBD was performed for SEMS-related acute cholecystitis in 30 patients with MBO. The technical and clinical success rates were 96.7% (29/30) and 96.6% (28/29), respectively. The median procedure time was 15min, and rate of procedure-related adverse event was 3.3% (1/30). The median duration from the procedure to tube removal was 9days. No adverse events were observed after removal. The median hospitalization duration after the procedure was 14days, and the median duration to the (re-)start of chemotherapy from cholecystitis onset was 13days. The median overall survival after EUS-NGBD was 123days, and the rate of cholecystitis recurrence until death was 4.2% (1/28). This study demonstrated that EUS-NGBD possesses good technical and clinical feasibility with an acceptable adverse event rates and short hospitalization and chemotherapy withdrawal period. Therefore, EUS-NGBD may be a good option for the treatment of SEMS-related cholecystitis in patients with MBO.

Usefulness of endoscopic ultrasound-guided transhepatic biliary drainage with a 22-gauge fine-needle aspiration needle and 0.018-inch guidewire in the procedure's induction phase.

Endoscopic ultrasound (EUS)-guided transhepatic biliary drainage is usually performed with a 19-gauge fine-needle aspiration (FNA) needle and a 0.025-inch guidewire. The combination of a 22-gauge FNA needle and a 0.018-inch guidewire is reported to be effective as a rescue option when the bile duct diameter is small or technically challenging. Experts in EUS-guided transhepatic biliary drainage have reported that bile duct puncture with a 19-gauge FNA needle is possible in most cases, but is not easy to reproduce by endoscopists with less experience in EUS-guided transhepatic biliary drainage. We investigated the usefulness of EUS-guided transhepatic biliary drainage using a 22-gauge FNA needle and a 0.018-inch guidewire during the procedure's induction phase. Consecutive patients who underwent EUS-guided transhepatic biliary drainage at our institution from March 2021 to May 2023 were evaluated, and 37 were included. Biliary drainage was performed for malignant bile duct stricture in 36 patients and choledocholithiasis in one patient. The median target bile duct diameter was 4.5 mm (2.5-9.4). Biliary access, fistula dilation, and stent placement were successful in the 37 patients (100%). The median procedure time was 35 min (16-125). Adverse events occurred in four (10.8%) patients. EUS-guided transhepatic biliary drainage using a 22-gauge FNA needle and a 0.018-inch guidewire is a useful and promising option for endoscopists with limited experience in EUS-guided transhepatic biliary drainage in the procedure's induction phase.

Endoscopic evaluation of neonates with signs of upper airway obstruction in the neonatal unit of a tertiary hospital.

The aim of the study is to evaluate major causes of upper airway obstruction in newborns receiving healthcare at our institution, their method of endoscopic assessment and the rate of complications related to these procedures. This is a case series study of patients from institutional neonatal intensive care unit (NICU) presenting signs of ventilatory dysfunction for whom an endoscopic airway assessment was warranted. Information of interest was collected from medical records according to a Clinical and Endoscopic Assessment Protocol created for the study. The protocol included clinical manifestations needing ENT evaluation, clinical signs of ventilatory dysfunction, comorbidities (pulmonary, cardiac, neurological, and gastrointestinal), examination method (airway endoscopy under general anesthesia or awake), exam complications, and final diagnosis. One hundred sixty-nine newborn patients who underwent airway endoscopy (awake bedside flexible fiberoptic laryngoscopy (FFL) or direct laryngoscopy and bronchoscopy (DLB) in the surgical ward) were included. Thirty-nine patients (23.07%) underwent bedside FFL. For the remaining 130 who underwent DLB under general anesthesia, the median procedure time was 30 min (20-44). Only 9 (5.32%) patients presented complications: desaturation (4), laryngospasm without desaturation with spontaneous resolution (2), apnea with resolution after stimulation (1), seizures (1), nasal bleeding (1). The most frequent diagnoses found were glossoptosis, posterior laryngeal edema, and laryngomalacia. This retrospective case series describes the prevalence of different pathologies that cause upper airway obstruction in neonates. Airway endoscopy seems an effective and safe diagnostic tool in neonatal airway obstruction. Glossoptosis was the most prevalent cause of obstruction in our center.

Intraventricular Lavage vs External Ventricular Drainage for Intraventricular Hemorrhage

Intraventricular lavage has been proposed as a minimally invasive method to evacuate intraventricular hemorrhage. There is little evidence to support its use. To evaluate the safety and potential efficacy of intraventricular lavage treatment of intraventricular hemorrhage. This single-blinded, controlled, investigator-initiated 1:1 randomized clinical trial was conducted at Aarhus University Hospital and Odense University Hospital in Denmark from January 13, 2022, to November 24, 2022. Follow-up duration was 90 days. The trial was set to include 58 patients with intraventricular hemorrhage. Prespecified interim analysis was performed for the first 20 participants. Data were analyzed from February to April 2023. Participants were randomized to receive either intraventricular lavage or standard drainage. The main outcome was risk of catheter occlusions. Additional safety outcomes were catheter-related infections and procedure time, length of stay at the intensive care unit, duration of treatment, and 30-day mortality. The main outcome of the prespecified interim analysis was risk of severe adverse events. Efficacy outcomes were hematoma clearance, functional outcome, overall survival, and shunt dependency. A total of 21 participants (median [IQR] age, 67 [59-82] years; 14 [66%] male) were enrolled, with 11 participants randomized to intraventricular lavage and 10 participants randomized to standard drainage; 20 participants (95%) had secondary intraventricular hemorrhage. The median (IQR) Graeb score was 9 (5-11), and the median (IQR) Glasgow Coma Scale score was 6.5 (4-8). The study was terminated early due to a significantly increased risk of severe adverse events associated with intraventricular lavage at interim analysis (risk difference for control vs intervention, 0.43; 95% CI, 0.06-0.81; P = .04; incidence rate ratio for control vs intervention, 6.0; 95% CI, 1.38-26.1; P = .01). The rate of catheter occlusion was higher for intraventricular lavage compared with drainage (6 of 16 patients [38%] vs 2 of 13 patients [7%]; hazard ratio, 4.4 [95% CI, 0.6-31.2]; P = .14), which met the prespecified α = .20 level. Median (IQR) procedure time for catheter placement was 53.5 (33-75) minutes for intraventricular lavage vs 12 (4-20) minutes for control (P < .001). This randomized clinical trial of intraventricular lavage vs standard drainage found that intraventricular lavage was encumbered with a significantly increased number of severe adverse events. Caution is recommended when using the device to ensure patient safety. ClinicalTrials.gov Identifier: NCT05204849.

Implementation and use of a supraglottic airway device in the management of out-of-hospital cardiac arrest by firefighter first responders – A prospective feasibility study

AimWe wanted to assess the implementation and use of a supraglottic airway (SGA) for on-call firefighter first responders in out-of-hospital cardiac arrest. MethodsWe trained 502 firefighter first responders, located at 35 fire stations in the South-East of Norway, in the use of SGA during cardiopulmonary resuscitation in adult out-of-hospital cardiac arrest. Training consisted of 45 minutes of theoretical and practical training in small groups.Primary outcome was successful ventilation with SGA assessed by both firefighter first responders and first paramedic arriving on-scene. Secondary outcomes included time expenditure and complications related to the procedure, evaluation of the training, and descriptive characteristics of the out-of-hospital cardiac arrest cases. ResultsAn SGA was used by firefighter first responders in 23 out-of-hospital cardiac arrests, and successful ventilation was achieved in 20 (87%) cases. Air-leak was described in the three unsuccessful cases. The median procedural time was 30 seconds (IQR = 15–40), with no observed procedural complications. Firefighter first responders arrived in median time 9 minutes (IQR = 6–10 min) before the ambulance. They performed chest compressions on all patients and 6 (26%) of the patients received shock with semi-automatic external defibrillator. After training, all participants were able to successfully ventilate a manikin with the SGA. The cost of the SGA equipment for all fire stations was 3955 GBP. ConclusionImplementation of an SGA for firefighter first responders in out-of-hospital cardiac arrest management seems feasible, safe and can be introduced with limited amount of training and limited use of resources.

Complete circumferential endoscopic submucosal dissection for early Barrett’s neoplasia

Background and aimsEndoscopic submucosal dissection (ESD) is carving out an increasing role in the treatment of esophageal neoplasia in the western world. Contrary to Asia, the majority of esophageal cancers in North America are associated with Barrett’s esophagus. Patients with circumferential advanced neoplasia were previously managed by esophagectomy. Increased experience with ESD has allowed for an endoscopic alternative. We aim to present our experience with complete circumferential esophageal ESD at a North American referral center. MethodsAll patients undergoing 100% circumferential esophageal ESD between Oct 2016 and Jan 2023 at a single tertiary care center in Canada were included in the cohort. Demographic, procedural data and lesion characteristics are presented in this series. ResultsEleven patients underwent 100% circumferential esophageal ESD during this period for Barrett’s neoplasia. All patients had technically successful procedures with en bloc resection. Nine patients (82%) had R0 resections, defined as clear lateral and deep margins on histologic examination. Two patients had positive deep margins on histologic examination and proceeded to esophagectomy. Seven patients (64%) had adenocarcinoma on final pathology, of which 6 (86%) had upstaging from their initial biopsy.The median area of resected specimen was 48cm2 (IQR 26-80) and the median procedure time was 231 minutes (IQR 180-246). Procedural efficiency was 4.0 min/cm2 (IQR 2.7-5). Two patients (18%) developed refractory strictures following the procedure, which were endoscopically managed to resolution. ConclusionMultifocal dysplastic Barrett’s esophagus remains a challenging entity to treat. Circumferential ESD is a possible therapeutic option, with high procedural success and low adverse outcomes. This should be balanced against the risk of stricture development, as the optimal post procedural prophylaxis regimen is investigated.