Number Of Endoscopic Interventions Research Articles

Surgical Outcomes by Early Airway Endoscopy Findings after Pediatric Staged Laryngotracheoplasty.

To determine how initial postoperative airway endoscopy findings after stent removal predict successful decannulation in children undergoing double-staged laryngotracheoplasty (dsLTP). Secondary objectives assessed timing of decannulation and number of endoscopic interventions needed after dsLTP. A case series with chart review included children who underwent dsLTP at a tertiary children's hospital between 2008 and 2021. Rates of decannulation, time to decannulation, and number of interventions after dsLTP were recorded for children with high- or low-grade stenosis at the first bronchoscopy after stent removal. Of the 65 children who were included, 88% had high-grade stenosis and 98% had a preoperative tracheostomy. Successful decannulation happened in 74% of the children, and 44% of the children were decannulated within 12 months of surgery. For children with low-grade stenosis at the first endoscopy after stent removal, 84% were successfully decannulated compared with 36% of the children with high-grade stenosis (p = 0.001). After dsLTP, children with high-grade stenosis required 7.5 interventions (SD: 3.3) compared with 4.0 interventions (SD: 3.0) for children with low-grade stenosis (p < 0.001). Decannulated children with high-grade stenosis necessitated more endoscopic procedures (7.0 vs. 3.7, p = 0.02). Time to decannulation was similar between children with high- and low-grade early postoperative stenosis (21.9 vs. 17.8 months, p = 0.63). Higher grade stenosis identified on the first airway endoscopy after suprastomal stent removal is correlated with lower decannulation rates and more postoperative endoscopic interventions. Although time to decannulation was not impacted by early stenosis grade, surgeons might utilize these early airway findings to counsel families and prognosticate possible surgical success. 4 Laryngoscope, 134:963-967, 2024.

On the degree of effectiveness of surgical aids for mechanical jaundice

Relevance. The problem of mechanical jaundice is the most urgent in abdominal surgery. This is primarily because the frequency of this pathology is steadily increasing, and the mortality rate does not have a distinct downward trend. Surgical tactics in case of mechanical jaundice remains multivariate, and a differentiated approach is needed for treating this contingent of patients, which is decisive in improving the results of surgical aids.The aim of the study. To improve the results of treatment of patients with mechanical jaundice of calculous etiology.Materials and methods. The analysis of the results of treatment and specially conducted studies in 554 patients with mechanical jaundice of calculous etiology was carried out. The patients underwent ultrasound, CT, and MRI. The concentration of adrenaline, norepinephrine, dopamine, 11-oxycorticosteroids, histamine, and serotonin, as well as toxic metabolic products were determined. The state of the autonomic nervous system was assessed by determining the autonomic index and mathematical analysis of the heart rate using variational pulsometry.Results. All the patients were operated on. Priority was given to stage-by-stage surgical tactics combining endoscopic decompression of the biliary tract with endoscopic papillosphincterotomy in the early stages of hospitalization and open surgical treatment after cupping the clinic of mechanical jaundice. There was a 3-fold increase in the number of endoscopic interventions. The mortality rate for the entire period decreased by 2.1 times. The reason for the results obtained is the degree of trauma of the operation. The parameters of the musculoskeletal, autonomic nervous, and sympathoadrenal systems were determined in patients divided into three groups. In the first group, primary open surgery on the biliary tract was performed, in the second — endoscopic papillosphincterotomy and abdominal surgery on the biliary tract, in the third — only endoscopic papillosphincterotomy. Endoscopic papillosphincterotomy had the most sparing effect on the functioning of the cardiovascular system and normalization of vegetative homeostasis. The volume of the surgical aid for mechanical jaundice affects the content of the sympathoadrenal system and biologically active substances in the blood plasma. When performing abdominal operations, compared with minimally invasive ones, the concentration of adrenaline, norepinephrine, serotonin, histamine, and 11-oxycorticosteroids in the blood increased by 1.5–2.5 times.Conclusion. The effectiveness and priority of minimally invasive operations for treating mechanical jaundice have been confirmed. The use of endoscopic resolution of biliary hypertension makes it possible to reduce the mortality rate against the background of a steady trend toward normalization of the indicators of the sympathoadrenal system and variational pulsometry.

PD31-09 PROSPECTIVE ASSESSMENT OF GENITAL PAIN IN PATIENTS UNDERGOING URETHROPLASTY: INCIDENCE, ASSOCIATIONS AND IMPACT OF SURGERY

You have accessJournal of UrologyCME1 May 2022PD31-09 PROSPECTIVE ASSESSMENT OF GENITAL PAIN IN PATIENTS UNDERGOING URETHROPLASTY: INCIDENCE, ASSOCIATIONS AND IMPACT OF SURGERY Declan Rourke, Jordan Bekkema, and Keith Rourke Declan RourkeDeclan Rourke More articles by this author , Jordan BekkemaJordan Bekkema More articles by this author , and Keith RourkeKeith Rourke More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002582.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Genital pain is an exceedingly common urological condition with a probable but unclear association with urethral stricture. The objective of this prospective study is to assess the incidence of genital pain in patients with urethral stricture and examine the impact of urethroplasty. METHODS: Over a 7-year period (2011-2018), patients were offered enrollment in a prospective single-centre study assessing patient-reported genital pain pre- and 6-months post-urethroplasty. Genital pain was assessed with the question, “Do you experience genital (scrotal or penis) pain?” answered on a five-point scale [“Never” (1), “Occasionally” (2), “Sometimes” (3), “Most of the Time” (4) or “All of the Time” (5)]. Responses of 3, 4, or 5 were considered clinically significant. Descriptive statistics were used to summarize findings, Wilcoxon signed-rank test was used to compare pre- and post-operative states and logistic regression was used to evaluate the association between genital pain and clinical variables. RESULTS: 387 patients completed enrollment with a mean age of 49.5 years and stricture length of 4.5cm. Pre-operatively, 36.4% (141/387) of patients reported genital pain with overall responses of 5.7% “all of the time”, 9.8% “most of the time”, 20.9% “sometimes”, 29.7% “occasionally” and 33.9% “never”. Patients with panurethral stricture reported significantly higher rates (57.1%) of pre-operative pain (Odds Ratio 2.93, 95%CI 1.32-6.50; p=0.008) while others factors were not (including age (p=0.07), stricture length (p=0.08), etiology (p=0.43), number of endoscopic treatments (p=0.52), and prior urethroplasty (p=0.42)). Overall, pain scores improved post-urethroplasty (p<0.0001) with responses of 1.0% “all of the time”, 3.6% “most of the time”, 9.6% “sometimes”, 21.2% “occasionally”, and 64.6% “never”. Specifically, in those reporting pre-operative genital pain, 88.7% (125/141) experienced improvement (p<0.0001), 8.5% were unchanged and 2.8% reported worse pain. On logistic regression analysis patients with penile strictures (O.R. 0.24, 95%CI 0.06-0.91; p=0.04), hypospadias (O.R. 0.14, 95%CI 0.02-0.88; p=0.04), and staged reconstruction (O.R. 0.22, 95%CI 0.05-0.90; p=0.04) were less likely to report improvement in genital pain (80.0%, 76.5% and 69.2% respectively). No identifiable clinical factor was associated with worsening pain. In the entire study cohort, 50.4% reported improvement in genital pain after urethroplasty, 37.0% were unchanged and 12.7% reported worsening pain. In the overall cohort, patients undergoing staged reconstruction were again less likely to report an improvement in genital pain status (O.R. 0.49, 95%CI 0.26-0.95; p=0.04) with no factor associated with worsening of genital pain post-urethroplasty. CONCLUSIONS: Genital pain is common in patients presenting with urethral stricture and more common in those with panurethral stricture. While the exact mechanism remains to be determined, genital pain improves in the majority of patients undergoing urethroplasty but less so in patients with penile strictures, hypospadias and staged reconstruction. Source of Funding: Northern Alberta Urology Foundation © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e544 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Declan Rourke More articles by this author Jordan Bekkema More articles by this author Keith Rourke More articles by this author Expand All Advertisement PDF DownloadLoading ...

Anesthesiological support during gastroscopy and colonoscopy: availability, effectiveness and safety of applied methods

The article presents the literature review on anesthesiological support during gastroscopy and colonoscopy including evaluation of availability, effectiveness, safety and patient’s comfort of the used methods. Data on the number of endoscopic interventions in gastrointestinal tract performed under general anesthesia and controlled sedation in Vladivostok hospitals is provided. Low availability of anesthesiological support for these procedures in public hospitals is stated. Reasonability of widespread use of moderate analgosedation during gastroscopy and colonoscopy is demonstrated.

Nationwide survey of pediatric gastrointestinal endoscopy in Japan.

The implementation rates of pediatric gastrointestinal endoscopy are increasing with advancements in the devices used and pediatricians' skills. As part of the Japan Pediatric Endoscopy Study Group, we aimed to investigate the rates of pediatric gastrointestinal endoscopy use and the associated adverse events through a nationwide survey. A questionnaire was sent to 630 institutions in Japan. The numbers of pediatric gastrointestinal endoscopy cases and adverse events occurring during endoscopy, from April 2011 to March 2016, were investigated. Responses were obtained from 445 facilities. The total number of pediatric gastrointestinal endoscopies was 37447 and that of endoscopic examinations was 32219 (86.0%), with esophagogastroduodenoscopy accounting for 18484 cases; ileal colonoscopy, 11936; endoscopic retrograde cholangiopancreatography, 389; wireless capsule endoscopy, 897; and balloon-assisted enteroscopy, 513. The number of endoscopic treatments was 5228, followed by balloon dilatation (1703), foreign body removal (989), and polypectomy (822); 201 adverse events (0.54%) occurred, 79 of which presented during endoscopic examination (0.25%). Eight serious perforations were noted in 0.0054% and 0.025% of those undergoing esophagogastroduodenoscopy and colonoscopy, respectively. Overall, 122 adverse events (2.33%) occurred in association with endoscopic treatment. One case of cardiopulmonary arrest occurred because of accidental extubation. However, no deaths occurred. Endoscopic examinations had a slightly higher adverse event rate, because of an increase in endoscopic retrograde cholangiopancreatography and small intestine enteroscopy, than that reported in previous studies, but the adverse event rate of endoscopic treatment did not increase.

612 Impact of a Pharmacist-Managed Protocol Limiting Continuous Infusion of Proton Pump Inhibitor Use in Patients With an Upper Gastrointestinal Bleed

INTRODUCTION: In patients with an upper gastrointestinal bleed, previous reports have shown that there is no difference among clinically significant endpoints when prescribed a continuous infusion of pantoprazole versus intermittent bolus administration. Our study evaluates the impact of a pharmacist-managed protocol aimed at reducing continuous infusion proton pump inhibitor use in upper gastrointestinal bleeds. METHODS: We performed a retrospective analysis of patients receiving intravenous pantoprazole for suspected upper gastrointestinal bleeding before and after the implementation of a pharmacist managed protocol. Prior to implementation, patients were continued on pantoprazole continuous infusions (8 mg/hr) at the physician's discretion. After implementation, all hemodynamically stable patients were allowed one dose of pantoprazole as a continuous infusion (8 mg/hr for 10 hours) and then were transitioned by the pharmacist to intermittent 40 mg IV injections twice daily. The primary endpoint assessed was the incidence of upper gastrointestinal re-bleeding within 7 days of treatment. Secondary endpoints included the number of pantoprazole continuous infusions and IV push injections, number of blood transfusions, number of endoscopic interventions, length of hospital stay, and mortality. RESULTS: After screening 702 patients, 222 patients met inclusion criteria (115 in the pre-protocol group and 107 in the post-protocol group). The re-bleeding rate at day 7 was 7% in the pre-protocol group, compared to 4% in the post-protocol group (P = 0.17). As expected, use of the protocol reduced the median number of continuous infusions per patient [4 (IQR 2-4) vs 2 (IQR 1-3); P &lt; 0.001] and increased the median number of IV push injections [2 (IQR 2-4) vs 4 (IQR 2-7); P &lt; 0.001] in the pre- and post-protocol groups, respectively. There were no significant differences between the pre- and post-intervention groups regarding blood transfusions (65% vs. 63%; P = 0.78), endoscopic interventions (79% vs. 79%; P = 1.0), hospital length of stay [4 days (IQR 3-8) vs. 4 days (IQR 2-8); P = 0.521], or hospital mortality (5% vs. 2%; P = 0.28) (See Tables 1 and 2). CONCLUSION: Implementation of this pharmacy-managed protocol, allowing automatic transition from pantoprazole continuous infusions to intermittent injections in hemodynamically stable patients with an upper gastrointestinal bleed, had no detrimental effect on the incidence of re-bleeding within 7 days.

Over-the-scope clip management of non-acute, full-thickness gastrointestinal defects.

Endoscopic management of full-thickness gastrointestinal tract defects (FTGID) has become an attractive management strategy, as it avoids the morbidity of surgery. We have previously described the short-term outcomes of over-the-scope clip management of 22 patients with non-acute FTGID. This study updates our prior findings with a larger sample size and longer follow-up period. A retrospective analysis of prospectively collected data was conducted. All patients undergoing over-the-scope clip management of FTGID between 2013 and 2019 were identified. Acute perforations immediately managed and FTGID requiring endoscopic suturing were excluded. Patient demographics, endoscopic adjunct therapies, number of endoscopic interventions, and need for operative management were evaluated. Success was strictly defined as complete FTGID closure. We identified 92 patients with 117 FTGID (65 fistulae and 52 leaks); 27.2% had more than one FTGID managed simultaneously. The OTSC device (Ovesco Endoscopy, Tubingen, Germany) was utilized in all cases. Additional closure attempts were required in 22.2% of defects. With a median follow-up period of 5.5months, overall defect closure success rate was 66.1% (55.0% fistulae vs. 79.6% leaks, p = 0.007). There were four mortalities from causes unrelated to the FTGID. Only 14.9% of patients with FTGID underwent operative management. There were no complications related to endoscopic intervention and no patients required urgent surgical intervention. Over-the-scope clip management of FTGID represents a safe alternative to potentially morbid operative intervention. When strictly defining success as complete closure of all FTGID, endoscopy was successful in 64.4% of patients with only a small minority of patients ultimately requiring surgery.

Urosymphyseal Fistulas Resulting From Endoscopic Treatment of Radiation-induced Posterior Urethral Strictures

To describe the inciting events leading to urosymphyseal fistulas (UFs) and pubic osteomyelitis (PO) in patients who had radiation-induced urethral strictures. We retrospectively reviewed patients who underwent simultaneous pubic debridement, simple cystectomy, and urinary diversion for refractory UF and PO from 2014 to 2016. We investigated inciting events leading to UF, as well as patient presenting symptoms, diagnosis, management, and outcomes. Five patients were identified over a 2-year period. All patients had a previous history of radiation for prostate cancer. The median age was 67 years. All patients developed UF and PO after endoscopic intervention for urethral stricture. The number of endoscopic interventions per patient for stricture ranged from 1 to 7, including serial dilation, balloon dilation, and urethrotomy. Sterile urine cultures were obtained before all endoscopic interventions. All patients had pelvic pain with ambulation and recurrent urinary tract infections at presentation. Patients were diagnosed using a combination of retrograde urethrography and magnetic resonance imaging. Simultaneous pubic debridement with simple cystectomy and diversion was used for management in all cases. One patient died postoperatively with the remainder recovering well without PO or fistula recurrence, with a median follow-up of 16 months. UF can occur as a complication of endoscopic treatment of posterior urethral stricture in patients with a history of radiation therapy for prostate cancer. This study demonstrates that UF and PO may develop even with minimally traumatic procedures and sterile urine. All patients treated for posterior stricture must be considered at risk of development of fistulas and osteomyelitis.

Current status of superficial pharyngeal squamous cell carcinoma in Japan.

To investigate the status and treatment of superficial pharyngeal squamous cell carcinoma in Japan. We analyzed all cases diagnosed between 2011 and 2013, as recorded in the national database of hospital-based cancer registries. We extracted data on patient sex, age, tumor locations, histology, presentation routes, initial treatments, and TNM stages. Additionally, we compared the characteristics of pharyngeal carcinoma to those of esophageal cancer. A total of 16,521 oropharyngeal and hypopharyngeal cancers from 409 institutions were included. Diagnosis of Tis tumors was infrequent, and both cancers were likely to be diagnosed at an advanced stage (n=866, 5.3%). Tis diseases were the most commonly detected during follow-up examinations for other diseases (n=608, 70%). While more oropharyngeal Tis patients were men compared to T1-4 patients (88 vs 82%, respectively), hypopharyngeal cancer patients comprised an equally high proportion of men (94 vs 92%, respectively). The most common location of oropharyngeal Tis tumors was the posterior wall (32%), whereas T1-4 tumors were most commonly found on the lateral wall (36%). In hypopharyngeal cancer, both Tis and T1-4 were most commonly located in the pyriform sinus (62%). The proportion of Tis tumors diagnosed at individual institutions showed a positive correlation with the number of endoscopic treatments (r=0.32, P<0.001) and the number of esophageal cancer cases (r=0.37, P<0.001). Our national database study elucidated the current characteristics of superficial pharyngeal squamous cell carcinoma patients in Japan. Further improvements in early diagnosis and standardized treatments are warranted.

Multiple plastic stents versus covered metal stent for treatment of anastomotic biliary strictures after liver transplantation: a prospective, randomized, multicenter trial

Treatment of anastomotic biliary strictures (ABSs) after orthotopic liver transplantation by endoscopic insertion of multiple plastic stents (MPSs) is well established. The use of covered self-expandable metal stents (cSEMSs) for this indication is less investigated. In an open-label, multicenter, randomized trial, patients with confirmed ABSs were randomly assigned 1:1 to receive either an MPS or a cSEMS. The primary endpoint was the number of endoscopic interventions until ABS resolution. Secondary endpoints were frequency of adverse events, treatment success rates, and time to treatment success and recurrence of ABS during follow-up of at least 1 year. Fifty-eight patients were included between 2012 and 2015, and 48 patients completed follow-up. Patients receiving MPS (n= 24) underwent a median of 4 (range, 3-12) endoscopic retrograde cholangiography examinations, whereas those in the cSEMS group (n= 24) underwent a median of 2 (range, 2-12) sessions until ABS resolution (P< .001). A median of 8 (range, 2-32) stents was used until ABS resolution within the MPS group and 1 (range, 1-24) in the cSEMS group (P< .0001). cSEMS migration occurred in 8 (33.3%) patients. Treatment duration did not differ significantly. Initial treatment success rates were high with 23 (95.8%) in the MPS group and 24 (100%) for cSEMSs (P= 1). Five (20.8%) patients in both groups showed stricture recurrence after a median follow-up of 500 days (range, 48-1317 days). cSEMSs for treatment of ABSs needed less endoscopic interventions to achieve similar efficacy as MPS and might become a new treatment standard. However, the optimal duration of cSEMS therapy and cost-efficacy have to be evaluated. (Clinical trial registration number: NCT01393067.).

PD14-04 REPEAT ENDOSCOPIC MANIPULATION FOR BULBAR URETHRAL STRICTURES INCREASES STRICTURE LENGTH AND URETHROPLASTY COMPLEXITY BUT DOES NOT AFFECT URETHROPLASTY OUTCOMES

You have accessJournal of UrologyTrauma/Reconstruction: Urethral Reconstruction (including Stricture) II1 Apr 2015PD14-04 REPEAT ENDOSCOPIC MANIPULATION FOR BULBAR URETHRAL STRICTURES INCREASES STRICTURE LENGTH AND URETHROPLASTY COMPLEXITY BUT DOES NOT AFFECT URETHROPLASTY OUTCOMES David W. Chapman, Abhaya Prasad, Adam Kinnaird, and Keith Rourke David W. ChapmanDavid W. Chapman More articles by this author , Abhaya PrasadAbhaya Prasad More articles by this author , Adam KinnairdAdam Kinnaird More articles by this author , and Keith RourkeKeith Rourke More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2015.02.1333AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Endoscopic procedures, in the form of dilation or direct vision urethrotomy remain the most commonly used treatments for urethral stricture. Repeat endoscopic procedures, however, do not typically offer cure and may increase stricture complexity, threatening urethroplasty outcomes. Our objective was to evaluate the association between the number of endoscopic procedures with stricture length, urethroplasty complexity and urethroplasty outcomes. METHODS A retrospective review of 840 consecutive urethral reconstructions performed by a single surgeon between August 2003 and May 2014 was completed. Exclusion criteria were prior urethroplasty, penile or panurethral strictures, posterior stenosis, staged repair or incomplete datasets. Number of endoscopic treatments were analysed as an ordinal variable by dividing the number of endoscopic treatments into 4 groups (group 1 = 0 treatments, group 2= 1-2, group 3 = 3-5, group 4 = greater than 5) and as a continuous variable. Preoperative patient demographics and postoperative outcomes were first compared using univariate binary regression, followed by multivariate binary regression. Outcomes measures were stricture length (measured intra-operatively), complexity of urethroplasty (either an anastomotic technique or a more complex tissue substitution), urethroplasty success (defined as the easy passage of a 16Fr cystoscope), and Clavien complications. RESULTS Of the 430 patients with bulbar urethral strictures eligible for analysis, 49 were in group 1, 182 were group 2, 141 in group 3, and 58 were group 4. Using linear regression as both an ordinal and continuous variable, an increase in the number of endoscopic manipulations was strongly associated with increased stricture length (p<0.001 and p=0.01) and urethroplasty complexity (p<0.001 and p=0.02). Using multivariate binary regression, no association of urethroplasty success or complications were found with number of endoscopic treatments (p=0.85 and p=0.56, respectively). Urethroplasty failed in 2% of group 0 (1/50), 6.6% of group 1 (12/182), 9.0% of group 3 (13/143), and 8.6% of group 4 (5/65). CONCLUSIONS Temporizing patients with repeat endoscopic procedures is associated with increasing stricture length and urethroplasty complexity. Despite this, no association was found between the rate of stricture recurrence or accompanying urethroplasty complications. © 2015 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 193Issue 4SApril 2015Page: e320 Advertisement Copyright & Permissions© 2015 by American Urological Association Education and Research, Inc.MetricsAuthor Information David W. Chapman More articles by this author Abhaya Prasad More articles by this author Adam Kinnaird More articles by this author Keith Rourke More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Invasive treatment trends in urinary calculi in a third level hospital

ObjectiveIn the following study, we observe the progress of various invasive calculi treatments that have taken place in our hospital in the last 15 years. Materials and methodsWe extracted data from our hospital database on patients who underwent extracorporeal shock wave lithotripsy (ESWL), endoscopic surgery and open surgery. We analyzed how the incidence of these treatments has evolved over the last 15 years. We also studied the number of publications in PubMed that reference invasive calculi treatments. ResultsFrom January 1998 to December 2012, a total of 10,947 patients were treated instrumentally for lithiasis, 9695 of whom (90.4%) underwent ESWL and 1034 of whom underwent endoscopic or open surgery (9.6%). The incidence of lithotripsy treatments reached its maximum in 2006, with a progressive reduction thereafter. The incidence of endoscopic surgery increased progressively until 2009 and then leveled off. We can see how in recent years there has been a clear increase in the number of studies that have covered endoscopic surgery, with a decreasing number covering ESWL. ConclusionsIn our community, ESWL remains the most widely used invasive treatment for calculi. In recent years, there has been a reduction in the number of ESWL treatments and an increase in the number of endoscopic treatments, with open surgery showing a clearly decreasing trend.

Tendencia en los tratamientos invasivos en la litiasis urinaria en un hospital de tercer nivel

ObjectiveIn the following study, we observe the progress of various invasive calculi treatments that have taken place in our hospital in the last 15 years. Material and methodWe extracted data from our hospital database on patients who underwent extracorporeal shock wave lithotripsy (ESWL), endoscopic surgery and open surgery. We analyzed how the incidence of these treatments has evolved over the last 15 years. We also studied the number of publications in PubMed that reference invasive calculi treatments. ResultsFrom January 1998 to December 2012, a total of 10,947 patients were treated instrumentally for lithiasis, 9,695 of whom (90.4%) underwent ESWL and 1,034 of whom underwent endoscopic or open surgery (9.6%). The incidence of lithotripsy treatments reached its maximum in 2006, with a progressive reduction thereafter. The incidence of endoscopic surgery increased progressively until 2009 and then leveled off. We can see how in recent years there has been a clear increase in the number of studies that have covered endoscopic surgery, with a decreasing number covering ESWL. ConclusionsIn our community, ESWL remains the most widely used invasive treatment for calculi. In recent years, there has been a reduction in the number of ESWL treatments and an increase in the number of endoscopic treatments, with open surgery showing a clearly decreasing trend.

Endoscopic closure of esophageal intrathoracic leaks: stent versus endoscopic vacuum-assisted closure, a retrospective analysis

Placement of covered self-expanding metal or plastic stents (SEMS or SEPS) is an established method for managing intrathoracic leaks. Recently, endoscopic vacuum-assisted closure (EVAC) has been described as a new effective treatment option. Our aim was to compare stent placement with EVAC for nonsurgical closure of intrathoracic anastomotic leaks. In a retrospective analysis we were able to identify 39 patients who were treated with SEMS or SEPS and 32 patients who were treated with EVAC for intrathoracic leakage. In addition to successful fistula closure, we analyzed hospital mortality, number of endoscopic interventions, incidence of stenoses, and duration of hospitalization. In a multivariate analysis, successful wound closure was independently associated with EVAC therapy (hazard ratio 2.997, 95 % confidence interval [95 %CI] 1.568 - 5.729; P = 0.001). The overall closure rate was significantly higher in the EVAC group (84.4 %) compared with the SEMS/SEPS group (53.8 %). No difference was found for hospitalization and hospital mortality. We found significantly more strictures in the stent group (28.2 % vs. 9.4 % with EVAC, P < 0,05). EVAC is an effective endoscopic treatment option for intrathoracic leaks and showed higher effectiveness than stent placement in our cohort.

Effectiveness, safety, and cost-effectiveness of photodynamic therapy in Barrett's esophagus: a systematic review

Barrett's esophagus, the management of which remains controversial, is the precursor condition to esophageal adenocarcinoma. A number of endoscopic treatments have been designed as an alternative to surgical resection for patients with high-grade dysplasia. One of these, photodynamic therapy, involves the light activation of a photosensitizer that causes local tissue destruction via oxidation reactions. The present work reviews the effectiveness, safety, and cost-effectiveness of this treatment. A systematic review of the literature recorded in the Medline, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Database, and the National Health Service Economic Evaluation Database was undertaken. Articles reporting randomized clinical trials of photodynamic therapy for the treatment of Barrett's esophagus, and economic assessments of the procedure, were selected. The quality of the articles was checked. Twelve articles were included in this review: eight randomized, controlled clinical trials and four economic assessments. The clinical trials suffered from methodological limitations, but the economic assessments were considered to be good quality. Photodynamic therapy is effective for the ablation of dysplasia in Barrett's esophagus, although the frequency of adverse events is quite high. The procedure is presented as a cost-effective alternative to intense endoscopic monitoring and esophagectomy. However, the evidence regarding its effectiveness in reducing the number of patients who go on to develop cancer is only incipient. Rigorous, controlled studies with longer follow-up times, in which photodynamic therapy is compared with surgical resection and other endoscopic techniques, are needed.

Successful stenting in ductal disruption favorably impacts treatment outcomes in patients undergoing transmural drainage of peripancreatic fluid collections

The role of pancreatic duct (PD) stenting in patients undergoing endoscopic transmural drainage of peripancreatic fluid collection (PFC) remains unclear. The objective of this study is to evaluate the effect of PD stenting on treatment success in patients undergoing endoscopic transmural drainage of PFC. This is a retrospective follow-up study of all patients who underwent endoscopic and endoscopic ultrasonography-guided transmural drainage of PFC during a 5-year period. Double-pigtail stents were deployed in all patients; in addition, nasocystic catheters were deployed in those with abscess/necrosis. An endoscopic retrograde cholangiopancreatogram was attempted whenever feasible in all patients, and pancreatic stents were placed when the duct disruption could be bridged. Success was defined as an improvement in symptoms and resolution of PFC upon follow-up computed tomography at 8 weeks. Of the 110 patients who underwent PFC drainage, 40 (36%) underwent simultaneous PD stenting. Treatment was successful in 95 of the 110 patients (86%). The PFC types were: pseudocyst (62%), necrosis (20%), and abscess (18%). The median duration of follow up was 9.9 months. Those who underwent PD stenting were significantly more likely to have treatment success than those who did not undergo PD stenting (97.5% vs 80%; risk ratio [RR](crude) = 1.48, P = 0.01). In the multivariable analysis, this association remained significant (RR(adjusted) = 1.14, 95% confidence interval: 1.01-1.29, P = 0.036), even after adjusting for the etiology of pancreatitis, type and location of PFC, luminal compression at endoscopy, enteral nutrition, white blood cell count, and number of endoscopic interventions. Transpapillary PD stenting improves treatment outcomes in patients undergoing endoscopic transmural drainage of PFC.

Is transcatheter arterial embolization a safer alternative than surgery when endoscopic therapy fails in bleeding duodenal ulcer?

Objective. Emergency surgery after unsuccessful endoscopic therapy for bleeding duodenal ulcer has been reported to have a high mortality. Transcatheter arterial embolization (TAE) of the gastroduodenal artery is an alternative strategy when endoscopic therapy fails. This study is a retrospective analysis comparing these two treatment strategies. Material and methods. Patients who underwent TAE (n = 24) or open surgery (n = 50) after unsuccessful endoscopic therapy for bleeding duodenal ulcers at two university hospitals between 2000 and 2007 were compared. Mortality, morbidity, length of hospital stay, age, number of endoscopic interventions and acute physiology and chronic health evaluation (APACHE) II score were evaluated. Results. The groups were comparable concerning gender and length of hospital stay. The mean age (69.6 ± 16.1 versus 61.9 ± 14.1 years; P = 0.043), APACHE II score (17.0 ± 5.1 versus 12.8 ± 5.7; P = 0.004) and number of gastroscopies (P = 0.009) were significantly higher in the embolization group. Five patients (20.8%) died in the embolization group compared to 11 (22%) in the surgery group. However, mortality in high-risk patients (APACHE II score ≥ 16.5) was lower in the TAE group (23.1% versus 50.0%; P = 0.236). Method-related as well as other complications were not significantly different between the two groups. There was, however, a higher re-bleeding rate in the TAE group. Conclusions. TAE of the gastroduodenal artery appears to be a safe alternative when endoscopic therapy for bleeding duodenal ulcer fails, at least in high-risk patients. The role of TAE in low-risk patients with bleeding from duodenal ulcer needs to be defined by means of a prospective controlled trial.

Endoscopic Pancreatic Necrosectomy in 28 Patients By EUS-Guided NOTES®: Improved Method with Reduced Number of Procedures and Low Complication Rates

Background: Surgery of infected pancreatic necrosis is associated with considerable high mortality. It remained to be shown if endoscopic necrosectomy via the stomach or duodenum using EUS-guided NOTES (Natural Orifice Transluminal Endoscopic Surgery) is feasible and can reduce complications and mortality. Methods: Endoscopic necrosectomy was performed in 28 patients between 2002 and 2008 (median age 58y [21-83y], 23 male, 5 female). Indications for treatment were uncontrolled infection, sustained pain or symptomatic gastroduodenal compression. Our procedure included three major steps. Step I: EUS-guided access to the necrotic cavity and access enlargement. Step II: endoscopic necrosectomy in combination with interval stenting. Step III: readmission and stent change until complete collapse of the cavity was achieved. Results: A median of 6 [1-16] sessions were needed for access, necrosectomy and removal/exchange of stents. Hospital discharge of patients was considered once complete removal of the necrotic material was achieved. Median follow up was 20 months. In-patient mortality was 4% (1/28) and related to aspiration of cyst-derived fluid two hours after drainage. Clinical and morphological remission was obtained in the remaining patients (96%). Nasocystic and transabdominal irrigation or extra endoscopic sessions for pure flushing could be avoided in all patients. Severe immediate complications were encountered in 2 cases (one arterial and one variceal bleeding). During follow up additional surgery was necessary in seven patients (cholecystectomy due to acute cholecystitis (n=2), elective cholecystectomy (n=3), symptomatic duodenal stenosis (n=1), ileus due to intestinal adhesions (n=1)). Surgery was neither related to pancreatic necrosis nor to endoscopic treatment. Five deaths occured during follow-up which were unrelated to endoscopy or pancreatic necrosis. Overall, the number of complications related to pancreatic necrosis was far below that of conventional necrosectomy in historical series. Conclusion: The number of patients undergoing endoscopic necrosectomy is the largest cohort reported so far. The number of endoscopic interventions and the procedure related morbidity and mortality in our cohort is low as compared to historical data. In the light of the superior outcome of patients undergoing endoscopic necrosectomy, the role of conventional surgery of infected necrosis has to be redefined.

Management of persistent gastroesophageal anastomotic strictures with removable self-expandable polyester silicon-covered (Polyflex) stents: an alternative to serial dilation

A benign gastroesophageal anastomotic stricture occurs in up to 42% of patients after transhiatal esophagectomy for esophageal cancer. Management of anastomotic strictures may require extended periods of serial endoscopic dilation, with significant risk, cost, and inconvenience for the patient. To determine if placement of removable self-expandable polyester silicon-covered (Polyflex) stents (SEPSs) prolonged the interval between endoscopic interventions in the management of persistent anastomotic stricture. Retrospective cohort study. National Cancer Institute designated comprehensive cancer center. Eight patients after a transhiatal esophagectomy referred for management of benign persistent anastomotic strictures. Serial balloon and bougie dilations and SEPS placement. The interval between endoscopic interventions and the number of endoscopic interventions before and after SEPS placement. Over a 365-day period, 13 SEPS were placed in 8 patients with benign persistent anastomotic strictures after a transhiatal esophagectomy. A SEPS placement delayed the interval between endoscopic interventions from a mean of 7 days before stent insertion to 62 days after insertion (P < .008). The median number of preinsertion interventions was 4 and was reduced to 1 after insertion (P < .005). The small number of patients. A SEPS placement did not result in stricture resolution or stabilization after SEPS removal. The SEPS migration rate was much higher in our patients with postesophagectomy anastomotic strictures than previously reported for other types of strictures. However, a SEPS placement did significantly delay the interval between endoscopic interventions in patients with persistent gastroesophageal anastomotic strictures after transhiatal esophagectomy. SEPS placement should be considered as an alternative to continued serial dilation in patients with persistent anastomotic strictures after transhiatal esophagectomy.

Use of Kirschner Wires as Endoscopic Retractors

We read with great interest the article of Dr. da Silva Freitas [1] titled Poland’s Syndrome: Different Clinical Presentations and Surgical Reconstructions in 18 Cases, which presents an up-to-date and useful therapy scheme. Of special interest to us was the use of the endoscopic technique for latissimus dorsi musculocutaneous flap harvest as an option for reconstruction of pectoralis major muscle agenesis in one of their cases. This demonstrates clearly that the number of endoscopic interventions in the repertoire of the plastic surgeon is growing very rapidly. Unfortunately, the steep learning curve and dependence on expensive equipment can be discouraging for the beginner. Innovative alterations of the technique are therefore of the utmost importance because they can cut down on equipment costs and overcome technical obstacles. The technique for endoscopically assisted harvest of latissimus dorsi muscle has been given detailed description in the literature previously by various authors [2,3]. Except for personal preferences and differences of infrastructure, the technique is well settled and reliable. One of the few technical points about which a disagreement still exists concerns the creation and maintenance of the optic cavity. Various techniques have been used besides carbon dioxide insufflation, with varying degrees of success, such as balloon dissection and hydrodissection [4]. Both of these methods have received positive and negative criticism. We present a simple method for assisting flap dissection and increasing exposure in a patient with Poland’s syndrome. A 19-year-old boy presented with a left pectoralis muscle agenesis. An axillary incision and three 5-mm ports were used for flap harvest and inset. Figure 1 shows the use of two Kirschner wires with a diameter of 3 mm to maintain the subcutaneous working space. The first Kirschner wire is placed through the axillary incision parallel to the anterior axillary line. The second wire is placed parallel and posterior to the first one. When both wires are elevated simultaneously, they create a ‘‘tent’’ over the dissected portion of the muscle, which leads to greater exposure of the working space. As the dissection proceeds, the wires can be repositioned for better visualization. The dissection of the most medial portions of the latissimus dorsi muscle where it fuses with the spinal muscles is especially facilitated. The wires can be used for the recipient site in a similar fashion. This innovation enabled us to control a wide field endoscopically with little effort and to reduce the operation time.