Olympus America Research Articles

Flexible Endoscopic Zenker’s Diverticulotomy After Recurrence of Dysphagia Following Open and Rigid Endoscopic Stapled Diverticulotomies: Presidential Poster

SymbolIntroduction: Zenker’s diverticulum (ZD) is a posterior pouch through the wall of the Killian triangle due to high pressure at the crycopharyngel (CP) bar. It is more common in males >70 who present with dysphagia. Open diverticulotomies are becoming less frequent with the available rigid and flexible endoscopic approaches. All these procedures have primary success rates >90%, but more than 1 treatment may be necessary. We report 2 cases of recurrence of dysphagia in 2 patients with ZD; 1 following open diverticulotomy and the other after 2 rigid stapled diverticulotomies, both treated successfully by flexible endoscopic diverticulotomy.SymbolMethods: We perform flexible endoscopic Zenker’s diverticulotomies and we are seeing more patients after recurrence of dysphagia. Two recent cases are presented. The procedures are performed under general anesthesia and a NGT is passed under direct endoscopic visualization or via guidewire. A transparent hood is placed on the tip of the endoscopes. Assorted wire knives are used to perform the diverticulotomies. The NGT is removed once patients are awake, deny pain, and have no SC emphysema or bleeding. Patients are instructed to observe a soft diet and hold antiplatelet medication for 48 hours. Patients are typically discharged the same day. We do not routinely perform barium esophagrams post-procedure. Results: Case 1: A 72-year-old male had an open Zenker’s diverticulotomy with recurrence of dysphagia and food regurgitation 6 months later. Scarring and clips from the previous intervention caused traction of the CP, which appeared obliquely oriented, and a second smaller diverticulum had also formed. A combination of dual and IT wire knives (Olympus America, Center Valley, PA) were used to perform the diverticulotomy. The procedure took 24 minutes. The patient reported immediate resolution of the dysphagia. Case 2: An 82-year-old male had 2 previous rigid stapled Zenker’s diverticulotomies with immediate recurrence of dysphagia. The diverticulum was actually shallow, but a prominent scar was seen at the previous intervention sites, and the remnant CP bar was prominent, creating a shelf which was likely causing the dysphagia. The dual knife was used to perform the diverticulotomy. The procedure took 12 minutes. The patient reported gradual improvement of dysphagia over 1 week. Conclusion: Flexible endoscopic treatment of ZD is successful, and may become the choice, especially after recurrence of dysphagia following other procedures. The flexibility of the scope, the ability to approach the CP bar, the various instruments now available, and efficacy comparable to other interventions make flexible endoscopy an attractive option to treat ZD and recurrence of dysphagia.

A Case of Severe Sprue-like Enteropathy Associated With Olmesartan

Introduction: Small intestinal villous atrophy and inflammatory infiltrates with negative celiac serologies, also known as sprue-like enteropathy, presents a diagnostic challenge. The differential diagnosis for this finding is broad, including autoimmune enteropathies, malignancies, infections, and immunodeficient disorders. Extensive evaluation of these patients often fails to identify an etiology, diminishing patients’ quality of life. A 69-year-old woman presented to our hospital system with weight loss, post-prandial emesis, volume depletion, and electrolyte abnormalities. Her medical history was remarkable for hypertension with blood pressure controlled using metoprolol, amlodipine, and olmesartan. Upper endoscopy (EGD) was performed, with gross scalloping throughout the duodenum. Biopsies of the duodenum showed villous blunting and intraepithelial neutrophilic infiltrates. Labs revelaed a normal IgA (204mg/dL), negative tissue transglutaminase IgA (<3U/mL), positive HLA-DQ2, and negative DQ8. A strict gluten-free diet for 2 months did not help, and she was empirically treated with prednisone given the severe inflammatory infiltrates of the small intestine. Symptoms improved rapidly, but recurred when the prednisone was weaned. She was started on azathioprine as a steroid-sparing medication with successful cessation of steroids. Repeat EGD showed persistent villous blunting similar to the previous biopsy, asymptomatic on prednisone and azathioprine. Due to financial constraints, the anti-hypertensive regimen was adjusted, with olmesartan switched to losartan. Following reports of sprue-like enteropathy linked to olmesartan, azathioprine was discontinued while she was kept on all other medications. EGD 6 months later showed normal histology with normal villous architecture and no inflammatory infiltrates. She continues to feel well on losartan at 12 months. Sprue-like enteropathy associated with olmesartan generally presents with diarrhea, vomiting, normocytic anemia, and low albumin. As in our case, steroids ameliorate symptoms in 95% of the cases. In our case, azathioprine and prednisone offered clinical relief, but did not restore histological changes. Replacing olmesartan with losartan provided both clinical and histologic improvement, exemplifying that sprue-like enteropathy is not a class effect with ARBs, but rather specific to olmesartan. Disclosure - Dr. Corral - no financial relationships to declare. Dr. Yarur - no financial relationships. Dr. Diaz - no financial relationships. Dr. Garcia-Buitrago - no financial relationships. Dr. Sussman - Consultant: ExactSciences. Research support: Bankhead-Coley Team Science (2BT02), Olympus America Inc., American Cancer Society (IRG-98-277-13), and Sylvester Comprehensive Cancer Center.

Control of immediate post-EMR bleeding by using monopolar hemostatic forceps

A 58-year-old patient with hypertension was referred for EMR of a large flat polyp in the ascending colon. Colonoscopy revealed a Paris IIa lesion measuring roughly 3 cm in diameter. The polyp was removed by first injecting diluted indigo carmine to achieve an adequate submucosal lift. A 25-mm snare (Snaremaster Spiral; Olympus America Inc, Center Valley, Pa) was used to capture the lifted polyp. Using a blended cut current (Endocut; ERBE USA, Inc, Marietta, Ga), we removed the polyp en bloc. Immediately an arterial bleed was identified with brisk spurting of blood from the submucosa.

Accuracy of in vivo colorectal polyp discrimination by using dual-focus high-definition narrow-band imaging colonoscopy

Discriminating neoplastic from non-neoplastic polyps can significantly reduce the cost of colonoscopy. The American Society for Gastrointestinal Endoscopy (ASGE) recently set threshold levels for optical diagnostic accuracy to be acceptable for clinical use. In this study, we compare a novel colonoscope capable of dual-focus imaging with standard colonoscopy with respect to the ASGE guidelines. An academic medical center ambulatory surgical center. Patients at average risk were randomized to standard colonoscopy (Olympus CF-H180 and Exera II 180 colonoscopes, Olympus America, Center Valley, Pa) or dual-focus colonoscopy (Olympus CF-HQ190 and Exera III 190 colonoscopes, Olympus America). All polyps were given an optical diagnosis and compared with histology. A total of 600 patients were consented and 522 completed all aspects of the procedure. A total of 927 polyps were analyzed. Optical diagnostic accuracy was 79% (95% confidence interval, 74%-83%) for the 190 and 77% (95% confidence interval, 73%-81%) for the 180 colonoscope. Adenoma detection rates were also similar between the 2 groups (50% for the 190 vs 52% for the 180 colonoscope). For small distal rectosigmoid polyps with a high confidence diagnosis, the negative predictive value for adenoma was 96% (range 89%-99%) for the 180 in the narrow-band imaging (NBI) mode and 97% (range 88%-99%) for the 190 colonoscope in NBI mode. Agreement of surveillance intervals by using optical diagnosis was 94% to 95% for all modalities (180 and 190 colonoscopes, white light imaging, NBI). Our study evaluated the accuracy of the 180 and 190 colonoscopes at a center with already-established expertise in endoscopic imaging. Both traditional and new dual-focus colonoscopes provide highly accurate optical polyp discrimination. There was no difference between the 2 systems in terms of discrimination or adenoma detection. Both systems are consistent with ASGE guidelines for optical diagnosis of selected colorectal polyps without histological confirmation.

PD37-07 IN VIVO AND EX VIVO COMPARISON OF OPTICS AND PERFORMANCE OF A NOVEL DUAL CHANNEL FIBEROPTIC URETEROSCOPE

You have accessJournal of UrologyStone Disease: New Technology II1 Apr 2014PD37-07 IN VIVO AND EX VIVO COMPARISON OF OPTICS AND PERFORMANCE OF A NOVEL DUAL CHANNEL FIBEROPTIC URETEROSCOPE Achim Lusch, Zhamshid Okhunov, Ramtin Khanipour, Ashleigh Menhadji, Renai Yoon, Michael Del Junco, and Jaime Landman Achim LuschAchim Lusch More articles by this author , Zhamshid OkhunovZhamshid Okhunov More articles by this author , Ramtin KhanipourRamtin Khanipour More articles by this author , Ashleigh MenhadjiAshleigh Menhadji More articles by this author , Renai YoonRenai Yoon More articles by this author , Michael Del JuncoMichael Del Junco More articles by this author , and Jaime LandmanJaime Landman More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.2025AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Vision during ureteroscopic laser ablations of large kidney stones can be challenging due to the diminished flow during the procedure. Hence we evaluated and compared characteristics of a novel dual working channel fiberoptic ureteroscope [Cobra (Richard Wolf, Knittlingen, Germany)] to two single channel fiberoptic ureteroscopes and a single channel distal sensor ureteroscope [the Viper (Richard Wolf, Knittlingen, Germany)], the X2 (Karl Storz, Tuttlingen, Germany) and the URF-V (Olympus America Inc., Center Valley, USA)]. METHODS The four ureteroscopes (Cobra, Viper, X2, URF-V) were compared for active deflection, irrigation flow and optical characteristics. Each ureteroscope was evaluated with an empty working channel and with various accessories. We performed a porcine ureteroscopy and measured the time for cleaning the middle calyx after injection of 10 cc’s of an standardized bloody solution (simulated bloody vision). RESULTS The URF-V showed a higher resolution [7.42 lines/mm] [p=0.0001] compared to the fiberoptic ureteroscopes. Among the fiberoptic ureteroscopes the Cobra had the highest resolution compared to Viper and X2 [4,86 vs. 4.33 vs. 3.56 lines/mm, <p=0.0001]. The Cobra also showed a significant superior illumination at all distances [p<0.0001]. Grayscale distribution and color representation was identical for the fiberoptic ureteroscopes, whereas the URF-V provided superior color representation and a significant higher depth of field. The dual channel ureteroscope provided superior flow with empty working channel [86cc/min vs. 68cc/min [Viper] vs. 62,5cc/min [X2] vs. 62cc/min [URF-V], p=0.0001] and with various accessories in the working channel [p<0.0001]. With regards to deflection the Storz X2 and the Cobra provided superior deflection up and down with empty working channel and several accessories [p<0.0001], except for downward deflection with a guide wire and 3.2 F delta wire grasper, where the URF-V showed superior results. When evacuating a standardized bloody field, the Cobra provided significant shorter evacuation times compared to Viper, X2 and URF-V [36.6 sec. vs. 72 sec. vs. 65.6 sec. vs. 72.6 sec, p=0.0001]. CONCLUSIONS In this in vitro porcine evaluation the dual channel ureteroscope demonstrated superior flow without and with various accessories. The additional working channel may improve vision and performance during challenging ureteroscopic cases by providing an increased flow. The enhanced irrigation capabilities of the Cobra have to be balanced with a larger diameter of this ureteroscope. © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e948 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Achim Lusch More articles by this author Zhamshid Okhunov More articles by this author Ramtin Khanipour More articles by this author Ashleigh Menhadji More articles by this author Renai Yoon More articles by this author Michael Del Junco More articles by this author Jaime Landman More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

A Proficiency-Based Skills Training Curriculum for the SAGES Surgical Training For Endoscopic Proficiency (STEP) Program

The surgical training for endoscopic proficiency program is a collaborative project between Society of American Gastrointestinal and Endoscopic Surgeons and Olympus America Inc. dedicated to providing flexible endoscopy training to surgery residency programs. Currently it lacks models for proficiency-based training. This study developed 2 novel flexible endoscopy simulators, purchased a third, and established face and content validity as well as proficiency metrics for all 3. Three simulators were tested-a foam and cardboard upper gastrointestinal tract model, a commercially available colonoscopy model (CM-15, Olympus, Japan), and an endoscopic targeting model created from the Operation Game (Hasbro). Time and errors for the performance of 12 expert surgical endoscopists on each model were used to calculate proficiency scores. Face validity and content validity were established through posttest questionnaires using a 5-point Likert scale. Experts had a mean of 8 years of endoscopic practice (range: 1-24y). Among them, 83% teach residents or fellows using simulation. Most perform more than 50 upper endoscopies (51 to >500) and 100 colonoscopies (101 to >500) per year. The average time for completing the upper gastrointestinal tract model with correct identification of all targets was 133 ± 56 seconds. Complete navigation of the colonoscopy model averaged 325 ± 156 seconds. Proper orientation and targeting using the Operation Game model averaged 273 ± 109 seconds with 3 errors. This study proves face and content validity for 3 physical flexible endoscopy simulators that can be used to train upper and lower endoscopy as well as instrument targeting. It also establishes expert proficiency metrics that can be used by trainees for structured rehearsal. These relatively inexpensive models will be incorporated into the surgical training for endoscopic proficiency curriculum.

PERK Activation Preserves the Viability and Function of Remyelinating Oligodendrocytes in Immune-Mediated Demyelinating Diseases

Remyelination occurs in multiple sclerosis (MS) lesions but is generally considered to be insufficient. One of the major challenges in MS research is to understand the causes of remyelination failure and to identify therapeutic targets that promote remyelination. Activation of pancreatic endoplasmic reticulum kinase (PERK) signaling in response to endoplasmic reticulum stress modulates cell viability and function under stressful conditions. There is evidence that PERK is activated in remyelinating oligodendrocytes in demyelinated lesions in both MS and its animal model, experimental autoimmune encephalomyelitis (EAE). In this study, we sought to determine the role of PERK signaling in remyelinating oligodendrocytes in MS and EAE using transgenic mice that allow temporally controlled activation of PERK signaling specifically in oligodendrocytes. We demonstrated that persistent PERK activation was not deleterious to myelinating oligodendrocytes in young, developing mice or to remyelinating oligodendrocytes in cuprizone-induced demyelinated lesions. We found that enhancing PERK activation, specifically in (re)myelinating oligodendrocytes, protected the cells and myelin against the detrimental effects of interferon-γ, a key proinflammatory cytokine in MS and EAE. More important, we showed that enhancing PERK activation in remyelinating oligodendrocytes at the recovery stage of EAE promoted cell survival and remyelination in EAE demyelinated lesions. Thus, our data provide direct evidence that PERK activation cell-autonomously enhances the survival and preserves function of remyelinating oligodendrocytes in immune-mediated demyelinating diseases.

Abstracts from the 28th Annual Meeting of the Engineering and Urology SocietyMay 4, 2013San Diego, CA

Abstracts from the 28th Annual Meeting of the Engineering and Urology SocietyMay 4, 2013San Diego, CA

Gender Disparities in Remission of Esophageal Intestinal Metaplasia after Radio-frequency Ablation: ACG/Naomi Nakao Gender-Based Research Award

Purpose: Among the available ablative modalities, radiofrequency ablation (RFA) is the most commonly used for treatment of Barrett's esophagus (BE) with dysplasia. Few studies have assessed the effect of gender on remission rates after RFA. Preliminary studies indicate a potential biological difference between males and females with BE. We aim to assess the effect of gender on the time to achieve complete remission of intestinal metaplasia (CRIM) among patients with BE who underwent RFA. Methods: This was a retrospective, observational study using large RFA database in a tertiary referral center. The primary outcome was time to CRIM compared between males and females. Candidate predictor variables included patient age, sex, race, smoking history, use of endoscopic mucosal resection (EMR), and initial biopsy before RFA. Time to CRIM (in months) was calculated using the Kaplan-Meier method. Log-rank test was used for comparison. We used Multivariable cox-proportional hazard model to assess for any association between time to CRIM and predictor variables. Results: Two hundred fifty-seven patients underwent RFA for BE between May, 2005 and June, 2012. Of those, only 11% (n=26) were females. Males and females were similar in mean age, race, smoking history, median BE length, history of EMR, and baseline histology. Females required less RFA sessions compared to males (p=0.027). For males, median time to CRIM was 11.7 months [95% confidence interval [CI] 10 - 15]. For females, median time to CRIM was 24 months [95% CI 10.3 - 60.2]. The Log Rank χ2 statistic for the difference in time to CRIM was 4.7, with p=0.03. Kaplan-Meier curves of the time to CRIM stratified by gender are presented in Figure 1. Using cox-regression analysis, there was no evidence of confounding, collinearity, or effect modification in the final model. When controlling for age, use of EMR, BE segment length, and the number of RFA sessions, female gender was associated with 55% decrease in the rate of CRIM compared to males (HR = 0.45 [95% CI 0.25-0.82], p=0.009).FigureConclusion: Female patients take longer time to achieve remission of intestinal metaplasia when treated with radiofrequency ablation with or without endoscopic mucosal resection when compared to males of similar age and BE length. Further studies are needed to understand the potential factors leading to those important differences. Disclosure - Dr. Wolfsen is a consultant for CSA Medical, Ninepoint Medical, and Oncoscope. He receives research funding from BARRx Medical and Olympus America, Inc. Dr. Wallace is a consultant for Ninepoint Medical. He receives research funding from Olympus America, Inc, American BioOPTICS, and Fujinon.

Magnets in the GI tract

Magnets in the GI tract

Reply to: doi: 10.1007/s00464-013-3111-4: TEM or TAMIS: what is the future of transanal endoscopic surgery?

We read with much interest the letter by Atallah and Albert [1] about our article comparing transanal minimally invasive sugery (TAMIS) and transanal endoscopic microsurgery (TEM) in a dry lab [2]. There are three reports on the use of single-port devices for transanal endoscopic surgery in which the conclusions are not as straightforward as reported by Atallah and Albert, and their use is not always possible. The first is the clinical series reported by Van den Boezem et al. [3], who found that 2 of 12 lesions were judged too close to the SILS Port and the procedures were converted to conventional transanal surgery. A clinical report by Barendse et al. [4] presented 2 of 15 cases in which the single-port device did not reach sufficient intrarectal retractor expansion and conversion to conventional TEM was necessary. The device used was the one selected by the same authors in a comparative study performed in a porcine model [5], in which the authors judged the insertion of the GelPOINT (Applied Medical, Rancho Santa Margarita, CA, USA) impossible with the SILS Port (Covidien, Mansfield, MA) and the TriPort (Olympus America Inc., Center Valley, PA, USA), which were not stable enough and demanded manual fixation, while CO2 leaked through the TriPort trocar ports. So, it is not only our opinion that TEM equipment is necessary as backup. It is true that we decided to compare TEM/TEO (transanal endoscopic microsurgery/transanal endoscopic operation) (Karl Storz GmbH, Tuttlingen, Germany) with only one of the available single-port devices. It is one of the two most commonly used for this purpose and, not by chance, one of the two FDA approved for this indication. We did not take into consideration the use of what Atallah and Albert referred to as ‘‘the accessory devices commonly used by TAMIS surgeons, such as automated suturing and knot forming devices’’ because their use is not at all common in TEM/TEO procedures. This confirms the fact that visualization and tissue manipulation are worse under TAMIS conditions. Difficulty, of course, is not the litmus test of a new technique, but when one wants to show that the new technique is an alternative to an established technique with comparable benefits for the patient, one has to prove equivalence or benefits in terms of clinical outcomes and/or costs. It was not the goal of our study to answer to these fundamental questions, nor can the existing published series, which include a maximum of 110 cases, with lesions in some cases as small as 0.7 cm in diameter. Being well aware of the complexity of the original TEM setup, which we used for more than 15 years, we opted to use TEO since 2008; this equipment was used in the comparative study. Its setup time is in line with that for single port, and it allows the use of the dorsal lithotomy position because the rectoscope profile has a flute beak much less pronounced than the original TEM. However, we still recommend turning the patient for large anterior lesions, especially if the distance from the anal verge is in a range where there might be the risk of opening the peritoneum. Lateral positioning of the patient is almost not used anymore by surgeons who use the original TEM device, a maneuver that was mostly responsible of the consistent setup time mentioned by Atallah and Albert [1]. R. Rimonda (&) Department of Surgery, ASLCN1, Mondovi (CN) Hospital, 12084 Mondovi, Italy e-mail: roberto@rimonda.it

Not all through-the-scope endoscopic clipping devices are born equal: some can be rotated while others cannot

We appreciate Drs. Saxena and Khashab’s [1] comments on our benchtop comparison study data of three commonly used through-the-scope (TTS) endoclips [2]. QuickClip2 long (Olympus America, Center Valley, PA, USA) and Instinct clip (Cook Medical, Winston-Salem, NC, USA) are designed and built to provide precise rotational capability. On the other hand, the Resolution clip (Boston Scientific, Natick, MA, USA) is not built to rotate. The lack of ability to rotate had been observed since its release through clinical observation. Our study objectively demonstrated and confirmed this long-held practical observation. In our study, we tested the Resolution clip for rotational ability with and without a sheath. Based on their experience, Drs. Saxena and Khashab indicated that the Resolution clip can be rotated with careful technique. Their tricks include removing the outer plastic sheath from the clip prior to use, having the endoscopist rotate the metal cable of the clip close to the biopsy valve, providing small incremental turns, and expecting a short delay. They correctly pointed out that in our study the clips were rotated at the device handle instead of the metal cable. We elected to rotate the device handle since this is the controlling part of nearly all endoscopic devices. It is intuitive to have the assistant control the clip opening, rotation, and deployment by manipulating the handle. In the past, I tried using a hemostat forceps to turn the metal cable of the Resolution clip and straightened the endoscope. My experience has been mostly frustrating. When the endoscope is looped or when using the duodenoscope, the Resolution clip can barely move, not to mention ‘‘dance’’ smoothly with any maneuver. Many endoscopic devices can be ‘‘rotated or jiggered’’ by rotating the metal cable close to the biopsy valve, yet they are not rotational devices and precisely controlled rotation cannot be achieved. We can drive and turn an automobile by handling the steering wheel, yet we can also move the vehicle by pushing it. When we performed the study, we video recorded clip movement and hand movement for analysis. Each clip was given equal time to respond and handle rotation was performed by the only one investigator, myself. We tried our best to control possible study bias.

Feasibility of Dynamic Telecytopathology for Rapid On-Site Evaluation of Endobronchial Ultrasound-Guided Transbronchial Fine Needle Aspiration

Rapid on-site evaluation (ROSE) at the time of endobronchial ultrasound-guided transbronchial fine needle aspiration (EBUS-TBFNA) is useful in obtaining adequate samples and providing preliminary diagnosis. We present our experience with ROSE of EBUS-TBFNA using telecytopathology. Real-time images of Diff-Quik (Mercedes Medical, Sarasota, FL)-stained cytology smears were obtained with an Olympus (Olympus America, Center Valley, PA) digital camera attached to an Olympus CX41 microscope and transmitted via ethernet by a cytotechnologist to a cytopathologist in a cytopathology laboratory who rendered a preliminary diagnosis while communicating with an on-site cytotechnologist via the Vocera (San Jose, CA) voice communication system. The endoscopy suite was located a block away from the cytopathology laboratory. Accuracy of ROSE via telecytopathology was compared with an equal number of cases that received ROSE, prior to introduction of telecytopathology, via conventional microscopy. ROSE was performed on a total of 200 EBUS-TBFNAs. The telecytopathology system and conventional microscopy were used to evaluate equal numbers of cases (100 each). Preliminary diagnoses of negative/benign, atypical/suspicious, and positive for malignancy were 58%, 14%, and 24% for telecytopathology and 57%, 10%, and 31% for conventional microscopy. Four percent of telecytopathology cases and 2% of conventional microscopy cases were deemed unsatisfactory at the time of ROSE. The overall concordance between the preliminary and final diagnoses was 96% for telecytopathology and 93% for conventional microscopy. The causes of discordant preliminary and final diagnoses could be mainly attributed to difficulty in distinguishing small cell carcinoma versus reactive lymph node due to crush artifact, atypia related to reactive bronchial epithelial cells, and availability of cell block material and Papanicolaou-stained slides for review at the time of final cytologic sign out. Telecytopathology is comparable with conventional microscopy in ROSE of EBUS-TBFNA. It can serve as a valid substitute for conventional microscopy for on-site assessment of EBUS-TBFNA.

Durability of Flexible Cystoscopes in the Outpatient Setting

To ascertain cystoscope durability in relation to usage and cost in the outpatient setting. Six flexible cystoscopes were provided to our outpatient clinic by 2 vendors. Five Wolf 7305.006S02 cystoscopes (Richard Wolf Medical Instruments Corporation, Vernon Hills, IL) and 1 Olympus CYF-5 (Olympus America, Center Valley, PA) were used 2477 times over a 14-month study period. Prospective data were accumulated on each cystoscope including type of procedure, number of uses until mechanical failure, physician usage, and maintenance costs. All staff was trained in proper handling and maintenance of cystoscopes utilizing an Occupational Safety and Health Administration (OSHA) approved protocol. Retrospective comparison was performed of 1346 cystoscopic procedures during the previous 8 months before implementation of the processing protocol, with data including type and quantity of mechanical failures along with maintenance costs. Five total study period failures occurred in 4 cystoscopes, with a mean of 495.4 procedures/failure. In 3 separate cystoscopes, failure occurred after 70 (perforation of working channel), 194 (leak in bending rubber), and 236 uses (hole in bending rubber). One cystoscope had 2 failures after 168 (cut in bending rubber) and 255 uses (failed leak test). During the retrospective period, there were 10 failures, with a mean of 134.6 procedures/failure. Four failures were secondary to crushed insertion tubes. Comparison of retrospective and study period costs revealed a 43.9% decrease from $9.64 per procedure to $5.41 per procedure. Outpatient flexible cystoscope durability seems directly related to optimization of handling and storage of cystoscopes. Costs related to mechanical failure were reduced with a rigorous reprocessing protocol.

Comparison of two ultrasonic coagulating shears in sealing pulmonary vessels

Ultrasonic cutting and coagulating devices have been used successfully in thoracic applications such as pulmonary resection or artery harvesting, but few studies have evaluated their use in sealing pulmonary vessels. In this study we compared two commercially available devices, Harmonic Ace+ (HAR, Ethicon Endo-Surgery, Inc., Cincinnati OH, USA) and Sono- Surg (SS, Olympus America, Center Valley, PA, USA), in a canine preclinical model. There were three sections to the study: acute, survival, and ex vivo (burst pressure). Hemostasis of sealed pulmonary arteries and veins was assessed for the initial application and during a simu- lated hypertensive crisis, both immediately after vessel sealing and after a survival period of 30 days. Other intraoperative measures were also evaluated, including transection time, tissue sticking, tissue tags, and char on the seal. Histological evaluation was performed both after initial sealing and after the survival period. Burst pressure of sealed vessels was measured ex vivo. For both devices, hemostasis was excellent, including those measurements made under simulated hypertensive crisis. There were no differences in any of the intraoperative measures or thermal damage evaluated histologically. Wound healing was normal. The burst pressures for ex vivo vessels sealed by HAR (median 619.2 mmHg) were significantly higher than those of SS (350.3 mmHg, P = 0.022). Both devices displayed acceptable characteristics in sealing canine pulmonary arteries and veins. The only difference observed was that HAR produced burst pressures 76.8% greater than SS, which may lead to a lower percentage of failures in the region of physiological interest. Use of ultrasonic devices in thoracic applications provides a high rate of initial hemostasis, supraphysiological burst pressures, and durable seals that heal normally.

Dual Effects of Isoflurane on Proliferation, Differentiation, and Survival in Human Neuroprogenitor Cells

Previous studies have demonstrated that isoflurane can provide both neuroprotection and neurotoxicity in various tissue culture models and in rodent developing brains. The cellular and molecular mechanisms mediating these dual effects are not clear, but the exposure level and duration of isoflurane appear to be determinant factors. Using the ReNcell CX (Millipore, Billerica, MA) human neural progenitor cell line, the authors investigated the impact of prolonged exposure to varying isoflurane concentrations on cell survival and neurogenesis. In addition, the authors assessed the impact of short isoflurane preconditioning on elevation of cytosolic Ca concentration and cytotoxic effects mediated by prolonged isoflurane exposures and the contribution of inositol-1,4,5-trisphosphate or ryanodine receptor activation to these processes. Short exposures to low isoflurane concentrations promote proliferation and differentiation of ReNcell CX cells, with no cell damage. However, prolonged exposures to high isoflurane concentrations induced significant ReNcell CX cell damage and inhibited cell proliferation. These prolonged exposures suppressed neuronal cell fate and promoted glial cell fate. Preconditioning of ReNcell CX cultures with short exposures to low concentrations of isoflurane ameliorated the effects of prolonged exposures to isoflurane. Pretreatment of ReNcell cultures with inositol-1,4,5-trisphosphate or ryanodine receptor antagonists mostly prevented isoflurane-mediated effects on survival, proliferation, and differentiation. Finally, isoflurane-preconditioned cultures showed significantly less isoflurane-evoked changes in calcium concentration. The commonly used general anesthetic isoflurane exerts dual effects on neuronal stem cell survival, proliferation, and differentiation, which may be attributed to differential regulation of calcium release through activation of endoplasmic reticulum localized inositol-1,4,5-trisphosphate and/or ryanodine receptors.

Efficiency, Efficacy, and Safety of EZ-Blocker Compared with Left-sided Double-lumen Tube for One-lung Ventilation

Double-lumen tubes (DLTs) or bronchial blockers are commonly used for one-lung ventilation. DLTs are sometimes difficult or even impossible to introduce, and the incidence of postoperative hoarseness and airway injuries is higher. Bronchial blockers are more difficult to position and need more frequent intraoperative repositioning. The design of a Y-shaped bronchial blocker, the EZ-Blocker (Teleflex Life Sciences Ltd., Athlone, Ireland) (EZB), combines some advantages of both techniques. The objective of this study was to assess whether EZB performs clinically better than left-sided DLTs (Broncho-cath; Mallinckrodt, Athlone, Ireland) without causing more injury. Primary outcome was the frequency of initial malpositions. Eligible patients were adults scheduled for surgery requiring one-lung ventilation who met criteria for placement of both devices. In this parallel trial, 100 consecutive and blinded patients were assigned randomly using a computer-generated list to two groups. The incidence of malposition and ease and time of placement were recorded. Blinded assessors investigated quality of lung deflation, postoperative complaints, and damage to the airway. Placement of a DLT was unsuccessful twice. The incidence of initial malposition was high and comparable between EZBs (37 of 50) and DLTs (42 of 49) (P = 0.212). Placing single-lumen tubes and EZBs took more time but was rated easier. Quality of lung deflation was comparable. Fewer patients in the EZB group complained of sore throat at day 1. There was a higher incidence of tracheal hematoma and redness and bronchial hematoma in the DLT group. The EZB is an efficient and effective device for one-lung ventilation and causes less injury and sore throat than a DLT.

Endoscopic closure of an iatrogenic duodenal perforation: a novel technique using endoclips, endoloop, and fibrin glue

An 80-year-old woman with a flat duodenal tubulovillous adenoma presented for endoscopic mucosal resection (EMR). This lesion had received treatment with EMR and Nd:YAG laser in the past. The lesion was located in the proximal second portion of duodenum (D2), measured approximately 2cm, andwas half-circumferential from the 12-o’clock to the 6-o’clock position. The lesion was lifted with submucosal injection of methylene blue and saline. A multibanding cap was used to place ligation bands around two areas for EMR. One area was targeted with a hexagonal snare, and after resection a 1-cm perforation became obvious at the lateral aspect of D2 (● Fig.1). Endoscopic clipping of the defect was attempted but, due to the large size of the defect and the wall being taut, the edges were not able to be approximated. A “clutching rose stems” technique was used to close the defect (● Fig.2), as follows. A total of eight endoclips (Resolution clip; Boston Scientific, Natick, Massachusetts, USA) were placed circumferentially around the perimeter of the wound edge. This was followed by placing a detachable endoloop (Polyloop; Olympus America Inc., Melville, New York, USA) around the perimeter base of the clips. The snare was tightened, which successfully brought all the edges of the wound together, and was then detached. In order to ensure a complete seal, a total of 8ml of fibrin glue (Tisseel; Baxter, Deerfield, Illinois, USA) was injected at the center of the “rose stems”. A large, transparent glue “clot” formed over the entire wound. The total time for endoscopic closure was 45 minutes. Post procedure, the patient was noted to be asymptomatic despite the presence of free air on abdominal computed tomography (CT). An upper gastrointestinal contrast study failed to show any extravasation of contrast out of the bowel. The patient received nasogastric tube decompression with bowel rest and broad spectrum antibiotic coverage, and had an uneventful hospital course. Multiple case reports have been published on iatrogenic duodenal perforations closed using endoclips [1–5]. To our knowledge, this is the first case of a duodenal perforation closed using a “clutching rose stems” technique using endoclips, an endoloop, and fibrin glue. In this case, the fibrin glue was essential in sealing the center hole after the endoclips and endoloop had brought the edges of the defect together. In the advent of newer resection techniques, further progress needs to be made in the area of endoscopic closure, such that perforations can easily be managed by the endoscopist. Endoscopy_UCTN_Code_TTT_1AR_2AI

Magnetic Endoscope Imaging (ScopeGuide®) Elucidates the Mechanism of Action of the Pain-alleviating Impact of Water Exchange Colonoscopy - Attenuation of Loop Formation

Purpose: Water exchange colonoscopy produces a significant reduction of pain (scheduled unsedated patients), a lower patient-controlled medication requirement (scheduled sedated patients) and a higher proportion of patients completing unsedated colonoscopy (on-demand sedated patients). The method entails omission of air insufflation and removal of residual air to minimize lumen distension and flexure angulation. Less need for abdominal pressure and position change indirectly suggest less looping may account for pain alleviation. No objective evidence currently exists to substantiate the claim. A recent editorial on magnetic endoscope imaging (MEI) recommended its use in water exchange colonoscopy to elucidate the mechanism of pain alleviation / avoidance of loop formation. Aim: To show that MEI documents less frequent loop formation when water exchange is used. Methods: The MEI equipment (ScopeGuide®, Olympus) with built-in magnetic sensors displays the configuration of the colonoscope inside the patient. Colonoscopy using air or water exchange method was performed as previously described (Endoscopy 2011;43:816-21). During colonoscopy, the endoscopist was blinded to the ScopeGuide images which were recorded. Subsequent review of the recordings was performed. Loop formation was scored based on a visual guide provided by Olympus. Loop formation was defined as full (scope crossing itself); partial (exaggeration of the curvature) and none (a smooth and straight configuration of the scope). Results: Recordings were collected prospectively in routine cases not enrolled in clinical trials (Table). There were 41 and 32 non consecutive cases in the water exchange and air group, respectively. Review of the MEI recording showed that the sigmoid N loop was most common, followed by the sigmoid alpha loop, and exaggeration of scope curvature at the splenic flexure/transverse colon. Of these, 20/32 vs 9/41 patients (p=0.0007) had sigmoid looping, and 17/32 vs 9/41 patients (p=0.0007) had sigmoid/splenic looping when the scope tip was in the transverse colon, in the air and water exchange group, respectively. Limitation: Single center, small number, observational study.Table: Comparison of air vs. water exchange colonoscopyConclusion: For the first time, recorded MEI data objectively demonstrated significantly less loop formation during water exchange colonoscopy, elucidating the mechanism of pain alleviation by water exchange / attenuation of loop formation. Coupled with the emerging RCT data that MEI feedback enhances cecal intubation by trainees, the role of MEI combined water exchange in speeding up trainee learning curves deserves further evaluations. Disclosure: Dr. Joseph Leung: Olympus America. Research and Education support, on loan of MEI for study purposes. Other authors have no conflict of interests to disclose related to this study. This research was supported by an industry grant from Olympus America: on loan of MEI for study purposes.

Water Exchange Method in Scheduled Unsedated Colonoscopy Significantly Enhanced Patient-Centered Outcomes Without Prolonging Procedural Times - A RCT

Purpose: A proof-of-principle U.S. RCT in scheduled unsedated patients was conducted with deliberate procedural caution to obviate avoidable discomfort due to the evaluation of a novel but non time-tested water exchange method. Despite significant attenuation of insertion pain, enhancement of cecal intubation and willingness to repeat the unsedated option (GIE 2010;72:693) the prolonged insertion time was deemed a hurdle to widespread adoption in private practice models (GIE 2010;72:710). Aim: Using the subsequently time-tested method we reassessed the impacts of water exchange in a RCT (NCT01383252). Methods: Veterans who requested (scheduled) unsedated colonoscopy were randomized to water exchange or air method used as described (Endoscopy 2011;43:816-821). Outcomes included demographic, patient and procedure-related variables. Results: (Table). 90 of 100 randomized patients requested scheduled unsedated colonoscopy due to lack of escort. Intention-to-treat (ITT) cecal intubation rate was 98% (water) vs. 88% (air), p=0.2687. Fewer patients in the water exchange group required abdominal pressure (13 vs. 27, p=0.0076). During insertion there was a significantly lower maximum pain score 3 (2.8) vs. 5 (3.0) (p=0.0008) in the water exchange group. Willingness to repeat: 76% vs. 48% (p<0.0007, Fisher's exact test) was superior with water exchange. Overall (54% vs. 48%) and proximal (40% vs. 28%) and proximal <10 mm (36% vs. 28%) ADR were in favor of water exchange. Limitations: Single site, unblinded, small number of elderly male veterans.Table: Patients demographics and outcomeConclusion: The results confirm that water exchange produces significantly lower maximum pain scores during insertion, greater willingness to repeat unsedated colonoscopy, and less assistant burden to provide abdominal pressure. Although numerically superior, this study is underpowered to reconfirm a significant improvement (by water exchange) of an already high ITT cecal intubation rate (due to accumulated experience in unsedated patients), and overall and proximal ADR already far exceeding quality standards. However, for individuals without escorts, with a preference for no sedation, or screened by flexible sigmoidoscopy (no escort requirement), scheduled unsedated water exchange colonoscopy (akin to extended flexible sigmoidoscopy) may be relevant. It can examine the entire colon or offer an extended view beyond the splenic flexure without the costs and potential side-effects of sedation. More germane to concerns in private practice models, when the established and time-tested method is used, the favorable impacts on patient-centered outcomes are no longer at the expense of excessively prolonged procedural times. Disclosure: Olympus America - research and educational grant support. Cook Endoscopy - educational grant support.