Percutaneous Endoscopic Technique Research Articles

Minimally Invasive Management of Pancreatic Abscess, Pseudocyst, and Necrosis: A Systematic Review of Current Guidelines

Minimally invasive techniques have been used to manage infected pancreatic necrosis and its local complications, although there are no randomised trials to evaluate these techniques. The aims of this study were to review the scope and quality of recommendations in current clinical practice guidelines on the role of percutaneous catheter drainage and endoscopic techniques for pancreatic abscess, pseudocyst, and infected pancreatic necrosis and identify the degree of consensus between guidelines. A MEDLINE search was performed to identify current guidelines from any professional body published in the English language. Guidelines were analysed to determine their specific recommendations for using percutaneous catheter drainage and endoscopic techniques to manage pancreatic abscess, infected pseudocyst, and infected pancreatic necrosis. Sixteen guidelines were reviewed. Percutaneous catheter drainage for pancreatic abscess was recommended by eight guidelines; for infected pseudocysts, one guideline did not recommend its use and six recommended its use; for infected necrosis, two guidelines did not recommend its use and four recommended its use. Endoscopic management of both pancreatic abscess and infected pseudocyst was recommended by seven guidelines; for infected necrosis, endoscopic management was recommended by ten guidelines. Ten guidelines did not include levels of evidence to support their recommendations. Guidelines lacked consensus in their recommendations for minimally invasive management of pancreatic abscess, infected pseudocyst, and infected necrosis, and few recommendations were graded according to the strength of the evidence. More prospective trials are needed to provide evidence where it is lacking, which should be incorporated into clinical practice guidelines.

Cardiac output following fetoscopic coagulation of major placental vessels in fetal sheep

To measure changes in cardiac output (CO) after partial cord occlusion in fetal sheep in order to investigate pathophysiological fetal adaptation mechanisms in a simulated acute placental insufficiency model under standardized conditions, with the aim of finding relevant methods for monitoring human fetuses during stress situations. We used minimally invasive, percutaneous endoscopic techniques to close umbilical vessels in mid-gestational fetal sheep. Placental blood flow was reduced by preferentially closing first arterial and then the concomitant venous umbilical vessels within a short time interval. The investigations were carried out on 11 pregnant ewes at a median gestational age of 86 (range, 73-95) days. Major placental arteries and veins were occluded permanently by coagulation with bipolar forceps under percutaneous fetoscopic control. The fetal CO and Doppler parameters in the ductus venosus (DV), umbilical artery (UA) and umbilical vein (UV) were measured. In spite of heart rate reduction, the CO was not significantly affected by vessel occlusion (mean +/- SD, 500 +/- 194 mL/min before and 457 +/- 219 mL/min after coagulation) because stroke volume slightly increased from 2.65 +/- 1.16 mL/beat to 3.1 +/- 1.5 mL/beat. The right to left CO ratio remained at 1.4. The UV flow/combined CO ratio decreased from 34 +/- 14% to 25 +/- 10% after vessel coagulation. The pulsatility index in the DV increased from 0.4 +/- 0.1 to 0.7 +/- 0.4. The DV blood flow volume remained relatively constant after the intervention. The DV shunting rate, given as DV/UV flow ratio, increased significantly from 30.8 +/- 4.7% to 59.3 +/- 25.0%. The nearly simultaneous closure of arterial and venous umbilical vessels changed the flow pattern in the UA and significantly reduced placental blood perfusion. It did not distinctly change the blood flow volume rate through the DV, and consequently the DV shunting rate was increased. The combined CO was not significantly affected by the vascular obstruction, whereas the fraction of combined CO directed to the placenta was reduced.

Percutaneous Endoscopic Approach for Highly Migrated Intracanal Disc Herniations by Foraminoplastic Technique Using Rigid Working Channel Endoscope

A retrospective analysis of 59 patients operated for excision of soft highly migrated intracanal lumbar disc herniations by percutaneous endoscopic foraminoplasty. To describe a safe and effective percutaneous endoscopic technique for removal of migrated herniations and report the results on the basis of modified MacNab criteria. Migrated herniations pose a great challenge even for experienced endoscopic surgeons. These herniations are hidden from the endoscopic view by anatomic barriers like hypertrophied facet, inferior pedicle and foraminal ligaments rendering percutaneous endoscopic transforaminal lumbar discectomy (PELD) by conventional approach, difficult with high failure rate. Foraminoplasty, which means enlargement of foramen by undercutting ventral part of superior-facet, upper border of inferior pedicle along with ablation of foraminal ligament, can help us to address this issue. Fifty-nine patients with soft highly migrated herniations who underwent PELD with foraminoplasty under local anesthesia from January 2002 to June 2006 were analyzed retrospectively. Patients were evaluated by postoperative Visual Analog Scale for leg pain and Oswestry Disability Index scores. Outcomes were graded according to modified MacNab criteria. Mean follow-up was 25.4 months. Mean visual analog scale score for radicular pain improved from 8.01 to 1.56, and mean Oswestry disability Index improved from 61.6 to 10.76. Based on modified MacNab criteria, 91.4% of patients experienced satisfactory outcome. Three patients had persistent leg pain after surgery. One patient underwent a repeat-PELD on next day and the other after 1 month. Both were relieved of symptoms. Third patient was subjected to open discectomy after 25 weeks from the first operation and showed improvement. Two patients had recurrent herniation at same level after 6 months; 1 patient underwent repeat PELD, and the other underwent open discectomy. Both patients had good results. Foraminoplastic-PELD is safe and effective procedure for surgical treatment of soft migrated herniations. The results are comparable to results of open discectomy.

The prospective experience of a maxillofacial surgeon with the percutaneous endoscopic gastrostomy technique

Percutaneous endoscopic gastrostomy (PEG) may be safely performed by a maxillofacial surgeon trained to use it.

Endoscopic insertion of Cystostomy Button for Bladder Drainage

PURPOSE Our aim is to present our experience with insertion of buttons for bladder drainage and cycling in children. MATERIAL AND METHODS This is an ongoing prospective study for over 5 years from 2002 looking at our experience with endoscopic insertion of cystostomy buttons in children. We initially performed this procedure by an open surgical approach but have now modified our practice to an percutaneous endoscopic technique. This new technique involves insertion of a cystoscope into the bladder which is then punctured with a needle under vision. A guide wire is introduced, needle removedand replaced with a peel away sheath. The outer sheath is then peeled, obturator removed and the appropriate size button device is inserted. The balloon is then inflated with 5 mls of water to allow a snug fit. The button can then be used to drain the bladder intermittently or cycle it with the extension set. RESULTS Twenty-five children (11 girls:14 boys) with a mean age of 8.6 years underwent insertion of a cystostomy button (15 open: 10 endoscopic). Mean follow up was 16 months (2–44). Indications include neuropathic bladder, prune belly syndrome, previous major bladder neck surgery, those unsuitable for mitrofanoff and bladder cycling prior to reconstruction. Complications include 1 wound infection (treated with antibiotics); four children had leakage of urine (all open approach) successfully treated with a change in button size. Twenty buttons remain in situ. Change of button is a straightforward procedure and can be performed in an outpatient setting. The endoscopic insertion allows a snug fit (no leakage with this technique) and is performed in less than 10 minutes. CONCLUSIONS Button cystostomy is a safe and effective form of bladder drainage in children. It is a good alternative to standard suprapubic drainage and it gives children a less restricted quality of life. Endoscopic insertion allows insertion of buttons under vision with good snug fit and no leakage.

A novel and inexpensive model for practicing upper gastrointestinal endoscopy and percutaneous endoscopic gastrostomy techniques

A novel and inexpensive model for practicing upper gastrointestinal endoscopy and percutaneous endoscopic gastrostomy techniques

An Audit of Percutaneous Gastrostomy in The Cayman Islands

Gastrostomy tube placement by the percutaneous endoscopic (PEG) technique is the current method of placing gastrostomy tubes. The technique has been used at the Cayman Islands Hospital for approximately five years. There have been no prior reports on the outcomes of PEG tube placement in this setting since its introduction. An audit of PEG placement was performed at the Cayman Islands Hospital to determine the outcomes in this setting. The hospital records of all patients who had PEG tube placements were retrospectively examined over 44 months from January 2004 to September 2007. There were 35 PEG tubes placed in 28 patients during the study period. Three patients experienced PEG specific complications (8.57%), including bleeding (1 patient), aspiration (1 patient) and PEG dislodgment (1 patient). There were no reports of wound infection, perforation, intra-abdominal sepsis or fistula formation. No early mortality was recorded within the post-operative hospitalization period that averaged 3.25 days. The case volume has increased since the procedure was introduced. Currently, 18 PEG tubes are placed per year with good success and acceptable rates of PEG-specific morbidity.

The prospective experience of a maxillofacial surgeon with the percutaneous endoscopic gastrostomy technique

Insertion of a percutaneous endoscopic gastrostomy (PEG) was attempted on 225 occasions, mainly for oral malignancy. Seventy-five percent (169/225) were inserted at the time of definitive surgery. There were significant incidental findings during 5% (11/225). The rate of successful insertion was 97% (219/225). The incidence of minor complications was 12% (26/225) and major complications 3% (7/225). There was no procedure-related mortality. The 30-day mortality rate, including those with terminal malignant disease, was 6% (14/225). An increased risk of death was associated with age of 65 years and over ( P = 0.004). The median PEG duration was 337 (SE 31) days. Duration was significantly longer for stage T3–4 tumours ( P = 0.028), N1 or greater neck disease ( P = 0.034), following surgery with radiotherapy when compared to surgery alone ( P < 0.001), particularly glossectomy ( P = 0.038) and maxillectomy procedures ( P = 0.003), after two separate surgical procedures and radiotherapy ( P = 0.046) and following a composite bone resection ( P = 0.031), or radiotherapy alone when compared to surgery alone ( P = 0.003). There was no relationship to the type of flap used for reconstruction. Four patients have a long-term PEG. Only two patients did not use the PEG. The early insertion of a PEG in all patients undergoing free or pedicled flap reconstruction appears to be appropriate. The PEG procedure may be safely performed by an appropriately trained maxillofacial surgeon.

Endolaparoscopic Approach in the Management of Gastroesophageal Reflux Disease: An Experimental Study in Pigs

Chronic reflux of gastric content to the esophagus causes retrosternal burning, pain, and regurgitation, and results in histopathologic changes that may culminate in adenocarcinoma. Insufficiency of the lower esophageal sphincter and hiatal hernia are the two principal causative factors. In this paper, we present the early results of a new antireflux operation in pigs. The status of physiologic reflux was determined in 5 pigs (approximately 40-45 kg) with 24-hour pH monitorization. Under endoscopic guidance, a trocar was inserted into the stomach (similar to the percutaneous endoscopic gastrostomy technique). The endoscope was put into the retroflexed position; a mucomuscular pursestring suture was placed around the endoscope at the cardia and tied. Ten days later, pH monitorization was repeated to evaluate the effectiveness of the method. Late postoperative results have been reevaluated by 24-hour pH monitorization in the sixth month. The procedure achieved statistically significant improvements in total reflux time, number of reflux periods, number of long reflux periods, the longest reflux period, and the DeMeester score. The preoperative and postoperative DeMeester scores of the individual animals were 179.24-0.94, 11.48-0.98, 68.4-3.74, 132.2-46.49, and 38.72-5.86, respectively. Even though there appeared to be a slight increase in the pH monitorization levels after 6 months, these results did not reach significant degrees, and compared to the physiological reflux, the results were remarkable. The results obtained showed considerable decreases in physiologic reflux in all animals. We believe that this endoluminal, laparoendoscopic operation can be used in the treatment of gastroesophageal reflux disease as a minimally invasive method.

Transmuscular Trocar Technique - Minimal Access Spine Surgery for Far Lateral Lumbar Disc Herniations

Minimal access spine surgery (MASS) is gaining increasing importance in microsurgery of the lumbar spine. From a current prospective series we present data on MASS for far lateral lumbar disc herniations (LLDH) via a transmuscular trocar technique (T(2)). The surgical procedure and operative results are demonstrated in detail. In contrast to conventional percutaneous endoscopic techniques, T(2) allows one to operate in the typical microsurgical fashion combined with the advantages of a minimal endoscopic approach with three-dimensional visualization of the surgical target using the operating microscope. Microsurgery was performed through a 1.6-cm skin incision with an 11.5-mm diameter trocar that is obliquely inserted into the paraspinal muscles pointing at the lateral isthmus of the upper vertebral body. Fifteen patients were evaluated after a median follow-up period of 24 months. Overall outcome according to the modified MacNab criteria, effect of surgery on radicular pain and sensory or motor deficits, duration of surgery, complication rate, and duration of hospital stay were evaluated. Good to excellent clinical outcomes were achieved in 14/15 patients. Radicular pain and motor deficits improved in all patients postoperatively, while sensory deficits recovered in 13/15 patients. The cosmetic results were excellent in all patients. No aggravation of symptoms after surgery was observed in any of the patients. The T(2) technique represents an auspicious alternative to standard open microsurgery for LLDH, which allows achievement of excellent clinical and cosmetic results, preservation of segmental spine stability, and avoidance of excessive soft tissue trauma.

Percutaneous Endoscopic Discectomy for Extraforaminal Lumbar Disc Herniations

A retrospective analysis of 41 patients operated for excision of soft lumbar extraforaminal disc herniation (EFDH) by percutaneous endoscopic extraforaminal approach under local anesthesia by a new technique. To describe a new and safer percutaneous endoscopic technique for the removal of soft EFDH and report the results on the basis of a new objective criterion modified from Oswestry Disability Index (ODI). EFDHs usually occur in older patients and present with atypical symptoms. Their diagnosis and treatment are still controversial, with various authors describing open midline or paraspinal approaches using the microscope with varying amounts of success. Percutaneous endoscopic techniques have traditionally been considered unsuitable for these herniations. Forty-one patients with a soft EFDH were subjected to percutaneous endoscopic discectomy with the new technique. In our technique, the skin entry point is medial and the angle of approach steeper as compared with the earlier described endoscopic techniques. This might help in avoiding exiting root injury and increasing the efficacy of the procedure. The results were analyzed on the basis of percentage change in ODI as compared with preoperative values. Mean follow-up was 34.1 month. Mean VAS score for radicular pain improved from 8.6 to 1.9, and mean ODI improved from 66.3 to 11.5. Overall, 92% of patients experienced satisfactory outcome. Two patients had poor outcome due to the need for subsequent open surgery. Percutaneous endoscopic discectomy using the "extraforaminal targeted fragmentectomy" technique is an effective and safe procedure for the select group of patients with a soft EFDH.

A case of transitional cell bladder carcinoma prolapsed from the external urethral orifice: A 6-year follow-up after percutaneous suprapubic bladder

A 30-year-old female was admitted in emergency with acute urinary retention due to bladder tumour prolapsed from the external urethral orifice. The patient underwent immediate endoscopic surgery via suprapubic percutaneous approach. The histological examination confirmed a superficial highly differentiated transitional cell bladder carcinoma. During the 6-year follow-up no evidence of local recurrence or metastatic tumour spread was revealed. The comprehensive Medline search confirmed that this is the fourth case of bladder tumour prolapsed from the external urethral orifice, reported so far. The case deserves the interest of practising urologists because of the exceptional rarity of the entity and the unconventional treatment approach which involves using a percutaneous suprapubic endoscopic technique. Based on the results achieved, we can recommend this unconventional endoscopic approach as specifically indicated in certain situations.

Percutaneous endoscopic gastrostomy

The many variations of surgical gastrostomy for nutritional support or for long-term gastric decompression all have a significant morbidity and mortality. An 'incisionless' technique under local anaesthesia, namely percutaneous endoscopic gastrostomy, was described in 1980. A review of the literature shows that the percutaneous technique is safer for the patient, easier and faster to perform and considerably cheaper than surgical gastrostomy. As the few complications usually require surgical management, percutaneous endoscopic gastrostomy should be considered a surgical technique. Few patients are unsuitable for the percutaneous endoscopic technique and this route should be considered for all patients referred for a gastrostomy.

Radiologically inserted gastrostomy is as safe as percutaneous endoscopic technique in amyotrophic lateral sclerosis patients

Radiologically inserted gastrostomy is as safe as percutaneous endoscopic technique in amyotrophic lateral sclerosis patients

Extraction of retained gallstones from an abscess cavity: a percutaneous endoscopic technique.

A novel technique to retrieve spilled gallstones in an abscess cavity with the use of minimally invasive techniques is described.

The scientific development of maxillofacial surgery in the 20th century and an outlook into the future

Maxillofacial surgery is a relatively young speciality of medicine and it was not established as an organized specialty until the second half of the 20th century. At first it was supported by general surgeons with particular interest in this field, and also by inspired, extremely talented dentists. During the past few years modern techniques have brought decisive progress also in maxillofacial surgery, leading to rapid further development of diagnostic and therapeutic possibilities. The development of our specialty in the past century is discussed on the four main points of our scope, traumatology, orthognathic, cleft and tumour surgery.Considering the future prospects of our specialty one should realize that in the near future maxillofacial surgery will also be influenced by further medical-technical progress in the field of micro-robots, by percutaneous endoscopic techniques and by minimal invasive or laser surgery.Basic research will also cause a more profound change in our specialty, especially in the field of tumour therapy. Molecular biological research shows some good signs, which could already be transmitted to the prevention, diagnosis and also the therapy of tumours. In the field of tissue transplantation it is no longer utopia that autogenous tissue sampling can be almost completely be avoided. By further developing ‘tissue engineering’ it will be possible to cultivate bones as well as soft tissue with the aid of gene technology and transplant them into the face using relevant carrier substances. Altogether, the complexity of maxillofacial surgery in the coming century will increase, necessitating the best and widely trained maxillofacial surgeons for successful accomplishment.

PEG using a preexisting abdominal surgical incision in an obese patient with situs inversus

Since its introduction by Gauderer et al., 1 Gauderer MW Ponsky JL Izant Jr, JR Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg. 1980; 15: 872-875 Abstract Full Text PDF PubMed Scopus (1751) Google Scholar PEG has become a popular method for providing enteral nutrition in patients who are unable to eat but have a functioning GI tract. However, the procedure is usually aborted in the absence of adequate transillumination of the anterior abdominal wall. This may occur in patients with morbid obesity or secondary to altered anatomy because of prior abdominal surgery or congenital anomalies. In such cases, surgical gastrostomy with its associated morbidity and mortality is usually recommended. 2 Klein S Fleming CR Enteral and parenteral nutrition. in: Sleisenger and Fordtran's gastrointestinal and liver disease: pathophysiology/diagnosis/management. WB Saunders, Philadelphia1998: 254-277 Google Scholar We report a case of PEG tube placement in a morbidly obese patient with situs inversus. The procedure was facilitated by opening the subcutaneous layer of a recent surgical incision.

Surgical treatment of lumbar disc herniation. Indication and methods.

The decision about operative or non-operative treatment of herniated lumbar discs has to be based on the results of clinical and neurological examination. Results of imaging techniques as CT or MRI are secondary. Various percutaneous endoscopic or open techniques have been described. The most appropriate technique is determined by the anatomical situation of the dislocated lumbar disc tissue. Intradiscal percutaneous therapies such as percutaneous nucleotomy and laser decompression are possible, but they revealed poor results in prospective randomized and controlled studies. Chemonucleolysis remains as an effective intradiscal technique at the time, but is afflicted with side effects and complications. Endoscopic transforaminal or interlaminary techniques are still experimental. Whenever open surgery is necessary, microsurgical techniques are preferred. If a certain technique is to be applied, there has to be the correct indication, technical support for and experience in using the choosen method.

Gastrostomy by Various Techniques: Evaluation of Indications, Outcome, and Complications

Background: Gastrostomy can be performed with a percutaneous fluoroscopic technique, a percutaneous endoscopic technique, or open surgery. Since all three methods are in use at our hospital, we made this retrospective study to compare indications, complications, and outcomes for the different techniques. Methods and Results: During the period January 1990 to December 1994, 147 patients admitted to Lund University Hospital required gastrostomy. The records of these patients were retrospectively studied. Six patient records could not be found, and these patients were therefore excluded. Of the remaining 141 patients, 94 had undergone fluoroscopic percutaneous gastrostomy, 12 percutaneous endoscopic gastrostomy (PEG), and 35 gastrostomy at open surgery. The 30-day overall mortality was 15% in the fluoroscopy group, 17% in the endoscopy group, and 29% in the open surgery group. The 30-day mortality as related to the procedure was 3.2% in the fluoroscopy group, 0% in the PEG group, and 2.9% among the patients with open surgery. The morbidity related to the procedure was 16%, 8%, and 20%, respectively. For the 30-day overall mortality and for the procedure-related mortality there was no statistically significant difference between the groups (P = 0.2019, P = 0.8215). For the percutaneous procedures the indication was nutrition in most patients. For the patients receiving gastrostomy at open surgery drainage was the main indication. Even though the complication rate was higher in this group, most complications were minor, and there was only one procedure-related death. Gastrostomy at open surgery is often performed in severely ill patients. Despite this, it does not seem to cause more complications than the percutaneous techniques in our study. Conclusion: The study shows that gastrostomies are safe procedures, with few complications and a low procedure-related mortality independent of the technique being used.

17th Course for Percutaneous Endoscopic Spinal Surgery and Complementary Techniques

17th Course for Percutaneous Endoscopic Spinal Surgery and Complementary Techniques