Rigid Scope Research Articles

Alternative Hybrid Technique of Intubation Using C-MAC and Yankauer Suction Catheter: Case of A Floppy Supraglottic Mass.

Supraglottic masses can be an anaesthesiologist's nightmare due to the difficult airway scenario and bleeding risk during airway manipulation. Awake fibreoptic intubation is the primary method to secure the airway in such cases. However, most practising anaesthesiologists are not experts at handling the fibreoptic scope, especially in cases with a floppy supraglottic mass where it becomes difficult to displace the mask with the thin flexible bronchoscope. A hybrid technique of intubation in supraglottic masses using Bonfils rigid scope and C-MAC is often described but frequently not available. Here we describe a case of an elderly patient in their 80s presenting with a floppy supraglottic mass where an awake fibreoptic bronchoscope failed to secure the airway. Without access to a rigid Bonfils scope, we intuitively used a C-MAC to visualize the larynx and a yankauer suction catheter to displace the mass and perform a bougie-guided endotracheal intubation.

Challenges and practical considerations in delivering botulinum neurotoxin to adults with congenital neurogenic lower urinary tract dysfunction with history of genitourinary reconstruction

Purpose:While intradetrusor botulinum neurotoxin (BoNT) injection is a well-established treatment of neurogenic detrusor overactivity, its administration in individuals with complex genitourinary (GU) reconstruction can be difficult. The objective of this report is to highlight our institution’s experience with challenges and practical solutions in delivering BoNT to this unique patient population. Materials and Methods:We performed a retrospective review of our institution’s database of adults with congenital neurogenic lower urinary tract dysfunction (NLUTD) with history of complex GU reconstruction who received intradetrusor BoNT injections performed by a single surgeon between 2016 and 2023. In patients with multiple injections, the most recent procedure was used as the index case for analysis. Results:A total of 17 patients were included, with a mean age of 27 years (range 21–46). The most common diagnosis was myelomeningocele (n=13), followed by sacral agenesis (n=2), Williams syndrome (n=1), and urethral atresia (n=1). The most common GU reconstruction was augmentation cystoplasty (n=11). 75% (12/16) of the patients had a continent catheterizable channel (CCC) and 31% (5/16) had undergone prior bladder neck reconstruction or closure. Conclusion:Additional considerations and instruments are required for safe and effective BoNT injections in individuals with congenital NLUTD and reconstruction. Adequate preparation by the staff and the provider may be needed. Our recommendation generally favors the utilization of a flexible cystoscope or a rigid scope with a smaller sheath size to minimize trauma to the CCC, bladder neck, or urethra. Additionally, it is advisable to consider reconstituting BoNT in higher concentrations to enable the administration of fewer injections. Furthermore, performing these procedures in the operating room under anesthesia allows for the development of a well-considered strategy prior to any attempts in the office setting We hope that this manuscript sparks discussion between pediatric urologists and adult urologist to expand our knowledge on strategies needed for delivering BoNT to individuals with complex and restricting GU surgeries.

Endoscopic Management of Chronic Subdural Hematoma Using a Novel Brain Retractor

Endoscopic procedures are useful in chronic subdural hematoma especially when there are septations, solid/organized hematoma, and the presence of bridging or neovessels in the cavity. Visualizing the distal hematoma cavity by a rigid scope is challenging in large and curved ones due to the hindrance by the brain surface. Combining rigid endoscopy and brain retractor can overcome this limitation. A retrospective study of 248 patients managed by endoscopic technique was performed and the relevant literature was reviewed. The brain retractor was used in all patients. Average operative time, subgaleal drainage duration, and hospital stay were 56minutes, 3.1days, and 4.6days, respectively. The average preoperative Glasgow coma scale (GCS) score was 12, which improved to 14 and 15 in 223 and 23 patients, respectively at discharge. There were solid clots, septations, bridging vessels, curved hematoma cavities, rapid expansion of the brain after partial hematoma removal, and recurrences in 59, 52, 15, 49, 19, and 2 patients, respectively. There were 2 deaths, without any procedure-related mortality. Endoscope was very effective and safe in the management of chronic subdural hematoma, especially in about 51% patients with solid clots, septations, and bridging vessels which could have been difficult to treat by conventional burr hole. It can avoid craniotomy in such patients. Good visualization and complete hematoma removal were possible with the help of an endoscope and brain retractor in about 27% of patients which could have been difficult with a rigid endoscope alone.

Pragmatic algorithm for management of common bile duct calculi in resource-limited settings in India.

Endoscopic retrograde cholangiopancreatography (ERCP) facilitates the removal of common bile duct (CBD) calculi by endoscopy. When ERCP fails, exploration of CBD is required for the clearance of CBD calculi. The optimum way for the exploration of CBD is by choledochoscopy. Dedicated flexible or rigid choledochoscopes are expensive and available only in few places in India. Since 1991, we subjected patients with suspected CBD calculi to ERCP, followed by laparoscopic cholecystectomy (LC). Patients in whom ERCP failed to clear CBD were subjected to open exploration of CBD using any easily available, suitable, straight rigid scope for choledochoscopy. Since March 1991, out of 8866 patients with cholelithiasis, 862 underwent ERCP. Ninety-six patients in whom ERCP failed to clear CBD underwent open exploration of CBD. In each case of exploration of CBD, choledochoscopy was performed using a straight rigid scope, either a cystoscope, paediatric cystoscope, hysteroscope or 5-mm laparoscopy telescope with a 5-mm cannula. The CBD clearance was complete in 95 patients, and one patient had an impacted calculus at the ampulla. CBD explorations were followed by choledochoduodenostomy, T-tube placement or suturing of choledochotomy. No residual calculi were observed after such exploration. From our results, we advocate the following algorithm for CBD calculi in resource-limited settings. Subject patients with CBD calculi to ERCP followed by LC. In case of failed ERCP, open exploration of CBD with choledochoscopy using any suitable rigid scope. Dedicated flexible or rigid choledochoscope is not essential. This approach is cost-effective and successful.

An Actuated Variable-View Rigid Scope System to Assist Visualization in Diagnostic Procedures.

Variable-view rigid scopes offer advantages compared to traditional angled laparoscopes for examining a diagnostic site. However, altering the scope's view requires a high level of dexterity and understanding of spatial orientation. This requires an intuitive mechanism to allow an operator to easily understand the anatomical surroundings and smoothly adjust the scope's focus during diagnosis. To address this challenge, the objective of this work is to develop a mechanized arm that assists in visualization using variable-view rigid scopes during diagnostic procedures. A system with a mechanized arm to maneuver a variable-view rigid scope (EndoCAMeleon - Karl Storz) was developed. A user study was conducted to assess the ability of the proposed mechanized arm for diagnosis in a preclinical navigation task and a simulated cystoscopy procedure. The mechanized arm performed significantly better than direct maneuvering of the rigid scope. In the preclinical navigation task, it reduced the percentage of time the scope's focus shifted outside a predefined track. Similarly, for simulated cystoscopy procedure, it reduced the duration and the perceived workload. The proposed mechanized arm enhances the operator's ability to accurately maneuver a variable-view rigid scope and reduces the effort in performing diagnostic procedures.Clinical and Translational Impact Statement: The preclinical research introduces a mechanized arm to intuitively maneuver a variable-view rigid scope during diagnostic procedures, while minimizing the mental and physical workload to the operator.

Purely Endoscopic Evacuation of Intracranial Hematomas.

Cerebral hemorrhage is a frequent disease and one of the main causes of disabilities. Even in the case of cerebral hemorrhage, if there were a treatment that would improve the functional prognosis, the benefits would be immeasurable. Although there are limited reports with a high level of evidence in past studies, it has been found that surgery can be effective if a large amount of hematoma can be removed in a minimally invasive manner. Also, it has become clear that the control of bleeding becomes a problem when surgery is performed within 2days after the onset of stroke and that the therapeutic time window might be longer. In Japan, since the introduction of the transparent sheath by Nishihara et al., endoscopic hematoma removal has been widely performed and has become the standard surgical procedure. The three basic equipment needed for this surgery are a rigid scope, a suction coagulator, and a transparent sheath. The key point of the surgery is to search for hematomas and bleeding points through a transparent sheath and coagulate the bleeding vessels. In this chapter, we will introduce surgical techniques using these devices, but it is important to carefully decide on surgical options by considering your own technique, the condition of each patient, and the devices available in the area.

A Case of Sellar Arachnoid Cyst Operated Using the Endoscopic Supraorbital Keyhole Approach

BACKGROUND AND IMPORTANCE: In recent years, sellar arachnoid cysts (ACs) have been increasingly treated using an endoscopic transnasal approach. It is important to connect the subarachnoid space with the AC to prevent recurrence; however, a high frequency of postoperative cerebrospinal fluid (CSF) leakage has been reported with the endoscopic transnasal approach, and the suitability of the endoscopic transnasal approach for treating sellar ACs is questionable to begin with. CLINICAL PRESENTATION: A man in his 40s underwent surgery for a sellar AC compressing the optic chiasm. The normal pituitary gland was compressed dorsally by the cyst, and an endoscopic supraorbital keyhole approach was adopted to reduce the risk of postoperative CSF leakage. A small incision was made in the right eyebrow, and a small craniotomy was performed. A rigid scope was used to approach the cyst and incise the arachnoid membrane of the prechiasmatic cistern and the anterior wall of the cyst. Postoperatively, the cyst shrank, and the preoperative visual field defects improved. The duration of the endoscopic manipulation was approximately 40 minutes. DISCUSSION: The endoscopic supraorbital keyhole approach eliminates the need to incise the dura mater of the anterior skull base and reduces the risk of CSF leakage compared with the transnasal approach. In addition, cumbersome dural reconstruction using fat and fascia is not required during the supraorbital keyhole approach, which reduces operation time. CONCLUSION: The endoscopic supraorbital keyhole approach may be more suitable than the transnasal approach for surgery of sellar ACs.

EGS P24 Management of oesophageal denture impaction and complications - a case series

Abstract Background Dentures are sometimes inadvertently ingested and can impact in the oesophagus. This can lead to complications such as mediastinitis, perforation and major vascular fistulae. In 1914, Chiari coined ‘aorto-oesophageal syndrome’ following foreign body ingestion. Usually diagnosed post-mortem, he described a triad of chest pain, haematemesis and cardiac arrest resulting from perforation and aortic fistula. Modern dentures are radiolucent, have complex configurations and commonly impact in the oesophagus at the level of the aortic arch. Early specialist intervention by experienced oesophago-gastric (OG) surgeons is crucial to the prognosis. We present our personal experience of managing oesophageal denture impaction and complications. Methods A retrospective review of electronic health records of the authors’ case series of patients with a diagnosis of oesophageal denture impaction over a 13-year period from 01/01/2010 to 31/12/2022 was performed. The inclusion criteria was adult patients with a clinical diagnosis of oesophageal denture/dental bridge impaction. Pathology and complications from impaction and mode of intervention was reviewed. Other outcome measures evaluated were treatment complications, length of stay and 90-day mortality. Results Seven patients (6 males) with median age 54 were reviewed. Dentures were impacted at or above the aortic arch in 6 patients. Attempted retrieval with ENT rigid scope in 3 caused migration of denture causing perforation. Attempted retrieval with flexible gastroscope was successful in 3 but led to opening up of a fistula in one. Five patients underwent surgical intervention (results summarised in tables 1 and 2). 90-day mortality was 0%. The median length of stay in the surgical intervention group was 30 days. Two patients who had aorto-oesophageal fistulae required additional input by cardiac surgery and vascular radiology teams. Conclusions This is a report of the authors’ experience of managing oesophageal denture impaction and it’s sequelae. A favourable 0% 90-day mortality rate despite complex presentations including aorto-oesophageal fistulae has been described. For patients presenting with haematemesis or prolonged history of denture impaction a triple phase CT scan should be performed prior to intervention. The variable complex configuration of dentures complicates their impaction or attempts at extraction. Attempts at extraction with a rigid endoscope can lead to oesophageal perforation. Successful management of these complex cases requires an effective multidisciplinary approach in a specialist OG surgery centre.

Control of bleeding from a recurrent tumor at a uretero‐ileal anastomosis by electrocoagulation via an ileal conduit

IntroductionBladder cancer is characterized by spatial and temporal recurrence in the urinary tract. We describe a case of recurrence at a uretero‐ileal anastomosis after radical cystectomy and nephroureterectomy. It was difficult to control bleeding from the tumor, but hemostasis was achieved.Case presentationA 73‐year‐old man with a history of radical cystectomy and reconstruction of the ileal conduit and right nephroureterectomy was diagnosed with recurrence at the uretero‐ileal anastomosis site. Bleeding from the tumor could not be controlled by flexible gastrointestinal endoscopy. The patient underwent coagulation via an ileal conduit approach using a rigid scope and bipolar electrocautery, which is usually a modality for transurethral resection.ConclusionThis is the first report in which a modality normally used for transurethral resection was used to control bleeding in a patient with an ileal conduit. This application is useful in cases open surgery or additional irradiation might be difficult.

Interventional Pulmonology: Approaches to the Treatment of Benign Subglottic and Tracheal Stenosis

Benign subglottic/tracheal stenosis is a condition that negatively impacts patient quality of life and often morbidity. In cases of benign tracheal stenosis, a multidisciplinary and multimodal approach to treatment has been shown to result in the best outcomes with respect to successful management and recurrence rate. Interventional Pulmonology (IP) physicians work in conjunction with other specialties to manage these conditions. The procedures employed by IP physicians incorporate techniques via rigid bronchoscopy, flexible bronchoscopy, and occasionally hybrid approaches. Often, multiple modalities are utilized during a case, including mechanical dilation (rigid scope and balloon), laser therapies, electrocautery, spray cryotherapy, and pharmacologic therapies. The goal is to reduce the risk of restenosis and/or palliate symptoms in patients who may not be operative candidates for short-segment tracheal stenosis or laryngotracheal resection and reconstruction. Benign subglottic/tracheal stenosis is a condition that negatively impacts patient quality of life and often morbidity. In cases of benign tracheal stenosis, a multidisciplinary and multimodal approach to treatment has been shown to result in the best outcomes with respect to successful management and recurrence rate. Interventional Pulmonology (IP) physicians work in conjunction with other specialties to manage these conditions. The procedures employed by IP physicians incorporate techniques via rigid bronchoscopy, flexible bronchoscopy, and occasionally hybrid approaches. Often, multiple modalities are utilized during a case, including mechanical dilation (rigid scope and balloon), laser therapies, electrocautery, spray cryotherapy, and pharmacologic therapies. The goal is to reduce the risk of restenosis and/or palliate symptoms in patients who may not be operative candidates for short-segment tracheal stenosis or laryngotracheal resection and reconstruction.

Day Case Local Anaesthetic Thoracoscopy: Experience from 2 District General Hospitals in the United Kingdom

Local anaesthetic thoracoscopy (LAT) can be a vital procedure for diagnosis of unexplained pleural effusions. Traditionally, poudrage for pleurodesis and insertion of a large bore drain necessitated admission. There has been a shift towards performing LAT as a day case procedure with indwelling pleural catheter (IPC) insertion. This was advocated during the COVID pandemic by the British Thoracic Society (BTS). To determine the feasibility of such pathways, continuous evaluations are required. All day case LAT procedures with IPC insertion, performed in theatre, were identified at two large district general hospitals (Northumbria HealthCare in the North East of England and Victoria Hospital, NHS Fife, in Scotland). Rapid pleurodesis with talc was not performed due to local staffing problems. All patients had their LAT in theatre under conscious sedation with a rigid scope. Demographics, clinical, radiological and histopathological characteristics and outcomes were collected. 79 patients underwent day case LAT. The lung did not deflate, meaning biopsies were not enabled, in four of the patients. The mean age was 72 years (standard deviation 13). Fifty-five patients were male and twenty-four were female. The main diagnoses were lung cancers, mesotheliomas and fibrinous pleuritis with an overall diagnostic sensitivity of 93%. Other diagnoses were breast, tonsillar, unknown primary cancers and lymphomas. Seventy-three IPCs were simultaneously placed and, due to normal macroscopic appearances in two patients, two large bore drains were placed and removed within one hour of LAT termination. Sixty-six (88%) patients were discharged on the same day. Seven patients required admission: one for treatment of surgical emphysema, four because they lived alone, one for pain control and one for control of a cardiac arrythmia. Within 30 days, there were five IPC site infections with two resultant empyemas (9%), with no associated mortality. Two patients developed pneumonia requiring admission and one patient required admission for pain management. The median number of days for which the IPCs remained in situ was 78.5 days (IQR 95). The median length of stay (LoS) was 0 days (IQR 0). No patients required further interventions for pleural fluid management. Day case LAT with IPC insertion is feasible with this current set up, with a median stay of 0 days, and should be widely adopted. The health economics of preventing admission are considerable, as our previous analysis showed a median length of stay of 3.96 days, although we are not comparing matched cohorts.

Use of a Fiberoptic-Laser Approach During Endoscopic Sinus Surgery: A Cadaver Feasibility Study.

The aim of the present study is to evaluate the clinical applicability of laser energy during an oro-nasal endoscopic approach (ONEA) in the management of the anterior maxillary sinus wall. An experiment on three adult human cadavers was performed to study the nasal cavities with angled rigid scopes and using the ONEA technique. In order to evaluate the effectiveness of laser energy on the bone, the drilling effect was compared to laser energy (1470 nm diode laser, continuous wave, power 8, 9 and 10 W). Compared to a rigid angled scope, the ONEA technique allowed complete visualization of the anterior wall of the maxillary sinus. Microscopic analysis of frontal bone revealed similar bone Exeresis with high-speed drilling (270.28 μm) and laser approaches (285.73-456.6 μm). The laser ONEA technique is an innovative, mini-invasive, and safe approach to the anterior wall of the maxillary sinus. Additional study is warranted to further develop this technique.

Novel Modality of Endoluminal Anastomotic Integrity Assessment with Fluoroangiography After Left-sided Colorectal Resections

BackgroundSeveral methods have been described for the intraoperative evaluation of colorectal anastomotic integrity. Technological evolution has allowed to progress from basic mechanical methods to the use of more sophisticated techniques. This study describes a novel endoluminal modality of colorectal anastomotic assessment through the use of a Disposable Rigid Scope Introducer (DRSI) also allowing for intraoperative endoluminal perfusion evaluation by indocyanine green (ICG) fluoroangiography in patients undergoing left-sided colorectal resection.MethodsThe DRSI consists of an endoluminal introducer device made up of an insertion tube and port connected to an insufflation bulb to manually insufflate the sigmoid and rectum and is compatible with any laparoscopic camera, also allowing for ICG fluoroangiography for perfusion purposes.ResultsThe DRSI was successfully used to assess anastomotic integrity after left-sided colorectal resections performed in 16 consecutive patients. The DRSI allowed to visualize by fluoroangiography the quality of tissue perfusion at the anastomotic site in all cases, contributing to the decision of avoiding loop ileostomies in low rectal resections. In 2 cases, the DRSI showed the presence of significant anastomotic bleeding which was successfully controlled by laparoscopic suture placement. No adverse event resulted from the use of this device.ConclusionsThe DRSI combines direct endoluminal visualization of the anastomosis together with real-time evaluation of its blood flow. This device holds great potential for prompt intraoperative detection of anastomotic alterations, possibly reducing the risk of postoperative anastomotic bleeding or leaks related to mechanical construction/perfusion issues. Potential advantages of this device warrant larger cohort studies and prospective randomized trials.

Comparison of convolutional neural networks for classification of vocal fold nodules from high-speed video images.

Deep learning is in this study used through convolutional neural networks (CNN) to the determination of vocal fold nodules. Through high-speed video (HSV) images and computer-assisted tools, a comparison of convolutional neural network models and their accuracy will be presented. The data have been collected by an Ear Nose Throat (ENT) specialist with a 90° rigid scope in the years from 2007 to 2019, where 15.732 high-speed videos have been collected from 7909 patients. A total of 4000 images have been carefully selected, 2000 images were of normal vocal folds and 2000 images were of vocal folds with varying degrees of vocal fold nodules. These images were then split into training-, validation-, and testing-data set, for use with a CNN model with 5 layers (CNN5) and compared to other models: VGG19, MobileNetV2, and Inception-ResNetV2. To compare the neural network models, the following evaluation metrics have been calculated: accuracy, sensitivity, specificity, precision, and negative predictive values. All the trained CNN models have shown high accuracy when applied to the test set. The accuracy is 97.75%, 83.5%, 91.5%, and 89.75%, for CNN5, VGG19, MobileNetV2, and InceptionResNetV2, respectively. Precision was identified as the most relevant performance metric for a study that focuses on the classification of vocal fold nodules. The highest performing model was MobilNetV2 with a precision of 97.7%. The average accuracy across all 4 neural networks was 90.63% showing that neural networks can be used for classifying vocal fold nodules in a clinical setting.

DIAGNOSTIC UTILITY OF THORACOSCOPY IN UNDIAGNOSED AND MISDIAGNOSED PLEURAL EFFUSION AT A TERTIARY CARE CENTRE

Background Pleural effusion results from accumulation of abnormal volumes ->( 10-20) ml of uid in pleural space . Signicant number of cases of pleural effusion remains undiagnosed after simple diagnostic pleural aspiration. Thoracoscopy allows direct visual assessment of the pleura and subsequent biopsy of visually abnormal areas, hence maximising diagnostic yield. A retrospective study of all Thoracoscopic Methods procedure performed with rigid and semi- rigid scope in patients admitted in Respiratory department of SRMS, Bareilly. Post-procedural diagnoses were obtained from the clinical records and using relevant hospital databases. A total of 40 patients underwent Thoracoscopy in Results time span of 2020-2021 to diagnose a wide spectrum of benign and malignant conditions. The diagnosis of 23 malignant conditions - 13 Adeno Carcinoma, 3 Non – small cell carcinoma and 7 cases of other malignancies , along with 17 benign cases were made . Conclusion Thoracoscopy can be used as a diagnostic tool for investigation of various pathologies of undiagnosed pleural effusion . In our study the sensitivity of thoracoscopy was more than 90%

Artificial urinary sphincter cuffs and safe instrument/catheter passage guidelines

The artificial urinary sphincter (AUS) is the gold standard for males with urinary incontinence. It is generally a safe procedure with a high degree of satisfaction. However, there is a lifelong risk of infection and erosion. AUS cuffs are commonly placed around the bulbar urethral area. There is always a risk of trauma and erosion of cuffs with catheterization or endoscopy. At this time, there is little guidance as to which size catheters or scopes can pass through each AUS cuff sizes safely. The goal of this study was to determine which size of catheters/scopes can pass through different cuff sizes safely in an ex vivo setting. All AUS cuff sizes available (3.5 cm up to 6.0 cm), catheter sizes between 12and22 Fr, and scope sizes 19 Fr flexible/rigid, 21-26 Fr rigid scopes were examined. We used deflated assembled cuffs on the bench (ex vivo) and three different blind observers to measure the free space left between the wall of the cuff and the catheter/scope to be sure that there was consistency. We created a scale from 1 to 3 to determine the ease of passage for each catheter/scope. We also had an MRI radiologist examine bulbar urethra thickness in 20 male patients to determine the average thickness without the bulbospongiosus muscle. Using our average bulbar urethral thickness, we were able to estimate how much free space remained within the urethral lumen and how easy and safe it was to pass each catheter/scope. For 3.5 cm cuffs, 12 Fr catheters pass easily and safely, 14-16 Fr catheters and 19 Fr flexible/rigid scopes can pass through with some mild risk of trauma. Larger catheter/scope sizes cannot pass through without a significant risk of trauma. For 4.0 cm cuffs, 12-14 Fr catheters pass easily and safely. 16-18 Fr catheters and 19-21 Fr rigid/flexiblescopes can pass with some mild risk of trauma. Larger catheter/scope sizes cannot pass through safely. For 4.5 cm cuffs, 12-18 Fr catheters and 19 Fr flexible/rigid scopes pass easily and safely. 20-22 Fr catheters and 21 Fr rigid scopes can pass with some mild risk of trauma. Larger catheter/scope sizes cannot pass through safely. For 5.0 cm cuffs, 12-22 Fr catheters and 19-21 Fr flexible/rigid scopes can pass easily and safely. 22-26 Fr scopes can pass with some mild risk of trauma. For 5.5 cm cuffs, all catheters/scopes can pass easily and safely. However, the 26 Fr rigid scope can pass with some mild risk of trauma. For 6 cm cuffs, all catheters/scopes examined can pass easily and safely. Our study can guide urologists in the management of patients with an AUS who need urethral catheters or endoscopy. These recommendations are based on the measurements of our study along with bulbar urethral thickness. In general, greater caution is needed with smaller cuff sizes (3.5-4.5 cm). Our recommendations, with minimal urethral compression, are purposely conservative and safe to avoid trauma and erosion of the AUS cuffs.

Therapeutic bronchoscopy followed by sequential radiochemotherapy in the management of life-threatening tracheal adenoid cystic carcinoma: a case report

BackgroundAdenoid cystic carcinoma of the lung is a distinctive salivary-gland-type malignant epithelial neoplasm that rarely presents as a primary tumor of the respiratory tract. Complete surgical resection remains the treatment of choice for adenoid cystic carcinoma. We present a case of large ACC tumors that caused severe central airway obstruction and were effectively treated with therapeutic bronchoscopy followed by radiotherapy and chemotherapy.Case presentationA 31-year-old Malay Indonesian female patient who was a nonsmoker and had no family history of cancer was admitted to the emergency ward because of worsening breathlessness accompanied by stridor since 1 week prior. Chest computed tomography revealed segmental atelectasis of the left lung; a mass on the left main bronchus, with infiltrates in segments 1, 2, and 3 of the left lung; and consolidation in the left inferior lobe, with narrowing of the main left bronchus. Lobulated masses obstructing almost the entire distal trachea up to the carina and the entire left main bronchus were found on bronchoscopy. Owing to the large tumors causing severe central airway obstruction, the medical team decided to perform central airway mass removal through rigid bronchoscopy. A neodymium-doped yttrium-aluminum-garnet laser was used first to facilitate mass shrinkage. After the laser treatment, mechanical mass removal using a rigid scope was performed. The tracheal and carinal lumens were opened to > 50% of their diameter, with the left main bronchus lumen opened only slightly. After the treatment, the patient was stable, and no stridor was found. Adjuvant intensity-modulated radiotherapy and chemotherapy were performed after the therapeutic bronchoscopy. At the end of the entire treatment, reevaluation by thoracic computed tomography scan and bronchoscopy revealed no remaining mass.ConclusionsIn cases of nonresectable large adenoid cystic carcinoma tumors with life-threatening central airway obstruction, therapeutic bronchoscopy followed by sequential radiochemotherapy might achieve a complete response outcome.

Transvaginal mesh excision with urethral reconstruction: tips and tricks

Share our surgical technique with tips to safely perform urethral mesh removal. Retropubic midurethral sling is commonly performed for the treatment of stress urinary incontinence. Transurethral mesh erosion occurs rarely with an incidence of 0.02-0.03%. Our patient with a history of transvaginal tape procedure done 13 years ago was found to have a urethral mesh erosion when she complained of recurrent urinary tract infection, incomplete bladder emptying and increased frequency. She was consented for mesh removal with urethral reconstruction. Intraoperatively, urethral obstruction was noted with no patent, visible lumen. Vaginal dissection was done, and urethral tunnels were created. Mesh was felt, grasped using Kocher clamps and released from retropubic arms after lateral dissection. Urine extravasation was noted when dissecting the mesh near the urethra. Flexible cystoscope was introduced through the orifice and retroflexion of the scope confirmed this to be a urethrotomy which was noted to be approximately 1 cm after removing the mesh completely. Transurethral catheter was difficult, hence urethral dilator with ureteral guidewire was used to facilitate trans-urethral placement. Urethrotomy was closed in multiple layers using 4-0 monocryl for the urethral mucosa, 3-0 vicryl for the second layer and 2-0 vicryl for the epithelium. Foley was removed and cystoscopy performed with ease. Urethroscopy revealed no further defects or mesh inside the urethra. Foley was replaced and removed 7 days postop. She continued to report ease of voiding 6week postop. Smaller gauge scope or flexible cystoscope is a helpful alternative tool to do cystourethroscopy when rigid scope cannot be passed. Urethral dilators with a guidewire can help with difficult catheter insertion. Cystotomy and urethrotomy should always be distinguished intraoperatively.

T3-T4 Disc Herniations: Clinical Presentation, Imaging, and Transaxillary Approach

To describe a cohort of T3-T4 thoracic disc herniations (TDHs), their clinical and radiologic characteristics, and unique thoracoscopic transaxillary approach (TAA). All patients operated on for a T3-T4 TDH with minimal follow-up of 1 year were selected. Eight TAA procedures (6 males and 2 females) were included (1.4%). Six patients reported axial pain, irradiating in 2, 4 sensory changes, 1 objective and 1 merely subjective motor weakness. Only 1 TDH was calcified, none was giant, 2 were accompanied by myelomalacia, and 2 by a small segmental syrinx. A cardiothoracic surgeon helped with exposure through a curved axillary incision using anterior cervical and more recently double-ring wound retractors. All patients were operated on using a 10-mm 30° rigid (three-dimensional) high-definition scope. There were no major complications and a good outcome with symptomatic relief in 7 of 8 patients. T3-T4 TDHs are infrequent but may be underdiagnosed because they tend to be small and their signs and symptoms may mimic a cervical problem involving the shoulders and even the arms. There may be a male predominance. The TAA is straightforward, safe, efficacious, and well tolerated despite the supposed vulnerability of the upper thoracic spinal cord. Dissection between large crowded subpleural veins characteristic for the upper thoracic spine and ensuring adequate dura decompression when the steep angle may partially obscure the tip of the instruments does require some extra time. Thorough knowledge of the unique anatomy of the upper thorax is mandatory and the assistance of a cardiothoracic surgeon is highly recommended.

LET'S MEET IN THE MIDDLE: SIMULTANEOUS ENDOSCOPIC AND BRONCHOSCOPIC SUTURE REPAIR TO CLOSE A LEFT MAIN-STEM MALIGNANT BRONCHO-ESOPHAGEAL FISTULA

TOPIC: Procedures TYPE: Fellow Case Reports INTRODUCTION: This case highlights a unique approach to manage broncho-esophageal fistula which is refractory to esophageal stenting. CASE PRESENTATION: We describe the case of a 68 year old female with stage IV squamous cell carcinoma of the esophagus status post chemotherapy, immunotherapy and radiation complicated by esophageal stricture requiring a fully covered 18mmx12.3cm WallFlex stent. Approximately three months after stent placement, she developed coughing with oral intake. Swallow study revealed contrast refluxing into the trachea, and CT scan showed presence of left mainstem broncho-esophageal fistula. Bronchoscopy demonstrated thick purulent secretions and a 1-1.5 cm defect of the left main, 5mm distal to the main carina. The esophageal stent was visualized through the defect. She underwent EGD with removal of the stent and was also found to have a large 3cm deep defect in the proximal esophagus and ulceration throughout the mid-esophagus. Due to high risk of perforation, the esophagus was not stable enough to safely allow stent replacement. Her defect was deemed non-operable. Bronchial stenting was considered; however, there was increased risk of pressure necrosis and mediastinits plus proximity of the fistula to the main carina made stenting difficult to size. We opted to pursue simultaneous flexible endoscopy with rigid bronchoscopy to close her broncho-esophageal fistula. We utilized an X-Tack Endoscopic HeliX Tacking System with one running suture as well as placed two 2.0 36 inch braided non-absorbable pledgeted sutures from the esophageal side with closure on the bronchial side with a Cor-Knot device. There was no evidence of saline leak over the fistula. Post-closure, she tolerated bedside swallow and was able to drink liquid without coughing. Follow up esophagram is pending. DISCUSSION: The current standard of care for management of malignant tracheal-esophageal fistula is esophageal with/without broncho-tracheal stent and is palliative in intent. Stenting was not a safe option in our patient. The use sutures placed via rigid scopes from the esophageal side to tracheal side with closure with a Cor-Knot device for management of tracheo-esophageal fistula has been described in one prior case report.(1) Our case further demonstrates the feasibility of this technique for management of airway-esophageal fistula. Our case is unique as it treats a fistula in the left mainstem bronchus as opposed to the trachea. Due to the distal location of the defect, we were unable to use the rigid esophageal tube to pass the sutures, so we straightened the sutures and successfully passed them through a flexible EGD scope. Our case also used an X-Tack running suture device to further stabilize our closure. CONCLUSIONS: This case demonstrates an effective alternative approach and potentially more viable solution to treat broncho-esophageal fistulas when endoscopic/endobronchial stenting is not permissible. REFERENCE #1: Mozer AB, Michel E, Gillespie C, Bharat A. Bronchoendoscopic Repair of Tracheoesophageal Fistula. Am J Respir Crit Care Med. 2019 Sep 15;200(6):774-775. doi: 10.1164/rccm.201812-2255IM. PMID: 30973758; PMCID: PMC6775884. DISCLOSURES: No relevant relationships by Navtej Buttar, source=Web Response No relevant relationships by Sangita Goel, source=Web Response No relevant relationships by Ryan Kern, source=Web Response No relevant relationships by John Mullon, source=Web Response No relevant relationships by Darlene Nelson, source=Web Response Research grant relationship with Intuitive Surgical Please note: $5001 - $20000 by Janani Reisenauer, source=Web Response, value=Grant/Research Support No relevant relationships by Linh Vu, source=Web Response