Shorter Procedure Time Research Articles

PO-03-094 IMAGE INTEGRATION IN VENTRICULAR TACHYCARDIA (VT) ABLATION USING SENSE2 PROTOCOL MAPPING

We have previously developed the sense protocol functional substrate mapping technique for VT ablation. This involves targeting areas of decremental signal delay during single extra pacing at short coupling interval. However, functional substrate characterization can involve protracted mapping time. We incorporated the MRI and CT data using ADAS-3D software into the mapping workflow to integrate structural mapping information into the functional mapping substrate characterization to improve procedural efficiency. Cardiac MRI/CTs were performed on 33 patients with ischemia-related VT (group A). These were processed with the ADAS-3D software to characterize the extent of ventricular scars. Focused substrate maps were then performed in patients, guided by the extent of ADAS scar and corridors, looking at the scar substrate in intrinsic rhythm and then functional channels using single extra pacing from the RV apex. Following the delineation of functional channels pace mapping and entrainment mapping were used to confirm targets for ablation. Group A was then compared to a matched cohort who underwent sense protocol mapping without MRI (group B) and an institutional cohort who underwent conventional mapping and ablation using entrainment or pace mapping (group C). 33 patients (mean age 68 years; 31 male subjects, mean EF 32%) underwent ablation. Median procedure time was 175 minutes compared with 305 and 246 minutes in groups B and C(p=<0.001) Mean substrate mapping time was 17 mins vs 80 and 63 mins in groups B and C (p=<0.001). 85% of patients were free from symptomatic VT/ anti-tachycardia pacing or implantable cardioverter defibrillator shocks at a median follow-up of 171 days. The mean VT burden was reduced from 22 events per patient in the six months pre-ablation to 1 event per patient in the median follow-up period of 171 days post-ablation (p=0.02). Sense2 protocol showed a reduced probability of device therapy compared with institutional and sense protocol (Log-rank p=0024 in the figure). The Sense2 protocol integrated structural MRI findings into functional signal ablation of VT. It shortened procedure times by enabling focused substrate maps to be performed without requiring complete geometry. Outcomes compare favourably with our previous data from sense protocol but with significantly shorter procedure times. There were improved outcomes compared to our institutional standard ablation cohort.

AB-452672-3 PRE-CLINICAL PULSED-FIELD ABLATION (PFA) USING A SINGLE-SHOT CIRCULAR LINEAR ABLATION CATHETER FOR PV ISOLATION

Pulsed field ablation (PFA) is becoming the preferred energy treatment for pulmonary vein (PV) isolation. PFA application appears safe and effective and shortens procedure time. A circular linear ablation catheter may have advantages for single-shot delivery of PFA for PV isolation. To evaluate the feasibility of pusled field ablation for PV isolation with a circular linear ablation catheter. The Fiore™ catheter (EP Frontiers S.p.A., Italy; Figure) has two unique features: (1) an over the wire anchor and (2) an ablation element with linear electrodes. The anchor is positioned in the PV and guides the Circular Linear Ablation (CLA). The CLA can deliver PFA from a customized generator. Optimization of PFA parameters was conducted with a potato model in a saline bath by testing various energy pulses with bipolar and biphasic energy (500-1000 volts, pulse duration of 10-100 μs, interpulse pause of 10-400 μs, with a changing number of repetitions). The goal was to create circular ablations with a minimal depth of 3-4 mm. Following energy application images were acquired acutely and 18-24 hours after. Porcine in vivo testing (n=5 swine under general anaesthesia) with a deflectable sheath, evaluated PFA application at the left and right superior pulmonary vein, superior vena cava, and lateral wall of the right atrium with histopathology. In vitro ablations with three separate pulse trains demonstrated circular lesions with a diameter of up to 40 mm that were visible hours after the energy delivery. Average cross section of the circular lesions revealed an average depth of 3.2 mm with a surface width of 36 mm (Figure). Four applications (vs eight), from linear electrodes resulted in the most optimal and controlled circular lesions with central sparing and no off-target tissue destruction. Under fluoroscopic guidance, all positions in left and right atria, were easily accessed in all 5 animals (Figure). During PFA delivery, minimal skeletal muscle contraction was observed, without thermal ablation effect. Histopathology examination revealed acute changes in the atrial muscle structure. Chronic animal testing is ongoing to provide optimization of pulse trains and electrode to electrode sequencing to allow precise measurements of the PFA lesions depth. Following lesion optimization in an in vitro model, we demonstrate feasibility of delivering reproducible single-shot circumferential PFA lesions using a unique designed circular linear ablation catheter.

PO-03-165 INTRACARDIAC OR TRANSESOPHAGEAL ECHOCARDIOGRAPHY-GUIDED LEFT ATRIAL APPENDAGE OCCLUSION: CLINICAL PROTOCOL AND OUTCOMES

Left atrial appendage occlusion (LAAO) has historically been guided by transesophageal echocardiography (TEE) and fluoroscopy imaging. Intracardiac echocardiography (ICE) has emerged as a safe and feasible alternative to TEE, eliminating the need for general anesthesia. To evaluate the safety and efficacy of a protocol to select TEE or ICE guidance for LAAO procedures. The study population was comprised of all patients undergoing LAAO with the Watchman device (Boston Scientific, Marlborough, MA) from January 2018 to March 2022 at the University of Nebraska Medical Center. Patients with a left atrial appendage thrombus or an anatomical contraindication for device implantation were excluded. A novel protocol (Figure 1) was applied to select TEE or ICE guidance beginning in January 2020. In-hospital outcomes were compared between patients who underwent LAAO with TEE vs. ICE. The composite endpoint of safety and efficacy was defined as device implantation without peri-device leak, freedom from procedural complications, and no need to convert from ICE to TEE guidance. A total of 234 patients were included; the mean age was 76.1±8.27 years old, and 42.3% were female. The mean CHA2DS2-VASc score was 5.1±1.7. ICE guidance was used for 63 procedures; TEE guidance was used for 171 procedures. For the composite outcome, ICE-guided LAAO was superior to TEE-guided LAAO (96.8% vs. 86.5%; p=0.029). In comparison to the TEE-guided LAAO group, the ICE-guided group had shorter procedure times (99.8±30.0 vs. 89.1±26.3 minutes, p=0.0087) and a significantly lower need for general anesthesia (98.8 vs 26.6%, p<0.0001). Utilization of a protocol to select appropriate patients for ICE vs. TEE guidance for LAAO is safe and effective. Use of this protocol resulted in improved outcomes, shorter procedures, and less general anesthesia for ICE-guided procedures compared to TEE-guided procedures.

PO-02-193 A COMPARISON OF THIRD GENERATION CRYOABLATION VERSUS X3 LASER BALLOON SYSTEMS FOR PULMONARY VEIN ISOLATION FOR TREATMENT OF ATRIAL FIBRILLATION

As the incidence of atrial fibrillation (AF) increases operators are looking to improve the efficiency of pulmonary vein isolation (PVI) with similar clinical outcomes. In a recent study the 2nd generation cryo-balloon (CB) and the 1st and 2nd generation laser balloon (LB) was compared with similar clinical efficacy but with shorter procedure time in the CB group. Improvements were made to both modalities in subsequent generation catheters. The 3rd generation CB (CB3) has a 40% shorter tip that allows for improved stability during cryo-applications. The X3 LB (LB3) introduced a “rapid” ablation mode which utilizes a motorized handle to allow for continuous 360-degree energy delivery to decrease ablation time and improve lesion effectiveness We sought to compare if these improvements impacted the overall efficacy, procedural and/or fluoroscopy time between the two modalities. To compare clinical outcomes of CB3 and X3 LB ablation in patients with AF in a multi-center prospective registry. Between November 2019 and November 2020, 69 patients with atrial fibrillation underwent ablation with either CB3 or LB3 at two large US medical centers. Patients were followed for at least 180 days after index procedures. The primary outcome was time to recurrence of AF. Secondary outcomes included time to anti-arrhythmic drug (AAD) therapy after the 90-day blanking period, and procedural characteristics. A total of 69 patients were enrolled in the study (baseline characteristics in Table 1). Forty patients (58%) underwent PVI ablation with CB3, and 29 patients (42%) underwent PVI ablation with LB3. There was no significant difference in the time to recurrent AF between treatment groups (p=0.865) (Figure 1). There was also no significant difference in the time to treatment with AAD therapy after the 90-day blanking period (p=0.125). Both procedural and fluoroscopy time were significantly shorter in the LB group (mean procedure time was 122 minutes in CB3 group versus 104 minutes in LB3 group and mean fluoroscopy time of 19.4 minutes in CB3 group versus 6.7 minutes in LB3 group) which was statistically significant for both parameters (p<0.001). There was no significant difference in adverse events between the two groups. LB and CB are safe and effective PVI modalities. Using the X3 LB system, procedure and fluoroscopy time were shorter than with the CB3 system with similar efficacy and safety. Larger prospective randomized studies are needed to confirm these results.

EUS-Guided Choledocho-duodenostomy Using Lumen Apposing Stent Versus ERCP With Covered Metallic Stents in Patients With Unresectable Malignant Distal Biliary Obstruction: A Multicenter Randomized Controlled Trial (DRA-MBO Trial)

Several studies have compared primary endoscopic ultrasound (EUS)-guided biliary drainage to endoscopic retrograde cholangiopancreatography (ERCP) with insertion of metal stents in unresectable malignant distal biliary obstruction (MDBO) and the results were conflicting. The aim of the current study was to compare the outcomes of the procedures in a large-scale study. This was a multicenter international randomized controlled study. Consecutive patients admitted for obstructive jaundice due to unresectable MDBO were recruited. Patients were randomly allocated to receive EUS-guided choledocho-duodenostomy (ECDS) or ERCP for drainage. The primary outcome was the 1-year stent patency rate. Other outcomes included technical success, clinical success, adverse events, time to stent dysfunction, reintervention rates, and overall survival. Between January 2017 and February 2021, 155 patients were recruited (ECDS 79, ERCP 76). There were no significant differences in 1-year stent patency rates (ECDS 91.1% vs ERCP 88.1%, P= .52). The ECDS group had significantly higher technical success (ECDS 96.2% vs ERCP 76.3%, P < .001), whereas clinical success was similar (ECDS 93.7% vs ERCP 90.8%, P= .559). The median (interquartile range) procedural time was significantly shorter in the ECDS group (ECDS 10 [5.75-18] vs ERCP 25 [14-40] minutes, P < .001). The rate of 30-day adverse events (P= 1) and 30-day mortality (P= .53) were similar. Both procedures could be options for primary biliary drainage in unresectable MDBO. ECDS was associated with higher technical success and shorter procedural time then ERCP. Primary ECDS may be preferred when difficult ERCPs are anticipated. This study was registered to Clinicaltrials.gov NCT03000855.

Transcatheter edge-to-edge mitral valve repair with extended clip arms for ventricular functional mitral regurgitation

BackgroundThe new sizing options of the MitraClip system (Abbott Vascular, Abbott Park, IL, USA) with extended clip arms were recently developed. Its applicability and effectiveness for ventricular functional mitral regurgitation (VFMR) are yet to be investigated. MethodsWe retrospectively reviewed consecutive patients with symptomatic VFMR who underwent transcatheter edge-to-edge repair between 2018 and 2022 at the Sakakibara Heart Institute. Pre- and post-procedural mitral valve morphologies were assessed using three-dimensional transesophageal echocardiography. ResultsIn a total of 104 VFMR patients, the posterior mitral leaflet length was 12.8 ± 2.8 mm and 92 % was indicative of the extended arm (≥9 mm). Although baseline VFMR was more severe in the patients treated with the extended arms (n = 35, XT group) than the patients treated with the standard arms (n = 69, NT group), the decrease in VFMR was greater in the XT group (delta three-dimensional vena contracta area − 43 ± 33 mm2 vs. -31 ± 22 mm2, p = 0.030) and residual VFMR was similar between the groups, with a significantly greater reduction in the mitral annulus anterior-posterior diameter (−4.9 ± 2.2 mm vs −3.1 ± 2.1 mm, p < 0.001) and mitral annulus area in the XT group. The use of extended arms was independently associated with shorter procedure time (81 ± 26 min vs 108 ± 41 min) after adjustment for device generation and the number of clips (p = 0.017). ConclusionsMost VFMR patients had enough leaflet lengths for transcatheter edge-to-edge repair using the MitraClip with the extended arms, which was associated with shorter procedure time and a greater decrease in the mitral annular size.

Pulmonary Recruitment Prior to Intraoperative Multiple Pulmonary Ground-Glass Nodule Localization Increases the Localization Accuracy-A Retrospective Study.

The standard treatment for early-stage lung cancer is complete tumor excision by limited resection of the lung. Preoperative localization is used before video-assisted thoracoscopic surgery (VATS) to improve the accuracy of pulmonary nodule excision. However, lung atelectasis and hypoxia resulting from controlling apnea during the localization procedure may affect the localization accuracy. Pre-procedural pulmonary recruitment may improve the respiratory mechanics and oxygenation during localization. In this study, we investigated the potential benefits of pre-localization pulmonary recruitment prior to pulmonary ground-glass nodule localization in a hybrid operating room. We hypothesized that pre-localization pulmonary recruitment would increase the localization accuracy, improve oxygenation, and prevent the need for re-inflation during the localization procedure. We retrospectively enrolled patients with multiple pulmonary nodule localizations before surgical intervention in our hybrid operating room. We compared the localization accuracy between patients who had undergone pre-procedure pulmonary recruitment and patients who had not. Saturation, re-inflation rate, apnea time, procedure-related pneumothorax, and procedure time were also recorded as secondary outcomes. The patients who had undergone pre-procedure recruitment had better saturation, shorter procedure time, and higher localization accuracy. The pre-procedure pulmonary recruitment maneuver was effective in increasing regional lung ventilation, leading to improved oxygenation and localization accuracy.

Self-Expandable Metal Stent (SEMS) Versus Lumen-Apposing Metal Stent (LAMS) for Drainage of Pancreatic Fluid Collections: A Randomized Clinical Trial.

Background and aim Endoscopic ultrasound (EUS)-guided drainage is the gold standard approach for the treatment of encapsulated pancreatic collections (EPCs) including pseudocyst and walled-off pancreatic necrosis (WON), and is associated with an equivalent clinical efficacy to surgical drainage with fewer complications and less morbidity. Drainagemay be achieved via several types of stents including a fully covered self-expandable metallic stent (SEMS) and lumen-apposing metal stent (LAMS). However, to date there have been no randomized trials to compare these devices. This study aimed to compare the efficacy and safety of the SEMS versus LAMS for EUS-guided drainage of EPCs. Methods A phase IIB randomized trial was designed to compare the SEMS versus LAMS for the treatment of EPCs. Technical success, clinical success, adverse events (AEs), and procedure time were evaluated. A sample size of 42 patients was determined. Results There was no difference between the two groups in technical (LAMS 80.95% vs 100% SEMS, p=0.107), clinical (LAMS 85.71% vs 95.24% SEMS, p=0.606) or radiological success (LAMS 92.86% vs 83.33% SEMS, p=0.613). There was no difference in AEs including stent migration rate and mortality. The procedure time was longer in the LAMS group (mean time 43.81 min versus 24.43 min, p=0.001). There was also a difference in the number of intra-procedure complications (5 LAMS vs 0 SEMS, p=0.048). Conclusion SEMS and LAMS have similar technical, clinical, and radiological success as well as AEs. However, SEMS has a shorter procedure time and fewer intra-procedure complications compared to non-electrocautery-enhanced LAMS in this phase IIB randomized controlled trial (RCT). The choice of the type of stent used for EUS drainage of EPCs should consider device availability, costs, and personal and local experience.

Two traction methods that can facilitate esophageal endoscopic submucosal dissection.

Different traction devices that can provide a visual field and attain appropriate tension at the dissection plane during endoscopic submucosal dissection (ESD) have been developed. Clip-with-line (CWL) is a classic traction device that can offer per-oral traction toward the direction where the line is drawn. A multicenter randomized controlled trial (CONNECT-E trial) comparing the conventional ESD and CWL-assisted ESD (CWL-ESD) for large esophageal tumors was conducted in Japan. This study showed that CWL-ESD was associated with a shorter procedure time (defined as the time from initiating submucosal injection to completing tumor removal) without increasing the risk of adverse events. Multivariate analysis revealed that whole-circumferential lesion and abdominal esophageal lesion were independent risk factors for technical difficulties, which were defined as a procedure time of > 120 min, perforation, piecemeal resection, inadvertent incision (any accidental incision caused by the electrosurgical knife within the marked area), or handover to another operator. Therefore, techniques other than CWL should be considered for these lesions. Several studies have shown the usefulness of endoscopic submucosal tunnel dissection (ESTD) for such lesions. A randomized controlled trial conducted at five Chinese institutions showed that compared with the conventional ESD, ESTD had a significantly reduced median procedure time for lesions covering ≥ 1/2 of the esophageal circumference. In addition, a propensity score matching analysis conducted at a single Chinese institution showed that compared with the conventional ESD, ESTD had a shorter mean resection time for lesions at the esophagogastric junction. With the appropriate use of CWL-ESD and ESTD, esophageal ESD can be performed more efficiently and safely. Moreover, the combination of these two methods may be effective.

A Prospective, Randomized Comparison of the Classical Altemir's Method With the Newer Seldinger's Technique of Submental Intubation.

Submental intubation performed using the classical Altemir's technique is a well-accepted, safe technique for providing optimal operating field to the maxillofacial surgeon, in cases where either nasotracheal or orotracheal intubation is impossible. We propose a new, percutaneous Seldinger's technique of submental intubation as an interesting alternative to the classical Altemir's technique, wherein a percutaneous dilatational tracheostomy kit is used to dilate the submental tract, instead of bluntly dissecting it. We hypothesized that Seldinger's technique would be associated with reduced procedure time and minimal scar formation in patients with maxillofacial fractures. We enrolled 60 patients scheduled to undergo maxillofacial injury fixation under general anesthesia. After consent, the cohort was randomly allocated to undergo submental intubation by either the classical Altemir's technique or Seldinger's technique. As our primary objective, we noted the time taken to complete the procedure of submental intubation. Our secondary objectives were the components of primary outcome, such as disconnection/apnea time, bleeding, and technical difficulties during the procedure. We also observed for complications such as presence of salivary fistula/infection at hospital discharge and scar characteristics at 1- and 3-month follow-up. The median time for performing submental intubation in the Seldinger group was significantly lower than that in the Altemir group (170.5 [136.5-256.0] seconds vs 220.0 [205.5-289.0] seconds; P value, .040). The median disconnection time was also significantly lower in the Seldinger group (12.0 [10.8-20.0] seconds vs 19.0 [15.0-23.0] seconds; P value, .036). Furthermore, significant bleeding was absent in nearly 53.8% of the study participants in the Seldinger group as compared to 25.9% in the Altemir group. At follow-up, there was no evidence of differences in scar characteristics between the 2 groups. Seldinger's technique is associated with shorter procedure time and reduced apnea time due to easier and better tract formation, thus minimizing the effort required to exteriorize the endotracheal tube. Furthermore, as dilation reduces tissue damage, Seldinger's technique is associated with significantly less procedural bleeding. Thus, Seldinger's technique can be safe, easy, and faster to perform compared with the classical Altemir's technique of submental intubation in patients with maxillofacial trauma.

309 Mechanical Thrombectomy for Acute Basilar Artery Occlusion, Where Do We Stand? A Safety and Efficacy Analysis

INTRODUCTION: Acute basilar artery occlusion accounts for 1% of all ischemic strokes, but more often than not, leads to devastating neurological injury and mortality. Many institutions still opt for best medical therapy for this type of ischemic stroke, however there is increasing evidence that mechanical thrombectomy for these patients leads to better outcomes. METHODS: This study was a retrospective chart review of a prospectively maintained database for patients with acute basilar artery occlusion treated with mechanical thrombectomy from January 2014 through March 2022. RESULTS: Our study included a total of 74 patients. The mean age was 62.7 years and 55.4% were male. The most common comorbidity was hypertension (73%). The mean door to puncture time was 75 minutes and the mean procedure time was 54 minutes. 86.5% of patients had a good mTICI score (≥ 2b). There were 4 patients who had procedural complications, and symptomatic intracerebral hemorrhage occurred in 3 patients. At 90 days, 62.5% of patients had a favorable functional outcome (mRS, 0 – 3). The mortality rate was 32.4% and 2% during the hospital admission and at 90 days respectively. Finally, on univariate analysis, the need for adjunct treatment and higher presenting NIHSS score was associated with poor functional outcome at 90 days (p-value, 0.03 and &lt;0.001 respectively). Shorter procedure time was associated with better revascularization (mTICI score ≥ 2b) (p-value, 0.0015). CONCLUSIONS: Our findings showed that MT is safe and effective for patients presenting with acute basilar artery conclusion and is in conjunction with previous literature. Final results from upcoming trials should hopefully establish MT as gold standard for these patients.

MP25-16 EVALUATING THE LEARNING CURVE FOR IN-OFFICE COGNITIVE FREEHAND TRANSPERINEAL PROSTATE BIOPSY

You have accessJournal of UrologyCME1 Apr 2023MP25-16 EVALUATING THE LEARNING CURVE FOR IN-OFFICE COGNITIVE FREEHAND TRANSPERINEAL PROSTATE BIOPSY Sofia Gereta, Michael Hung, and Jim C. Hu Sofia GeretaSofia Gereta More articles by this author , Michael HungMichael Hung More articles by this author , and Jim C. HuJim C. Hu More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003253.16AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: In-office MRI-ultrasound cognitive fusion targeted transperineal biopsy (CTPB) is a cost-effective approach to a percutaneous, clean wound classification approach to biopsy. However, because transrectal biopsy remains the predominant U.S. approach to CTPB, the barriers to the adoption of the relatively novel CTPB include the learning curve to proficiency and comparative detection rates of clinically significant prostate cancer (csPC, Gleason Grade Group (GG) ≥2). Therefore, our study objective was to define the CTPB learning curve, which is heretofore unstudied, by assessing cancer detection, biopsy core quantity, procedure times, and adverse events (AEs) over time. METHODS: We performed a retrospective review for 110 consecutive CTPB performed using PrecisionPoint (Cumberland, MD) without antibiotic prophylaxis between March 2021 and September 2022, excluding biopsies performed after focal therapy. All CTPB were performed by a single urologist (JCH) without prior experience with the platform. The cohort was divided into quarters and analyzed by univariate methods. RESULTS: There was no significant difference in demographic or MRI characteristics between quarters. There was no difference in the detection of csPC (Q1 50%, Q2 52%, Q3 50%, Q4 48%, p=0.99) or GG upgrading by targeted biopsy across quarters (Figure 1B, 1D). The median number of cores sampled per biopsy significantly decreased after approximately 28 cases (Q1 18, Q2 16, Q3 16, Q4 15, p=0.01). There was no change in the proportion of fibromuscular (non-prostate) cores sampled across quarters (Figure 1B). Total procedure time decreased from a median of 4:06 min in Q3 to 3:00 min in Q4 (p=0.04). Rates of AEs did not differ and remained low across quarters. A single patient reported UTI with irritative voiding symptoms was found to have a negative urine culture (Figure 1C). CONCLUSIONS: Our novel study demonstrates that MRI-ultrasound cognitive fusion targeted transperineal biopsy is safe and effective without a significant learning curve, as shown by consistent csPC detection across the study period. There was a significant decrease in the number of cores obtained after approximately 28 cases with a shorter procedure time, suggesting greater procedural efficiency or refinement in the core sampling approach. Source of Funding: There was no direct funding from an outside organization or sponsor. © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e349 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Sofia Gereta More articles by this author Michael Hung More articles by this author Jim C. Hu More articles by this author Expand All Advertisement PDF downloadLoading ...

An evaluation of the use of double-curved endoscopes for gastric gastrointestinal stromal tumors

Background Endoscopic full-thickness resection (EFTR) is a standard treatment method for gastric gastrointestinal stromal tumors (gGISTs). Evidence of the safety and efficacy of a double-curved endoscope (DCE) in EFTR of gGISTs is limited. We aimed to compare the operative outcomes of DCE versus single-curved endoscopes (SCE) in EFTR of gGISTs. Material and methods This retrospective observational study was conducted at four Chinese tertiary institutes. From January 2019 to November 2021, 104 patients who underwent EFTR by SCE (n = 57) or DCE (n = 47) were enrolled. One-to-one propensity score matching (PSM) was performed between the two groups to compare the demographics and operative outcomes. Results All gGISTs were resected successfully with no recurrence during follow-up. The median (range) tumor size was 1.2 (0.5, 3.5) cm in DCE and 2.0 (0.6, 4.8) cm in SCE (p < .001), and the procedure time was shorter in the DCE group than in the SCE group (50.0 min vs. 62.0 min, p < .05). After PSM, 41 pairs were selected, and no difference was noted in demographics. The procedure time was also shorter in the DCE group than in the SCE group (50.0 min vs. 55.0 min, p < .05). Subgroup analysis showed that the DCE group had a shorter procedure time in the gastric fundus than the SCE group (47.0 min vs. 55.0 min, p < .05). In multiple linear regression analysis, significant factors related to prolonged procedure time were the type of endoscope of SCE and larger tumor size (p < .05). Conclusions EFTR of gGISTs using DCE is safe and effective. Compared with SCE, DCE had an advantage in terms of operative time, especially in the gastric fundus.

Eliminating transseptal sheath exchange for pulsed field ablation procedures using a direct over-the-needle transseptal access with the Faradrive sheath.

Pulsed field ablation (PFA) for pulmonary vein isolation (PVI) combines the benefits of high procedural efficacy and safety. Transseptal puncture (TSP) to obtain left atrial (LA) access during PVI remains an important source of complications during LA procedures. For PFA procedures, TSP is generally performed using a standard transseptal sheath that is then exchanged over the wire for a dedicated PFA sheath, which might be a potential source for air embolism. We aimed to prospectively evaluate the feasibility and safety of a simplified workflow using the PFA sheath (Faradrive, Boston Scientific) directly for TSP. We prospectively enrolled 100 patients undergoing PVI using PFA at two centres. TSP was performed using the PFA sheath and a standard 98 cm transseptal needle under fluoroscopic guidance. TSP via the PFA sheath was successfully performed in all patients and no complications occurred. The median time from the first groin puncture to the completed LA access was 12 min (IQR 8-16 min). An over-the-needle TSP directly with the PFA sheath proved feasible and safe in our study. This simplified workflow has the potential to reduce the risk of air embolism, to shorten procedure time, and to reduce cost.

The perioperative outcomes of uniportal robotic-assisted thoracic surgeries-a systematic review and meta-analysis of surgical cohort studies and case reports.

Early results have illustrated the multiportal robotic approach to be safe and oncologically efficacious in the treatment of thoracic malignancies. Industry leaders have improved upon the lessons learned during the early multiportal studies and have now come to establish the feasibility of the biportal, and subsequently the uniportal robotic-assisted approach, all in an effort to offer patients equivalent or better outcomes with less surgical trauma. No current, coherent body of evidence currently exists outlining the early-term outcomes of patients undergoing uniportal robotic-assisted thoracic surgery. This systematic review and meta-analysis sought to clarify the early-phase outcomes of these patients. An electronic search of four databases was performed to identify relevant studies outlining the immediate post-operative outcomes of patients undergoing uniportal robotic-assisted thoracic surgeries. The primary endpoint was defined as technical success (i.e., no conversion to secondary robotic, video-assisted thoracoscopic, or open approaches). Secondary endpoints of interest included post-operative outcomes and complication rates. A meta-analysis using a random effects model of proportions or means was applied, as appropriate. The search strategy ultimately yielded 12 relevant studies for inclusion. A total of 240 patients (52% male) split across cohort studies and case reports were identified. The mean age of the two groups was 59.7±3.0 and 58.1±6.8 years, respectively. The mean operative time was 133.8±38.2 and 150.0±52.2 minutes, respectively. Length of hospital stay was 4.4±1.6 and 4.3±1.1 days, respectively. The mean blood loss was 80.0±25.1 mL The majority of identified procedures were lobectomies, segmentectomies, and wedge resections, though complex sleeve resections and anterior mediastinal mass resections were also completed. Cumulative technical success was 99.9%. The uniportal robotic-assisted approach, when completed in expert hands, has been illustrated to have exceedingly low rates of conversion to secondary procedures, along with short length of stay (LOS), minimal blood loss, and short procedural times (variable depending on operation type). Current evidence on the feasibility of this approach will be bolstered by upcoming multi-institutional series.

Çocuk Yaş Grubu Yabancı Cisim Aspirasyonu Tedavisinde Kullanılan Rijit Bronkoskopi Esnasında Uygulanan İki Anestezi Tekniğine Cerrahi Bir Bakış

Objective: In our study, we aimed to reveal the advantages and disadvantages of inhalation and intravenous anesthesia techniques in the maintenance of anesthesia in pediatric patients whose tracheobronchial foreign body was removed by rigid bronchoscopy under general anesthesia, from both anaesthesia and surgical perspectives, different from the literature.&#x0D; Methods: The patients were divided into two groups, each consisting of 34 individuals, whose anaesthesia was maintained with sevoflurane inhalation or propofol infusion. Demographic characteristics of the patients, symptoms at presentation, radiological examinations, anaesthesia and surgical procedures, complications were analyzed. In addition, surgical difficulty and surgical comfort scales created from the experiences of our institution were used. The results obtained and the effects of inhalation and intravenous anaesthetics used in maintenance on the duration of the procedure, clinical, hemodynamic and surgical comfort were compared.&#x0D; Results: Vital signs during the procedure were similar in both groups. was similar. The duration of bronchoscopy was statistically significantly shorter in the intravenous anaesthesia group (p=0.014), and secondarily, the duration of anaesthesia was significantly longer in the inhalation anaesthesia group (p=0.027). While the surgical difficulty scale was similar in both groups, the surgical confort scale was significantly higher in the intravenous anesthesia group (p=0.017). Intraoperative, postoperative complications were similar in both groups.&#x0D; Conclusion: Anaesthesia maintenance with sevoflurane prolongs the duration of bronchoscopy and accordingly the duration of anaesthesia, and also reduces surgical satisfaction independent of processing time. For these reasons, we think that while rigid bronchoscopy is performed for the removal of childhood foreign body aspirations, propofol can be preferred for anaesthesia maintenance, resulting in a shorter procedure time and higher surgical satisfaction.

Outcomes of chlorhexidine lavagewithout capsulectomy versuscomplete capsulectomy after lead extraction for the treatment of cardiac implantable electronicdevice infection.

Capsulectomy is recommended in patients with cardiac implantable electronic device (CIED) infection after transvenous lead extraction (TLE) but is time-consuming and requires extensive tissue debridement. In this study, we describe the outcomes of chlorhexidine gluconate (CHG) lavage in lieu of capsulectomy for the treatment of CIED infections. This retrospective study included patients who underwent TLE for CIED-related infections in two institutions in Colombia. In the capsulectomy group, complete capsulectomy was performed after hardware removal. In the CHG group, exhaustive lavage of the generator pocket with 20 cc of CHG at2%followed by irrigation with approximately 500 cc of normalsaline(0.9%sodiumchloride) was performed. The primary outcomes included reinfection and hematoma formation in the generator pocket. Secondary outcomes included the occurrence of any adverse reaction to chlorhexidine, the need for reintervention, infection-related mortality, and total procedural time. A total of 102 patients (mean age 67.2 ± 13 years, 32.4% female) underwent CIED extraction with either total capsulectomy (n = 54) or CHG (n = 48) lavage. Hematoma formation was significantly higher in the capsulectomy group versus the CHG group (13% vs. 0%, p = .014), with no significant differences in the reinfection rate. Capsulectomy was associated with longer procedural time (133.7 ± 78.5 vs. 89.9 ± 51.8 min, p = .002). No adverse reactions to CHG were found. Four patients (4.3%) died from worsening sepsis: three in the capsulectomy group and one in the CHG group (p = .346). In patients with CIED infections, the use of CHG without capsulectomy resulted in a lower risk of hematoma formation and shorter procedural times without an increased risk of reinfection or adverse events associated with CHG use.

Transcatheter Mitral Valve-in-Valve Implantation Applying a Long Pre-Curved Sheath for Patients with Degenerated Bioprosthetic Mitral Valve.

Percutaneous transseptal transcatheter mitral valve-in-valve implantation (TMViV) has become an alternative minimally invasive treatment choice for patients with degenerated mitral bioprosthesis and high surgical risk. However, transseptal approach is more technically challenging than transapical approach in TMViV procedures. The objective of this study was to introduce the experience of applying long pre-curved sheaths in transseptal TMViV procedures and to evaluate the effect of long pre-curved sheath techniques in TMViV procedures. Between January 2020 and December 2021, 27 patients with degenerated bioprosthetic mitral valve underwent TMViV procedures using a balloon-expandable valve via the transseptal approach. The regular 14/16F expandable sheath were used for low-profile delivery in first 10 cases, and 22F long pre-curved sheath were used in the next 17 cases during procedures. We retrospectively reviewed the catheter techniques, perioperative characteristics, and prognosis. The median follow-up time was 12 (1-21) months. To further scrutinize our data, we divided the group into the early 10 patients using 14/16F expandable sheath and the subsequent 17 patients with long pre-curved sheath in order to assess the impact of different sheaths and procedural details on outcomes. Procedural success was obtained in all patients with no in-hospital mortality. Seventeen patients received 26 mm prostheses; the remaining ten patients received 29 mm prostheses. Post balloon dilatation was performed in one case. Total procedure time was (96.1 28.2) min, the fluoroscopic time was (27.4 6.5) min, and total contrast volume was (50.7 10.1) mL. One patient received blood transfusion because of hemorrhage at the femoral puncture site. One patient received a permanent pacemaker implantation due to high-degree atrioventricular block at postoperative day 3. There were no other major post-procedure complications and the median length of hospital stay was 4 days. Twenty-five (92.6%) patients improved by 1 New York Heart Association (NYHA) functional class at 30 days. In subsequent sub analysis, there were shorter procedural time [(85.2 24.3) vs. (115.2 25.6) min, p = 0.0048] and shorter fluoroscopic time [(24.3 5.2) vs. (31.3 5.1) min, p = 0.0073] in cases with the long pre-curved sheath than ones with regular expandable sheath. The iatrogenic atrial septal defect (ASD) closure was performed because of the transeptal large right to left shunt in 2 cases with regular expandable sheath, but no patient needed intraoperative ASD closure in cases with the long pre-curved sheath. Transseptal TMViV using long pre-curved sheath could simplify transseptal approach with reliable outcomes for patients of degenerated mitral bioprosthesis.

Feasibility and efficacy of endoscopic purse-string suture-assisted closure for mucosal defects induced by endoscopic manipulations.

Large or transmural defects induced by gastrointestinal endoscopic manipulations are difficult to close, although complete closure is recommended for better recovery. Endoscopic purse-string assisted suturing (EPSS) has been used in clinical practice and has proven to be an effective and safe technique for the closure of large mucosal defects. However, details regarding the efficacy of endoscopic pre-purse-string suture (P-EPSS) are unknown, especially that it offers several advantages over conventional EPSS (C-EPSS). To elucidate the outcomes of EPSS-assisted closure in different clinical situations, and evaluate the efficacy of P-EPSS. This retrospective observational study included a total of 180 patients who underwent closure assisted by P-EPSS (n = 63) or C-EPSS (n = 117) between July 2014 and June 2020. The P-EPSS and C-EPSS groups were compared and the intergroup differences in aspects such as the lesion size, location, and mor-phology, incidence of complete closure, intraoperative perforation, and delayed adverse events were evaluated. Data on the features and clinical course of cases with adverse events were collected for further analysis. Patients with lesion size larger than 3 cm, lesions located at the fundus of stomach, or submucosal tumors originating from the deep mucosa were more likely to undergo P-EPSS-assisted closure. The P-EPSS group showed a sign-ificantly higher proportion of intraoperative perforation (56% vs 17%) and a much shorter procedure time (9.06 ± 6.14 min vs 14.84 ± 7.25 min). Among adverse events, the incidence of delayed perforation (5% vs 4%; P = 0.82) and delayed bleeding (3% vs 4%; P = 0.96) did not differ significantly between the groups. Multivariate analysis revealed that lesions with incomplete closure [odds ratio (OR) = 21.33; 95% confidence interval (CI): 5.45-83.45; P < 0.01] or size greater than 3 cm (OR = 3.14; 95%CI: 1.08-9.18; P = 0.039) showed a statistical tendency to result in an increase in delayed adverse events. The present study revealed that EPSS could achieve secure complete closure of mucosal defect. P-EPSS could shorten the procedure and yield complete closure of mucosal defects. Rather than closure-type selection, incomplete closure or lesion size larger than 3 cm were associated with worse outcomes.

Out-of-Plane Needle Placements Using 3D Augmented Reality Protractor on Smartphone: An Experimental Phantom Study.

To evaluate the accuracy of needle placement using a three-dimensional (3D) augmented reality (AR) protractor on smartphones (AR Puncture). An AR protractor that can be rotated in three directions against the CT plane with angle guidance lines for smartphones was developed. The protractor center can be adjusted to an entry point by manually moving the smartphone with the protractor center fixed at the center of the screen (Fix-On-Screen) or by image tracking with a printed QR code placed at an entry point (QR-Tracking). Needle placement was performed by viewing a target line in the tangent direction with the Bull's eye method. The needle placement errors placed by four operators in six out-of-plane directions in a phantom using a smartphone (iPhone XR, Apple, Cupertino, CA, USA) were compared with two registration methods. No significant difference in the average needle placement error was observed between the Fix-On-Screen and QR-Tracking methods (5.6 ± 1.7mm vs. 6.1 ± 2.9mm, p = 0.475). The average procedural time of the Fix-On-Screen method was shorter than that of the QR-Tracking method (71.0 ± 23.9s vs. 98.4 ± 59.5s, p = 0.042). The accuracies of out-of-plane needle placements using the 3D AR protractor with the two registration methods were equally high, with short procedure times. In clinical use, the Fix-On-Screen registration method would be more convenient because no additional markers are required.