Space Endoscopy Research Articles

Endoscopic Intramural Surgery Part 1: Resectional Therapies

AbstractEndoscopic resectional therapies for lesions of gastrointestinal tract have progressed rapidly over the past two decades. Advances in minimally invasive endoscopic approaches continue to emerge and evolve, while boundaries of resection techniques continue to be pushed. The concept of third space endoscopy with mucosal flap as a safety valve has emerged arguably as the most innovative technique among these approaches. We review several techniques for intramural endoscopic resection of lesions of the gastrointestinal tract, but to gain a full understanding of why these exist, we must first examine the background from which they emerged.

Anatomy of the Pudendal Nerve and Other Neural Structures Around the Proximal Hamstring Origin in Males

To define the anatomy of the pudendal nerve in relationship to the proximal hamstring and other nearby neurological structures during proximal hamstring repair. Six fresh-frozen human cadaveric hemi-pelvises from male patients ages 64.0 ± 4.1years were dissected in prone position with hips in 10° flexion to identify the relationship of proximal hamstring origin to surrounding neurologic structures including the pudendal nerve, sciatic nerve, and posterior femoral cutaneous nerve. Two independent observers used digital calipers to measure distances. The pudendal nerve emerged at the inferior border of the piriformis muscle 6.3 ± 1.4cm from the superior aspect of the proximal hamstring origin. It passed the superior border of the sacrotuberous ligament 3.0 ± 0.6cm from the superior aspect and 3.9 ± 0.7cm from the medial aspect of the hamstring origin. It crossed the inferior border of the sacrotuberous ligament 3.0 ± 0.4cm from the superior aspect and 2.7 ± 0.7cm from the medial aspect of the proximal hamstring origin. The shortest distance from the hamstring origin to the pudendal nerve was 2.6 ± 0.5cm from the superior aspect and 2.3 ± 0.8cm from the medial aspect. The shortest distance from the hamstring origin to the pudendal nerve was located deep to the sacrotuberous ligament in all cadavers. The sciatic nerve was an average of 1.1 ± 0.1cm lateral to the lateral aspect of the proximal hamstring origin. The posterior femoral cutaneous nerve was located between the hamstring origin and the sciatic nerve, 0.7 ± 0.2cm lateral to the lateral aspect of the proximal hamstring origin. The proximal hamstring origin lies in close proximity to surrounding nerves, including the pudendal, sciatic, and posterior femoral cutaneous nerves. Knowledge that the pudendal nerve lies 2 to 3cm superior and medial to the proximal hamstring origin may help to prevent iatrogenic damage during surgical dissection and retraction when performing proximal hamstring repair or deep gluteal space endoscopy.

Expanding Role of Third Space Endoscopy in the Management of Esophageal Diseases.

OPINION STATEMENT: "Third space" endoscopy, also commonly referred as submucosal endoscopy, is founded on the principle that the deeper layers of the gastrointestinal (GI) tract can be accessed by tunneling in the submucosal space without compromising the integrity of the overlying mucosa. Peroral endoscopic myotomy (POEM), endoscopic submucosal dissection (ESD), and submucosal tunneling endoscopic resection (STER) are innovative techniques within the field of third space endoscopy in the management of esophageal disorders. POEM has become an accepted minimally invasive therapy for achalasia and related motility disorders with excellent short-term results, with early studies yielding similar efficacy to surgical myotomy and increased durability when compared to pneumatic balloon dilation (PBD). Data are needed to establish long-term outcomes with POEM, with particular interest on the incidence of gastroesophageal reflux, which appears to be higher than initially anticipated. ESD, a mature endoscopic resection technique in Asia, has recently gained traction in the West as a viable option for the management of early Barrett's esophagus (BE) neoplasia. Compared to standard endoscopic mucosal resection (EMR), ESD allows the en bloc resection of lesions irrespective of size, which may facilitate histological interpretation and reduce recurrence rates. Large prospective randomized controlled trials are needed to validate the efficacy and safety of this technique and to further define its role in the endoscopic armamentarium in early BE neoplasia. STER is an attractive technique that theoretically permits the resection of subepithelial esophageal tumors (SETs) arising from the deeper GI layers. Initial studies from highly experienced endoscopic centers support its technical feasibility and safety, although these results should be interpreted with caution due to variability arising from small numbers and heterogeneity among studies. Overall, third space endoscopy is an expanding field within endoscopic therapeutics for the treatment of esophageal diseases. While initial results have been very promising, large prospective studies, long-term data, and structured training programs with the establishment of competency parameters are needed before third space endoscopy can be advocated outside of highly specialized centers.

3rd Space Endoscopy - The New Frontier of Endoscopic Intervention

3rd Space Endoscopy - The New Frontier of Endoscopic Intervention

Monopolar Radiofrequency Use in Deep Gluteal Space Endoscopy: Sciatic Nerve Safety and Fluid Temperature

The purpose of this study was to evaluate the temperature at the sciatic nerve when using a monopolar radiofrequency (RF) probe to control bleeding in deep gluteal space endoscopy, as well as assess the fluid temperature profile. Ten hips in 5 fresh-frozen human cadaveric specimens from the abdomen to the toes were used for this experiment. Temperatures were measured at the sciatic nerve after 2, 5, and 10 seconds of continuous RF probe activation over an adjacent vessel, a branch of the inferior gluteal artery. Fluid temperatures were then measured at different distances from the probe (3, 5, and 10 mm) after 2, 5, and 10 seconds of continuous probe activation. All tests were performed with irrigation fluid flow at 60 mm Hg allowing outflow. After 2, 5, or 10 seconds of activation over the crossing branch of the inferior gluteal artery, the mean temperature increased by less than 1°C on the surface and in the perineurium of the sciatic nerve. Considering the fluid temperature profile in the deep gluteal space, the distance and duration of activation influenced temperature (P < .05). Continuous delivery of RF energy for 10 seconds caused fluid temperature increases of 1.2°C, 2°C, and 3.1°C on average at 10 mm, 5 mm, and 3 mm of distance, respectively. This study found the tested monopolar RF device to be safe during use in vessels around the sciatic nerve after 2, 5, and 10 seconds of continuous activation. The maximum fluid temperature (28°C) after 10 seconds of activation at 3 mm of distance is lower than the minimal reported temperature necessary to cause nerve changes (40°C to 45°C). Monopolar RF seems to be safe to the neural structures when used at more than 3 mm of distance and with less than 10 seconds of continuous activation in deep gluteal space endoscopy with fluid inflow and outflow.

Submucosal endoscopy with mucosal flap safety valve

There is no reliable endoscopic method to selectively resect deeper layers of the gut wall or to access the peritoneal cavity and prevent peritoneal soiling. To determine the technical feasibility and safety of submucosal endoscopy with mucosal flap (SEMF) in accessing the peritoneal cavity through a large full-thickness gastric-muscle-wall resection. Ex vivo feasibility exploration and survival animal study. Ex vivo samples were obtained from fresh harvested organs. In vivo procedures were conducted with the pigs under standard general anesthesia. High-pressure carbon dioxide (CO(2)) injection and balloon dissection created a large submucosal working space for insertion of a cap-fitted endoscope. By using the EMR cap, a full-thickness resection of the muscularis propria was performed. This full-thickness defect was sealed with the overlying mucosal flap and the use of hemoclips or tissue anchors. By using the SEMF technique in the ex vivo experiment, the gastric wall was successfully traversed in each stomach after submucosal dissection and full-thickness resection of the musclaris. Similarly, by using the SEMF technique in the in vivo procedures, the peritoneal cavity was successfully accessed and the defect was completely sealed by using the mucosal flap. All animals survived 1 week after the procedure. Ulceration was noted in 3 pigs, and a small bowel injury was noted in 1 pig. Leak testing was negative in all stomachs. By using the SEMF technique, submucosal space endoscopy and deep-layer gastric-wall resection were successfully performed. Furthermore, the mucosa overlying the dissected submucosal space served as a safe flap valve, preventing peritoneal leakage.

Nucleoscopy--a new examination technique.

The examination technique of intervertebral space endoscopy (nucleoscopy) during nucleotomy is described. After nucleotomy intraoperative pictures of the intervertebral space can be taken using a common arthroscope. The nucleoscopy permits a qualitative statement about the extent of nucleotomy.