Working Channel Research Articles

Minimally Invasive Bimanual Fetal Surgery-A Review.

Background: The aim of this review is to discuss experimental and clinical techniques and interventions of fetal surgery which have been performed minimally invasively by the means of a three-port approach for the fetoscope and instruments for the left and right hand of the surgeon (bimanual minimally invasive fetal surgery). Methods: a print and electronic literature search was performed; the titles and abstracts were screened and included reports were reviewed in a two-step approach. First, reports other than minimally invasive fetal surgery were excluded, then a full text review and analysis of the reported data was performed. Results: 17 reports were included. The heterogeneity of the included reports was high. Although reports on human fetoscopic surgical procedures can be found, most of them do not pick out bimanual fetal surgery as a central theme but rather address interventions applying a fetoscope with a working channel for a laser fiber, needle or flexible instrument. Most reports were on experimentation in animal models, the human application of minimally invasive fetoscopic bimanual surgery is rare and has at best been explored for the prenatal treatment of spina bifida. Some reported bimanual fetoscopic procedures were performed on the exteriorized uterus via a maternal laparotomy and can therefore not be classified as being truly minimally invasive. Discussion: our results demonstrate that minimally invasive fetoscopic bimanual surgery is rare, even in animal models, excluding many other techniques and procedures that are loosely termed ‘minimally invasive fetal surgery’ which we suggest to better label as ‘interventions’. Thus, more research on percutaneous minimally invasive bimanual fetoscopic surgery is warranted, with the aim to reduce the maternal, uterine and fetal trauma for correction of congenital malformations.

Preclinical feasibility of bronchoscopic fluorescence-guided lung sentinel lymph node mapping

ObjectiveLung sentinel lymph node mapping, where peritumorally injected material is tracked through the lymphatics, aims to find the first potential sites of nodal metastasis. We sought to evaluate the preclinical feasibility of bronchoscopic fluorescence-guided sentinel lymph node mapping. MethodsHealthy Yorkshire pigs were used; sentinel lymph node mapping was performed with indocyanine green. The primary fluorescence imaging method was an ultrathin composite fiberscope placed in the bronchoscope working channel. Secondary methods used a fluorescence thoracoscope placed in the trachea (rigid bronchoscopy) and pretracheal fascial plane (mediastinoscopy) to validate ultrathin composite fiberscope settings for sentinel lymph node detection. A tracheostomy was created, and the pig was placed in a lateral decubitus position. Transbronchial intraparenchymal indocyanine green injection was performed primarily in the right lower lobe. Ultrathin composite fiberscope and rigid bronchoscopy were performed with (n = 6) or without (n = 2) mediastinoscopy, with the former group guiding dose and ultrathin composite fiberscope optimization. Fluorescent targets were interrogated by endobronchial ultrasound before ultrathin composite fiberscope–guided transbronchial needle aspiration. Specimen fluorescence was documented before creating cytological smears. Pigs were killed postprocedure for nodal dissection. ResultsA total of 100 μL of 10 mg/mL indocyanine green generated strong transbronchial fluorescence with low risk of indocyanine green contamination. Fluorescence was detectable by 10 minutes postinjection. There was concordance among ultrathin composite fiberscope, rigid bronchoscopy, and mediastinoscopy. Except for 1 pig with airway contamination, ultrathin composite fiberscope–guided endobronchial ultrasound transbronchial needle aspiration obtained fluorescent material in all pigs. Specimen fluorescence was associated with specimen adequacy. ConclusionsBronchoscopic fluorescence-guided sentinel lymph node mapping was feasible, with specimen fluorescence providing real-time feedback on sentinel lymph node biopsy success. If translated to clinical practice, attention must be paid to minimizing indocyanine green leakage.

Ultrathin bronchoscopic cryobiopsy of peripheral pulmonary lesions.

Ultrathin bronchoscopy aids in the diagnosis of peripheral pulmonary lesions. However, both the working channel and the specimens are small. A 1.1-mm ultrathin cryoprobe that can enter the working channel of the ultrathin bronchoscope is now available, which may overcome the limitations of small specimen size. The aim of this study was to evaluate the feasibility, efficacy and safety of ultrathin bronchoscopic cryobiopsy using an ultrathin cryoprobe for diagnosing peripheral pulmonary lesions. Patients with peripheral pulmonary lesions ≤30 mm in diameter were prospectively enrolled in the study. All patients underwent forceps biopsy followed by cryobiopsy using a 3.0-mm ultrathin bronchoscope under radial probe endobronchial ultrasound guidance, virtual bronchoscopic navigation and fluoroscopic guidance. The primary endpoint was the feasibility of cryobiopsy. In total, 50 patients with peripheral pulmonary lesions were enrolled in the study; the median longest diameter on computed tomography was 17.9 mm. Cryobiopsy was performed successfully in 49 patients (98%). Forceps biopsy, cryobiopsy and the combination of these two methods provided a specific diagnosis in 54% (27/50), 62% (31/50) and 74% (37/50) of patients, respectively. The median size of specimens obtained via cryobiopsy was significantly larger than the median size obtained via forceps biopsy (7.0 vs. 1.3 mm2 , respectively, p < 0.001). Mild bleeding during cryobiopsy occurred in 47 patients (94%). No moderate/severe bleeding or pneumothorax occurred. Ultrathin bronchoscopic cryobiopsy is feasible, effective and sufficiently safe for the diagnosis of peripheral pulmonary lesions.

Impact of the fiber cutting angle on fiber optic proximity sensors in endoscopy

Abstract In current endoscopes, the estimation of the proximity to the surrounding tissue is based on the experience of the user. To provide precise proximity meassurement, a suitable sensor is needed. This paper presents a fiber optic proximity sensor that is inserted through the working channel of an endoscope. The impact of the fiber cutting angle at the distal end of the optical fiber is investigated. If the fiber is cut at a 3° angle to the optical axis, the measurement signal in axial direction can be increased by 126mV at the peak (measurement accuray 4.9 mV). A 45° fiber cutting angle allows radial measurement but with a weak measurement signal compared to an axial measurement. A distance between endoscope tip and intestine wall up to 15 mm can be measured. In conclusion, optical fibers can be used to insert a low-cost sensor through a working channel of an endoscope. By modifying the fiber cutting angle, an increased sensor signal can be obtained in the axial direction and a measurement in radial direction is possible.

No relation between adenosine triphosphate after manual cleaning and presence of microorganisms on endoscopes after automated high-level disinfection.

Background and study aims Adenosine triphosphate (ATP) tests are increasingly used to detect biological material; however, their reliability to detect bacterial contamination in endoscopes is not proven. We investigated the predictive value of ATP tests after manual cleaning for presence or absence of microorganisms as shown by culture after automated high-level disinfection (HLD) in duodenoscopes and linear echoendoscopes (DLEs). Patients and methods After manual cleaning, ATP tests were performed on swab samples taken from the detachable cap and forceps elevator, and on flush samples of the DLE working channels. These results were compared to the growth of any microorganisms in cultures acquired after automated HLD. ATP tests with > 200 relative light units (RLU) were considered positive. Receiver operator characteristic (ROC) curves were used to compare the RLU levels with microbial presence in cultures. Results In total, 903 procedures were performed involving 26 distinct DLEs. Depending on sample site, 20.8 % (cap) to 63.8 % (channel brush) of the ATP negative samples were accompanied by positive post-HLD cultures. 54.4 % of the cap samples with a positive culture (growth of any kind of microorganism) and 91.8 % of the channel samples with a positive culture had a negative ATP test after manual cleaning. ROC curves per sample site, DLE type and microorganism type all had area under the curves below 0.6. Conclusions In our study, ATP tests performed after manual cleaning could not predict presence or absence of microorganisms after automated HLD as shown by culture. More than half of the positive cultures were preceded by a negative ATP test.

Towards Adaptive Network Resource Orchestration for Cognitive Radio Networks

&lt;p&gt;This work proposes an adaptive resource orchestration system for a Wireless Local Area Network (WLAN) that is based on the operating principle of Cognitive Radio (CR) technology. By collecting environmental parameters, including the retransmission rate and the channel occupancy rate, the proposed system has &amp;ldquo;knowledge&amp;rdquo; of overall transmission behavior and can regulate transmission resources. An Adaptive Connection Assignment (ACA) mechanism is proposed for end devices; it find out target end devices with poor transmission performance, analyzes their alternative Access Point (AP) availability and causes them to change connections to improve transmission performance. An Adaptive Channel Utilization (ACU) mechanism is designed for APs to identify a target AP that is suffering from interference, to analyze its alternative channel availability and to require it to change its working channel to improve transmission efficiency. Results of simulations of various scenarios indicate that the throughput of end devices is increased by 15 to 24%, the throughput of APs is increased by 6 to 47% and the retransmission rate of APs is reduced by 0.4 to 5.3%.&lt;/p&gt; &lt;p&gt;&amp;nbsp;&lt;/p&gt;

Predicting reachability to peripheral lesions in transbronchial biopsies using CT-derived geometrical attributes of the bronchial route.

The bronchoscopist's ability to locate the lesion with the bronchoscope is critical for a transbronchial biopsy. However, much less study has been done on the transbronchial biopsy route. This study aims to determine whether the geometrical attributes of the bronchial route can predict the difficulty of reaching tumors in bronchoscopic intervention. This study included patients who underwent bronchoscopic diagnosis of lung tumors using electromagnetic navigation. The biopsy instrument was considered "reached" and recorded as such if the tip of the tracked bronchoscope or extended working channel was in the tumors. Four geometrical indices were defined: Local curvature (LC), plane rotation (PR), radius, and global relative angle. A Mann-Whitney U test and logistic regression analysis were performed to analyze the difference in geometrical indices between the reachable and unreachable groups. Receiver operating characteristic analysis (ROC) was performed to evaluate the geometrical indices to predict reachability. Of the 41 patients enrolled in the study, 16 patients were assigned to the unreachable group and 25 patients to the reachable group. LC, PR, and radius have significantly higher values in unreachable cases than in reachable cases ([Formula: see text], [Formula: see text], [Formula: see text]). The logistic regression analysis showed that LC and PR were significantly associated with reachability ([Formula: see text], [Formula: see text]). The areas under the curve with ROC analysis of the LC and PR index were 0.903 and 0.618. The LC's cut-off value was 578.25. We investigated whether the geometrical attributes of the bronchial route to the lesion can predict the difficulty of reaching the lesions in the bronchoscopic biopsy. LC, PR, and radius have significantly higher values in unreachable cases than in reachable cases. LC and PR index can be potentially used to predict the navigational success of the bronchoscope.

Visualizing endoscopy-generated aerosols with laser light scattering (with videos)

Background and AimsUpper GI endoscopy is speculated to be an aerosol-generating procedure (AGP). Robust evidence exists for aerosol transmission of severe acute respiratory syndrome coronavirus 2. The quality of data available confirming aerosol generation during GI endoscopy is limited. We aimed to objectively demonstrate that GI endoscopy is an AGP and illustrate the mechanism by which the greatest risk for aerosolization of droplets during endoscopy may occur.MethodsAerosolized droplets generated during insertion and withdrawal of an endoscope and with passage of various tools through the endoscopic working channel using 2 experimental apparatuses modeling an upper GI tract (ie, a fluid-filled tube and a lamb esophagus) were qualitatively assessed by laser light scattering.ResultsInsertion and withdrawal of the upper endoscope into the upper GI tract models generated numerous aerosolized particles. A large number of brightly scattering particles were observed at the site of insertion and withdrawal of the endoscope. Passage of a cytology brush, biopsy forceps, and hemostatic clip through the working endoscope channel also generated aerosolized particles but in fewer numbers. There was no significant variation in quantity or brightness of droplets generated on testing different biopsy valve cap models or when suctioning fluid with an open versus closed biopsy valve cap. These results were reproducible over several trials.ConclusionsWe illustrate in an objective manner that upper GI endoscopy is an AGP. These findings may have implications for transmission of infectious airborne pathogens outside of severe acute respiratory syndrome coronavirus 2 and can help to inform guidance on appropriate personal protective equipment use and other measures for transmission risk mitigation during GI endoscopy.

Safety of office-based flexible endoscopic procedures of the pharynx and larynx under topical anesthesia.

Flexible endoscopic procedures (FEP) using a working channel allowed otolaryngologists to perform more procedures on the pharynx and the larynx under local anesthesia. The purpose of this work is to demonstrate the feasibility and safety of this technique by studying the adverse effects of this practice in an office-based setting. This is a monocentric retrospective cohort study. We searched the database using the French procedural code for FEP performed in an outpatient setting between January 2005 and December 2020. Data regarding the patient's characteristics, indications, and periprocedural complications were extracted. In total, we included 231 patients with a total of 308 FEP: 36% biopsy, 20% hyaluronic acid injection (including 3.5% at the level of the cavum), 20% injection of other substances (in descending order: botulinum toxin, cidofovir, physiological serum, cortisone), 20%exploration for an occult tumor, 3% samples for microbiological analysis, 1% other procedures. Of the 308 FEP included in this study, 24 patients (10.3%) had complications corresponding to 7.8% of the procedures performed. During the procedures, reported complications include minor laryngeal bleeding (n = 5), vasovagal syncope (n = 5), laryngospasm (n = 1) or nausea (n = 3), dysphagia (n = 3), and voice disorders (n = 3). Post-procedural complications were hypertensive crisis (n = 1), asthma attack (n = 1), pneumonia (n = 1), laryngitis (n = 1). Using the Clavien-Dindo classification system, these complications could be defined as grade I (laryngeal bleeding, vasovagal syncope, laryngospasm, dysphagia, nausea, voice disorders, and laryngitis) and grade II (hypertensive crisis, asthma attack, pneumonia) in 9.1% and 1.2% of cases, respectively. Most of these complications were self-limiting, while asthma attacks, pneumonia, laryngitis, and voice disorders required a medical intervention. All complications were managed without sequelae. There was no serious complication grade (no grade III, IV or V). FEP, which is now well standardized in our institution, makes it possible to carry out a wide range of interventions with little morbidity. These results are in line with those of literature but this technique remains out of nomenclature in France. Our experience led to the development of an evidence-based standard of care that can serve as a framework for practitioners on a nationwide level, while the work to establish official guidelines by the French society of phoniatrics and laryngology is in progress.

Design and Functionality of a Multilumen Thoracic Access Port for Pericardial Access Under Direct Visualization.

Small vasculature, venous obstruction, or congenital anomalies can preclude transvenous access to the heart, often resulting in open chest surgery to implant cardiac therapy leads for pacing, defibrillation, or cardiac resynchronization. A minimally invasive approach under direct visualization could reduce tissue damage, minimize pain, shorten recovery time, and obviate the need for fluoroscopy. Therefore, PeriPath was designed as a single-use, low-cost pericardial access tool based on clinical requirements. Its mechanical design aids in safe placement of conductive leads to the pericardium using a modified Seldinger technique. The crossed working channels provide an optimal view of the surgical field under direct visualization. Finite element analysis (FEA) confirms that the device is likely not to fail under clinical working conditions. Mechanical testing demonstrates that the tensile strength of its components is sufficient for use, with minimal risk of fracture. The PeriPath procedure is also compatible with common lead implantation tools and can be readily adopted by interventional cardiologists and electrophysiologists, allowing for widespread implementation. Prior animal work and a physician preliminary validation study suggest that PeriPath functions effectively for minimally invasive lead implantation procedures.

Initial Experience With the NICO Myriad Device for Minimally Invasive Endoscopic Evacuation of Intracerebral Hemorrhage.

Intracerebral hemorrhage (ICH) is a devastating form of stroke for which there is no consensus treatment. Although open craniotomy has been explored as a surgical treatment option, multiple minimally invasive (MIS) techniques have been developed including endoscopic evacuation. An adjunctive aspiration device can be used through the working channel to provide an additional degree of freedom and increased functionality regarding clot manipulation and morcellation. To report our single-center technical experience with the Myriad device used as an adjunctive aspiration device during endoscopic ICH evacuation in an exploratory case series. Demographic, clinical, and radiographic data were collected on patients who underwent MIS endoscopic ICH evacuation using the Myriad aspiration device from December 2018 to March 2019. Eight patients underwent ICH evacuation with the Myriad aspiration device. Bleeding was confined to the cortex in 4 patients, subcortical region in 2 patients, and the cerebellum in 2 patients. One of the cerebellar cases also underwent suboccipital craniotomy. The mean preoperative hematoma volume was 65.1 ± 68.9 mL, and the median postoperative volume was 7.6 ± 9.0 mL, for an average evacuation percentage of 88.1% ± 12.1%. In 75% of the cases, a bleeding vessel was identified and treated with either cautery or irrigation alone. There was no hemorrhagic recurrence or mortality within 30 days. Data from this initial experience suggest that MIS endoscopic ICH evacuation with the NICO Myriad aspiration device is feasible and technically effective. Multicenter exposure is necessary to verify broader applicability.

Preliminary study of the safety of acrinol in probe-based confocal laser endomicroscopy during transurethral resection of bladder tumors.

We previously reported that probe-based confocal laser endomicroscopy using acrinol can depict cancerous nuclei. The objective of this study was to confirm the safety of acrinol in patients. For all seven patients, '50 ml' of a 0.1% acrinol and '1ml' of 10% fluorescein in 99 ml of normal saline were introduced into the bladder. The laser probe adhered to the suspicious lesion from the working channel of the cystoscope. The patients underwent mucosal biopsy and transurethral resection after observation. Adverse events were noted during a valuation using common terminology criteria for adverse events version 4.0. Confocal laser endomicroscopy detected the nuclei of cancer cells in all seven patients. No adverse event was observed in any of the seven patients. Confocal laser endomicroscopy using acrinol as a novel dye can help visualize the cancerous nuclei of bladder urothelial carcinoma during cystoscopy without severe adverse events.

Comparison of irrigation flows between different irrigation methods for flexible ureteroscopy: An in vitro study

To compare the irrigation flows between different irrigation methods for f-URS. We compared the automatic irrigation system Endoflow II to gravity-based irrigation, and gravity-based irrigation with pressure cuff. Irrigation pressures were set at 40 and 100cmH2O. A LithoVue f-URS with a 3.6Fr working channel was used for the experiments. The f-URS was placed in straight alignment without active deflection on the operating table. For each irrigation pressure level, we evaluated the influence of the occupation of the working channel of the f-URS with an empty working channel, a 272μm laser fiber, a 1.9Fr nitinol basket. The outflow from f-URS was measured by the volume of irrigation fluid collected using a graduated glass at 1min, 2min, 3min and 5min. Irrigations flows remained constant over the time for the Endoflow II and the gravity-based irrigation methods regardless of the irrigation pressure and setting. For the pressure cuff method, the irrigation flow remained constant only when the working channel was occupied either by the nitinol basket or the laser fiber. Irrigation flow with the Endoflow II were constantly higher than gravity-based irrigation methods. Irrigation flow significantly increased with increased irrigation pressure. In the presence of any instruments at any irrigation pressure, the flow decreased as the size of the instrument in the working channel increased. Automatic irrigation system Endoflow II provided higher irrigation flows than gravity-based irrigation methods. The irrigation flow decreased as the size of the instrument in the working channel increased. Further studies conducted in vivo are needed to investigate if the differences found between irrigation methods result in higher intrarenal pressure during procedures. 4.

Cost-Effectiveness of 90-day Single-use Flexible Cystoscope Trial: Single Center Micro-Costing Analysis and User Satisfaction

To evaluate cost-effectiveness and user satisfaction of a single-use flexible cystoscope at a tertiary care center we conducted a 90-day trial. Single-use flexible cystoscope advancements have introduced alternative options to reusable scopes. However, there is a paucity of cost-effectiveness and provider satisfaction studies examining the implementation of a hospital-based transition to single-use cystoscopes. Following institutional device-approval we initiated a 90-day trial period (November 1, 2020-January 29, 2021) where all flexible, transurethral, and percutaneous, urologic care was provided with a disposable AMBU aScope. We performed a micro-costing analysis examining payor per case cost of the reusable flexible cystoscope (including servicing and processing) to the disposable units. Provider surveys assessed visual quality, deflection, ease of working channel and overall satisfaction on a 10-point Likert scale. Over the 90-day period, we encountered 84 cases (78 operative, 5 inpatient, 1 emergency department) where flexible cystoscopy was required. One disposable flexible cystoscope was successfully used in 78 of 84 (93%) cases. Of the 6 failures, 2 were due to an inability to access a disposable scope/monitor. Per use cost of the reusable flexible cystoscope at our center was $272.41 versus $185.00 for the single use. Extrapolating our average case volume and conservative failure rate (3 single use failures/month, requiring reusable), transitioning to predominately single use scopes results in $39,142.84 annual cost savings. This single center 90-day trial of disposable flexible cystoscopy identified per-use costs to be less when a single-use flexible cystoscope was utilized at a high-volume tertiary care center.

Primary impact of simultaneous use of double devices through one-working channel when performing flexible ureteroscope with ureteral access sheath for single ureteral stone: In bench and retrospective clinical study.

This study aimed to compare the simultaneous use of two devices versus a single device through a single working channel in flexible ureteroscopy using a ureteral access sheath for single ureteral stones. In a bench study, the time to (i) set laser fiber, (ii) exchange laser fiber and nitinol basket through working channel, and (iii) pull out the device from working channel were measured 10 times in each step. In a clinical study, 156 patients who underwent flexible ureteroscopy with a ureteral access sheath for a ureteral stone in middle and upper ureter between April 2019 and November 2021 were assessed. One device was used at a time for 79 patients (S-Group) and two were simultaneously used for 77 (D-Group). Surgical outcomes and complications were compared. In the bench study, the mean time to change from laser fiber to basket and from basket to laser fiber through the working channel were 26.1 ± 3.7 s and 23.6 ± 2.0 s (p = 0.084), respectively, which were significantly longer than the laser setup time (p < 0.001). In the clinical study, although the stone-free rate was not significantly different between the groups (S-Group 89.8%, D-Group 93.5%; p = 0.412), the median operation time was significantly shorter (p < 0.001) and the rate of postoperative stenting was significantly lower (p = 0.002) in the D-Group. There were no significant between-group differences in intra- and post-operative complications. The simultaneous use of two devices through a single working channel is safe and could help save the time needed to exchange the laser fiber and nitinol basket.

A Practical Guide for Intra-Renal Temperature and Pressure Management during Rirs: What Is the Evidence Telling Us.

Introduction: One of the main limitations of Ho:YAG lithotripsy is represented by its advancement speed. The need for faster lithotripsy has led to the introduction of high-power laser equipment. This general trend in increasing Ho:YAG lithotripsy power has certain points that deserve to be considered and analyzed. The objective is to carry out a narrative review on intrarenal temperature and pressure during ureteroscopy. Methods: A literature search using PUBMED database from inception to December 2021 was performed. The analysis involved a narrative synthesis. Results: Using more power in the laser correlates with an increase in temperature that can be harmful to the kidney. This potential risk can be overcome by increasing either the irrigation inflow or outflow. Increasing irrigant flow can lead to high intrarenal temperature (IRP). The factors that allow the reduction of intrarenal pressure are a low irrigation flow, the use of a ureteral access sheath of adequate diameter according to the equipment used, and the occupation of the working channel by the laser or basket. Conclusion: To maintain a safe temperature profile, it has been proposed to use chilled irrigation fluid, intermittent laser activation or to increase irrigation flow. This last recommendation can lead to increased IRP, which can be overcome by using a UAS. Another option is to use low power laser configurations in order to avoid temperature increases and not require high irrigation flows.

TIC in postgraduate studies: narratives from teachers about the challenge of performing remote classes

The article deals with the use of Communication and Information Technologies by graduate professors of a public higher education institution in the state of Bahia. The study aimed to understand how postgraduate professors experienced the challenges of developing remote activities. The research was based on qualitative research, as it excelled in revealing the meanings found in the information, enabling interpretive paths to understand and explore the challenges that postgraduate professors faced to make use of ICT in remote classes. As a device for collecting information, narratives were used, which make it possible to know experiences that teachers produce in a certain context of professional activity. In general, the study made it possible to conclude that teachers have an instrumental skill. In the research, it was possible to identify challenges faced by teachers in remote classes, and how teachers moved to experience new ways of working and new channels of communication.

A Novel Electromagnetic Navigation Bronchoscopy System for the Diagnosis of Peripheral Pulmonary Nodules: A Randomized Clinical Trial.

Rationale: Endobronchial ultrasound (EBUS) combined with a guide sheath (GS) as an instrument for confirming the proximity of the bronchoscope and its relationship to the lesion can increase the diagnostic yield when conducting transbronchial lung biopsy of peripheral pulmonary nodules (PPNs). A novel electromagnetic navigational bronchoscopy (ENB) system comprising a thinner locatable sensor probe as a guidance instrument was developed to be suitable for a thin bronchoscope with a working channel 2 mm in diameter. The diagnostic efficacy of EBUS-GS with or without this ENB system has not been confirmed. Objectives: To compare the diagnostic value and safety of EBUS-GS with or without the ENB system for diagnosing PPNs. Methods: A prospective, multicenter, randomized controlled clinical trial was designed and conducted at three centers. Patients with PPNs suspected to be malignant were enrolled and randomly assigned to the ENB-EBUS-GS group or the EBUS-GS group. The primary endpoint was the diagnostic yield in each group. The secondary endpoint was the procedural time and other factors affecting diagnostic yield. The safety endpoint was procedural complications. Results: Four hundred participants were enrolled from July 2018 to October 2019, and 385 patients were analyzed, 193 in the ENB-EBUS-GS group and 192 in the EBUS-GS group. The mean nodule size was 21.7 ± 5.3 mm. The diagnostic yields were 82.9% (95% confidence interval [CI], 77.6-88.2%) in the ENB-EBUS-GS group and 73.4% (95% CI, 67.2-79.7%) in the EBUS-GS group. The difference between the two groups was 9.5% (95% CI, 2.6-16.3%), with an adjusted difference of 9.0% (95% CI, 2.3-15.8%) after adjusting for the stratification factors and center. The time to find lesions in the ENB-EBUS-GS group was shorter than in the EBUS-GS group (213.2 ± 145.6 vs. 264.8 ± 189.5 s; P = 0.003). Intraoperative hemorrhage occurred 3.6% of subjects in the ENB-EBUS-GS group and 3.1% in the EBUS-GS group, without significant differences between the two groups. Conclusions: The novel ENB system combined with EBUS-GS demonstrated improved ability to locate PPNs, achieving a high diagnostic yield for PPNs compared with EBUS-GS alone in a safe and efficient procedure. Clinical trial registered with www.clinicaltrials.gov (NCT03569306).

Continuous Microdebrider-Based Dynamic Subcortical Motor Mapping: A Technical Advance in Tubular Retractor-Assisted Surgery.

Transsulcal minimally invasive parafasicular (TsMIP) approaches to brain tumor resection use tubular retractors to minimize iatrogenic brain injury. Dynamic cortical and subcortical continuous neurophysiological mapping facilitates safer resection of motor-eloquent tumors. To describe a new technique to address the challenge of combining TsMIP with tubular retractors and dynamic subcortical mapping using a single electrified stimulating microdebrider instrument. We adapted the NICO Myriad microdebrider with continuous monopolar stimulation electrification using high-frequency stimulation with the train-of-5 technique. We performed continuous subcortical mapping using this device and compared it with standard dynamic monopolar subcortical mapping using a suction stimulation device. We found no significant difference in recorded stimulation response. Using a single operating instrument that provides synchronous tumor resection and monopolar subcortical mapping with the NICO Brainpath tubular retractor, we observed increased degrees of movement, faster surgical resection times with an enlarged working channel down the retractor, and improved safety because the stimulating probe sits 2 mm deep to the resection window. We show that the adapted device is reliable and provides similar stimulation response as conventional subcortical mapping. We advocate the use of our adapted microdebrider in TsMIP tubular retractor approaches.

CRYOBIOPSY WITH ROBOTIC NAVIGATIONAL BRONCHOSCOPY: IS THIS THE NEXT STEP TO IMPROVING DIAGNOSTIC YIELD FOR PULMONARY NODULES? FOR MY PATIENT, IT DEFINITELY WAS!

TYPE: Case Report TOPIC: Lung Cancer INTRODUCTION: The introduction of robotic navigational bronchoscopy has helped to reach out to the lung periphery to safely biopsy nodules while improving diagnostic yield. Tools such as the brush, fine needle and forceps are the standard. However, the 1.1mm cryoprobe with the use of Ion robotic bronchoscopy could change the way we collect samples for diagnosis. CASE PRESENTATION: 64 year old male with significant tobacco abuse history found to have an incidental right upper lobe ground glass nodule measuring 1.5 cm. Upon further workup, it was not PET avid. The decision was made to follow up with a repeat CT chest in 3 months. The repeat CT suggested a slight change in size but remained ground glass. I proceeded with robotic navigational bronchoscopy and biopsy. During the case, standard brush, 21G FNA needle and forceps were used to collect samples. Afterwards, decision was made to proceed with use the 1.1mm cryoprobe with the Ion Robotic bronchoscopy to collect further samples for diagnosis. DISCUSSION: After several cryobiopsy samples were taken, no significant bleeding was noted for. Post procedure CXR did not show any pneumothorax. Final diagnosis was made via cryobiopsy samples of bronchoalveolar carcinoma while the brush, fine needle aspirate and forcep samples did not show any malignancy according to the pathologist. CONCLUSIONS: With the ability of the Ion robotic bronchoscopy to reach the periphery with ease and equipped with a 2.0 outer diameter working channel, the use of cryoprobe and cryobiopsy could change the way we proceed with doing lung biopsies for pulmonary nodules. DISCLOSURE: Medical Consultant for Intuitive Surgical KEYWORD: Interventional Pulmonary, robotic bronchoscopy