Pediatric hydrocephalus in East Africa: prevalence, causes, treatments, and strategies for the future

The burden of infant hydrocephalus in East Africa is significant, with more than 6000 new cases estimated per year. The majority is caused by neonatal infection, and should thus be preventable. With about 1 neurosurgeon per 10,000,000 people in East Africa, initial treatment for hydrocephalus is often unavailable. This also renders shunt dependence more dangerous in East Africa than in the developed world. Endoscopic third ventriculostomy combined with choroid plexus cauterization (ETV/CPC) has proven effective in avoiding shunt dependence in the majority of infants. Unlike shunts, most failures of endoscopic treatment are evident in the early months after surgery, with later failures being rare. Easily accessible clinical parameters can be used to predict the likelihood of success in a given patient. There appears to be no developmental advantage to shunt dependence compared to treatment by ETV/CPC. Cooperative efforts such as the East African Neurosurgical Research Collaboration are needed to broaden the scope of research and training needed to significantly reduce the morbidity and mortality of this disease.

[Endoscopy in sleep medicine]

Endoscopic evaluation of the upper airway in patients with sleep disordered breathing (SDB) using rigid and flexible endoscopes is a typical investigation in otorhinolaryngology. Visualizing the anatomic structure as well as the dynamic mechanism of snoring and pharyngeal obstruction during wakefulness, natural sleep, and under sedation are of special interest. The results obtained have increased our understanding of SDB with obstruction of the upper airway. Videoendoscopy under sedation (ViSe) has become increasingly established as a tool to identify the therapeutic concept in cases of CPAP failure, leading to changes compared to the concept derived from basic awake endoscopy. The success of mandibular advancement devices can be adequately predicted. However, it remains unclear to what extent the success rate of surgery can be improved by ViSe. Further research into these approaches is needed in order to become valuable tools in the diagnostic work-up of patients with sleep apnea.

[Current status and perspectives of endoscopic surgery]

In these twenty years, an endoscopic surgery has been widely applied to the patients as the treatment of benign and malignant diseases in the various fields, such as digestive surgery, respiratory surgery, endocrine surgery, urological surgery, and gynecological surgery. It has been generally accepted that the endoscopic surgery is less invasive and more beneficial compared with the conventional surgery in retrospective multicenter studies. In near future, with rapid advances of instruments and techniques, the establishments of EBM by prospective clinical trials, further education and training systems, and technical overcome in NOTES, SPS, and robotics, would be needed to be more widely accepted for the endoscopic surgery as extremely less invasive therapy.

[Present state and foresight of endoscopic therapy]

The advent of magnifying chromoendoscopy has enabled endoscopists to observe the mucosal structures in great detail for precise diagnosis; the pit patterns, irregular vascular patterns with narrow band imaging(NBI), and intra-epithelial papillary capillary loop (IPCL) pattern. The achievement of high resolution images has also improved accuracy of diagnosis for neoplasm in gastroenterology. Endocytoscopy is developed from magnifying chromoendoscopy, and is now under clinical investigation for use. Many of early gastrointestinal carcinoma has been treated endoscopically, and ESD (endoscopic submucosal dissection) technique, resection of the neoplasm en bloc, has disseminated recent years. The indication for ESD will be broadened in the near future, and the precise diagnosis for the neoplasm is essential, not to loose the interest of patients.

[Horizons of endoscopic surgery]

Minimally invasive surgery (MIS) has been one of the most important developments in surgery in the last century. By reducing the incision to small puncture wounds, morbidity, pain, adhesions and scarring are reduced. Due to their small size, neonates have not benefited from the advances in endoscopic surgery as rapidly as their adult counterparts. In the last 10 years, miniaturization of instruments and the development of sophisticated new techniques have enabled paediatric surgeons to apply endoscopic surgery to neonates. MIS is now being performed in both the neonatal chest and abdomen. This presentation will review these new developments and discuss the potential for even further improvements in neonatal surgery in the future. Also, a profile of the patient at risk for an insufflation-related incident and selection of neonates who will benefit most from these techniques in conditions of maximal safety will be drawn.

[Surgical therapy focusing mainly on endoscopic treatment]

Endoscopic surgery was popularized at the beginning of the 1990s in Japan, along with the development of video optical instruments, and it was soon applied to the treatment of solid cancers. Less invasive surgical techniques were sought using various approaches in various fields in the 2000s, and now in 2010 three approaches are notable: (1) single incision laparoscopic surgery using a one window method, which is attracting considerable interest because of its low invasiveness; (2) natural orifice translumenal endoscopic surgery (NOTES); and (3) robotic surgery, which is being pursued as a new modality. Further improvements in all these methods are anticipated as a result of the development of new instruments and the mastery of surgical techniques. However, an assurance of the safety of surgical procedures and a good prognosis are requisites for all these methods, and a level of quality equivalent to that of surgical techniques such as traditional thoracic and abdominal surgery must be maintained. Although these methods seem to represent difference paths, investigations of the various surgical techniques pursued by surgeons reveal that the various paths merge to reach the same goal. Therefore, extensive studies of new surgical techniques in various fields are needed to ensure that these new techniques hold up to the expectations of surgeons.

[Anesthesia during diagnostic endoscopic interventions in the outpatient setting]

The review of the literature is devoted to the urgent problem of today--anesthetic maintenance of diagnostic endoscopic studies. The authors of the review have attempted to systematize the results of numerous publications to provide a deeper insight into the existing problems and perspectives in this field of anesthesiology, which can facilitate an anesthesiologist in his/her decision on anesthesia to be performed in diagnostic endoscopy.

Microscope and endoscopic pituitary surgery

Having just celebrated the centenary of the first transsphenoidal pituitary operation by (Schloffer in Austria in Beitr Klin Chir 50:767-817, 1906), and this year the quarter centenary of the first published report of a therapeutic use of the neuroendoscope (for colloid cysts of the third ventricle) (Powell et al. in Neurosurgery 13:234-237, 1983), it is time to consider the relative merits of microscopic and endoscopic approaches for pituitary surgery. Although transsphenoidal endoscopic surgery has only been utilised by pioneers such as Jho since the mid-1990s (Jho et al., 1996), there is no doubt that it has already gained an important place in the neurosurgical armamentarium, but there is both confusion and propaganda about which method of surgery has most to offer, and indeed whether or not there is any real difference at all.

The future of NOTES from the conservative point of view

Recently, the unfamiliar term "natural orifice transluminal endoscopic surgery (NOTES)" appeared in my field. Actually, I am hesitant to accept this technique in my surgical practice. In this paper, I will review some references and try to establish my position toward NOTES. The author has been skeptical and ironical about the clinical potentiality of NOTES since hearing the presentation about NOTES for the first time. I have been concerned about making a puncture in the gastrointestinal tract as an old surgeon who believes that intestinal injury must not occur during surgery. However, recent advances in the research of NOTES are changing my stubborn belief. What I have to do is to avoid interrupting or disturbing young surgeons' challenges to develop NOTES. I remember that some senior surgeons were against us when we started laparoscopic surgery around 1990. Senior surgeons and physicians must be generous, considerate, helpful and supportive to our followers. I have been enthusiastic about the development and spread of laparoscopic surgery since 1987 and have been doing various surgical procedures myself, including those involving the biliary tract, pancreas, spleen, upper and lower gastrointestinal tract, adrenal, kidney and gynecologic organs. Recently, the unfamiliar term "NOTES" appeared in my field. Actually, I am hesitant to accept this technique in my surgical practice. In this paper I will review some references and try to establish my position toward NOTES.

[Endoscopic rhinosurgery: from simple intranasal surgery to interventions on orbital apex and base of the skull]

This paper is focused on the main methods and indications for endoscopic intranasal surgery, from conventional infundibulotomy for the management of chronic rhinosinusutis resistant to conservative therapy to up-to-date endoscopic techniques for the treatment of lacrimal duct obstruction, nasal liquorrhea, endocrine ophthalmopathy, benign and malignant tumours of paranasal sinuses, and skull base lesions. A review of the literature data is supplemented by original clinical observations.

Perspectives in endoscopic cardiac surgery

Surgical telemanipulators are obviously used in cardiac surgery to provide the surgeon in a confined space the same stereoscopic vision, full dexterity, unimpaired hand-eye alignment and tactile feedback as in open surgery. This is the basic concept that enables the controlled fine soft tissue manipulation that is needed in bypass grafting and valve surgery. In 2005, a total of 2984 cardiac procedures were performed worldwide using the da Vinci system. This includes totally endoscopic coronary artery bypass grafting (TECAB), mitral valve repair (MVR) procedures, ASD closure and cardiac tissue ablation for atrial fibrillation.

Endoscopic Mitral and Tricuspid Valve Surgery After Previous Cardiac Surgery

BACKGROUND

The purpose of this study was to evaluate the feasibility and effectiveness of a right video-assisted approach for atrioventricular valve disease after previous cardiac surgery.

METHODS AND RESULTS

Between December 1st 1997 and May 1st 2006, 80 adults (mean age 65+/-12 years; 56% female) underwent reoperative surgery using a video-assisted approach without rib spreading. Previous cardiac operations included mitral valve (39%), CABG (29%), congenital (10%), and other (23%). For 25% of patients, this was at least their third cardiac operation. Mean time to redo surgery was 15+/-12 years. Femoral vessel cannulation and endoaortic clamping were routinely used. Mean preoperative Euroscore was 9.0+/-2.7 (5 to 20) and predicted mortality was 16.0+/-14.2% (4 to 86). Median preoperative NYHA class was II and mean follow-up was 25+/-22 months. Lung adhesions necessitated sternotomy in 4 cases and cannulation problems in another patient. Total operative mortality was 3.8% (n=3), O/E for mortality being 0.24. Procedures were mitral valve repair (45%; n=36), replacement (50%; n=40) and tricuspid valve replacement (5%; n=4). Additional procedures were performed in 44% (n=35). Mean aortic crossclamp and procedure time were 92+/-37 and 267+/-64 minutes. Mean postoperative blood loss was 815+/-1083 mL. Postoperative morbidity included 2 strokes (2.5%). Mean hospital stay was 10.7+/-6.7 days. Survival at 1 and 4 years was 93.6+/-2.8% and 85.6+/-6.4%. There was 1 late reoperation at 5 years. Median NYHA class at follow-up was II. When comparing, all but 1 patient (98.8%) preferred their minimally invasive approach when considering perioperative pain, postoperative rehabilitation, and final esthetic result.

CONCLUSIONS

Video-assisted minimal access correction of atrioventricular valve disease after previous cardiac surgery is not only feasible but had lower than predicted mortality and strong patient satisfaction. It should therefore be used more frequently in today's practice.

[Trends in endoscopic surgery for inguinal hernia: collective review of meta-analyses and randomized controlled trials]

Inguinal hernia repair is one of the most commonly performed general surgical procedures and endoscopic herniorrhaphy has been performed around the world. We review the meta-analysis and recent large randomized controlled trials of endoscopic versus open repairs for inguinal hernia. Currently available evidence shows that endoscopic herniorrhaphy, when compared with open herniorrhapy, is associated with less persisting pain and numbness, earlier return to normal activity, and a lower risk of hematoma and wound infection, but this technique takes longer and has more serious complications. Hernia recurrence is comparable to open mesh methods and less common than after open non-mesh methods. More carefully conceived and executed studies are needed to establish the future role of endoscopic surgery for inguinal hernia repair.

Surgical interventions for lumbar disc prolapse: updated Cochrane Review

STUDY DESIGN

An updated Cochrane Review.

OBJECTIVES

To assess the effects of surgical interventions for the treatment of lumbar disc prolapse.

SUMMARY OF BACKGROUND DATA

Disc prolapse accounts for 5% of low back disorders yet is one of the most common reasons for surgery. There is still little scientific evidence supporting some interventions.

METHODS

Use of standard Cochrane review methods to analyze all randomized controlled trials published up to January 1, 2007.

RESULTS

Forty randomized controlled trials (RCTs) and 2 quasi-RCTs were identified. Many of the early trials were of some form of chemonucleolysis, whereas the majority of the later studies either compared different techniques of discectomy or the use of some form of membrane to reduce epidural scarring. Four trials directly compared discectomy with conservative management, and these give suggestive rather than conclusive results. However, other trials show that discectomy produces better clinical outcomes than chemonucleolysis, and that in turn is better than placebo. Microdiscectomy gives broadly comparable results to standard discectomy. Recent trials of an interposition gel covering the dura (5 trials) and of fat (4 trials) show that they can reduce scar formation, although there is limited evidence about the effect on clinical outcomes. There is insufficient evidence on other percutaneous discectomy techniques to draw firm conclusions. Three small RCTs of laser discectomy do not provide conclusive evidence on its efficacy. There are no published RCTs of coblation therapy or transforaminal endoscopic discectomy.

CONCLUSION

Surgical discectomy for carefully selected patients with sciatica due to lumbar disc prolapse provides faster relief from the acute attack than conservative management, although any positive or negative effects on the lifetime natural history of the underlying disc disease are still unclear. The evidence for other minimally invasive techniques remains unclear except for chemonucleolysis using chymopapain, which is no longer widely available.

History of endoscopic skull base surgery: its evolution and current reality

✓The history of the endoscope exemplifies the manner in which technological advances influence medicine and surgery. Endoscopic systems have evolved and improved, and they currently provide detailed visualization of a variety of deep organ structures. Otorhinolaryngological surgeons have used the endoscope for more than 30 years. In the 1990s, a number of influential neurosurgeons and otorhinolaryngological surgeons began performing purely endoscopic pituitary surgery. Endoscopic transsphenoidal operations are now extending beyond the sella. The collaboration between otorhinolaryngologists and neurosurgeons has produced a new subspecialty of “endoscopic skull base surgery.” There is a great deal of progress still to be made in developing skills, instruments, and improving skull base repair. The extended skull base approaches allow surgical exposures from the olfactory groove to C-2 and to the infratemporal region and jugular fossa laterally. This article discusses the history of the endoscope, the pivotal technological advances, and the key figures in the burgeoning field of endoneurosurgery.

NOTES: a gastroenterologist's perspective

Once in a few decades in science or medicine, an idea emerges that is so powerful that it changes forever how we think about the field. Such is the case of natural orifice transluminal endoscopic surgery (NOTES). NOTES has yet to prove its value in patients. However, having challenged one of the most fundamental and deeply entrenched dogmas in surgery and endoscopy, many of us feel that "we will never be the same again." In this article I will discuss the implications of this paradigm shift and suggest strategies for both gastroenterologists and surgeons that will allow us to test its full potential.

NOTES: a surgeon's perspective

Natural orifice transluminal endoscopic surgery (NOTES) is an exciting concept gaining national attention as a novel and minimally invasive approach to gastrointestinal surgery and endoscopy. The hope of combining the talents and experience of surgeons and gastrointestinal endoscopists with emerging technologies has created enthusiasm for developing this approach as a specialty itself. Upon initial review, many procedures seem to naturally lend themselves to this approach and include endoscopic mucosal resection, small tumor excision, and access to the peritoneum. The main question to be answered in this short article is: What is gained and what is lost with NOTES?

Flexible robotics: a new paradigm

PURPOSE OF REVIEW

The use of robotics in urologic surgery has seen exponential growth over the last 5 years. Existing surgical robots operate rigid instruments on the master/slave principle and currently allow extraluminal manipulations and surgical procedures. Flexible robotics is an entirely novel paradigm. This article explores the potential of flexible robotic platforms that could permit endoluminal and transluminal surgery in the future.

RECENT FINDINGS

Computerized catheter-control systems are being developed primarily for cardiac applications. This development is driven by the need for precise positioning and manipulation of the catheter tip in the three-dimensional cardiovascular space. Such systems employ either remote navigation in a magnetic field or a computer-controlled electromechanical flexible robotic system. We have adapted this robotic system for flexible ureteropyeloscopy and have to date completed the initial porcine studies.

SUMMARY

Flexible robotics is on the horizon. It has potential for improved scope-tip precision, superior operative ergonomics, and reduced occupational radiation exposure. In the near future, in urology, we believe that it holds promise for endoluminal therapeutic ureterorenoscopy. Looking further ahead, within the next 3-5 years, it could enable transluminal surgery.

New methods for the management of esophageal varices

Bleeding from esophageal varices (EVs) is a catastrophic complication of chronic liver disease. Many years ago, surgical procedures such as esophageal transection or distal splenorenal shunting were the only treatments for EVs. In the 1970s, interventional radiology procedures such as transportal obliteration, left gastric artery embolization, and partial splenic artery embolization were introduced, improving the survival of patients with bleeding EVs. In the 1980s, endoscopic treatment, endoscopic injection sclerotherapy (EIS), and endoscopic variceal ligation (EVL), further contributed to improved survival. We combined IVR with endoscopic treatment or EIS with EVL. Most patients with EVs treated endoscopically required follow-up treatment for recurrent varices. Proper management of recurrent EVs can significantly improve patients’ quality of life. Recently, we have performed EVL at 2-mo (bi-monthly) intervals for the management of EVs. Longer intervals between treatment sessions resulted in a higher rate of total eradication and lower rates of recurrence and additional treatment.

The role of endoscopic extraperitoneal herniorrhaphy: where do we stand in 2005?

Inguinal hernia repair is a common surgical procedure, but the most effective surgical technique remains controversial. The evolution of laparoscopic techniques has allowed reproduction of open preperitoneal repair via an endoscopic total extraperitoneal (TEP) approach. More recently, the advent of comprehensive training in laparoscopy has allowed TEP to continue evolving as the feasibility of this approach gains recognition as a preferable technique. Once considered very difficult to learn, TEP currently is adequately taught in many surgical training programs. This report reviews the fundamentals and details various modifications that make this procedure more desirable than open procedures and other laparoscopic techniques. A resultant decrease in operative time, cost of the procedure, and morbidity to the patient is routine. In addition, the authors review their institutional experience and examine other current evidence-based data.

Anterior endoscopic skull-base surgery getting started: an otolaryngologist's perspective

PURPOSE OF REVIEW

Anterior endoscopic skull-base surgery is a relatively new field requiring new levels of cooperation between otolaryngology and neurosurgery. The formation of these teams is discussed along with their challenges.

RECENT FINDINGS

A significant amount of literature has been produced in the last few years, chronicling new and innovative techniques for anterior endoscopic skull-base surgery. These techniques are requiring close coordination between otolaryngologist and neurosurgeon in a multidisciplinary approach. However, there are obstacles to overcome in forming these teams.

SUMMARY

Anterior endoscopic skull-base surgery is a technically challenging skill set which requires multiple factors to perform successfully. Factors to overcome require surgical training, appropriate patient base, specialized equipment and institutional inertia. These obstacles may be overcome in the majority of centers.

A primer on natural orifice transluminal endoscopic surgery: building a new paradigm

Access to the abdominal cavity is required for diagnostic and therapeutic endeavors for a variety of medical and surgical diseases. Historically, abdominal access has required a formal laparotomy to provide adequate exposure. Natural orifice transluminal endoscopic surgery (NOTES) is an emerging experimental alternative to conventional surgery that eliminates abdominal incisions and incision-related complications by combining endoscopic and laparoscopic techniques to diagnose and treat abdominal pathology. During NOTES, commercially available flexible video endoscopes are used to create a controlled transvisceral incision via natural orifice access to enter the peritoneal cavity. Common incision-related complications such as wound infections, incisional hernias, postoperative pain, aesthetic disdain, and adhesions could be minimized or eliminated by NOTES. NOTES has evolved from more than 2 centuries of technological innovations and continued growth in the field of surgical endoscopy. Innovative surgical endoscopists have slowly developed means to surpass the constraints of the gastrointestinal lumen by using a flexible endoscope. The future of surgical endoscopy may be the shared entity of NOTES, which further integrates endoscopy, gastroenterology, and minimally invasive and general surgery. Although the promise of NOTES is electrifying to surgeons and endoscopists, several key issues need to be characterized prior to the incorporation of NOTES into routine practice. This article reviews the status, contemporary body of literature, limitations, and potential future implications accompanying the development of NOTES.

The role of the surgeon in the evolution of flexible endoscopy

Several cultures, including the Egyptians, Greeks, Romans, and Arabs, made attempts to view accessible human body cavities using a variety of instruments such as spatulas and specula. The first endoscope was created in 1806 when Phillip Bozzini, a German-born urologist, constructed the lichtleiter, which used concave mirrors to reflect candlelight through an open tube into the esophagus, bladder, or rectum. Maximilian Carl-Friedrich Nitze, another German urologist, produced the first usable cystoscope in 1877 by using series of lenses to increase magnification. He was also the first to place light inside the organ of interest to aid visualization. In 1880 Mikulicz made the first gastroscope using a system similar to Nitze's cystoscope. Modern endoscopy was born with the introduction of the fiberoptic endoscope in the late 1950s. Over the ensuing 50 years endoscopy revolutionized many aspects of the surgeon's practice. Endoscopy can now be used to diagnose and often treat gastrointestinal cancer, hemorrhage, obstruction, and inflammatory conditions. This review was initiated by the SAGES Flexible Endoscopy Committee to chronicle the role of the surgeon in the development and introduction of flexible endoscopy into clinical practice, historically and in contemporary surgery. Flexible endoscopy evolved out of surgeons' need to overcome diagnostic and therapeutic challenges. There have been many recent technological advances that facilitate endoluminal therapies, and flexible endoscopy is now traversing new ground. Surgeons have been major contributors in the development of all aspects of endoscopy. There is a continually expanding list of therapeutic options available to patients. The difficult questions of which procedure, on which patient, and when can be answered best by the surgeon versed in endoscopic, laparoscopic, and open surgical techniques.