Vocal cord assessment with transnasal endoscopy in intubated patients after esophagectomy

BACKGROUND

Vocal cord paralysis (VCP) is one of the postoperative complications after radical esophagectomy. VCP may also lead to serious morbidities such as respiratory distress and aspiration pneumonia. Therefore, an early diagnosis of VCP is meaningful in the postoperative management of patients undergoing esophagectomy. We evaluated a new practical method for diagnosing postoperative VCP.

METHODS

The laryngeal assessment of 30 patients was performed, and the presence of VCP was inferred while the following 15 patients by endoscopy before extubation after performing consecutive radical esophagectomy in 45 esophageal cancer patients. The vocal cord mobility, including adduction and abduction, were assessed by inserting the tip of a transnasal endoscope near the vocal cord in the awake patients with orotracheal intubation on the first postoperative day. The presence of VCP was reevaluated after extubation.

RESULTS

Eleven of the 30 patients assessed after radical esophagectomy had unilateral VCP and one patient had bilateral VCP. The abduction findings were useful for assessing VCP and the sensitivity, specificity, positive and negative predictive values and accuracy were 97.9%, 100%, 100%, 92.9% and 98.3%, respectively. The results of the following 15 patients were closely similar.

CONCLUSIONS

The VCP during orotracheal intubation is assessable by transnasal endoscopy.

[Pigtail stent for gallbladder drainage]

Endoscopic transpapillary gallbladder drainage is a new, relatively non-invasive treatment for patients with symptomatic gallbladder disease and a high surgery risk. Placement of an internal pigtail stent is an alternative treatment for percutaneous gallbladder drainage. This procedure can be performed in patients with a temporary contra-indication - in preparatory process to a cholecystectomy - as well as in patients with a prolonged contra-indication where the pigtail stent can remain in situ for a longer period of time. This technique appears to be an effective and safe procedure for patients with acute cholecystitis or symptomatic gallbladder disease and a high surgery risk.

[Modern methods of low-invasive treatment of the stricture and damage of the pancreatic duct, pancreatolithiasis]

The authors analyzed the experience of diagnostics and treatment of 49 patients. It was shown, that low-invasive methods of treatment (the endoscopic lithoextraction, stenting, surgical drainage) should be the priority means in treatment of pancreatolithiasis, strictures and cases of the pancreatic duct damage. The lethality consisted of 2.04% in these interventions.

[Confocal laser endomicroscopy in the diagnosis of diseases of biliary ducts]

Are clinical observations of various diseases of the bile ducts, including cholangiocarcinoma, developed with chronic diseases pancreato-biliary zone. Reflected the complexity of instrumental diagnostics at an early stage of the disease. For the first time at the given pathology diagnostic purposes was applied the method of probe confocal laser endomicroscopy allowed in all cases to clarify and verify the diagnosis. Describes the technique of the research, its results are compared with other diagnostic methods. The authors suggest that in the diagnosis of pancreatic and biliary zone method probe confocal laser endomicroscopy can be crucial in inefficiency or uninformative other methods.

Endotherapy in chronic pancreatitis

Chronic pancreatitis (CP) is a progressive disease with irreversible changes in the pancreas. Patients commonly present with pain and with exocrine or endocrine insufficiency. All therapeutic efforts in CP are directed towards relief of pain as well as the management of associated complications. Endoscopic therapy offers many advantages in patients with CP who present with ductal calculi, strictures, ductal leaks, pseudocyst or associated biliary strictures. Endotherapy offers a high rate of success with low morbidity in properly selected patients. The procedure can be repeated and failed endotherapy is not a hindrance to subsequent surgery. Endoscopic pancreatic sphincterotomy is helpful in patients with CP with minimal ductal changes while minor papilla sphincterotomy provides relief in patients with pancreas divisum and chronic pancreatitis. Extracorporeal shock wave lithotripsy is the standard of care in patients with large pancreatic ductal calculi. Long term follow up has shown pain relief in over 60% of patients. A transpapillary stent placed across the disruption provides relief in over 90% of patients with ductal leaks. Pancreatic ductal strictures are managed by single large bore stents. Multiple stents are placed for refractory strictures. CP associated benign biliary strictures (BBS) are best treated with multiple plastic stents, as the response to a single plastic stent is poor. Covered self expanding metal stents are increasingly being used in the management of BBS though further long term studies are needed. Pseudocysts are best drained endoscopically with a success rate of 80%-95% at most centers. Endosonography (EUS) has added to the therapeutic armamentarium in the management of patients with CP. Drainage of pseudcysts, cannulation of inaccessible pancreatic ducts and celiac ganglion block in patients with intractable pain are all performed using EUS. Endotherapy should be offered as the first line of therapy in properly selected patients with CP who have failed to respond to medical therapy and require intervention.

Prospective randomized comparison of short-access mother-baby cholangioscopy versus direct cholangioscopy with ultraslim gastroscopes

BACKGROUND

Mother-baby technologies, the criterion standard for cholangioscopy, have several limitations. A novel, short-access, mother-baby (SAMBA) system may improve this technique. Direct cholangioscopy (DC) was recently developed as an alternative to mother-baby cholangioscopy.

OBJECTIVE

Comparison of success rates with SAMBA and DC.

DESIGN

Single-center, randomized, controlled trial.

SETTING

Academic tertiary-care referral center.

PATIENTS

Sixty patients with suspected cholangiopathies randomized to either SAMBA (n = 30) or DC (n = 30).

INTERVENTION

Cholangioscopy under deep sedation.

MAIN OUTCOME MEASUREMENTS

Technical success rate of diagnostic or therapeutic procedure.

RESULTS

A total of 24 and 21 diagnostic procedures were performed in the SAMBA and DC groups, respectively. There were no significant differences in the overall technical success rates between SAMBA (90.0%) and DC (86.7%) (P = 1.0). There was better correlation between the endoscopic prediction and histologic findings in DC (P = .013). Procedure times were shorter in DC (P < .03). In patients without significant stenoses, SAMBA allowed intrahepatic bile duct exploration in all cases, compared with 10.5% of cases in DC (P < .01). No differences regarding adverse event rates between the groups occurred (10.0% both groups).

LIMITATIONS

Small sample size. Heterogeneous indications for cholangioscopy. DC requires advanced skills of the endoscopist. The study is not replicable.

CONCLUSION

SAMBA and DC offer high technical success rates for diagnostic and therapeutic interventions. The advantages of DC consist of superior imaging, shorter total procedure time, and a wider working channel for adequate tissue sampling. SAMBA is better than DC with regard to intraductal stability and accessibility of the intrahepatic bile ducts.

Residual common bile duct stones on direct peroral cholangioscopy using ultraslim endoscope

AIM: To detect and manage residual common bile duct (CBD) stones using ultraslim endoscopic peroral cholangioscopy (POC) after a negative balloon-occluded cholangiography.

METHODS: From March 2011 to December 2011, a cohort of 22 patients with CBD stones who underwent both endoscopic retrograde cholangiography (ERC) and direct POC were prospectively enrolled in this study. Those patients who were younger than 20 years of age, pregnant, critically ill, or unable to provide informed consent for direct POC, as well as those with concomitant gallbladder stones or CBD with diameters less than 10 mm were excluded. Direct POC using an ultraslim endoscope with an overtube balloon-assisted technique was carried out immediately after a negative balloon-occluded cholangiography was obtained.

RESULTS: The ultraslim endoscope was able to be advanced to the hepatic hilum or the intrahepatic bile duct (IHD) in 8 patients (36.4%), to the extrahepatic bile duct where the hilum could be visualized in 10 patients (45.5%), and to the distal CBD where the hilum could not be visualized in 4 patients (18.2%). The procedure time of the diagnostic POC was 8.2 ± 2.9 min (range, 5-18 min). Residual CBD stones were found in 5 (22.7%) of the patients. There was one residual stone each in 3 of the patients, three in 1 patient, and more than five in 1 patient. The diameter of the residual stones ranged from 2-5 mm. In 2 of the patients, the residual stones were successfully extracted using either a retrieval balloon catheter (n = 1) or a basket catheter (n = 1) under direct endoscopic control. In the remaining 3 patients, the residual stones were removed using an irrigation and suction method under direct endoscopic visualization. There were no serious procedure-related complications, such as bleeding, pancreatitis, biliary tract infection, or perforation, in this study.

CONCLUSION: Direct POC using an ultraslim endoscope appears to be a useful tool for both detecting and treating residual CBD stones after conventional ERC.

Endoscopic gallbladder stenting for acute cholecystitis: a retrospective study of 46 elderly patients aged 65 years or older

BACKGROUND

Endoscopic transpapillary pernasal gallbladder drainage and endoscopic gallbladder stenting (EGS) have recently been reported to be useful in patients with acute cholecystitis for whom a percutaneous approach is contraindicated. The aim of this study was to evaluate the efficacy of permanent EGS for management of acute cholecystitis in elderly patients who were poor surgical candidates.

METHODS

We retrospectively studied 46 elderly patients aged 65 years or older with acute cholecystitis who were treated at Japan Labour Health and Welfare Organization Niigata Rosai Hospital. In 40 patients, acute cholecystitis was diagnosed by transabdominal ultrasonography and computed tomography, while 6 patients were transferred from other hospitals after primary management of acute cholecystitis. All patients underwent EGS, with a 7Fr double pig-tail stent being inserted into the gallbladder. If EGS failed, percutaneous transhepatic gallbladder drainage or percutaneous transhepatic gallbladder aspiration was subsequently performed. The main outcome measure of this study was the efficacy of EGS.

RESULTS

Permanent EGS was successful in 31 patients (77.5%) with acute cholecystitis, without any immediate postprocedural complications such as pancreatitis, bleeding, perforation, or cholangitis. The most common comorbidities of these patients were cerebral infarction (n=14) and dementia (n=13). In 30 of these 31 patients (96.7%), there was no recurrence of cholecystitis and 29 patients (93.5%) remained asymptomatic until death or the end of the study period (after 1 month to 5 years).

CONCLUSIONS

EGS can be effective for elderly patients with acute cholecystitis who are poor surgical candidates and can provide a solution for several years.

Efficacy of cap-assisted endoscopy for routine examining the ampulla of Vater

AIM: To determine the efficacy of a cap-assisted endoscopy (CAE) to completely visualize the ampulla of Vater (AV) in patients failed by conventional endoscopy.

METHODS: A prospective study was conducted on 120 patients > 20 years of ages who visited the Health Promotion Center of Chungbuk National University Hospital for conscious sedation esophagogastroduodenoscopy (EGD) as a screening test from July to October, 2011. First, forward-viewing endoscopy was performed with reasonable effort using a push and pull method. We considered complete visualization of the AV when we could observe the entire AV including the orifice clearly, and reported the observation as complete or incomplete (partial or not found at all). Second, in cases of complete failure of the observation, an additional AV examination was conducted by attaching a short cap (D-201-10704, Olympus Medical Systems, Tokyo, Japan) to the tip of a forward-viewing endoscope. Third, if the second method failed, we replaced the short cap with a long cap (MH-593, Olympus Medical Systems) and performed a re-examination of the AV.

RESULTS: Conventional endoscopy achieved complete visualization of the AV in 97 of the 120 patients (80.8%) but was not achieved in 23 patients (19.2%). Age (mean ± SD) and gender [male (%)] were not significantly different between the complete observation and the incomplete observation groups. Additional short CAE was performed in patients in whom we could not completely visualize the AV. This group included 13 patients (10.9%) with partial observation of the AV and 10 (8.3%) in which the AV was not found. Short CAE permitted a complete observation of the AV in 21 of the 23 patients (91.3%). Patients in whom visualization of the AV failed with short CAE had satisfactory outcomes by replacing the short cap with a long cap. The additional time for CAE took an average of 141 ± 88 s. There were no complications and no significant mucosal trauma.

CONCLUSION: CAE is safe to use as a salvage method to achieve complete visualization of the AV when a regular EGD examination fails.

Choledochoscopy/cholangioscopy

Miniature endoscopes that can be introduced into the bile duct through the duodenoscope during endoscopic retrograde cholangiopancreatography were developed to allow nonsurgical management of difficult biliary stones. The direct visualization enabled by these cholangioscopes of the biliary epithelium provides additional data in the assessment of biliary strictures. Cholangioscopy allows assessment of the biliary lumen, biliary epithelium, targeted tissue acquisition, targeted therapy, and wire guidance.

[Results of the upper digestive tract stenting with self-expanding stents]

The work is based on the analysis of the palliative treatment of 66 patients with malignant upper digestive tract obstruction who underwent implantation of 75 self-expanding metallic stents in the period of 2003-2012 yy. Early postoperative complications developed in 10 (15.2%) cases. Procedure-related complications were observed in 8 (12.1%) patients, non-specific complications occurred in 2 (3.0%) patients. In-hospital lethality was 4.5% (3 patients). 51 patients were followed until death. Symptomatic relapse of obstruction was observed in 4 cases. Median survival was 97 days. Stenting with self-expanding metal stents was concluded to be an effective and safe method of palliation of malignant upper digestive tract stenosis.

Steady progress seen in endoscopic surgery on major salivary glands

INTRODUCTION

The objective of this study was to investigate the development in sialendoscopy (SE) in East Denmark. Data were compared with previously published data to assess the learning curve.

MATERIAL AND METHODS

In this retrospective consecutive study, all patients who had SE performed at Hillerød Hospital from November 2009 to April 2011 were included. Data were extracted from medical records and interviews. Two surgeons performed all SEs. Z-test and Fisher's exact test were used for statistical analysis.

RESULTS

A total of 118 patients met the inclusion criteria. In all, 156 diagnostic and 139 therapeutic SEs were performed. The median age was 44 years (3-85 years) and the female-to-male-ratio was 1.81. A total of 96% of patients had pre-operative ultrasound performed (the positive predictive value for detection of stone was 0.82, 95% confidence interval 0.70-0.90. Indication for SE was recurrent or chronic swelling, pain, identified stone or recurrent infections. The only exclusion criterion was neoplasms. The success rate of diagnostic SE was 98%, and the therapeutic SE success rate was 67%. Total or partial relief from symptoms was obtained in 77% of patients which was a significant improvement (Z-test: p < 0.001). No serious persistent complications occurred.

CONCLUSION

SE is a safe and effective treatment for benign obstructive disease of the major salivary glands. The surgeon's results improve significantly over time. Updated equipment and an experienced surgeon yielded patient symptom relief in 77% of cases.

FUNDING

not relevant.

TRIAL REGISTRATION

This study was approved by the Danish Committee on Biomedical Research Ethics and the Danish Data Protection Agency.

Normalized autofluorescence imaging diagnostics in upper GI tract: a new method to improve specificity in neoplasia detection

BACKGROUND & AIMS

This study was performed to improve the autofluorescence imaging (AFI) in the upper GI tract by applying a new method of normalized autofluorescence (NAFI) obtained via tri-modal imaging.

OBJECTIVE

NAFI may provide lower false positive rate to achieve ultimately better specificity at acceptable sensitivity.

PATIENTS AND METHODS

This is a prospective, controlled single-centre study. 18 patients with suspected esophagus or stomach cancer undergoing esophagogastroduodenoscopy (EGD) were enrolled between February and May 2010. After endoscopy each patient was assigned into one of two groups: (1) non-cancer, including inflammation; (2) cancer group. EGDs were performed using video white light endoscopy, followed by AFI/NAFI. The targeted biopsy samples were taken from the abnormal areas as well as from adjacent mucosa. NAFI was compared versus AFI for cancer diagnostics in terms of specificity and sensitivity.

RESULTS

NAFI detected all neoplastic lesions. WLE or NBI detected no additional neoplasia. The AFI displayed mucosal inflammation and carcinomas of esophagus and stomach as dark red color, the normal mucosa background was displayed as light green. The NAFI didn't differentiate inflamed tissue from normal in majority of cases, but in tumorous mucosa, the cancer areas were detected precisely. AFI shows 100% sensitivity but 50% specificity which correlates with previous literature data. On the other hand, NAFI demonstrated lower sensitivity (88%) but higher specificity compared to AFI (69%).

CONCLUSIONS

Measuring the NAFI instead of the AFI was found improving the specificity of cancer diagnosis. Use of fiber-optic endoscopes to analyze AFI and possible endoscopic and histological sampling error are the main potential limitations of this method.

[Successful application of cholangioscope as an intravascular endoscope in hybrid operation for a child]

We performed hybrid operation on a 3-year-old boy with thrombosis in the pulmonary arterial conduit which had been implanted concomitantly at the time of Fontan operation. We used a cholangioscope as a substitute of intravascular endoscope. It visualized the organized thrombus and the suture line in the conduit. Hybrid operation was successfully performed based on the detailed findings gained by cholangioscopy.

Transvaginal cholecystectomy without laparoscopic support using prototype flexible endoscopic instruments in a porcine model

BACKGROUND

Transvaginal cholecystectomy with laparoscopic assistance has been performed safely in humans. The next goal was to develop a natural orifice transluminal endoscopic surgery (NOTES) technique to perform cholecystectomy without laparoscopic instruments using one flexible endoscope and flexible accessories. The aim of the study was to test the feasibility of the procedure in a survival porcine model.

METHODS

Cholecystectomies were attempted in five 88-130-lb. pigs with a planned 2-week survival. Prototype flexible instruments (NOTES Toolbox, Ethicon Endo-Surgery, Inc.) were used to aid in access, dissection, and removal of the gallbladder via the transvaginal route.

RESULTS

Cholecystectomy could be completed without abdominal incision using prototype instruments in four out of five pigs. The cystic duct could be exposed with a flexible hook knife and clips applied. The steerable trocar improved stability and the precision of the dissection. The critical view was established in all five pigs. Dissection of the gallbladder off the liver bed was imprecise resulting in gallbladder perforation in all pigs and liver hemorrhage in two. At necropsy, all clips on the cystic duct were secure and no bile leak, bowel injury, or adhesions were present.

CONCLUSIONS

NOTES cholecystectomy without laparoscopic support is feasible but challenging using prototype flexible endoscopic devices. A prototype clip applier was effective in controlling the cystic duct. Further improvements in instrument design to ensure precision and safety are needed before flexible devices should be used for pure NOTES procedures in humans.

Design and application of a new series of gallbladder endoscopes that facilitate gallstone removal without gallbladder excision

In recent years, some Chinese doctors have proposed a new concept, gallstone removal without gallbladder excision, along with transition of the medical model. As there is no specialized endoscope for gallstone removal without gallbladder excision, we designed and produced a new series of gallbladder endoscopes and accessories that have already been given a Chinese invention patent (No. ZL200810199041.2). The design of these gallbladder endoscopes was based on the anatomy and physiology of the gallbladder, characteristics of gallbladder disease, ergonomics, and industrial design. This series of gallbladder endoscopes underwent clinical trials in two hospitals appointed by the State Administration of Traditional Chinese Medicine. The clinical trials showed that surgeries of gallstones, gallbladder polyps, and cystic duct calculus could be smoothly performed with these products. In summary, this series of gallbladder endoscopes is safe, reliable, and effective for gallstone removal without gallbladder excision. This note comprehensively introduces the research and design of this series of gallbladder endoscopes.

ENBD tube placement prior to laparoscopic cholecystectomy may reduce the rate of complications in cases with predictably complicating biliary anomalies

BACKGROUND

The risk factors predisposing to bile duct injury or postoperative bile leakage associated with laparoscopic cholecystectomy (LC) include the presence of an accessory hepatic duct, the anomalous cystic duct confluence, and duct of Luschka. One method to prevent bile duct injury is preoperative placement of an endoscopic nasobiliary drainage tube (ENBD assisted LC). The aims of this investigation are first, to report the incidence of bile duct anomalies according to the classification system proposed by Wakayama Medical University and second, to evaluate the efficacy of ENBD assisted LC with regard to prevention of intraoperative bile duct injury and postoperative bile duct injury or leakage.

METHODS

A total of 1,835 consecutive LCs performed at our institution during a recent 10-year period were reviewed.

RESULTS

Anomalous cystic duct confluence was detected in 11 cases and an accessory hepatic duct was detected in 37 cases. These anomalies were risk factors for bile duct injury in our series. However, there was no significant difference in the length of surgery, conversion rate to laparotomy, or frequency of bile duct injury or leakage between the standard LC group and ENBD assisted LC group.

CONCLUSION

A bile duct anomaly was seen in 2.6% of LC cases. Placement of an ENBD tube prior to LC in predictably complicating bile duct anomalies may have successfully decreased the incidence of complications.

Updates in small bowel imaging and endoscopy

The field of gastroenterology has had an abundance of technological advances in recent years, especially in the field of endoscopy. These advances are helpful to clinicians approaching gastrointestinal blood loss, especially in the small bowel. The authors report a case of a man who presented to the emergency department with obscure gastrointestinal blood loss. Results of an esophagogastroduodenoscopy and a colonoscopy suggested the source of the blood loss was within the small bowel. On an outpatient basis, the patient underwent video capsule endoscopy, which revealed scattered distal duodenal arteriovenous malformations. He then underwent oral double balloon endoscopy with ablation of the arteriovenous malformations, with no further bleeding or drop in hemoglobin. The authors review advances in small bowel imaging and endoscopy, including video capsule endoscopy, double balloon endoscopy, and computed tomography enterography. A comprehensive data review was conducted by searching the National Library of Medicine's PubMed database to identify recent published literature in the fields of radiology and gastroenterology. The authors apply these findings to the workup and diagnosis of obscure gastrointestinal blood loss.

Endotics system vs colonoscopy for the detection of polyps

AIM

To compare the endotics system (ES), a set of new medical equipment for diagnostic colonoscopy, with video-colonoscopy in the detection of polyps.

METHODS

Patients with clinical or familial risk of colonic polyps/carcinomas were eligible for this study. After a standard colonic cleaning, detection of polyps by the ES and by video-colonoscopy was performed in each patient on the same day. In each single patient, the assessment of the presence of polyps was performed by two independent endoscopists, who were randomly assigned to evaluate, in a blind fashion, the presence of polyps either by ES or by standard colonoscopy. The frequency of successful procedures (i.e. reaching to the cecum), the time for endoscopy, and the need for sedation were recorded. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of the ES were also calculated.

RESULTS

A total of 71 patients (40 men, mean age 51.9 ± 12.0 years) were enrolled. The cecum was reached in 81.6% of ES examinations and in 94.3% of colonoscopies (P = 0.03). The average time of endoscopy was 45.1 ± 18.5 and 23.7 ± 7.2 min for the ES and traditional colonoscopy, respectively (P < 0.0001). No patient required sedation during ES examination, compared with 19.7% of patients undergoing colonoscopy (P < 0.0001). The sensitivity and specificity of ES for detecting polyps were 93.3% (95% CI: 68-98) and 100% (95% CI: 76.8-100), respectively. PPV was 100% (95% CI: 76.8-100) and NPV was 97.7% (95% CI: 88-99.9).

CONCLUSION

The ES allows the visualization of the entire colonic mucosa in most patients, with good sensitivity/specificity for the detection of lesions and without requiring sedation.

A new, safer, controllable field-of-view endoscope avoiding movement inside body cavities

One of the greatest difficulties in endoscopic surgery is the limited field-of-view (FOV) of endoscopes. During endoscopic manipulation in body cavities to expand the FOV, there is the risk of inadvertent damage to body tissues, nerves, and internal organs. The risk increases especially in surgery that is performed inside a very small cavity, or in which body tissues are very fragile. To overcome these issues, we developed a novel endoscope that can provide various FOVs without moving or bending the endoscope itself inside the body cavity and investigated the feasibility of using the new endoscope in vivo. A beam splitter was used to visualize both forward and side views, and two polarization plates and observation windows were used to avoid overlap of the two views. An endoscope having a 7-mm diameter was fabricated through which both views were clearly visualized in vivo. It took only 0.7s to change the FOV with high repeatability, with a maximum distance error of 2.8%. The new endoscope can provide forward and panoramic views without moving the endoscope; therefore, the risk of inadvertent damage to fragile body tissues can be significantly decreased.