Outcomes of sinonasal mucosal melanomas with endoscopic and open resection: a retrospective cohort study

PURPOSE

To compare the outcomes of Sinonasal Mucosal Melanomas (SNMM) treated with endoscopic and open resection.

METHODS

A retrospective case review of 20 patients with SNMM treated surgically at UCSF. Kaplan-Meier analyses were calculated to determine outcome differences in endoscopic vs. open resections.

RESULTS

From 2005 to 2014, 20 cases of SNMM were confirmed and treated at UCSF. All cases underwent surgical resection, with 10 cases by open resection and 10 cases by endoscopic resection. Using Kaplan-Meier analyses, the open resection group had a 1-year survival of 30% whereas endoscopic resection group was 80% (p = 0.032). Endoscopic resection showed improved survival at all time points after surgery compared to open resection.

CONCLUSION

SNMM is a rare and aggressive tumor that is associated with low survival rates. In this small case series, endoscopic resection had improved survival outcomes compared to open resection.

Endoscopic surgery for primary sinonasal malignancies: Treatment outcomes and prognostic factors

We retrospectively reviewed the cases of 85 patients with primary sinonasal malignancies who had undergone endoscopic surgery with curative intent achieved by "regional resection." Our goal was to assess the efficacy of endoscopic surgical treatment vis-à-vis traditional open surgery. Kaplan-Meier data analysis revealed that the 1-, 3-, and 5-year disease-specific survival rates were 82, 60, and 49%, respectively. Multivariate Cox model survival analysis revealed that male sex, certain pathologic types of cancer (i.e., undifferentiated carcinoma, olfactory neuroblastoma, and rhabdomyosarcoma), and T3/T4 category negatively impacted survival (adjusted hazard ratios: 3.601, 0.012, 0.287, 0.068, and 0.339, respectively; p < 0.05 for all). We also performed a separate analysis of 47 patients who had category T3 or T4 cancer to determine if the type of surgical approach is a prognostic factor. For this, we identified 20 new patients who had undergone open resection, and we compared them to 27 of our endoscopically treated patients who had similar clinical characteristics. We found that the type of surgical approach did not appear to be a prognostic factor (p > 0.10), although those patients who had undergone endoscopic resection had significantly shorter hospital stays (p < 0.001). We conclude that patients with primary sinonasal malignancies who are treated with endoscopic surgery have acceptable survival rates and therefore endoscopic surgery is justified in the hands of highly experienced surgeons in selected cases.

Comparison of endoscopic evacuation, stereotactic aspiration and craniotomy for the treatment of supratentorial hypertensive intracerebral haemorrhage: study protocol for a randomised controlled trial

BACKGROUND

Hypertensive intracerebral haemorrhage (HICH) is the most common form of haemorrhagic stroke with the highest morbidity and mortality of all stroke types. The choice of surgical or conservative treatment for patients with HICH remains controversial. In recent years, minimally invasive surgeries, such as endoscopic evacuation and stereotactic aspiration, have been attempted for haematoma removal and offer promise. However, research evidence on the benefits of endoscopic evacuation or stereotactic aspiration is still insufficient.

METHODS/DESIGN

A multicentre, randomised controlled trial will be conducted to compare the efficacy of endoscopic evacuation, stereotactic aspiration and craniotomy in the treatment of supratentorial HICH. About 1350 eligible patients from 10 neurosurgical centres will be randomly assigned to an endoscopic group, a stereotactic group and a craniotomy group at a 1:1:1 ratio. Randomisation is undertaken using a 24-h randomisation service accessed by telephone or the Internet. All patients will receive the corresponding surgery based on their grouping. They will be followed-up at 1, 3 and 6 months after surgery. The primary outcome is the modified Rankin Scale at 6-month follow-up. Secondary outcomes include: haematoma clearance rate; Glasgow Coma Scale 7 days after surgery; rebleeding rate; intracranial infection rate; hospitalisation time; mortality at 1 month and 3 months after surgery; the Barthel Index and the WHO quality of life at 3 months and 6 months after surgery.

DISCUSSION

The trial aims to investigate whether endoscopic evacuation and stereotactic aspiration could improve the outcome of supratentorial HICH compared with craniotomy. The trial will help to determine the best surgical method for the treatment of supratentorial HICH.

TRIAL REGISTRATION

ClinicalTrials.gov, ID: NCT02811614 . Registered on 20 June 2016.

Risk factors for complications and mortality related to endoscopic procedures in adults

BACKGROUND AND AIM

The objective of this study is to identify and describe risk factors and complications in endoscopic procedures.

METHODS

This review presents the complications and the accompanying risk factors that were described in the selected full-text articles. The relevant full-text articles were found in Pubmed, ISI Web of Science and the CINAHL database.

RESULTS

The search resulted in 238 abstracts, 50 of which were finally selected for full-text analysis. The different types of endoscopic procedures each have specific complications, but bleeding and perforation occur in all procedures. It was found that bleeding, perforation, cardiovascular and respiratory complications were common complications.Furthermore, morbidity and mortality have been associated with risk factors such as older age, high ASA class and sedation.

CONCLUSION

Endoscopy is not without risk, although the prevalence of complications is low. Most complications seenin this analysis, are linked to known risk factors. Some complications might be preventable or avoidable, given a more systematic and comprehensive approach pre-, per- and postprocedural. The creation and implementation of an endoscopic safety checklist could be an -important supportive tool in lowering complications.

Randomized trials of endoscopic therapy and transjugular intrahepatic portosystemic shunt versus portacaval shunt for emergency and elective treatment of bleeding gastric varices in cirrhosis

IMPORTANCE

Bleeding esophageal varices has been studied extensively, but bleeding gastric varices (BGV) has received much less investigation. However, BGV has been reported in ≤ 30% of patients with acute variceal bleeding. In our studies of 1,836 bleeding cirrhotics, 12.7% were bleeding from gastric varices. BGV mortality rate of 45-55% has been reported. The BGV literature has mainly involved retrospective case reports, often with short-term follow-up.

OBJECTIVE

We sought to describe the results of a prospective, randomized, controlled trial (RCT) in unselected, consecutive patients with BGV comparing endoscopic therapy (ET) with portacaval shunt (PCS; n = 518), and later comparing emergency transjugular intrahepatic portosystemic shunt (TIPS) with emergency portacaval shunt (EPCS; n = 70).

DESIGN, SETTING, AND PARTICIPANTS

Initially, our RCT involved 518 patients with BGV comparing ET with direct PCS regarding control of bleeding, mortality rate, and disability. When entry of patients ended, the RCT was expanded to compare emergency TIPS with EPCS (n = 70). This RCT of BGV was separate from our other RCTs of bleeding esophageal varices.

INTERVENTIONS

Initially, ET was compared with PCS. In the second part of our RCT, emergency TIPS was compared with emergency PCS (EPCS).

MAIN OUTCOME MEASURES

Outcomes were survival, control of bleeding, portal-systemic encephalopathy (PSE), quality of life, and direct costs of care. In the RCT of ET versus PCS, 28 and 30%, respectively, were in Child class C. In the expanded RCT of TIPS versus EPCS, 40 and 41%, respectively, were in Child class C. Permanent control of BGV was achieved in 97-100% of patients treated by emergency or elective PCS, compared with 27-29% by ET. TIPS was even less effective, achieving long-term control of BGV in only 6%. Survival rates after PCS were greater at all time intervals and in all Child classes (P < .001). Repeated episodes of PSE occurred in 50% of TIPS patients, 16-17% treated by ET, and 8-11% treated by PCS. Shunt stenosis or occlusion occurred in 67% of TIPS patients, in contrast with 0-2% of PCS patients.

CONCLUSION

These results support the conclusion that PCS is uniformly effective, whereas ET and TIPS are not very effective.

The clinical research of the endoscopic sequential treatment for patients with intermediate-advanced esophageal cancer: a randomized clinical trial

We tried to find an ideal therapeutic regimen for patients with advanced esophageal cancer. Totally 240 patients with advanced esophageal cancer were randomly divided into experimental group (endoscopic sequential treatment, 126 cases) and control group (traditional treatment, 114 cases) with a 2-year follow-up period. The experimental group was randomly divided into three subgroups: group A: local chemotherapeutic drug injection with ordinary metal stent implantation; group B: local chemotherapeutic drug injection with iodine-125 particle implantation; and group C: radiofrequency (RF) therapy with ordinary metal stent group. The control group was also randomly divided into three subgroups: group D: local chemotherapeutic drug injection group; group E: RF therapy group; and group F: common metal stent implantation group. The survival rate, survival quality, adverse reactions, and complications were compared among these groups. A significant improvement of curative effect was found in the experimental group. Group A and B had higher survival rate and survival quality, and lower esophagotracheal fistula incidence and metastasis rate, compared with group C. There was no significant difference in survival rate between group A and group B, while the quality of life was higher in group B than in group A. While patients in group B had lower esophagotracheal fistula incidence and metastasis rate comparing with group A. Local chemotherapeutic drug injection combined with iodine-125 particle stent might be an effective sequential treatment to improve the life quality of advanced esophageal cancer patients.

A temporary self-expanding metallic stent for malignant colorectal obstruction

AIM: To investigate the clinical safety and efficacy of a temporary self-expanding metallic stent (SEMS) for malignant colorectal obstruction.

METHODS: From September 2007 to June 2012, 33 patients with malignant colorectal obstruction were treated with a temporary SEMS. The stent had a tubular configuration with a retrieval lasso attached inside the proximal end of the stent to facilitate its removal. The SEMS was removed one week after placement. Clinical examination, abdominal X-ray and a contrast study were prospectively performed and both initial and follow-up data before and at 1 d, 1 wk, and 1 mo, 3 mo, 6 mo and 12 mo after stent placement were obtained. Data collected on the technical and clinical success of the procedures, complications, need for reinsertion and survival were analyzed.

RESULTS: Stent placement and removal were technically successful in all patients with no procedure-related complications. Post-procedural complications included stent migration (n = 2) and anal pain (n = 2). Clinical success was achieved in 31 (93.9%) of 33 patients with resolution of bowel obstruction within 3 d of stent removal. Eleven of the 33 patients died 73.81 ± 23.66 d (range 42-121 d) after removal of the stent without colonic re-obstruction. Clinical success was achieved in another 8 patients without symptoms of obstruction during the follow-up period. Reinsertion of the stent was performed in the remaining 12 patients with re-obstruction after 84.33 ± 51.80 d of follow-up. The mean and median periods of relief of obstructive symptoms were 97.25 ± 9.56 d and 105 ± 17.43 d, respectively, using Kaplan-Meier analysis.

CONCLUSION: Temporary SEMS is a safe and effective approach in patients with malignant colorectal obstruction due to low complication rates and good medium-term outcomes.

Association between endoscopic vs open vein-graft harvesting and mortality, wound complications, and cardiovascular events in patients undergoing CABG surgery

CONTEXT

The safety and durability of endoscopic vein graft harvest in coronary artery bypass graft (CABG) surgery has recently been called into question.

OBJECTIVE

To compare the long-term outcomes of endoscopic vs open vein-graft harvesting for Medicare patients undergoing CABG surgery in the United States.

DESIGN, SETTING, AND PATIENTS

An observational study of 235,394 Medicare patients undergoing isolated CABG surgery between 2003 and 2008 at 934 surgical centers participating in the Society of Thoracic Surgeons (STS) national database. The STS records were linked to Medicare files to allow longitudinal assessment (median 3-year follow-up) through December 31, 2008.

MAIN OUTCOME MEASURES

All-cause mortality. Secondary outcome measures included wound complications and the composite of death, myocardial infarction, and revascularization.

RESULTS

Based on Medicare Part B coding, 52% of patients received endoscopic vein-graft harvesting during CABG surgery. After propensity score adjustment for clinical characteristics, there were no significant differences between long-term mortality rates (13.2% [12,429 events] vs 13.4% [13,096 events]) and the composite of death, myocardial infarction, and revascularization (19.5% [18,419 events] vs 19.7% [19,232 events]). Time-to-event analysis for those patients receiving endoscopic vs open vein-graft harvesting revealed adjusted hazard ratios [HRs] of 1.00 (95% CI, 0.97-1.04) for mortality and 1.00 (95% CI, 0.98-1.05) for the composite outcome. Endoscopic vein-graft harvesting was associated with lower harvest site wound complications relative to open vein-graft harvesting (3.0% [3654/122,899 events] vs 3.6% [4047/112,495 events]; adjusted HR, 0.83; 95% CI, 0.77-0.89; P < .001).

CONCLUSION

Among patients undergoing CABG surgery, the use of endoscopic vein-graft harvesting compared with open vein-graft harvesting was not associated with increased mortality.

Longterm outcome of photodynamic therapy compared with biliary stenting alone in patients with advanced hilar cholangiocarcinoma

OBJECTIVES

This study aimed to determine longterm outcomes and factors associated with increased survival after photodynamic therapy (PDT) compared with endoscopic biliary drainage alone in patients presenting with advanced hilar cholangiocarcinoma (CC).

METHODS

A retrospective analysis of the institutional database identifying all patients who presented with a diagnosis of hilar CC between December 1999 and January 2011 was conducted.

RESULTS

Of the 232 patients identified, 72 (31%) were treated with PDT (Group A) and 71 (31%) were treated with endoscopic biliary drainage alone (Group B). Median survival was 9.8 months [95% confidence interval (CI) 7.42-12.25] in Group A and 7.3 months (95% CI 4.79-9.88) in Group B (P= 0.029). On multivariate analysis, biliary drainage without PDT (P= 0.025) and higher T-stage (P= 0.002) were significant predictors of shorter survival in all patients. In a subgroup analysis of patients in the PDT group, lower pre-PDT bilirubin level (P= 0.005), multiple PDT treatments (P= 0.044) and shortened time to treatment after diagnosis (P= 0.013) were significant predictors of improved survival. Median metal stent patency was longer in Group A than in Group B (215 days vs. 181 days; P= 0.018).

CONCLUSIONS

Photodynamic therapy with stenting resulted in longer survival than stenting alone. Early PDT after diagnosis and multiple PDT treatments were shown to have survival benefits. Metal stent patency was longer in patients receiving PDT. Higher T-stage appears to be a predictor of early mortality in advanced bile duct cancer treated with PDT.

Endoscopic versus direct vision for saphenous vein graft harvesting in coronary artery bypass surgery

AIM

Recent reports have suggested harvesting of the greater saphenous vein for coronary artery bypass (CABG) using endoscopic techniques (endoscopic) results in early graft closure, higher rates of myocardial infarction (MI) and death. We explored the impact of this technique performed by experienced operators on postoperative morbidities, MI and death in our CABG patients.

METHODS

All non-emergent patients presenting for first time CABG surgery from 2006 to June 2009 were included. Data pertaining to surgery, readmissions, cardiac catheterization and interventions during long term follow-up were extracted from our local STS and ACC registries. Linear and logistic regressions with clinical covariates were conducted to determine if vein harvest technique group predicted the major outcomes. Propensity score matching (PSM) was completed to simulate randomization and improve covariate balance across the endoscopic and direct vision groups.

RESULTS

One thousand nine hundred and eighty-eight (N.=1988) patients were evaluated in this study (N.=1734 endoscopic group and N.=254 direct vision group). The perioperative major adverse outcomes (mortality within 30 days, stroke, reoperation for bleeding, prolonged ventilation and readmission within 30 days) were 17.8% in the endoscopic group and 25.2% in the direct vision group. The rate of leg infections was 0.3% for the endoscopic group and 1.6% for the direct vision group. After adjustment for covariates, the direct vision group had significantly greater risk for prolonged ventilation (P=0.03), MACE (P=0.02) and mortality within 30 days (P=0.01), but only marginally greater risk for leg infections (P=0.052). In the isolated CABG patients, operative death was 1% for the endoscopic group and 1.7% in the direct vision group (P=0.62). After PSM the endoscopic group was similar on all outcomes except for having fewer MACE (P=0.04). In a mean follow-up of 22.1±10.5 months, there were no significant differences in the overall rate and time to event for repeat revascularization, death and myocardial infarction. With maximum follow up of 39.6 months, 84 deaths were documented (N.=67 endoscopic and N.=17 direct vision).

CONCLUSION

The outcomes captured by the number of postoperative morbidities, incidence of myocardial infarction and/or the rate of death for the endoscopic technique were comparable to patients in whom the open techniques was used. There was a trend towards a decrease in leg infections with the use of the endoscopic device. Based on this study we consider the device safe and effective with experienced operators.

Fucosylated fraction of alpha-fetoprotein as a predictor of prognosis in patients with hepatocellular carcinoma after curative treatment

AIM

The aim of this study was to evaluate the clinical usefulness of measuring the Lens culinaris agglutinin-reactive fraction of alpha-fetoprotein (AFP-L3) for prognostic predictor in patients with hepatocellular carcinoma (HCC).

METHODS

A total of 477 HCC patients who underwent percutaneous ablative therapy or hepatectomy were enrolled. Overall survival and recurrence-free survival were respectively evaluated retrospectively and prospectively. Multivariate analyses of clinical prognostic factors were performed by Cox's stepwise proportional hazard model.

RESULTS

AFP-L3 status was a statistically significant independent prognostic factor of long-term survival (P = 0.013) and recurrence-free survival (P = 0.006) in patients who underwent percutaneous ablative therapy. In contrast, AFP-L3 did not affect prognosis in patients who underwent hepatectomy.

CONCLUSIONS

AFP-L3 had different impacts on prognosis in patients with HCC who underwent percutaneous ablative therapy and hepatectomy. Our results suggest that AFP-L3 positivity (>or=15%) might be a promising indicator for choosing therapeutic modalities in HCC patients.

Radiologic versus endoscopic placement of percutaneous gastrostomy in amyotrophic lateral sclerosis: multivariate analysis of tolerance, efficacy, and survival

PURPOSE

To compare percutaneous radiologic gastrostomy (PRG) and percutaneous endoscopic gastrostomy (PEG) in terms of tolerance, efficacy, and survival in patients with amyotrophic lateral sclerosis (ALS).

MATERIALS AND METHODS

Forty patients with ALS (17 men; mean age, 66.1 years; range, 39-83 y) underwent 21 PEG and 22 PRG attempts (including three unsuccessful PEG attempts) from 1999 to 2005. To assess tolerance and efficacy, a successful and well tolerated placement was defined as any successful placement with no major or minor local complications or pain requiring opioid analgesic agents. Univariate analysis was performed for all recorded parameters, followed by multivariate analysis for successful and well tolerated placement, 6-month mortality rate, and survival.

RESULTS

General success rates were 85.7% for PEG and 100% for PRG. Pain was more frequent in PRGs (81.8% vs 52.4%; P = .05). Successful and well tolerated placement was seen in 81.8% of PRGs and 57.1% of PEGs (P = 0.1). Advanced age (P = .02) and PRG (P = .07) were predictive of successful and well tolerated placement. The interval from diagnosis to placement (P = .001) and ability to perform spirometry (P = .002) were predictive of survival. Oximetry measurements (P = .007) and interval from diagnosis to placement (P = .02) were predictive of mortality at 6 months.

CONCLUSIONS

PRG is more efficacious and better tolerated than PEG, essentially because it avoids the respiratory decompensation that may occur in PEG. Therefore, PRG should be preferred in cases of ALS. Survival is linked to ALS evolution and not to the choice of PRG or PEG placement.

Modelling the long-term cost-effectiveness of endovascular or open repair for abdominal aortic aneurysm

Background

Recent randomized trials have shown that endovascular abdominal aortic aneurysm repair (EVAR) has a 3 per cent aneurysm-related survival benefit in patients fit for open surgery, but it also has uncertain long-term outcomes and higher costs. This study assessed the cost-effectiveness of EVAR.

Methods

A decision model was constructed to estimate the lifetime costs and quality-adjusted life years (QALYs) with EVAR and open repair in men aged 74 years. The model includes the risks of death from aneurysm, other cardiovascular and non-cardiovascular causes, secondary reinterventions and non-fatal cardiovascular events. Data were taken largely from the EVAR trial 1 and supplemented from other sources.

Results

Under the base-case (primary) assumptions, EVAR cost £3800 (95 per cent confidence interval (c.i.) £2400 to £5200) more per patient than open repair but produced fewer lifetime QALYs (mean − 0·020 (95 per cent c.i. − 0·189 to 0·165)). These results were sensitive to alternative model assumptions.

Conclusion

EVAR is unlikely to be cost-effective on the basis of existing devices, costs and evidence, but there remains considerable uncertainty.

Hospital and long-term outcome after percutaneous endoscopic gastrostomy

BACKGROUND

Percutaneous endoscopic gastrostomy (PEG) has become the preferred method of providing long-term enteral nutrition. While hospitalized patients frequently have PEG inserted to facilitate enteral nutrition, little is known about these patients. The objective of the study was to determine hospital and long-term survival in patients who receive PEG while hospitalized for medical or surgical reasons.

METHODS

Records of all patients aged 18 years and older who underwent PEG between January 1, 1999 and December 31, 2004 at a university-affiliated community-based tertiary care center were examined.

RESULTS

80 (11%) of 714 patients died during the index hospitalization. Older age, being married, mechanical ventilation, and dialysis were statistically significant predictors of hospital death (P < 0.05). There were nine complications and no deaths directly attributable to PEG. Overall survival was poor with 5.6% of patients dying within seven days of the procedure. Mortalities at 30, 60, and 365 days were 22%, 31% and 48%, respectively. Of the 80 patients who died prior to discharge, 40 (50%) died within one week of PEG placement. Fourteen (35%) of these 40 patients had treatment withdrawn. Kaplan-Meier median survival was 412 +/- 73 (mean +/- standard error) days. By Cox proportional hazard modeling, older age, cancer, heart disease, non-white race, and dialysis were significant predictors of post-PEG death (P < 0.05).

CONCLUSIONS

Outcome after PEG is dependent on demographic factors and patient comorbidities. Given the very low initial complication rates, it may be advisable to delay PEG placement until just prior to discharge in order to prevent unnecessary procedures on those patients who are not likely to survive.

Endovascular treatment of traumatic rupture of the thoracic aorta

Background

Traumatic rupture of the thoracic aorta is a life-threatening event. Open surgical repair is the ‘gold standard’, but is associated with high mortality and morbidity rates. Endovascular repair is emerging as a potentially safer alternative.

Methods

A systematic review was performed of all published literature on this subject, including the authors' own experience. Using Sumsearch, PubMed and cross-references, all published reports up to January 2006 were identified, and analysed for injuries, perioperative morbidity, mortality, operating time, hospital stay and follow-up.

Results

A total of 284 patients were identified. Reported mortality rates range from 0 to 6 per cent. The procedure-related mortality rate is about 1·5 per cent. Some 6·7 per cent of all procedures were complicated by endoleak and the overall procedure-related morbidity rate was 14·4 per cent. These results are promising compared with those of open repair, but individual experience is limited and there may be some publication bias.

Conclusion

Endovascular repair of traumatic rupture of the thoracic aorta seems to reduce morbidity and mortality in patients with multiple trauma. Ideally, both devices and experienced personnel should be available in trauma centres.

Long-Term Results of the Endoscopic Atraumatic Coronary Artery Bypass

BACKGROUND

This retrospective study was undertaken to determine the long-term angiographic patency and clinical outcomes of the endoscopic atraumatic coronary artery bypass (endoACAB) procedure.

METHODS

Between November 1997 and March 2005, 607 consecutive patients underwent an endoACAB consisting of (1) unilateral or bilateral manual, thoracoscopic internal mammary artery (IMA) harvesting, (2) creation of a needle-directed access port in the thoracic soft tissue (non-rib-spreading), (3) cardiac positioning and stabilization using port-based instrumentation, and (4) off-pump, direct-vision, hand-sewn anastomoses to the left anterior descending (LAD), diagonal, obtuse marginal, or main right coronary arteries, or a combination. Mean follow-up time was 18.0 +/- 16.0 months (range, 2.0 to 85.7 months).

RESULTS

The IMA was used to graft the LAD in all cases. A total of 721 anastomoses were constructed using 636 conduits. Thirty-day mortality was 1.0% (6/607). A total of 379 (62.4%) had coronary angiography after operation at a mean of 18.4 +/- 17.0 months. The overall patency for the LIMA to LAD was FitzGibbon A, 95.2% (324/340), and FitzGibbon A and B, 98.5% (335/340). At 5 years, event-free survival was 92% +/- 2.4%.

CONCLUSIONS

The clinical outcome and angiographic patency of grafting the LAD with the LIMA off pump through a non-rib-spreading incision compares favorably with the reported data of arrested heart grafting through a median sternotomy. The endoACAB offers an excellent alternative for patients with LAD disease as a stand-alone procedure, a multivessel grafting procedure in selected patients, or as part of a hybrid procedure in conjunction with a percutaneous intervention.

Transanal endoscopic microsurgery: risk factors for local recurrence of benign rectal adenomas

OBJECTIVE

Transanal endoscopic microsurgery (TEM) is a minimally invasive technique for excision of selected benign and malignant rectal neoplasms. It is considered a safe and effective treatment but recurrence rates of 1-13% are reported for benign lesions. The aim of this study was to assess risk factors for local recurrence of benign rectal lesions and to evaluate mortality and morbidity following TEM.

METHOD

Data were prospectively collected from all patients undergoing TEM for benign adenomas from January 1998 to March 2005. The procedure was performed by a single surgeon and patients were regularly followed up.

RESULTS

One hundred and forty-six procedures were included, with a median patient age of 74 years (range 22-92 years). The mean lesion area was 16 cm(2) (range 0.3-150 cm(2)) and the median distance from the dentate line was 9 cm (range 0-17 cm). Immediate complications included bleeding (six) and acute urinary retention (six). There has been one (0.68%) procedure-related death. After a median follow up of 39 months (range 4-89 months) there have been seven recurrences (4.8%), recurring at a mean time of 23.3 months (range 5-48 months). Only microscopic involvement of the circumferential resection margin was found to be significantly associated with recurrence (P = 0.0059). Recurrence was not associated with age, size of lesion, previous treatment, severity of dysplasia or use of the harmonic scalpel.

CONCLUSION

TEM is a safe and effective treatment for benign rectal adenomas. Circumferential resection margin involvement is associated with recurrence, which tends to occur late. Therefore extended follow up is recommended.

Endoscopic management of intracranial cysts

Object

Endoscopic fenestration has been recognized as an accepted treatment choice for patients with symptomatic arachnoid cysts. The success of this procedure, however, is greatly influenced by individual cyst anatomy and location as well as the endoscopic technique used. This review was conducted to assess what variables influence the treatment success for different categories of arachnoid cysts.

Methods

Thirty-three consecutive patients who underwent endoscopic fenestration for treatment of an intracranial arachnoid cyst were identified from a prospective database. The surgical indications and techniques were reviewed, and surgical success rates and patient outcomes were assessed. Specific examples of each cyst category are included to illustrate the technical aspects of endoscopic cyst fenestration.

Endoscopic fenestration of arachnoid cysts was successful when judged by cyst decompression, and symptom resolution was noted in 32 (97%) of 33 cases. The one patient with short-term treatment failure underwent a successful repetition of the operation. There were no surgery-related morbidities or deaths.

Conclusions

Arachnoid cysts are a relatively benign pathological entity that can be managed by performing endoscopically guided cyst wall fenestrations into the ventricular system or cerebrospinal fluid–containing cisterns. Proper patient selection, preoperative planning of endoscope trajectory, use of frameless navigation, and advances in endoscope lens technology and light intensity combine to make this a safe procedure with excellent outcomes.

Perioperative and long-term cardiovascular outcomes in patients undergoing endovascular treatment compared with open vascular surgery for abdominal aortic aneurysm or iliaco-femoro-popliteal bypass

The aim of the present study was to determine the perioperative and long-term cardiac outcomes of patients who underwent elective open or endovascular major vascular surgery corrected for cardiac risk factors and dobutamine stress echocardiography. Consecutive patients who underwent either endovascular (n = 123) or open (n = 560) vascular surgery from 1996 to 2004 at Erasmus Medical Center were enrolled. Patients were screened for cardiac risk factors (advanced age, gender, angina pectoris, myocardial infarction, heart failure, diabetes, stroke, renal failure), cardioprotective medication, and the presence of stress-induced ischemia by dobutamine stress echocardiography. Postoperative data on troponin release and electrocardiography were routinely collected on days 1, 3, and 7 and before discharge. After discharge, patients were regularly screened at the outpatient clinic. The main outcome measures were perioperative and long-term cardiac death and myocardial infarction. The incidence of perioperative cardiac events was significantly less in endovascular-treated patients compared with conventionally treated patients, also after adjustment for clinical risk factors, dobutamine stress echocardiography, and medication (hazard ratio [HR] 0.19, 95% confidence interval [CI] 0.07 to 0.53). In contrast, during long-term follow-up (median 3.8 years, range 0 to 8.4), the incidence of long-term cardiac mortality and myocardial infarction were similar in the 2 groups (HR 0.89, 95% CI 0.52 to 1.52). In conclusion, endovascular stent grafting is associated with a reduced incidence of perioperative complications compared with open vascular surgery. Despite the initial perioperative survival benefit, patients who undergo endovascular surgery remain at high risk for late cardiac events.

Death after late failure of endoscopic third ventriculostomy: a potential solution

OBJECTIVE

Late failure after successful third ventriculostomy is rare, and death caused by failure of a previously successful third ventriculostomy has been reported on four occasions. We describe a simple innovation that adds little morbidity and has the potential to reduce the advent of death after late failure of endoscopic third ventriculostomy.

METHODS

After endoscopic fenestration of the floor of the third ventricle, a ventricular catheter and subcutaneous reservoir are placed via the endoscope path. With acute blockage and neurological deterioration, cerebrospinal fluid can be removed via needle puncture of the reservoir until consultation with a neurosurgeon.

RESULTS

From 1979 to 2003, more than 240 endoscopic third ventriculostomies have been performed at our institution, with one death after late failure. The revised technique was devised after this death and has been performed on 21 patients to date.

CONCLUSION

The addition of a reservoir adds little time and morbidity to the procedure and offers the potential to sample cerebrospinal fluid, measure intracranial pressure, and reduce mortality associated with late failure of endoscopic third ventriculostomy.

Abdominal aortic aneurysmorrhaphy and cholelithiasis in the era of endovascular surgery

The incidence of acute cholecystitis complicating standard abdominal aortic aneurysm (AAA) repair has been reported between 0.3 and 18 per cent. This has prompted considerable debate regarding the management of cholelithiasis discovered incidentally during open aortic reconstruction. This study seeks to determine the incidence of cholelithiasis and acute cholecystitis after endovascular AAA repair and evaluate options for management. Between February 1996 and October 2001 492 patients underwent endovascular AAA repair. All the procedures were performed in the operating room under fluoroscopic guidance. Epidural (98.9%), local (0.5%), or general (1.7%) anesthesia was used during these cases. The incidence of cholelithiasis and acute cholecystitis was evaluated by CT scan and abdominal ultrasound. Serum measurements of alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, total and direct bilirubin, and amylase were performed and clinical assessment was conducted at 1, 6, and 12 months postoperatively and annually thereafter. The mean age of these patients was 76.6 years; 84% were male. Comorbid medical conditions were present in all patients (average 3.5 conditions/patient). Follow-up ranged from 2 to 35 months (mean 12.8 months). Endovascular stent graft deployment was successful in 486 of the 492 patients (98.8%). Six patients were converted to standard open repair because of inability to achieve successful endovascular aneurysm repair. The perioperative major morbidity rate was 14.9 per cent. Minor morbidity rate was 8.5 per cent. The perioperative mortality rate was 1.9 per cent. No deaths were related to biliary disease. Cholelithiasis was identified in 64 (13%) patients preoperatively. One of 64 patients with a prior Billroth II reconstruction for peptic ulcer disease developed jaundice 8 days after AAA repair as a result of choledocholithiasis that required surgical repair. One patient without gallstones developed acute acalculous cholecystitis on postoperative day 16 as determined on pathologic analysis of the gallbladder. A third patient who had gallstones identified on preoperative CT scan developed calculous cholecystitis 16 months after endovascular AAA repair. These two patients underwent uncomplicated laparoscopic cholecystectomy and recovered uneventfully. The incidence of postoperative symptomatic cholelithiasis is 1.6 per cent (one of 64). The incidence of postoperative acute cholecystitis was 0.2 per cent (one of 486) and was unrelated to the presence of gallstones. The incidence of delayed symptomatic cholelithiasis was 1.6 per cent (one of 64). Endovascular repair of AAA does not appear to predispose the patient to the development of symptomatic cholelithiasis during the perioperative period. Therefore a preoperative or intraoperative diagnosis of cholelithiasis does not necessitate cholecystectomy in the setting of planned endovascular AAA repair. Patients who develop cholecystitis after endovascular AAA repair may be effectively treated by standard laparoscopic techniques.

EUS-guided pancreatic pseudocyst drainage: review and experience at Harbor-UCLA Medical Center

Pancreatic pseudocyst, the most common cystic lesion of the pancreas, is a localized collection of fluid rich in amylase within or adjacent to the pancreas and enclosed by a nonepithelialized wall, occurring as a result of acute or chronic pancreatitis, pancreatic trauma, or pancreatic duct obstruction. Currently, at least 3 major forms of therapy are available: percutaneous drainage, surgical intervention, and endoscopic drainage. Controversy exists concerning which of these techniques should be offered to the patient as initial therapy. Three options exist for the surgical management of pancreatic pseudocysts: excision, external drainage, and internal drainage. Surgery, which traditionally was the major treatment approach for pancreatic pseudocysts, has been challenged by newer endoscopic techniques. Given the low complication and mortality rates and the high success rate of endoscopic drainage when compared with surgery, surgical intervention should be reserved only for certain cases. Addition of endoscopic ultrasonography (EUS) for endoscopic drainage is a new and exciting development and may decrease the risks associated with endoscopic drainage. We report our experience of 14 cases of EUS-guided pancreatic pseudocyst drainage and review the literature for advantages and disadvantages of these pancreatic pseudocyst drainage procedures. Complications, recurrence, success, and mortality rates for each procedure are described. Our approach to pancreatic pseudocyst management is described in the form of an algorithm.

Complications of endoscopic third ventriculostomy

OBJECT

The purpose of this prospective investigation was to determine the rate of complications associated with endoscopic third ventriculostomy (ETV).

METHODS

Between March 1993 and October 2001, 193 ETVs were performed in 188 patients at a single institution. The age of the patients ranged from 1 month to 85 years (mean age 39 years). One procedure had to be abandoned because a severe venous hemorrhage blurred the surgeon's view; however, third ventriculostomy was successfully accomplished in that patient 14 days later. In addition, there were two cases in which significant venous hemorrhages could be controlled endoscopically by using irrigation. Postoperative imaging revealed three subdural collections, one tiny thalamic contusion, one cortical hemorrhage at the puncture site, and one severe subarachnoid hemorrhage (SAH). There were two deaths (1% mortality rate) related to the endoscopic procedure; causes of death were one SAH from a torn basilar perforating artery and one wound infection leading to meningitis and septic multiorgan failure. Three permanent deficits occurred (confusion, oculomotor palsy, and diabetes insipidus [1.6% permanent morbidity rate]). Transient deficits included four cases of meningitis, three cases of cerebrospinal fluid leak, two cases of herniation syndrome, two cases of confusion, one case in which there was a decrease of consciousness, two cases of oculomotor palsy, and one case in which there was loss of thirst (7.8% transient morbidity rate). Misplacement of the fenestration was the main reason for severe complications. During the course of the study, the complication rate dropped significantly (no incidences of mortality or permanent morbidity occurred during the last 100 procedures).

CONCLUSIONS

All permanent and fatal complications occurred during the authors' very early experience, indicating that a steep learning curve was associated with the procedure. Endoscopic third ventriculostomy, if performed correctly, is a safe, simple, and effective treatment option for various forms of noncommunicating hydrocephalus.

Endovascular repair of abdominal aortic aneurysms: our early experience

Endovascular repair of abdominal aortic aneurysms (AAA) seems to hold the potential for decreased perioperative mortality and morbidity associated with the standard open repair by eliminating major surgical exposure of the aorta and prolonged aortic cross-clamping. After several years of FDA-approved clinical trials of multiple aortic-stented grafts, the FDA, in September 1999, approved two devices (the ANCURE and the AneuRx) for commercial use in the United States. We implanted the first device in the Tri-State area at the Charleston Area Medical Center (CAMC) on Feb. 6, 2000, and this study reviews our early experiences with 15 patients utilizing these two devices at CAMC.

Safety and efficacy of endoscopic repair of CSF leaks and encephaloceles: a survey of the members of the American Rhinologic Society

The purpose of this article is to review the endoscopic management of cerebrospinal fluid (CSF) leaks and encephaloceles, with particular emphasis on safety and efficacy, by retrospective assessment utilizing the results of a mailed questionnaire. Surveys were mailed to members of the American Rhinologic Society with practices in both academic centers and/or private settings. Survey results were then assessed and tabulated. There were 635 mailings, with 197 responses (31%). Seventy-two (36% of respondents) indicated that they performed endoscopic management of CSF leaks and encephaloceles, while 125 (64% of respondents) did not. Respondents reported approximately 522 cases of CSF leaks and approximately 128 cases of encephaloceles managed by endoscopy. Success rates after a single procedure were estimated at 90% for CSF leaks and 93% for encephaloceles. Success rates after a secondary procedure were estimated at 86% and 97%, respectively; 29% of respondents have, at some point, made a referral to neurosurgery. A total of 13 complications related to endoscopic repairs were reported (2.5%). For CSF leak repair, complications included seizures, 0.2%; meningitis, 1.1%; and one reported case each of cavernous sinus thrombosis, temporary visual problems, sinusitis, and intracranial hypertension/bleed. There was only one reported death in the approximately 522 cases. Eleven complications following encephalocele repairs (8.5%) included seizures, 3.1%; meningitis, 2.3%; and one reported case each of brain abscess, sinusitis, false aneurysm of middle cerebral artery, and mild dizziness. No deaths following encephalocele repair were reported. The endoscopic management of CSF leaks and encephaloceles has become increasingly popular and has proven to have low morbidity and mortality with high success. Overall, our results confirm that in the hands of the skilled endoscopist, endoscopic management of CSF leaks and encephaloceles is highly efficacious and has a very low incidence of significant complication.

An audit of percutaneous endoscopic gastrostomy in a general hospital in Singapore

OBJECTIVE

We conducted an audit on 50 percutaneous endoscopic gastrostomies (PEGs) performed by physician endoscopists from January 1996 up to November 1997.

DESIGN

A retrospective cohort study was conducted.

RESULTS

The mean age of the patients was 68.5 years (range 20-101) and the main indications were cerebrovascular accident in 40 (80%), neurological dysphagia in six (12%) and head injury in three (6%). The interval between the diagnosis of dysphagia and PEG was > 60 days in 19 patients (38%), 31-60 days in eight (16%) and < or = 30 days in 23 (46%). The commonest reason for PEG insertion was intolerance to nasogastric tube in 49 patients (98%). Twelve patients had antibiotics given concurrently for other infections and two had antibiotics given specifically to cover PEG insertion. There was evidence of post-PEG infection in two of 14 patients given antibiotics (14%) and in 14 of 36 patients not given antibiotics (39%). By Cox regression, the adjusted relative risk of infection in patients receiving antibiotics versus those not receiving was 0.6927 (95% CI 0.3396-1.4130; not significant). The 30-day mortality was 7/48 patients (15%), with two patients lost to follow-up before 30 days. There were no deaths directly attributable to PEG.

CONCLUSIONS

PEG is still not adequately requested by doctors for patients needing enteral feeding for more than 30 days. The use of antibiotics in this retrospective cohort study failed to show any benefit in reducing the rate of infective complications.

Endoscopic treatment of early-stage lung cancer

BACKGROUND

Disease-free survival after surgical resection of lung carcinoma in situ has been reported as over 90%. After resection of stage IA non-small cell lung cancer, survival at 5 years is approximately 60% to 70%. If endoscopic or bronchoscopic treatments of early-stage lung cancer can provide similar disease-free survival with less perioperative mortality, morbidity, and cost, then they may be alternative front-line therapies.

METHODS

The authors review early-stage lung cancer detection by fluorescence bronchoscopy and the potential treatment of this disease by endoscopic techniques (photodynamic therapy, brachytherapy, Nd:YAG laser, electrocautery, and cryotherapy).

RESULTS

Several reports have noted improved outcomes using endoscopic therapies for early-stage lung cancer, but insufficient data preclude firm conclusions regarding the role of fluorescence bronchoscopy, endobronchial brachytherapy, or electrocautery in early-stage lung cancer. Other than resection, photodynamic therapy may represent the best approach at this time. The principal indication for laser bronchoscopy is palliation of central airway obstruction.

CONCLUSIONS

The identification of early-stage lung cancer provides no advantage if we have little to offer the patient short of traditional therapy. The value of newer treatment techniques and methods requires verification.

Pericardoscopy for primary management of pericardial effusion in cancer patients

OBJECTIVE

To assess the usefulness of pericardoscopy via the subxyphoid route for the diagnosis and treatment of pericardial effusion in patients with a history of cancer.

METHODS

All patients with a recent or remote history of cancer and a pericardial effusion of unknown origin requiring drainage for diagnostic and therapeutic purposes were included in the study. They underwent complete exploration and cleansing of the pericardial cavity. Abnormal structures or deposits were biopsied under direct visual control, with a 24 cm long rigid pericardoscope.

RESULTS

Between 1985 and 1998, pericardoscopy was completed in 112 of the 114 patients included (feasibility 98%), resulting in the immediate relief of symptoms in all the cases. Peri-operative mortality was 3.5%, and post-operative morbidity, 6.1%. After pericardioscopy pericardial effusions were considered malignant in 43 cases. One more case (2.3%) due to a false negative result of pericardioscopy was diagnosed during follow-up. Overall, 44 of the 114 patients (38.6%) had a malignant effusion, and 70 (61.4%), a non-malignant effusion according the follow up. In 10 of the 44 patients with a malignant pericardial effusion (22.7%), pericardoscopy corrected the results of cytological pericardial fluid studies and pericardial window biopsy, both false negatives. The sensitivities of cytological studies of the pericardial fluid, pathological examinations of pericardial window biopsy and pericardioscopy were 75, 65 and 97%, respectively. One patient with a malignant effusion had a non-symptomatic recurrence 1 month after pericardioscopy (2.3%).

CONCLUSION

We recommend pericardioscopy to ascertain the malignant nature of the effusion and to diminish the recurrence rate, this avoiding repeat procedures in patients with a short life expectancy.

The cost-effectiveness of endovascular repair versus open surgical repair of abdominal aortic aneurysms: A decision analysis model

PURPOSE

Endovascular repair (EVR) is a less-invasive method for the treatment of abdominal aortic aneurysms (AAAs) as compared with open surgical repair (OSR). The potential benefits of EVR include increased patient acceptance, less resource utilization, and cost savings. This study was designed to determine whether the EVR of AAAs is a cost-effective alternative to OSR.

METHODS

A cost-effectiveness analysis was performed using a Markov decision analysis model to compute long-term survival rates in quality-adjusted life years and lifetime costs for a hypothetical cohort of patients who underwent either OSR or EVR. Probability estimates of the different outcomes of the two alternative strategies were made on the basis of a review of the literature. The average costs of (1) the immediate hospitalization ($16,016 for OSR, $20,083 for EVR), (2) the complications that resulted from each procedure, (3) the subsequent interventions, and (4) the surveillance protocol were determined on the basis of average resource utilization as reported in the literature and from our hospital's cost accounting system. Our measure of outcome was the cost-effectiveness ratio.

RESULTS

For our base-case analysis (70-year-old men with 5-cm AAAs), EVR was cost-effective with a cost-effectiveness ratio of $22,826-society usually is willing to pay for interventions with cost-effectiveness ratios of less than $60,000 (eg, cost-effectiveness ratios for coronary artery bypass grafting and dialysis are $9500 and $54,400, respectively). This conclusion did not vary significantly with increases in procedural costs for EVR (ie, if the cost of the endograft increased from $8000 to $12,000, EVR remained cost-effective with a cost-effectiveness ratio of $32,881). The cost-effectiveness of EVR was critically dependent on EVR producing a large reduction in the combined mortality and long-term morbidity rate (stroke, dialysis-dependent renal failure, major amputation, myocardial infarction) as compared with OSR (ie, a reduction in the combined mortality and long-term morbidity rate of OSR from 9.1% to 4.7% made EVR no longer cost-effective).

CONCLUSION

Despite the high cost of new technology and the need for close postoperative surveillance, EVR is a cost-effective alternative for the repair of AAAs. However, the cost-effectiveness of this new technology is critically dependent on its potential to reduce morbidity and mortality rates as compared with OSR. EVR may not be cost-effective in medical centers where OSR can be performed with low risk.

Should endovascular surgery lower the threshold for repair of abdominal aortic aneurysms?

PURPOSE

Because endovascular repair of abdominal aortic aneurysms (AAAs) is less invasive, some investigators have suggested that this increasingly popular technique should broaden the indications for elective AAA repair. The purpose of this study was to calculate quality-adjusted life expectancy rates after endovascular and open AAA repair and to estimate the optimal diameter for elective AAA repair in hypothetical cohorts of patients at average risk and at high risk.

METHODS

A Markov decision analysis model was used in this study. Assumptions were made on the basis of published reports and included the following: (1) the annual rupture rate is a continuous function of the AAA diameter (0% for <4 cm, 1% for 4.5 cm, 11% for 5.5 cm, and 26% for 6.5 cm); (2) the operative mortality rate is 1% for endovascular repair (excluding the risk of conversion to open repair) and 3.5% for open repair at age 70 years; and (3) immediate endovascular-to-open conversion risk is 5%, and late conversion rate is 1% per year. The main outcome measure in this study was the benefit of AAA repair in quality-adjusted life years (QALYs). The optimal threshold size (the AAA diameter at which elective repair maximizes benefit) was measured in centimeters.

RESULTS

The benefit of endovascular repair is consistently greater than that of open repair, but the additional benefit is small-0.1 to 0.4 QALYs. For men in average health with gradually enlarging AAAs with initial diameters of 4 cm, endovascular surgery reduces the optimal threshold diameter by very little: from 4.6 to 4.6 cm (no change) at age 60 years, from 4.8 to 4.7 cm at age 70 years, and from 5.1 to 4.9 cm at age 80 years. For older men in poor health, endovascular surgery reduces the optimal threshold diameter substantially (8.1 to 5.7 cm at age 80 years), but the benefit of repair in this population is small (0.2 QALYs).

CONCLUSION

For most patients, the indications for AAA repair are changed very little by the introduction of endovascular surgery. Only for older patients in poor health does endovascular surgery substantially lower the optimal threshold diameter for elective AAA repair.

Outcomes of surgical, percutaneous endoscopic, and percutaneous radiologic gastrostomies

OBJECTIVES

To evaluate and compare outcomes and complications in patients having undergone gastrostomy by surgical (SG), percutaneous endoscopic (PEG), or percutaneous radiological (PRG) procedure.

DESIGN

Retrospective analysis.

SETTING

University-based tertiary care center.

PATIENTS

Of 82 patients who met inclusion criteria, 14 patients (median age, 40 years) received a surgical tube placement (SG), in 24 patients (median age, 55 years) a PEG procedure was performed, and in 44 patients (median age, 57 years) the tube was placed under fluoroscopic guidance (PRG). Indications for gastrostomy were similar in all groups, representing mainly cancer of the oropharyngeal, head and neck region (51 [61%]) as well as the upper gastrointestinal tract (6 [8%]), neurological disorders (15 [18%]), and others (10 [13%]).

MAIN OUTCOME MEASURES

Catheter function rates, major and minor procedure-related complications, and survival.

RESULTS

Median follow-up was 17.2 months. Ten patients (71%) died in the SG group 7 to 855 days (median, 67 days) after the procedure, 7 patients (29%) died 5 to 263 days (median, 103 days) after PEG placement, and 30 patients (68%) died within 3 to 621 days (median, 112 days) after PRG, of their underlying disease or disease-related complications; 1 procedure-related death occurred 6 days after radiological tube placement. We observed a rate of minor complications of 43% (6 patients), 33% (8), and 36% (16) and a major complication rate of 14% (2 patients), 17% (4), and 11% (5) in the SG, PEG, and PRG groups, respectively. Tube function rates at 1 year were 67% (9 patients) and 68% (20) in the SG and PEG groups, respectively, and 10% lower (39) in the PRG group, although the difference was not statistically significant.

CONCLUSIONS

There is no major difference between SG, PEG, and PRG concerning procedure-related complications. Tube function tends to be inferior after radiological tube placement.

Endoscopic stereotaxy--an eight year's experience

During the 10th meeting of the WSSFN in Maebashi in 1989, we discussed 'endoscopic stereotaxy', and presented our preliminary results. This technique was first designed to optimize stereotactic biopsy, but it proved to be effective for other neurosurgical indications as well, including endoscopic stereotactic evacuation of intraparenchymal and intraventricular space-occupying cysts, endoscopic stereotactic cystoventriculostomy, third ventriculostomy, evacuation of brain abscess and intracerebral hematoma, and retrieval of adherent or free-floating ventricular catheters. Our results with endoscopic stereotaxy in different indications are encouraging, compared to conventional microsurgical techniques and pure stereotactic techniques. From 1989 to 1997 we have performed more than 400 stereotactic endoscopic procedures. The mortality rate is below 1%, the operative morbidity is below 3%.

Long-term results of endoscopic treatment of biliary duct obstruction due to pancreatic disease

BACKGROUND/AIMS

Endoscopic stenting has become an established method of providing palliative treatment in cases of malignant biliary obstruction, as well as in benign biliary stenosis. Several problems associated with the types of stent used have not yet been resolved, and an ideal stent has yet to be designed. Observation of the clinical course for patients with biliary obstruction of various etiologies, and evaluation of the results with various treatment methods are the aims of this study.

METHODOLOGY

In 1993 and 1994, biliary obstruction was treated endoscopically in 47 patients with a malignant pancreatic tumor and in 18 patients with chronic pancreatitis. The primary intervention was assessed retrospectively on the basis of the patients' records, and information concerning the clinical course was obtained by contacting the patients or their relatives or general practitioners.

RESULTS

Primary endoscopic drainage was successful in all cases. Only one of the patients with pancreatic tumors is still alive; survival after stent placement averaged 6.2 months. Metal stents remained patent significantly longer than plastic stents and percutaneous transhepatic biliary drains (PTBDs)(8.2 versus 3.5 or 1.9 months; p < 0.001). In cases of chronic pancreatitis, three of the nine patients who received only endoscopic treatment, without stenting, were able to continue without stents in the longer term, whereas seven of the nine who underwent surgery had no further problems.

CONCLUSIONS

Endoscopic drainage of biliary obstruction provides excellent short-term results. In long-term treatment for purely palliative purposes, metal stents remain patent for longer than plastic stents. In chronic pancreatitis, surgical treatment clearly seems to provide better long-term results than endoscopic therapy.

Respiratory management and outcome of non-malignant tracheo-bronchial fistula following esophagectomy

Tracheo-bronchial lesions with air leak are rare but a catastrophic complications of esophageal resections. We analyzed the management and outcome of 31 patients who developed a non-malignant lesion of the trachea or main stem bronchus after esophagectomy for esophageal cancer. All patients initially required endotracheal intubation to control respiratory distress. A modified respiratory therapy with a reduced tidal volume and high respiratory rate markedly decreased the air leakage from 2.8 to 1.1/min (P < 0.001). Early extubation was possible in 23 patients with a complete healing or decrease of the fistula size. Jet ventilation, endoluminal stenting of the fistula, bronchoscopic fibrin sealing of the fistula, and surgical closure of the fistula with a muscular pedicle flap were attempted with variable success in patients with otherwise not manageable air leaks. Ten of the 31 patients (33%) died during the postoperative course, in eight out of 10 patients, postoperative mortality resulted from an unhealed lesions at the bifurcation or in the left main stem bronchus. These data show that reduction of airway pressure and spontaneous breathing are the key to closure of the airway leak. The entire armamentarium of respiratory, bronchoscopic, and surgical techniques must be available for a successful management of these patients.

TEM--minimal invasive therapy of rectal cancer?

The aim of this study is to outline the use of transanal endoscopic microsurgery (TEM) for local excision of rectal carcinoma. Thus the clinical and long-term results regarding endorectal excision of the rectal lesions at the University Hospital of Cologne and Berlin will be presented. During the period July 1983 till December 1993 the system has been employed on 405 cases (17.8% carcinomas) at the University Hospital of Cologne and on 60 cases (20% carcinomas) during the period September 1994 till September 1996 at the University Hospital of Berlin, Charité. Early postoperative complications consisted of intraperitoneal perforations (five cases); rectovaginal fistulas (four cases); haemorrhages (four cases), death due to cardiopulmonary failure (two cases). All the complications occurred within the first 4 years of the learning phase. The cancer-specific 3-year survival rate of patients with "low risk" pT1 cancers amounted to 91%. Two recurrences after local excision of pT1 cancers occurred 1 year postoperatively, which were treated successfully using the TEM system. Most of the histologic findings of the subsequent radical operations following local resections of infiltrative rectal cancers revealed that the carcinoma had already been totally removed. The main indication for TEM is the removal of sessile adenomas. Early rectal carcinomas (pT1) of the "low risk" type, with favourable histological grading (grade 1 and 2) and clinical staging (CS I) were also considered for endorectal therapeutical approach. Even though our initial results do show encouraging results, regarding endorectal excision of pT2 cancers, more experience is needed to clarify the indication for locally amenable pT2 cancers of the "low risk" type and rule out the role of adjuvant therapy after complete excision of these carcinomas. The indication for TEM encloses also confined (< 4 cm) infiltrative cancers (> pT1) in cases where the patient is unwilling to undergo extensive surgery or due to medical reasons. The technique allows accurate endoscopic microsurgical excision of early cancers for cure with minimal morbidity and excellent presentation of specimen for complete histological analysis. Diligent follow-up is mandatory, since most (60-80%) of local recurrences can be treated successfully. Thus demolitive surgery can be avoided in selected cases with rectal cancer.

A new method of endoscopic mucosal resection of neoplastic lesions in the stomach: its technical features and results

BACKGROUND/AIMS

In gastric cancer, endoscopic treatment can be expected to provide an absolute cure only if the lesion is mucosal and not accompanied by metastatic lymph nodes. To further evaluate such possibly curable lesions, we retrospectively reviewed 208 cases of early gastric cancer surgically resected over the past 20 years.

METHODOLOGY

Our new method of endoscopic mucosal resection using a cap-fitted panendoscope, which is called EMRC, has been employed in the treatment of 73 gastric neoplastic lesions.

RESULTS

It was found that curable lesions would, as the primary condition, be histologically well-differentiated carcinomas and measure 2 cm or less of the elevated type and less than 1 cm of the depressed type. The lesions were consequently identified as 49 early cancers (46 mucosal, 3 submucosal), 23 adenomas and 1 carcinoid. Although resection was completed in a single session of EMRC treatment in all cases, approximately 40% of them required fractionated resection, leaving an ulcer measuring 3 cm or more in approximately 30%. Bleeding or muscle resection occurred in 7 patients, in whom conservative treatment was effective. No recurrence has been found in any of the 73 lesions, demonstrating a favorable outcome.

CONCLUSIONS

This method is advantageous in that it is simple and relatively easily applied at almost any location within the stomach. In addition, the size of the specimen obtained by en bloc resection is approximately 2 cm. The method is thus fairly likely to come into widespread use.

[The endoscopic treatment of extensive urethral strictures and obliteration of the urethra and bladder neck]

Extensive urethral strictures, obliteration of the urethra and bladder cervix are thought to be the most complicated urological diseases. They occur more frequently in young and middle-aged persons consequently to pelvic and perineal traumas or they are complications of surgical interventions. Open surgery often cause complications such as suppuration of the operative wound, emergence of urinary fistulas, enuresis, recurrence of the structure or obliteration. Negative results of these operations are also shortening of the penis, erectile dysfunction causing serious social dysadaptation. Current advances in endoscopic instruments and imaging provided design of endoscopic techniques able to represent an effective alternative to open surgical interventions in urethral strictures, obliteration of the urethra and bladder cervix. The experience gained in the Clinic of the Research Institute of Urology in the practice of updated and novel endoscopic interventions aimed at recovery of urethral patency (strictures longer than 1 cm--inner optic urethrotomy, obliteration of the urethra and bladder cervix--endoscopic recanalization) has proved the advantages of the endoscopic techniques over open operative interventions. They are most cost-effective, result in better outcomes, bring about no erectile dysfunction.

Endoscopic palliation of malignant obstructive jaundice using resterilized accessories: an audit of success, complications, mortality and cost

OBJECTIVE

To assess the success, complications and cost of endoscopic endoprosthesis placement for palliation of obstructive jaundice caused by malignancy.

METHODS

Four hundred and two consecutive patients with obstructive jaundice due to nonresectable malignancy undergoing endoscopic stenting were studied. Commercial or home-made 7F or 10F endoprostheses were placed using minor modifications of the standard technique. The accessories were sterilized and reused.

RESULTS

Endoprosthesis placement was successful in 291 patients (72.4%, 95% CI 67.7-76.7)-241 in one attempt, 49 in two attempts, and one in three attempts. Fifty nine patients (14.6%, 95% CI 11.4-18.6) had procedure-related complications, including cholangitis (30), pancreatitis (15), perforation (3) and bleeding (11). The incidence of cholangitis was significantly higher in bifurcation blocks than in other lesions (17.6% vs 4.7%, p = 0.0005). The success rate did not differ between distal and proximal lesions (68.1% vs 72.9%). The procedural cost per patient could be reduced from Rs 14,850 to Rs 6565 by reusing accessories after sterilization, and using home-made stents.

CONCLUSIONS

Endoscopic endoprosthesis placement is a safe and effective method for palliation of malignant obstructive jaundice. Preparation of indigenous stents and reuse of accessories can reduce the cost of the procedure by over 50%.

Endoscopic microsurgical dissection of the esophagus (EMDE)

This paper presents endoscopic microsurgical dissection of the esophagus (EMDE), a surgical technique for the therapy of esophageal cancer which improves blunt esophageal dissection with the aim of reducing postoperative morbidity and mortality. A mediastinoscope with integrated operative instrument channel, fibre bundles, optic and rinsing channel has been developed whereby precise and atraumatic esophageal dissection is possible via a cervical access incision. Between 1989 and 1993, 37 patients were operated on using the EMDE technique and are compared with 48 patients operated on during the same period by the thoraco-abdominal route. The operative duration was reduced by the new technique, and although the number of severe complications was not significantly different between both groups, the rate of pulmonary and cardiac complications was reduced. The mortality rate was 10% for EMDE patients and 14% for the thoraco-abdominal procedure, and there was no difference in the long-term survival rate. As distinct from procedures requiring a thoracotomy for esophageal dissection, EMDE permits ventilation of both lungs throughout the entire operation and reduces the total operative trauma.

Surgery in primary supratentorial intracerebral hematoma: a meta-analysis of randomized trials

OBJECTIVES

To examine through a meta-analysis whether a treatment strategy of surgery plus the routine medical management saves lives and reduces disability in survivors of primary supratentorial intracerebral hematoma compared to routine medical management alone.

MATERIAL AND METHODS

Computerized bibliographic search of published research, conference proceedings, monographs and experts yielded 373 articles, of which only four were randomized trials. The methodological quality of the trials was assessed by two observers (weighted kappa = 0.8). Two independent reviewers abstracted the data on patient sample, type of surgery and outcomes in terms of death and dependence versus independence. Based on the nature of the intervention and the results of test for homogeneity, we analyzed the results of craniotomy and endoscopic evacuation separately.

RESULTS

Review of the three trials of craniotomy suggests that it increases the risk of death or dependence (pooled risk difference 13%, 95% CI 3% to 23%), though the study with the largest sample size was conducted in the pre-CT period. Reanalysis of the endoscopic evacuation trial data showed decrease in risk of death or dependence (risk difference -18%, 95% CI -36% to 0%), the effect being similar across the different subgroups of patients according to the site of hematoma, but probably larger in patients aged less than 60 years or hematoma size of more than 50 cc.

CONCLUSIONS

The role of craniotomy and stereotactic surgery has not been adequately studied in randomized trials. The results of a single trial suggest that endoscopic evacuation is a promising form of treatment in patients with primary supratentorial intracerebral hematoma, but this finding needs confirmation in a larger trial.

Complications of surgical endoscopy. A decade of experience from a surgical residency training program

BACKGROUND

This study examines the notion that gastrointestinal endoscopy performed by supervised surgical residents is safe.

METHODS

We reviewed all gastrointestinal endoscopic procedures performed by surgical residents with faculty supervision for complications and deaths occurring up to 30 days following the procedures.

RESULTS

The overall complication rate for 9,201 upper and lower endoscopy procedures was 1.4% and 0.42%, respectively. Overall mortality rate was 0.76% for upper endoscopy and 0.6% for lower endoscopy. No mortality was a direct result of a procedure-related complication. Intestinal perforation, drug overdose, bleeding, and aspiration were the most common procedure-related complications. Each resident completed an average of 75 upper endoscopies and 79 lower endoscopies during their training period.

CONCLUSIONS

Gastrointestinal endoscopy can be performed safely by surgical residents with appropriate supervision. The higher morbidity and mortality of upper endoscopy are most likely related to the underlying disease rather than the procedure. Awareness of common complications and application of appropriate precautions and instruction are critical for minimizing complications.

Percutaneous endoscopic gastrostomy: a randomized prospective comparison of early and delayed feeding

BACKGROUND

It has been customary to initiate feeding through percutaneous endoscopic gastrostomy (PEG) tubes 24 hours or more after placement of these tubes. Recent changes in practice environment and emphasis on early discharge of hospitalized patients prompted us to evaluate early PEG feeding in a randomized prospective manner.

METHODS

Forty-one patients were included in the study. After an informed consent, the patients were randomly assigned to two groups. Groups I (21 patients) received tube feedings 3 hours and Group II (20 patients) received feedings 24 hours after PEG placement. All patients received an Iso-osmolar formula by continuous infusion at 30 ml/hour for the first 24 hours of feeding. The rates were then increased to 70 ml/hour. Residual volumes, tube length, peristomal leakage, and vital signs were checked, and a global assessment was done every 4 hours. Evaluation by a physician was done every 24 hours for 72 hours. If the residual volume was more than 60 ml (significant residual volume), the tube feedings were held for 2 hours. Patients exited the study at 72 hours from the time of procedure. All deaths were recorded to calculate 30-day mortality.

RESULTS

One patient (Group 2) died during the study period. Three patients (two in Group 1 and one in Group 2) had a significant residual volume. One patient (Group 1) had local skin infection requiring treatment. None of the patients had any signs of peritonitis or systemic infection.

CONCLUSION

Early PEG tube feeding (3 hours after tube placement) is as safe as next day feeding in elderly patients.

Morbidity and mortality after thoracoscopic pneumonoplasty

BACKGROUND

Both video-assisted thoracic surgery and open pneumonoplasty procedures have been used to achieve lung reduction in emphysema patients.

METHODS

The surgical and hospital course of 339 patients with a mean forced expiratory volume in 1 second of 750 mL and a mean ratio of forced expiratory volume in 1 second to forced vital capacity of 35% undergoing video-assisted thoracic surgical laser pneumonoplasty was analyzed.

RESULTS

The incidence of myocardial infarctions was 0.9% and the hospital mortality rate was 4.1%.

CONCLUSIONS

Factors leading to increased morbidity and mortality were advanced age (65 years and greater, especially greater than 75 years), sex (men greater than women), carbon dioxide retention in the resting state (especially an arterial carbon dioxide tension greater than 55 mm Hg), forced expiratory volume in 1 second less than 700 mL for men and 500 mL for women, maximum voluntary ventilation less than 25% predicted, and a ratio of residual volume/total lung capacity greater than 60%.

Complications of video-assisted thoracic surgery: a five-year experience

BACKGROUND

Although thoracoscopy was originally described in 1910, recent developments in video-assisted surgical techniques and endoscopic equipment has expanded the application of video-assisted surgical procedures in the field of thoracic surgery.

METHODS

In an effort to define both high-risk patients for video-assisted thoracic procedures and high-risk video-assisted thoracic surgical procedures, we reviewed the experience of four surgical institutions from June 1991 through May 1995. We looked specifically at complications resulting from the 937 video-assisted thoracic procedures performed during this period.

RESULTS

Perioperative incidents or complications occurred in 35 patients (3.7%), and 116 procedures (12.4%) were converted to a thoracotomy. The in-hospital mortality rate was 0.5%, and death occurred principally in patients operated on for malignant pleural effusion. The overall incidence of postoperative complications was 10.9%, and the most prevalent complications were prolonged air leak (6.7%) and pleural effusion (0.7%).

CONCLUSIONS

The incidence of complications was acceptable and, except for that of prolonged air leak, did not differ significantly from that resulting from analogous open procedures. Video-assisted thoracic surgery appears safe and particularly useful for some indications. However, the possibility of dramatic life-threatening perioperative complications requiring emergency conversion to thoracotomy justifies the fact that only trained thoracic surgeons should perform video-assisted thoracic surgical procedures.

Complications and failures of video-assisted thoracic surgery: experience from two centers in Asia

BACKGROUND

There have been few specific reports on negative outcomes after video-assisted thoracic surgery. We report our combined experience from two centers in Asia.

METHODS

From September 1992 to April 1995, 1,337 patients were operated on with the video-assisted thoracic surgical approach. All the patients were prospectively studied.

RESULTS

There was one death (mortality rate, 0.07%) and 56 nonfatal complications: persistent air leaks (21), bleeding (6), wound infection (13), empyema (2), cerebrovascular accident (1), reexpansion pulmonary edema (2), deep vein thrombosis (1), prolonged ventilatory support (4), intercostal neuralgia (5), and port-site recurrence (1), giving rise to an overall nonfatal complication rate of 4.26%. Procedure failures consisted of 7 recurrences of spontaneous pneumothorax (of 407 cases or 1.7%); 2 recurrences of malignant pleural effusion (of 39 cases or 5.1%), and 2 local recurrences after resections for stage I lung cancers (of 41 cases or 4.9%).

CONCLUSIONS

We conclude that video-assisted thoracic surgery is safe and effective for a wide range of procedures. A learning curve is present, and careful patient selection and attention to details are essential in optimizing surgical results.

[Risk of laparoscopic surgery. 100 records of complications. A qualitative study]

A total of 100 accidents occurring during laparoscopic surgery between 1969 and 1993 were studied. Fifty-five of the cases concerned gynaecology surgery over a 24 year period. The other 45 concerned digestive surgery over a 5 year period (1989-1993). The surgical risk was not statistically greater compared with open surgery. Overall morbidity was 1%. Overall mortality was 0.5/1000. A more precise statistical analysis was recently reported. The examination of the 100 cases was qualitative rather than quantitative. The study demonstrated an imbalance between age (mean age 38 years) in patients with major pathology initially and the gravity of the induced accidents: 26 deaths for 100 observations. These deaths were related to technology trocar, capnoperitoneum, electrocoagulation. Technical skill, cautiousness, vigilance and humility are qualities the surgeon must have to perform successful operations. The irreversible acceleration of the new surgical technique should not cloud the basic precepts of sound surgical technique.

[Incidents and complications of therapeutic thoracoscopy. Apropos of 898 operated patients]

The exceptional interest in endoscopic surgery, both in laparoscopic surgery and video-assisted thoracoscopic surgery have led many teams to widen their indications. This movement has developed into a revolution in techniques demanded by patients, the public, and the medias, requiring many practicians to use these techniques more and more often and consequently to attempt very delicate operations. This "explosion" of endoscopic techniques has largely benefited from advances in equipment development (optics, video instrumentation) but has also required that operators acquire rigorous procedures for the proposed techniques. With the development of new thoracoscopic techniques for therapeutic indications, there are an unavoidable number of incidents and complications. These incidents and complications are related both to the use of instruments undoubtedly not well enough adapted to the procedures used and also to "forced" indications. We humbly recognize that a certain number of incidents are related to the necessarily inadequate experience of the operators during the "run in" period. We emphasize that video-assisted thoracoscopic surgery is a complementary technique among the available therapeutic armamentarium. We evaluated the mid and long term results of cancerology exeresis with these two techniques and underscore that morbidity and complications are rare but sometimes unacceptable. In conclusion, whatever the form of the technique used, it is an important evolution in surgery which must abide by the classical rules, in particular for indications in cancer surgery.