Trends in Endoscopic and Microscopic Approaches to Transsphenoidal Pituitary Surgery in the US

OBJECTIVES

Among the transsphenoidal (TSS) approaches to pituitary tumors, the microscopic approach (MA) has historically been the predominant technique with the increasing adoption of the endoscopic approach (EA). This study investigates national trends in TSS approaches and postoperative outcomes for MA and EA through 2021.

METHODS

The TriNetX database was queried for patients undergoing TSS (MA and EA) between 2010 and 2021. Data were collected on demographics, geographic distribution of surgical centers, postoperative complications, stereotactic radiosurgery (SRT), repeat surgery, and postoperative emergency department (ED) visits.

RESULTS

8644 TSS cases were queried between 2010 and 2021. MA rates were highest until 2013 when rates of EA (52%) surpassed MA (48%) and continued to increase through 2021 (81%). From 2010 to 2015 EA had higher odds of a postoperative CSF leak (OR 3.40) and diabetes insipidus (DI (OR 2.30)) versus MA (p < 0.05); from 2016 to 2021 differences were not significant. Although there was no significant difference among approaches from 2010 to 2015 for syndrome of inappropriate antidiuretic hormone (SIADH), hyponatremia, or bacterial meningitis, from 2016 to 2021 EA had lower odds of SIADH (OR 0.54) and hyponatremia (OR 0.71), and higher odds of meningitis (OR 1.79) versus MA (p < 0.05). EA had higher odds of additional surgery (either EA or MA) after initial surgery from 2010 to 2021. From 2010 to 2015 EA had lower odds of postoperative SRT compared to MA, whereas in 2016-2021 there was no statistical difference among approaches.

CONCLUSION

This study demonstrates increasing EA adoption for TSS in the United States since 2013. Complication rates have overall improved for EA compared to MA, potentially as a result of improving surgeon familiarity and experience.

LEVEL OF EVIDENCE

4 Laryngoscope, 133:2135-2140, 2023.

Endoscopic Lateral Neck Dissection: A New Frontier in Endoscopic Thyroid Surgery

Background

Endoscopic thyroidectomy and robotic thyroidectomy are effective and safe surgical options for thyroid surgery, with excellent cosmetic outcomes. However, in regard to lateral neck dissection (LND), much effort is required to alleviate cervical disfigurement derived from a long incision. Technologic innovations have allowed for endoscopic LND, without the need for extended cervical incisions and providing access to remote sites, including axillary, chest-breast, face-lift, transoral, and hybrid approaches.

Methods

A comprehensive review of published literature was performed using the search terms "lateral neck dissection", "thyroid", and "endoscopy OR endoscopic OR endoscope OR robotic" in PubMed.

Results

This review provides an overview of the current knowledge regarding endoscopic LND, and it specifically addresses the following points: 1) the surgical procedure, 2) the indications and contraindications, 3) the complications and surgical outcomes, and 4) the technical advantages and limitations. Robotic LND, totally endoscopic LND, and endoscope-assisted LND are separately discussed.

Conclusions

Endoscopic LND is a feasible and safe technique in terms of complete resection of the selected neck levels, complications, and cosmetic outcomes. However, it is recommended to strictly select criteria when expanding the population of eligible patients. A formal indication for endoscopic LND has not yet been established. Thus, a well-designed, multicenter study with a large cohort is necessary to confirm the feasibility, long-term outcomes, oncological safety, and influence of endoscopic LND on patient quality of life (QoL).

Ambulatory Endoscopic Thyroidectomy via a Chest-Breast Approach Has an Acceptable Safety Profile for Thyroid Nodule

INTRODUCTION

With the growing esthetic requirements, endoscopic thyroidectomy develops rapidly and is widely accepted by practitioners and patients to avoid the neck scar caused by open thyroidectomy. Although ambulatory open thyroidectomy is adopted by multiple medical centers, the safety and potential of ambulatory endoscopic thyroidectomy via a chest-breast approach (ETCBA) is poorly investigated.

MATERIAL AND METHODS

Patients with thyroid nodules who received conventional or ambulatory ETCBA at Xiangya hospital, Central South University from January 2017 to June 2020 were retrospectively included. The incidence of postoperative complications, 30-days readmission rate, financial cost, duration of hospitalization, mental health were mainly investigated.

RESULTS

A total of 260 patients were included with 206 (79.2%) suffering from thyroid carcinoma, while 159 of 260 received ambulatory ETCBA. There was no statistically significant difference in the incidence of postoperative complications (P=0.249) or 30-days readmission rate (P=1.000). In addition, The mean economic cost of the ambulatory group had a 29.5% reduction compared with the conventional group (P<0.001). Meanwhile, the duration of hospitalization of the ambulatory group was also significantly shorter than the conventional group (P<0.001). Patients received ambulatory ETCBA showed a higher level of anxiety (P=0.041) and stress (P=0.016). Subgroup analyses showed consistent results among patients with thyroid cancer with a 12.9% higher complication incidence than the conventional ETCBA (P=0.068).

CONCLUSION

Ambulatory ETCBA is as safe as conventional ETCBA for selective patients with thyroid nodules or thyroid cancer, however with significant economic benefits and shorter duration of hospitalization. Extra attention should be paid to manage the anxiety and stress of patients who received ambulatory ETCBA.

Endoscopic treatments prior to urethroplasty: trends in management of urethral stricture disease

BACKGROUND

To determine if the number of endoscopic treatments of urethral stricture disease (USD) prior to urethroplasty has changed in the context of new AUA guidelines on management of USD. In addition to an increase in practicing reconstructive urologists and published reconstructive literature, the AUA guidelines regarding the management of male USD were presented in May 2016, advocating consideration of urethroplasty in patients with 1 prior failed endoscopic treatment.

METHODS

A retrospective review of a prospectively maintained, multi-institutional urethral stricture database of high volume, geographically diverse institutions was performed from 2006 to 2017. We performed a review of relevant literature and evaluated pre-urethroplasty endoscopic treatment patterns prior to and after the AUA male stricture guideline.

RESULTS

2964 urethroplasties were reviewed in 10 institutions. There was both a decrease in the number of endoscopic treatments prior to urethroplasty in the pre-May 2016 compared to post-May 2016 cohorts both for overall urethroplasties (2.3 vs 1.6, P = 0.0012) and a gradual decrease in the number of pre-urethroplasty endoscopic treatments over the entire study period.

CONCLUSION

There was a decrease in the number of endoscopic treatments of USD prior to urethroplasty in the observed period of interest. Declining endoscopic USD management is not likely to be a reflection of a solely unique influence of the guidelines as endoscopic treatment decreased over the entire study period. Further research is needed to determine if there will be a continued trend in the declining use of endoscopic treatment and elucidate the barriers to earlier urethroplasty in patients with USD.

Cocktail Treatment with a Gelatin Sponge Impregnated with Ropivacaine, Dexamethasone, and Vitamin B12 Promotes Early Postoperative Recovery after Percutaneous Endoscopic Lumbar Discectomy: A Retrospective, Case-Controlled Study

BACKGROUND

Percutaneous endoscopic lumbar discectomy (PELD) can only relieve mechanical compression but cannot directly reduce the inflammatory reaction of the adjacent nerve root, which contributes to persistent pain and physical disabilities postoperatively. Numerous studies have explored the application of epidural steroids after an open lumbar discectomy in relieving pain by reducing local inflammatory reactions and further peridural scar formation.

OBJECTIVES

To explore that whether "cocktail treatment" in which a gelatin sponge was impregnated with ropivacaine, dexamethasone, and vitamin B12 promoted early postoperative recovery after PELD.

STUDY DESIGN

Retrospective, case-controlled study.

SETTING

All data were from Hong-Hui Hospital in Xi'an.

METHODS

Between January 2016 and January 2017, 100 patients of single-level lumbar disc herniation were treated with PELD in our hospitals. The cocktail treatment was applied in the first 50 patients (group cocktail), and an equal size gelatin sponge without drugs was used in the other 50 patients as control (group noncocktail). The clinical outcome evaluation included the Visual Analog Scale (VAS) score for back and leg pain and Oswestry Disability Index (ODI) score.

RESULTS

There was a significant difference in the mean periods of return to work (4.25 ± 1.88 weeks in the cocktail group and 5.18 ± 2.19 weeks in the noncocktail group) (P < 0.01). Compared with the preoperative data, a significant improvement in VAS scores of back pain and sciatica and ODI were observed in each follow-up interval (P < 0.05, respectively). In the noncocktail group, there were visible fluctuations in the 3 indicators within the first week after surgery. This phenomenon was not observed in the cocktail group, a difference that was statistically significant (P < 0.05, respectively). In further follow-up, no significant differences were observed between the 2 groups (P > 0.05, respectively).

LIMITATIONS

The nonrandomized, single-center, retrospective design is a major limitation of this study.

CONCLUSIONS

The "cocktail treatment" with a gelatin sponge impregnated with ropivacaine, dexamethasone, and vitamin B12 promotes early and satisfactory back and leg pain relief and fast functional recovery after PELD.

KEY WORDS

Endoscopic lumbar discectomy, lumbar disc herniation, steroids, nerve root block, gelatin sponge.

Endoscopic versus external dacryocystorhinostomy: temporal and regional trends in the United States Medicare population

Purpose: Endoscopic surgeries, such as dacryocystorhinostomy (DCR), are increasingly performed for orbital and lacrimal conditions. This study describes and compares recent trends in endoscopic DCR with open, or external, DCR in the United States (US). Methods: Medicare-Part-B National Summary data files were analyzed from 2000 to 2015 for temporal and geographic trends in endoscopic and external DCR. Medicare Physician and Other Supplier public use files detailing provider information were collected and analyzed from 2012 to 2015. Results: Between 2000 and 2015, the number of external DCRs remained relatively unchanged (8008 to 7086, -0.7% average annual growth), while the number of endoscopic DCRs steadily increased (881 to 1674, 4.6% average annual growth). The greatest number of endoscopic DCRs were performed in the South Atlantic region, whereas the Mountain region had the greatest number per capita. From 2000 to 2015, the average payment per procedure for external DCR was $526.63, compared with $512.45 for endoscopic DCR. Of endoscopic DCRs performed from 2012 to 2015, 831 (79%) were performed by Ophthalmology, 184 (18%) were performed by Otolaryngology, and the remainder by other subspecialties. Conclusions: The number of endoscopic DCR surgeries increased over the last 15 years while the number of external DCR surgeries remained stable and continued to surpass endoscopic procedures. While ophthalmologists perform the overwhelming majority of endoscopic DCR, otolaryngologists are performing a growing number.

A comparison of the risk of postoperative recurrence between African-American and Caucasian patients with Crohn's disease

BACKGROUND

Many patients with Crohn's disease will develop complications that require surgery. Recurrence after surgery is common.

AIM

To assess racial differences in postoperative recurrence between African-Americans and Caucasians.

METHODS

Medical records of Crohn's disease patients who underwent surgery (ileal, colonic, or ileocolonic resection) between June 2014 and June 2016 were reviewed. The primary endpoints were clinical and endoscopic remission at 6-12 months after a Crohn's disease surgery. Secondary outcomes included biological and histologic remission. Risks of recurrence were assessed by univariate, multivariate, and propensity score-matched analysis.

RESULTS

Thirty-six African-American and 167 Caucasian patients with Crohn's disease were included for analysis. There was no difference in disease location, disease behaviour, type of surgery performed, and pre- or postoperative medication use between the two groups. The rate of endoscopic remission did not differ between African-American and Caucasian patients (50% vs 42%, P = 0.76), and race did not influence the risk of endoscopic recurrence on univariate, multivariate, or propensity score-matched analysis. The rate of clinical remission was significantly lower in African-American patients compared to Caucasian patients (36% vs. 63%, P = 0.008). African-American race was significantly associated with clinical recurrence on univariate (odds ratio (OR) 6.76, 95% CI 1.50-30.40; P = 0.01), multivariate (OR 5.02, 95% CI 1.60-15.80; P = 0.006), and propensity-matched analysis (68% vs. 32% in Caucasians, P = 0.005). Rates of biologic and histologic remission were similar between the two groups on all analyses.

CONCLUSIONS

We found that African-American patients with Crohn's disease have a similar degree of objective measures of mucosal inflammation after surgery including endoscopic recurrence as compared to Caucasian patients. However, African-American race was significantly associated with clinical recurrence, suggesting the presence of ethnic variation in postoperative presentation in Crohn's disease.

Devices and Endoscopic Bariatric Therapies for Obesity

PURPOSE OF REVIEW

In this review, we describe the FDA-approved and investigational devices and endoscopic bariatric therapies for the treatment of obesity. We focus on literature published in the past few years and present mechanisms of action as well as efficacy and safety data.

RECENT FINDINGS

Devices and endoscopic procedures are emerging options to fill the significant treatment gap in the management of obesity. Not only are these devices and procedures minimally invasive and reversible, but they are potentially more effective than antiobesity medications, often safer for poor surgical candidates and possibly less expensive than bariatric surgery. As many patients require a variety of management strategies (medications, devices, procedures, and/or surgery) in addition to lifestyle modifications to achieve clinically significant weight loss, the future of obesity treatment involves a multidisciplinary approach. Combinations of advanced treatment strategies can lead to additive or synergistic weight loss. This is an area that requires further investigation.

The Recovery of Motor Strength after Posterior Percutaneous Endoscopic Cervical Foraminotomy and Discectomy

OBJECTIVE

Cervical radiculopathy infrequently presents with motor weakness. Motor weakness was improved in >90% of patients after anterior cervical discectomy and fusion or posterior cervical foraminotomy. Posterior percutaneous endoscopic cervical foraminotomy and discectomy (PECF) is an alternative surgical technique, but the outcome of motor weakness has not been reported. Our objective was to demonstrate the longitudinal outcomes of motor weakness after PECF.

METHODS

A retrospective review of 106 consecutive patients was performed. Preoperative motor weakness was graded as mild (IV/V strength) or severe (less than III/V strength). The patients visited the outpatient clinic at 1, 3, 6, and 12 months after surgery and yearly thereafter. Improvement was defined as an improved weakness of more than 1 grade, and normalization was defined as the recovery of complete motor strength.

RESULTS

Motor weakness preoperatively presented in 76 of 106 (72%) patients (49%, mild weakness; 23%, severe weakness). After PECF, the weakness improved in 72 of 76 (95%) patients and normalized in 65 of 76 (86%) patients. In the patients with mild weakness, the normalization rates were 48%, 81%, 90%, and 96% at postoperative months 1, 3, 6, and 12, respectively. In the patients with severe weakness, the improvement rates were 50%, 71%, 83%, 88%, and 92%, and the normalization rates were 8%, 38%, 58%, 58%, and 63% at postoperative months 1, 3, 6, 12, and 24, respectively.

CONCLUSIONS

Preoperative motor weakness was improved in 95% of the patients after PECF, but motor weakness was not normalized in 37% of the patients with severe weakness.

Endoscope Holders in Cranial Neurosurgery: Part 2-An International Survey

BACKGROUND

Following a previous systematic review of currently available endoscope holders (EHs), we aspired to detect trends, task-specific preferences, and pitfalls of EH in various cranial neuroendoscopic procedures.

METHODS

A questionnaire was disseminated to members of the International Federation of Neuroendoscopy. The questionnaire evaluated indications and pitfalls of EH in different applications, in particular, differentiating between intraventricular and skull base endoscopy, as well as subcategories of these 2 main fields. Furthermore, interest or involvement in research projects on EH was investigated.

RESULTS

Fifty-two surgeons responded, with a broad geographic distribution represented. Most (54%) do not routinely use EH. Others use holders mainly for intraventricular rather than skull base procedures. Most surgeons (96%) regularly work with a co-surgeon. Reported weaknesses of EH included crude movements, downward drift, loss of depth perception, lack of flexibility, iatrogenic injury, cost, and bulky construct. There is still a lack of consensus on surgical indications. Tumor resections in intraventricular and skull base regions (not small sellar tumors) seem to stand out as good, widely accepted indications.

CONCLUSIONS

Although EH have a role in cranial neuroendoscopy, their use seems limited and their technical features are regarded as suboptimal by most neuroendoscopists. Weaknesses and implications were detected in all application categories (skull base and intraventricular) but may vary slightly. Potentially, separate systems with distinct features may be required for skull base versus intraventricular surgery. There is a need for further evolution of EH, which could lead to a future paradigm shift in their use.

Management trends of infantile hemangioma: A national perspective

INTRODUCTION

The primary management of infantile hemangioma (IH) has changed since 2008, with the initiation of propranolol. The change that propranolol has affected on resource utilization is unknown.

MATERIALS AND METHODS

The Kids' Inpatient Database (KID) in 2003, 2006, 2009, and 2012 was queried for ICD-9 codes for IH in children under age three. The number of patients undergoing the following procedures of interest: tracheostomy, tracheoscopy and laryngoscopy with biopsy, and excision of skin lesion were evaluated. Data was analyzed for demographics and details on the admission. Trends were identified. Weighted statistical analyses were performed with SAS 9.4.

RESULTS

The number of qualified admissions significantly increased over the years (9271 in 2003-12029 in 2012, OR 1.042 per year increase, p < 0.001). The mean age at admission ranged from 26 to 28 days but did not vary over time (p = 0.54). The percentage undergoing tracheostomy significantly decreased from 1.05% in 2003 to 0.27% in 2012 (p = 0.0055), and the percentage undergoing tracheoscopy and laryngoscopy with biopsy significantly decreased from 7.29% in 2003 to 4.20% in 2012 (p = 0.011) among those with IH of unspecified or other sites. The percentage undergoing skin lesion excision also significantly decreased from 1.87% in 2003 to 1.03%, in 2012 (p = 0.0038) among those with IH of skin and subcutaneous tissue. These findings suggest a potential impact of propranolol. After adjusting for inflation, the total hospital charges increased from a mean of $17,838 in 2003 to an adjusted mean of $41,306 in 2012 (p < 0.0001).

CONCLUSIONS

Total admissions and hospital charges in children with IH has increased from 2003 to 2012. The percentage of patients undergoing tracheostomy, tracheoscopy and laryngoscopy with biopsy, and skin lesion excision significantly decreased in 2012 compared to 2003, suggesting a potential impact of propranolol. Further studies are needed to examine these changes more closely.

A Quality Improvement Educational Intervention to Increase Knowledge of Cardiogastroenterology Amongst Medical Trainees and Nursing Staff

INTRODUCTION

The American Society of Gastrointestinal Endoscopy recommends continuing aspirin prior to routine endoscopy. National data show that few endoscopists follow the current guidelines due to concern about bleeding and perceived minimal downside to stopping aspirin. Utilizing the Kern model, we implemented an educational quality improvement initiative aimed at increasing knowledge of antithrombotic management periendoscopy and during acute gastrointestinal (GI) bleeding.

METHODS

We implemented an interactive lecture incorporating a large-group discussion to help residents learn to define low- versus high-risk procedures, distinguish thrombotic risk in medical conditions, present the procedural risks associated with use of antiplatelets, and list current practice guidelines. Nursing staff received a tailored lecture with the goal of learning proper management of current antiplatelets and holding parameters for anticoagulants prior to endoscopy. Both groups received pre-and posttest questionnaires evaluating their knowledge.

RESULTS

Eighteen nurses and 75 medical trainees received this intervention. Significant score improvement was noted in both groups. The greatest change was seen in aspirin management (30.5% vs. 95.0% for group 1, 43.7% vs. 91.9% for group 2; p < .0001). For management of antiplatelets after aspirin-induced GI bleed, the medical trainees improved from 50.7% to 93.3%. Chi-square analysis showed a statistically significant difference in knowledge across all areas among medical trainees pre-and posttest (p < .001).

DISCUSSION

This quality-based educational intervention significantly increased the knowledge of nurses and medical trainees in management guidelines that directly impact patient care. Similar educational programs may be very effective in improving quality and safety.

Career prospects and professional landscape after advanced endoscopy fellowship training: a survey assessing graduates from 2009 to 2013

BACKGROUND AND AIMS

The advanced endoscopy (AE) fellowship is a popular career track for graduating gastroenterology fellows. The number of fellows completing AE fellowships and the number of programs offering this training have increased in the past 5 years. Despite this, we suspect that the number of AE attending (staff physician) positions have decreased (relative to the number of fellows graduating), raising concerns regarding AE job market saturation. Our aim was to survey practicing gastroenterology physicians who completed an AE fellowship within the past 5 years regarding their current professional status.

METHODS

A 16-question survey was distributed using Research Electronic Data Capture by e-mail to practicing gastroenterologists who completed an AE fellowship between 2009 and 2013. The survey questions elicited information regarding demographics, professional status, and additional information.

RESULTS

A total of 96 invitations were distributed via e-mail. Forty-one of 96 respondents (43%) replied to the survey. Approximately half of the respondents were employed in an academic practice, with the remainder in private practice (56% and 44%, respectively). Nearly half (46%) of the respondents found it "difficult" to find an AE position after training. Thirty-nine percent of private-practice endoscopists were performing > 200 ERCPs/year, whereas 65% were doing so in academic settings (P = .09). Fifty-six percent of respondents were in small practices (0 to 1 partner), with a significantly smaller group size in private versus academic practice (72% versus 43%, P = .021). Seventy-eight percent of respondents believed the AE job market was saturated; most responded that the AE job market was saturated in both academic and private practice (44%), whereas 34% believed the job market was saturated in academics only. Most respondents (73%) who were training AE fellows found it difficult to place them in AE attending positions. Respondents from academic practice found it significantly more difficult to balance work and personal life compared with those in private practice (87% versus 33%, respectively; P = .0004).

CONCLUSION

This index survey highlights the trends related to the current state of the post-AE fellowship professional landscape. Further evaluation and discussion are needed to address these evolving issues in professional practice in the field of gastroenterology.

[Scarless surgery: a vision becoming reality?]

As minimal invasive abdominal surgery became established in the last decades, further minimization of the surgical access is in the focus now. Although laparoscopic instruments and camera systems become diminished in size there is still a need for a minilaparotomy for extraction and anastomosis of organs. NOTES (Natural orifice transluminal endoscopic surgery) aims to avoid this minilaparotomy. Consequently, laparoscopic-assisted procedures become pure laparoscopic surgery. The transvaginal access is the most common performed NOTES procedure. The acceptance in women is high. The feasibility of NOTES cholecystectomy is scientifically proofed. The procedure is associated with less pain than the common four-port laparoscopic surgery and does not interfere with the sexual well-being. There are no access-related infections; the abdominal wound infection and incisional hernia rate are low. In left sided colonic resection the transrectal access makes NOTES available for both genders.

Current Trends in and Indications for Endoscopy-Assisted Breast Surgery for Breast Cancer: Results from a Six-Year Study Conducted by the Taiwan Endoscopic Breast Surgery Cooperative Group

Background

Endoscopy-assisted breast surgery (EABS) performed through minimal axillary and/or periareolar incisions is a possible alternative to open surgery for certain patients with breast cancer. In this study, we report the early results of an EABS program in Taiwan.

Methods

The medical records of patients who underwent EABS for breast cancer during the period May 2009 to December 2014 were collected from the Taiwan Endoscopic Breast Surgery Cooperative Group database. Data on clinicopathologic characteristics, type of surgery, method of breast reconstruction, complications and recurrence were analyzed to determine the effectiveness and oncologic safety of EABS in Taiwan.

Results

A total of 315 EABS procedures were performed in 292 patients with breast cancer, including 23 (7.8%) patients with bilateral disease. The number of breast cancer patients who underwent EABS increased initially from 2009 to 2012 and then stabilized during the period 2012–2014. The most commonly performed EABS was endoscopy-assisted total mastectomy (EATM) (85.4%) followed by endoscopy-assisted partial mastectomy (EAPM) (14.6%). Approximately 74% of the EATM procedures involved breast reconstruction, with the most common types of reconstruction being implant insertion and autologous pedicled TRAM flap surgery. During the six-year study period, there was an increasing trend in the performance of EABS for the management of breast cancer when total mastectomy was indicated. The positive surgical margin rate was 1.9%. Overall, the rate of complications associated with EABS was 15.2% and all were minor and wound-related. During a median follow-up of 26.8 (3.3–68.6) months, there were 3 (1%) cases of local recurrence, 1 (0.3%) case of distant metastasis and 1 (0.3%) death.

Conclusion

The preliminary results from the EABS program in Taiwan show that EABS is a safe procedure and results in acceptable cosmetic outcome. These findings could help to promote this under-used surgical technique in the field of breast cancer.

How I changed my practice in the last five years and what is likely to change in the next five years

The fast development of our field in the last decades has had significant impact on the way we practice our profession. This year my editorials will focus on the impact of these developments on my own daily practice.

The transition from microscopic to endoscopic transsphenoidal surgery: the experience at Brigham and Women's Hospital

OBJECTIVE

As interest and enthusiasm for the use of the endoscope in transsphenoidal anterior skull base and pituitary surgery increases, neurosurgeons are increasingly adopting endoscopic technology and associated novel concepts. Often this involves a transition from the standard operating microscope as the main means of visualization to the operating endoscope (2D or 3D) during surgery.

METHODS

The authors' experience with this transition is described, including the rationale, advantages and disadvantages of the two surgical techniques.

RESULTS

The successful use of endoscopic surgery for a large variety of pathological problems involving the anterior skull base and the pituitary region is presented. Perceived advantages for the patient and the surgeon are described, as is the occasional need for transition back to the microscopic approach.

CONCLUSIONS

The endoscopic approach and its allied technology are here to stay. They are useful and occasionally preferable methods for treating a variety of suitable lesions involving the anterior skull base. The importance of incorporating the basic principles of skull base surgery is emphasized.

[Whether external dacryocystorhinostomy will be abandoned]

External dacryocystorhinostomy (DCR) has long been considered as the gold standard treatment for nasolacrimal duct obstruction or chronic dacryocystitis. Recently, however, endoscopic endonasal DCR is becoming increasingly popular with the development of endoscopic surgery technique in naso-orbit related diseases. Endoscopic DCR has the advantages of avoiding an external incision scar and simultaneously handling with nasal conditions. Nevertheless, the new method also has some disadvantages, for example, the lower long-term success rate, the high technical requirement, long learning curves, expensive equipment and the high cost of surgery. The choice of the surgical approaches should be based on the patient's condition, experience of the surgeon and available resources. After nearly a century of proven, external DCR still has incomparable superiority and should receive widespread attention and application.

Spectrum of use and effectiveness of endoscopic and surgical therapies for chronic pancreatitis in the United States

OBJECTIVE

This study aims to describe the frequency of use and reported effectiveness of endoscopic and surgical therapies in patients with chronic pancreatitis treated at US referral centers.

METHODS

Five hundred fifteen patients were enrolled prospectively in the North American Pancreatitis Study 2, where patients and treating physicians reported previous therapeutic interventions and their perceived effectiveness. We evaluated the frequency and effectiveness of endoscopic (biliary or pancreatic sphincterotomy, biliary or pancreatic stent placement) and surgical (pancreatic cyst removal, pancreatic drainage procedure, pancreatic resection, surgical sphincterotomy) therapies.

RESULTS

Biliary and/or pancreatic sphincterotomy (42%) were the most common endoscopic procedure (biliary stent, 14%; pancreatic stent, 36%; P < 0.001). Endoscopic procedures were equally effective (biliary sphincterotomy, 40.0%; biliary stent, 40.8%; pancreatic stent, 47.0%; P = 0.34). On multivariable analysis, the presence of abdominal pain (odds ratio, 1.82; 95% confidence interval, 1.15-2.88) predicted endoscopy, whereas exocrine insufficiency (odds ratio, 0.63; 95% confidence interval, 0.42-0.94) deterred endoscopy. Surgical therapies were attempted equally (cyst removal, 7%; drainage procedure, 10%; resection procedure, 12%) except for surgical sphincteroplasty (4%; P < 0.001). Surgical sphincteroplasty was the least effective (46%; P < 0.001) versus cyst removal (76% drainage [71%] and resection [73%]).

CONCLUSIONS

Although surgical therapies were performed less frequently than endoscopic therapies, they were more often reported to be effective.

Advanced endoscopic imaging: a review of commercially available technologies

The rapid strides made in innovative endoscopic technology to improve mucosal visualization have revolutionized endoscopy. Improved lesion detection has allowed the modern endoscopist to provide real-time optical diagnosis. Improvements in image resolution, software processing, and optical filter technology have resulted in the commercial availability of high-definition endoscopy as well as optical contrast techniques such as narrow-band imaging, flexible spectral imaging color enhancement, and i-scan. Along with autofluorescence imaging and confocal laser endomicroscopy, these techniques have complemented and enhanced traditional white light endoscopy. They have the potential to serve as red-flag techniques to improve detection of mucosal abnormalities as well as allow optical diagnosis and virtual histology of detected lesions. This review will focus on these emerging commercially available technologies and aims to provide an overview of the technologies, their clinical applicability, and current status.

Current state and future development of intracranial neuroendoscopic surgery

Since the introduction of the modern, smaller endoscopes in the 1960s, neuroendoscopy has become an expanding field of neurosurgery. Neuroendoscopy reflects the tendency of modern neurosurgery to aim towards minimalism; that is, access and visualization through the narrowest practical corridor and maximum effective action at the target point with minimal disruption of normal tissue. Transventricular neuroendoscopy allows the treatment of several pathologies inside the ventricular system, such as obstructive hydrocephalus and intra-/paraventricular tumors or cysts, often avoiding the implantation of extracranial shunts or more invasive craniotomic approaches. Endoscopic endonasal transphenoidal surgery allows the treatment of pathologies of the sellar and parasellar region, with the advantage of a wider vision of the surgical field, less traumatism of the nasal structures, greater facility in the treatment of possible recurrences and reduced complications. However, an endoscope may be used to assist microsurgery in virtually any kind of neurosurgical procedures (endoscope-assisted microsurgery), particularly in aneurysm and tumor surgery. Basic principles of optical imaging and the physics of optic fibers are discussed, focusing on the neuroendoscope. The three main chapters of neuroendoscopy (transventricular, endonasal transphenoidal and endoscope-assisted microsurgery) are reviewed, concerning operative instruments, surgical procedures, main indications and results.

[Current and future trends in natural orifice translumenal endoscopic surgery-related procedures: endoscopists' perspective]

The concept of "no-scar surgery" in natural orifice translumenal endoscopic surgery (NOTES) is appealing to both surgeons and endoscopists. However, it is challenging for endoscopists to perform surgery via a keyhole created in the gastrointestinal wall at a site distant from the gut lumen. Technologies developed to achieve the NOTES concept such as endoscopic suturing systems will greatly benefit endoscopists when they can be used for endolumenal intervention and push the envelope of endoscopic surgery toward deeper layers and treating the full thickness of the gut wall.

Algorithm changes in treatment of submandibular gland sialolithiasis

Our research was conducted to determine the algorithm changes during the treatment of submandibular sialolithiasis. Two time periods were compared between 2004-2008 and 2009-2012. The turning point was December 2008, when sialendoscopy procedure was introduced. In the first period, 48 patients were treated: 31 outpatient duct incisions with stone evacuation and 17 surgical excision of submandibular gland. In the second period, 207 sialendoscopy procedures were performed on 197 patients. Out of this particular group, 158 patients were diagnosed with pathological obstruction of salivary glands and 64 of them were confirmed to have sialolithiasis of submandibular gland. Deposits of calcifications in 40 individuals (62.5 %) affected by sialolithiasis were removed endoscopically; however, in 21 patients, due to the increased circumference of the stone, the intimate association of deposits within the wall of the duct along with its presence inside the deep portions of the gland, double approach (incision of the floor of the mouth in hilar area and sialendoscopy) was performed. Three individuals had their salivary glands totally removed due to the presence of calcified deposits within the glandular parenchyma. Our results allow us to affirm that sialendoscopy is the current treatment of choice for submandibular glands affected by sialoliths. Indication for a complete removal of the gland is becoming uncommon as a first line treatment although still indispensable in chosen cases.

[The evolution of adenoidectomy]

The critical analysis of publications concerning methods designed for the surgical treatment of adenoids is presented. Various surgical techniques are considered with special reference to their indications for use, invasiveness, effectiveness, and safety. Recent developments in this field give evidence that evolution of adenoidectomy brought about highly efficacious (up to 99%) mini-invasive and safe surgical procedures producing the minimal risk of relapses and postoperative complications. All these advancements became possible due to the introduction of endoscopic intraoperative control, general anesthesia, and the use of modern surgical instruments. Modern approaches make unnecessary radical removal of the lymphoid tissue.

Progress in molecular imaging in endoscopy and endomicroscopy for cancer imaging

Imaging is an essential tool for effective cancer management. Endoscopes are important medical instruments for performing in vivo imaging in hollow organs. Early detection of cancer can be achieved with surveillance using endoscopy, and has been shown to reduce mortality and to improve outcomes. Recently, great advancements have been made in endoscopic instruments, including new developments in optical designs, light sources, optical fibers, miniature scanners, and multimodal systems, allowing for improved resolution, greater tissue penetration, and multispectral imaging. In addition, progress has been made in the development of highly-specific optical probes, allowing for improved specificity for molecular targets. Integration of these new endoscopic instruments with molecular probes provides a unique opportunity for significantly improving patient outcomes and has potential to further improve early detection, image guided therapy, targeted therapy, and personalized medicine. This work summarizes current and evolving endoscopic technologies, and provides an overview of various promising optical molecular probes.

Introducing endoscopic ear surgery into practice

The otolaryngologist will find in this article a direct and frank discussion and useful advice for how to get started performing solely endoscopic ear surgery for abnormalities of the middle ear. The author provides discussion and photos based on his experience with this procedure. Presented herein are selection of the endoscope, how to approach the first fully endoscopic procedure, patient selection, preoperative planning, setting up the operating room, pitfalls typically encountered, and how to gain skills to perform this procedure successfully.

Endoscopic management of uterine fibroids: an update

Recent technological advances in endoscopy have allowed gynecological surgeons to expand the operative approaches that can be utilized in the conservative management of uterine myomas. Commonly used approaches in gynecological practice now include laparoscopic myomectomy, laparoscopic-assisted myomectomy through a mini-laparotomy incision and robotic-assisted laparoscopic myomectomy. Adequate preoperative evaluation with careful selection of the best operative approach for each particular patient constitutes the basis of safe and effective surgery for the operative management of uterine myomas.

Feasibility of in-office endoscopic sinus surgery with balloon sinus dilation

BACKGROUND

Balloon sinus dilation (BSD) tools are increasingly used in endoscopic sinus surgery (ESS) and post maximal may cause less tissue trauma/bleeding, potentially enabling office-based ESS. We evaluate the feasibility of ESS performed in-office using BSD instrumentation.

METHODS

All patients had a diagnosis with chronic rhinosinusitis. Because of symptom resolution failure postmaximal medical therapy (prolonged antibiotics, corticosteroids, and other adjuvant therapies), all patients were candidates for ESS. In-office ESS using BSD tools was performed on 37 subjects at nine sites. Procedure feasibility was assessed prospectively through technical success rate, procedure tolerability, quality of life, and radiographic outcomes. Subjects were followed at 1, 4, 24, and 52 weeks.

RESULTS

In-office technical success by subject was 89% (33/37). There was one nonserious adverse event. In-office BSD was tolerable, with 93% (27/29) of patients reporting the procedure as tolerable or highly tolerable. Two in-office subjects (7%) indicated poor procedure tolerability. Intraprocedure pain was also well managed during in-office BSD, with 66% (24/36) of patients reporting no pain or pain of low intensity. While 33% (12/36) reported higher-scale pain, usually during balloon inflation, only 2 patients experienced intense pain. At 52 weeks, 95% of the subjects stated they would have procedure again. Sino-Nasal Outcome Test-20 scores revealed clinically and statistically significant treatment effects at all time points, comparable to previous balloon dilation studies conducted in an operating room setting. Lund-Mackay scores revealed a statistically significant reduction at 24 weeks.

CONCLUSION

Office-based ESS with BSD is feasible with demonstration of high technical success rate, meaningful patient symptom improvement, and high patient satisfaction.

Critical review of laparoendoscopic single-site surgery versus multiport laparoscopy in urology

Continued advancement in laparoscopy and a desire for less-invasive surgical approach has led to the development of novel surgical approaches, including laparoendoscopic single-site surgery (LESS). LESS in urology has not reached the pinnacle yet. Objective of this study is to provide an evidence-based analysis of the current status and future directions of minimal access and minimally invasive urological surgery represented by LESS in comparison with classic multiport laparoscopic surgery. Since the initial report of single-port nephrectomy in 2007, the majority of laparoscopic procedures in urology have been described with a single-site approach. Multi-center experience has validated Urological LESS procedures as technically feasible and safe for various urologic diseases. Certainly, several issues must be overcome before LESS can practiced universally in urology. Development of instrumentation and platform, long term follow up and large-scale randomized controlled trials are needed to provide an accurate comparative analysis with other procedures to confirm the significant benefits of LESS.

Laparoendoscopic single site pelvic surgery: is there any room?

OBJECTIVES

Our purpose was to summarize the current status of Laparo-endocopic single site surgery (LESS) in the pelvis.

METHODS

A comprehensive literature search was conducted in May 2011 using the medline database to identify publications relating to LESS surgery in the pelvis.

RESULTS

LESS can be safely performed in the pelvis with comparable outcomes to standard minimally invasive approaches. Small series have demonstrated good outcomes in the hands of experienced surgeons in a number of urological settings in the pelvis. Challenges in LESS surgery are continual being overcome by advancing technologies such as with the robotic platform;however, significant improvements are necessary to reduce the difficulty with LESS surgery and dispersion amongst urological surgeons.

CONCLUSION

LESS pelvic procedures are evolving. Wide ranges of procedures have been described using LESS approach, however, in small series and short follow-up. Further examination of LESS pelvic approach with well-designed studies will be crucial to determine the future role of such an approach.

NOTES: basic and advanced surgical applications outside of the urological field

Ten years ago the American gastroenterologist Anthony Kalloo described for the first time the concept of Natural Orifice Transluminal Endoscopic Surgery - NOTES. His revolutionary vision generated such an unprecedented worldwide momentum of creativity and renovation in the surgical community to push the current limit of the research in the minimal invasive surgery field toward the unimaginable goal of non visible scar surgery. At present time several NOTES applications are continuously reported by many teams all around the world and the aim of the present paper was to illustrate the clinical evidence registered up to now as well as to inform about the ongoing research efforts made to perform non visible scar surgery to treat more complex surgical diseases.

Robotic laparoendoscopic single-site surgery: the way forward

OBJECTIVES

LaparoEndoscopic Single-Site (LESS) surgery presents many technical and ergonomic obstacles. The solution to these current limitations may lie within emerging technologies, primarily the daVinci robotic platform. The purpose of this review was to examine the available literature as it pertains to robotic laparoendoscopic single-site surgery (R-LESS) and detail our experience with this approach at our institution.

METHODS

An electronic literature search was conducted using the Medline database to identify all publications relating to R-LESS and/Mor robotic single port surgery in urology. Additionally, a retrospective review of our single center experience was completed.

RESULTS

Fifteen original articles and two abstracts were identified in the literature and included dry lab investigation, animal experiments, single case reports, cumulative series, and two retrospective comparative analyses. Most detailed technique, perioperative outcomes, and associated procedural nuances.

CONCLUSIONS

R-LESS urologic surgery is feasible and can be performed using several approaches. R-LESS reduces difficulties encountered with conventional LESS urologic surgery. An ideal robotic system is needed and would be task specific, deployable through a single incision, possess articulating instruments, and have reduced external housings.

Training in LESS and NOTES

LESS and NOTES are the further step forward the "scarless" surgery recently, which have challenged the main principles of conventional multiport laparoscopy. To develop the surgical skills for these novel techniques, the guideline for training program should be neccesary for its clinical practice to reduce the complications. In this paper, we will summary the challenges of these new technique and introduce our experience of training courses.

LESS and NOTES: rationale and terminology

Laparoendoscopic single site surgery (LESS) and natural orifice transluminal endoscopic surgery (NOTES) are emerging platforms to further reduce the invasive profile of surgery. As feasibility of an increasing array of procedures in both platforms is being demonstrated, with out comes comparable to multiport laparoscopy, there has been a parallel proliferation of concepts, terminology and technology. In this article, we describe the rationale behind the evolving paradigm shift towards truly "scarless" surgery and address the terminology associated with these surgical approaches.

Present and future of robot-assisted endoscopic thyroid surgery

OBJECTIVE

Robot-assisted endoscopic surgery has been increasingly accepted because of its unique three-dimensional vision and precise simulation-based technology. However, the utilization of robotic systems in thyroid surgery is limited. We conducted a systematic review to assess the application and development of robot-assisted endoscopic surgical technique in thyroid surgery.

DATA SOURCES

Articles published in PubMed before June, 2011 about robot-assisted endoscopic surgery were selected.

STUDY SELECTION

Original articles and critical reviews selected were related to robot-assisted (thyroid) surgery or endoscopic thyroid surgery, and a total of 3540 relevant articles were retrieved and 34 were finally cited.

RESULTS

Robot-assisted operation of benign thyroid diseases were successfully performed, although the operation time is too long to exhibit its advantages. Nevertheless, the superiority of robot-assisted endoscopic surgical technique compared to conventional endoscopic surgery in the treatment of thyroid carcinoma were obvious, since robotic radical thyroidectomy with central and lateral neck lymph node dissection could be achieved while maintaining operative results and cosmetic outcomes equivalent to or better than conventional endoscopic surgery. Furthermore, the learning curve duration of robot-assisted endoscopic thyroid surgery was shorter than that of conventional endoscopy, especially for the novices without any endoscopic surgical basis.

CONCLUSION

Robot-assisted endoscopic thyroid surgery, with its safety, feasibility, thoroughness, cosmetic benefits, and ability to overcome the limitations of conventional endoscopic surgery, will be further improved and applied, and is worthy of attention.

Anticipating implementation of colorectal cancer screening in The Netherlands: a nation wide survey on endoscopic supply and demand

BACKGROUND

Colorectal cancer (CRC) screening requires sufficient endoscopic resources. The present study aims to determine the Dutch endoscopic production and manpower for 2009, evaluate trends since 2004, determine additional workload which would be caused by implementation of a CRC screening program, and inventory colonoscopy rates performed in other European countries.

METHODS

All Dutch endoscopy units (N = 101) were surveyed for manpower and the numbers of endoscopy procedures performed in 2009. Based on calculations in the report issued by the Dutch Health Council, future additional workload caused by faecal immunochemical test (FIT) screening was estimated. The number of colonoscopies performed in Europe was evaluated by a literature search and an email-inquiry.

RESULTS

Compared to 2004, there was a 24% increase in total endoscopies (N = 505,226 in 2009), and a 64% increase in colonoscopies (N = 191,339 in 2009) in The Netherlands. The number of endoscopists had increased by 4.6% (N = 583 in 2009). Five years after stepwise implementation of FIT-based CRC screening, endoscopic capacity needs to be increased an additional 15%. A lack of published data on the number of endoscopies performed in Europe was found. Based on our email-inquiry, the number of colonoscopies per 100,000 inhabitants ranged from 126 to 3,031 in 15 European countries.

CONCLUSIONS

Over the last years, endoscopic procedures increased markedly in The Netherlands without a corresponding increase in manpower. A FIT-based CRC screening program requires an estimated additional 15% increase in endoscopic procedures. It is very likely that current colonoscopy density varies widely across European countries.

New technique for retraction of the strap muscles in endoscopic thyroidectomy

OBJECTIVE

It is extremely important to establish sufficient exposure and room for manipulation during endoscopic thyroidectomy. To solve this problem, the authors have developed a new technique for retraction of the strap muscles perfected during 500 cases of breast-approach endoscopic thyroidectomy.

METHODS

The new technique encompasses the use of 3 styles of retractor: the suture retractor, the button retractor, and the adjustable button retractor. These retractors are all easy to make and are all useful in different situations.

CONCLUSIONS

The new technique is a safe and cost-effective method. It reduces the operation time required to obtain good exposure without transecting the strap muscles. In addition, it is minimally invasive and confers cosmetic benefits.

[Interdisciplinary skull base surgery. From explorative crater cavity surgery to predictive tunnel surgery?]

Total endoscopic or endoscopy-assisted surgical procedures are becoming more and more important for skull base surgery. In particular at the frontal skull base endoscopic procedures with planned opening of the subarachnoidal space have mostly replaced the microscope because of the good experiences in functional endoscopic sinus surgery (FESS). The advantages for the patients of endoscopic procedures with planned opening of the subarachnoidal space measured by criteria, such as mortality, morbidity or recurrence rate are unclear due to a lack of valid study data according to the criteria of evidence-based medicine.