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PubMed2003

Surveillance cultures to monitor quality of gastrointestinal endoscope reprocessing.

OBJECTIVES: High-level disinfection of GI endoscopes can be reliably obtained under controlled conditions with approved reprocessing methods. However, there are scant data regarding the effectiveness of these methods in clinical practice and no published methods of verification. The purpose of this study is to review retrospectively the results of environmental cultures of flexible endoscopes and to analyze the pattern of results. METHODS: Cultures of selected GI endoscopes listed as ready to use were obtained by adding 5-15 ml of trypticase soy broth or saline or 30-50 ml of sterile water to the biopsy channel of an endoscope. This wash was collected in a sterile container, plated onto blood and MacConkey agar, incubated at 37 degrees C, and examined for growth at 24 and 48 h. Personnel trained in accordance with approved procedures performed endoscope reprocessing. RESULTS: A total of 312 surveillance cultures were performed between 1990 and 1999. Initially, three of 17 water bottles were found to be contaminated with Pseudomonas species. The bottles were sterilized daily; only sterile water was used and subsequent cultures were negative. Between 1992 and 1994, 15/129 (11.6%) cultures were positive; 14 (93%) were from duodenoscopes. From 1995 to 1997, 18/124 (14.5%) cultures were positive, but only six (33%) were from duodenoscopes. However, 10 (55.6%) positive cultures were obtained from therapeutic upper endoscopes, attributed to faulty mechanical cleaning by nonnursing personnel after emergent procedures. The reprocessing procedure was altered, with improvement. One duodenoscope was persistently culture positive and was found to have a damaged biopsy channel. There were no recognized iatrogenic infections associated with endoscopic procedures. Organisms cultured were commonly gram-negative rods. CONCLUSIONS: The use of environmental endoscope culturing is a rapid, simple, inexpensive method to monitor effectiveness of standard reprocessing procedures. Disinfection is less effective with poor mechanical cleansing, and high-titer positivity is a marker for poor cleaning technique. Standard upper and lower scopes are commonly culture negative. Duodenoscopes, because of their inherent complexity, and other scopes used in emergent conditions require particular attention. Surveillance culture results can be used to identify patterns of poor technique, to reinforce proper procedure, and to modify clinical practice. No associated clinical illness was apparent during this study.

Bacteria↗

PubMed2004

The Canadian Registry on Nonvariceal Upper Gastrointestinal Bleeding and Endoscopy (RUGBE): Endoscopic hemostasis and proton pump inhibition are associated with improved outcomes in a real-life setting.

OBJECTIVES: From the Canadian Registry of patients with Upper Gastrointestinal Bleeding and Endoscopy (RUGBE), we determined clinical outcomes and explored the roles of endoscopic and pharmacologic therapies in a contemporary real-life setting. METHODS: Analysis of randomly selected patients endoscoped for nonvariceal upper gastrointestinal bleeding at 18 community and tertiary care institutions between 1999 and 2002. Covariates and outcomes were defined a priori and 30-day follow-up obtained. Logistic regression models identified predictors of outcomes. RESULTS: One thousand eight-hundred and sixty-nine patients were included (66 +/- 17 yr, 38% female, 2.5 +/- 1.6 comorbid conditions, hemoglobin, 96 +/- 27 g/L, 54% received a mean of 2.9 +/- 1.7 units of blood). Endoscopy was performed within 24 h in 76%, with ulcers (55%) most commonly noted. High-risk endoscopic stigmata and endoscopic therapy were reported in 37%. Rebleeding, surgery, and mortality rates were 14.1%, 6.5%, and 5.4%, respectively. Decreased rebleeding was significantly and independently associated with PPI use (85% of patients, mean daily dose 56 +/- 53 mg) in all patients regardless of endoscopic stigmata, (odds ratio (OR):0.53, 95% confidence interval, 95% CI:0.37-0.77) and endoscopic hemostasis in patients with high-risk stigmata (OR:0.39, 95% CI:0.25-0.61). PPI use (OR:0.18, 95% CI:0.04-0.80) and endoscopic therapy (OR:0.31, 95% CI:0.11-0.91) were also each independently associated with decreased mortality in patients with high-risk stigmata. CONCLUSIONS: These results appear to confirm the protective role of endoscopic therapy in patients with high-risk stigmata, and suggest that acute use of PPIs may be associated with a reduction of rebleeding in all patients, and lower mortality in patients with high-risk stigmata. Independent prospective validation of these observational findings is now required.

Aged↗

PubMed2002

Variable use of endoscopic haemostasis in the management of bleeding peptic ulcers.

BACKGROUND: Randomised controlled trials (RCTs) have shown that endoscopic haemostasis is beneficial for patients with a bleeding peptic ulcer. The relevance of such data to management outside of RCTs is unclear. Therefore we examined management of patients with a bleeding peptic ulcer in a UK teaching hospital. METHODS: All patients who underwent upper gastrointestinal (UGI) endoscopy for bleeding peptic ulcer between 1997 and 1999 were identified from an endoscopy database and the clinical records reviewed retrospectively. RESULTS: A total of 872 patients underwent UGI endoscopy for presumed acute UGI haemorrhage; 179 (21%) had an endoscopic diagnosis of bleeding peptic ulcer. Seventy nine patients had a peptic ulcer with stigmata of recent haemorrhage (SRH) but only 61 (77%) of these patients received endoscopic haemostasis (77% adrenaline, 23% combination therapy). Re-bleeding occurred in 24 patients with SRH in whom transfusion requirement was the sole predictor of re-bleeding. The re-bleeding rate among patients who received adrenaline was 25% (n=12), compared with 57% (n=8) in the combination group and 31% (n=4) in those who did not receive endoscopic haemostasis. Patients who received combination endoscopic haemostasis had an increased incidence of active bleeding (p=0.007) and an increased transfusion requirement (p=0.002). Eleven of 20 patients who re-bled had repeat endoscopic haemostasis, with 45% eventually requiring surgery. CONCLUSIONS: Results of endoscopic management of bleeding peptic ulcers in the unit studied differ markedly from those published by specialised centres. The data reported here suggest that increased standardisation of endoscopic haemostasis is required, especially in units with provision for emergency "out-of-hours" endoscopy, performed by several individuals of different grades.

Adult↗

PubMed2003

Endoscopic management of common bile duct stones leaving the gallbladder in situ. A cohort study with long-term follow-up.

BACKGROUND: Obstructive jaundice caused by stones is a common disorder, mostly managed by endoscopic sphincterotomy followed by cholecystectomy. The aim of this study was to evaluate whether or not clearance of the common bile duct alone is sufficient as treatment for patients with choledocholithiasis. METHODS: A cohort with 447 patients with symptomatic cholecystocholedocholithiasis, undergoing endoscopic retrograde cholangiography (ERC) and if necessary sphincterotomy (ES). In 164 patients common bile duct stones were proven and treated endoscopically, without performing a subsequent cholecystectomy. All 164 patients were free of symptoms after the endoscopic intervention. This group of patients was compared with 78 patients who underwent cholecystectomy after endoscopic treatment of common bile duct stones. Patients were followed for 1-13 years after ERC and sphincterotomy results and complications were registered. RESULTS: The ages of the 164 patients in the in situ group were significantly higher than in the cholecystectomy group and the ASA classification (American Society of Anesthesiologists) was significantly higher in the in situ patients. Mean follow-up was 70.9 months. Of the in situ patients 27 (16%) returned with biliary symptoms; 12 with common bile duct stones, three with cholangitis, and one with stenosis of Vater's papilla. Eight patients returned with cholecystitis and 3 with symptomatic cholecystolithiasis. Thirteen patients underwent cholecystectomy and 11 were managed (also) endoscopically. Minor complications were 2 wound infections and 1 bleeding after cholecystectomy. Two patients (1%) died of abdominal sepsis due to cholecystitis. Of the patients who underwent cholecystectomy, 6 (7.6%) returned during follow-up. Three patients had common bile duct stones, 2 had cholangitis and 1 patient presented with papillostenosis. Three patients needed surgical common bile duct exploration and the other 3 were treated endoscopically. After reintervention, cardiopulmonary complications were observed in 1 patient. There was no related death. CONCLUSION: When common bile duct stones are treated successfully by endoscopic sphincterotomy and patients are free of symptoms, there is no need for routine prophylactic cholecystectomy.

Adolescent↗

PubMedDate not supplied

Is monocular perception of depth through the rigid endoscope a disadvantage compared to binocular vision through the operating microscope in paranasal sinus surgery?

Vision through the endoscope is strictly monocular. Perception of depth (stereopsis) during ethmoid surgery through the operating microscope would be expected to be superior due to binocular view. To investigate whether monocularity of the endoscope is a disadvantage in paranasal sinus surgery, we compared stereoacuity in a model of the nasal cavity using a headlamp, an operating microscope, and a 0 degree-Hopkins-endoscope. Twenty volunteers were asked to touch defined points in a spatial model of the nasal cavity. Due to the configuration of the model, which allowed binocular vision of all contact points with headlamp, performance was significantly better than with optical instruments. Manipulations were performed faster with the endoscope than with the microscope. Under microscopic guidance more faults in point sequence were made than with the endoscope. Various monocular phenomena obviously allow sufficient spatial orientation through the endoscope, so that monocularity of the endoscope appears not to be a disadvantage for quick and safe manipulations during functional endoscopic sinus surgery.

Depth Perception↗

PubMed1999

Application of a rigid endoscope to the microsurgical management of 54 cerebral aneurysms: results in 48 patients.

OBJECT: To enhance visual confirmation of regional anatomy, endoscopy was introduced during microsurgery for cerebral aneurysms. The risks and benefits are analyzed in the present study. METHODS: The endoscopic technique was used during microsurgery for 54 aneurysms in 48 patients. Forty-three aneurysms were located in the anterior circulation and 11 were in the posterior circulation. Thirty-eight aneurysms (70.4%) had not ruptured. All ruptured aneurysms in the present series produced Hunt and Hess Grade I or II subarachnoid hemorrhage. After initial exposure achieved with the aid of a microscope, the rigid endoscope was introduced to confirm the regional anatomy, including the aneurysm neck and adjacent structures. The necks of 43 aneurysms were clipped using microscopic control or simultaneous microscopic/endoscopic control. After clipping, the positions of the clip and nearby structures were inspected using the endoscope. Use of the neuroendoscope provided useful information that further clarified the regional anatomy in 44 cases (81.5%) either before or after neck clipping. In nine cases (16.7%), these details were available only with the use of the endoscope. In five cases (9.3%), the surgeons reapplied the clip on the basis of endoscopic information obtained after the initial clipping. There were two cases in which surgical complications were possibly related to the endoscopic procedures (one patient with asymptomatic cerebral contusion and another with transient oculomotor palsy). CONCLUSIONS: It is the authors' impression that the use of the endoscope in the microsurgical management of cerebral aneurysms enhanced the safety and reliability of the surgery. However, there is a prerequisite for the surgeon to be familiar with this instrumentation and fully prepared for the risks and inconveniences of endoscopic procedures.

Adult↗

PubMed2005

Endoscopic treatment and follow-up of gastrointestinal Dieulafoy's lesions.

AIM: To investigate retrospectively the clinical and endoscopic features of bleeding Dieulafoy's lesions and to assess the short- and long-term effectiveness of endoscopic treatment. METHODS: Twenty-three patients who had gastrointestinal bleeding from Dieulafoy's lesions underwent endoscopic therapy. Demographic data, mode of presentation, risk factors for gastrointestinal bleeding, blood transfusion requirements, endoscopic findings, details of endoscopic therapy, recurrence of bleeding and mortality rates were collected and analyzed retrospectively. RESULTS: Hemostasis was attempted by dextrose 50% plus epinephrine in 10 patients, hemoclipping in 8 patients, heater probe in 2 patients and ethanolamine oleate in 2 patients. Comorbid conditions were present in 17 patients (74%). Overall permanent hemostasis was achieved in 18 patients (78%). Initial hemostasis was successful with no recurrent bleeding in patients treated with hemoclipping, heater probe or ethanolamine injection. In the group of patients who received dextrose 50% plus epinephrine injection treatment, four (40%) had recurrent bleeding and one (10%) had unsuccessful initial hemostasis. Of the four patients who had rebleeding, three had unsuccessful hemostasis with similar treatment. Surgical treatment was required in five patients (22%) owing to uncontrolled bleeding, recurrent bleeding with unsuccessful retreatment and inability to approach the lesion. One patient (4.3%) died of sepsis after operation during hospitalization. There were no side-effects related to endoscopic therapy. None of the patients in whom permanent hemostasis was achieved presented with rebleeding from Dieulafoy's lesion over a mean long-term follow-up of 29.8 mo. CONCLUSION: Bleeding from Dieulafoy's lesions can be managed successfully by endoscopic methods, which should be regarded as the first choice. Endoscopic hemoclipping therapy is recommended for bleeding Dieulafoy's lesions.

Adult↗

PubMedDate not supplied

The efficacy of preoperative endoscopic retrograde cholangiopancreatography in the detection and clearance of choledocholithiasis.

BACKGROUND AND OBJECTIVES: Endoscopic retrograde cholangiopancreaticography has been reported to have a high success rate in the detection and treatment of choledocholithiasis. Although there is growing enthusiasm for laparoscopic common bile duct clearance, many patients who present with gallbladder disease and suspected choledocholithiasis have endoscopic retrograde cholangiopancreatography performed with choledocholithiasis cleared if detected. These patients are then referred for laparoscopic cholecystectomy. The purpose of this study is to determine the efficacy of preoperative endoscopic retrograde cholangiopancreatography in the diagnosis and clearance of bile duct stones at our institution. METHODS: A retrospective review was performed of all patients at this institution who underwent preoperative endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis followed by laparoscopic cholecystectomy from January 1997 through July 1998. RESULTS: Common bile duct stones were detected endoscopically in 12 of 17 (71%) patients. We found serum bilirubin level to be the best predictor of choledocholithiasis. In 12 of 12 procedures, the endoscopist performed an endoscopic sphincterotomy with stone extraction and reported a fully cleared common bile duct. Intraoperative cholangiogram performed during subsequent cholecystectomy revealed choledocholithiasis in 4 of these 12 patients. Laparoscopic techniques successfully cleared the choledocholithiasis in 3 of these patients with open techniques necessary in the fourth. CONCLUSIONS: Our data suggests that even after presumed successful endoscopic clearance of the bile duct stones, many patients (33% in our series) still have choledocholithiasis present at the time of cholecystectomy. We recommend intraoperative cholangiography at the time of cholecystectomy even after presumed successful endoscopic retrograde cholangiopancreatography with further intervention, preferably laparoscopic, to clear the choledocholithiasis as deemed necessary.

Adolescent↗

PubMed2006

Endoscopic approaches to upper gastrointestinal bleeding.

Treatment for most patients with upper gastrointestinal bleeding has shifted from the operating room to the endoscopy suite. Endoscopic treatment has resulted in substantial benefit for patients with bleeding from peptic ulcer. Ulcers associated with high-risk stigmata of recent hemorrhage (SRH) not treated endoscopically have 40 per cent to 100 per cent risk of continued or recurrent bleeding and up to a 35 per cent chance of requiring surgical control of bleeding. Endoscopic therapy has reduced the risk of recurrent bleeding to 10 per cent to 20 per cent and the need for surgery to 5 per cent to 10 per cent. These improvements translate to shorter hospital stays, fewer transfusions, lower costs, and less morbidity. Similar progress has been made for patients bleeding from esophageal varices. Mortality for a first variceal bleed is now approximately 20 per cent as compared with 40 per cent to 60 per cent in past decades. Rebleeding after initially successful endoscopic hemostasis is often best treated by a second attempt at endoscopic control. The decision regarding management of recurrent bleeding should be made at the time initial endoscopic control is achieved. Local factors such as experience of the endoscopic team, availability of interventional radiologists, and individual patient characteristics should guide these decisions. Failures of endoscopic control and patients with massive hemorrhage still require operative intervention.

Esophageal and Gastric Varices↗

PubMed1984

Endoscopic control of upper gastrointestinal hemorrhage with a bipolar coagulation device.

It has been difficult to determine the real efficacy of endoscopic treatment for upper gastrointestinal tract bleeding sites for several reasons. First, since 80 per cent of an unselected group are expected to stop bleeding spontaneously, it is important to focus upon those individuals who continue to bleed instead of a group in whom bleeding would have stopped spontaneously in the majority. Second, it is difficult, if not impossible, to have comparable groups of patients with similar lesions and similar rates of bleeding who can be randomized into different treatment groups. This report describes the use of a bipolar endoscopic coagulation device in 28 patients with active massive upper gastrointestinal tract hemorrhage who represent 10 per cent of the patients with hemorrhage during a one year interval. Endoscopic treatment controlled bleeding initially in 23 of these patients. Another eight patients with recent hemorrhage who were at high risk for recurrent bleeding (visible vessels) had endoscopic coagulation without subsequent hemorrhage. Immediate operations were required in five of the 28 and delayed operations in another four. Mortality in the patients treated by endoscopic or surgical therapy was comparable (20 per cent), but no patient died of hemorrhage. The high mortality in this group of patients is explained by associated illnesses. B-C is as effective as other endoscopic treatments for nonvariceal sources of upper gastrointestinal tract hemorrhage. This modality is relatively cheap compared with other devices, is theoretically less complicated and has minimal risk to the individual patient. Because of these considerations, it is a technique which deserves wider application and may become the endoscopic treatment of choice for control of upper gastrointestinal tract hemorrhage. Patients with endoscopic control of upper gastrointestinal tract bleeding avoid perioperative morbidity, have a lower transfusion requirement and may have a shorter hospital stay than comparable individuals who require operative control of bleeding sites.

Clinical Trials as Topic↗

PubMedDate not supplied

[The endoscopic treatment of carcinoma of Vater's ampulla].

UNLABELLED: The ampullary carcinoma is a rare tumor. Its early and accurate diagnosis will lead to early treatment and subsequent better prognosis. Endoscopic retrograde cholangiopancreatography (ERCP) has been shown to be one of the best diagnostic tools. Furthermore an endoscopic biliary drainage procedure: endoscopic sphincterotomy or endoprosthesis placement, can be performed immediately following the diagnostic procedure. PATIENTS AND METHODS: Endoscopic drainage was attempted in 20 patients with a success rate of 90 percent. There were 8 females and 12 males, with a mean age of 71 years (range 43-92), and were admitted to the hospital with obstructive jaundice. Endoscopic insertion of a biliary endoprosthesis (9 cms long 3.2 mm [10 Fr] diameter), was successful in 18 patients whom made uneventful recovery and their jaundice resolved completely. RESULTS: In 18 of them an endoscopic sphincterotomy was carried out. Two patients developed cholangitis, the endoprosthesis were removed and a new one inserted. The survival rate of these patients was 3 and 18 months respectively. Failure of endoscopic sphincterotomy or endoprosthesis insertion in 2 remaining patients, was ascribed to an inability to cannulate the papilla due to infiltrating tumor. The median survival time in 15 remaining patients was 4 months (1-18 months) and died by metastatic disease. Five patients underwent Whipple's procedure, and all survived the operation. Two died, by metastatic disease, with a median survival time of 16 months and 3 still alive at 46, 25 and 18 months post-operatively. Carcinoma of the ampulla of Vater is not resectable in 25-50% of the patients because of metastatic disease, deep extension of the tumor or general contraindications for major surgery. CONCLUSIONS: Endoscopic sphincterotomy or endoprosthesis insertion as a definitive treatment modality should be reserved for poor surgical candidates and those patients with limited life expectancy due to metastatic disease.

Adult↗

PubMed1995

Long-term follow-up of endoscopic treatment for bleeding gastric and duodenal ulcers.

OBJECTIVE: To examine the long-term consequences of endoscopic therapy for bleeding peptic ulcers. METHODS: Eighty-seven consecutive patients who underwent endoscopic treatment for bleeding gastric ulcer (GU) and/or duodenal ulcer (DU) over a 42-month period were identified. Long-term follow-up was available for 76 (mean, 495 days; SEM, 45 days). Therapy consisted of epinephrine injection, heater probe use, or both. Recurrent hemorrhage only at the primary treatment site was considered. RESULTS: The sites of hemorrhage were GU (40 patients), DU (34 patients), and both (2 patients). Emergent surgery was required in two GU patients for whom endoscopic treatment was ineffective. Recurrent hemorrhage ultimately occurred in 33% of patients--40% of GU and 25% of DU patients. Surgical therapy was eventually required in 26% of patients after endoscopic hemostasis and was more frequent in patients with recurrent hemorrhage from DU than GU (78% vs 56%). For those patients who re-bled within 8 days of the index endoscopy, 82% required surgery, compared with 33% of patients who re-bled more than 8 days after the index endoscopy (p = 0.03). CONCLUSIONS: The rate of recurrent hemorrhage after endoscopic hemostasis for bleeding GU and DU was 33% in our long-term follow-up. After endoscopic hemostasis, surgery was eventually required in 24% of all patients and in 64% of patients who had recurrent hemorrhage. Patients who had recurrent hemorrhage more than 1 wk after initial endoscopic hemostasis were effectively treated by repeated endoscopic therapy and were significantly less likely to require surgery than patients who re-bled within 1 wk.

Duodenal Ulcer↗

PubMed1993

[Current results of endoscopic sphincterotomy for lithiasis of the common bile duct].

Between January 1989 and June 1990, endoscopic sphincterotomy was performed in 308 consecutive patients with common bile duct stones (mean age: 74 years). Complete clearance of common bile duct was achieved at the first attempt in 65% of cases. This rate was significantly related to the size and the number of biliary stones. The success rate reached 97 percent after repeated endoscopic sessions (127 patients), mechanical lithotripsy (20 patients), extracorporeal or intracorporeal lithotripsy (18 and 11 patients, respectively). During the month following the endoscopic sphincterotomy, 39 patients (13%) developed one or more complications and 11 patients (3.7%) died. The complication rate was related to the time elapsed between biliary opacification and endoscopic sphincterotomy (P = 0.04) and between endoscopic sphincterotomy and total common bile duct clearance (P = 0.0007). No patient younger than 75 years died, but death occurred in 4.5% of the patients older than 75 years. Thirty patients (10%) developed endoscopic sphincterotomy-related complications. Cholangitis and bleeding were the most frequent complications (4 and 2%, respectively). Cholangitis occurred more frequently among the patients older than 75 (P < 0.05) or when transhepatic guided endoscopic sphincterotomy or intracorporeal lithotripsy was used (P < 0.005). Cholangitis led to death in 2 patients, 86 and 87 years old (0.7%). Endoscopic sphincterotomy related complications developed within 48 hours in all but 4 patients (2 patients with pancreatitis and 2 patients with cholecystitis).

Acute Disease↗

PubMedDate not supplied

Endoscopically assisted repair of subcondylar fractures of the mandible: an evolving technique.

OBJECTIVE: To review one surgeon's experience with the endoscopic approach to assist with reduction and rigid fixation of subcondylar fractures of the mandible. DESIGN: Chart review of all cases in which endoscopic techniques were used to assist with the reduction and, when possible, repair of these fractures. The numbers of fractures approached, successfully repaired with the use of plates and screws, and not successfully plated with this approach were documented. SETTING: All surgeries were performed in the operating room at a university hospital. PATIENTS: All patients who underwent endoscopic exploration of a single or bilateral subcondylar fractures of the mandible were included. Seventeen explorations were carried out in 12 patients (age range, 16-39 years). Associated mandibular and other facial fractures were noted. INTERVENTIONS: Endoscopic exploration via a transoral approach. A secondary port in the submandibular region was made in 13 of 17 fracture explorations, and this second port was used primarily for the application of downward traction on the angle of the mandible. Plates were introduced transorally, while screws were placed through a transbuccal trochar. MAIN OUTCOME MEASURE: Success was judged by the successful reduction of the fracture and application of a rigid fixation plate by means of the limited, endoscopically assisted approach, a measure of the ability to accomplish the procedure, not an evaluation of functional results. (With these criteria, 9 of 10 successes had normal function at last follow-up, as did the 10th after revision.) RESULTS: Rigid plate fixation was completed endoscopically for 10 fractures, and 2 were plated after conversion to a full open approach. Four were reduced but could not be plated, and in 1 exploration, a bent plate was removed, but a new plate was not applied. Nine of the 10 fractures plated endoscopically resulted in normal occlusion and function. In the 10th case, a persistent malocclusion necessitated reexploration and refixation, resulting in a successful functional outcome with normal occlusion. CONCLUSION: The endoscopically assisted approach for the repair of subcondylar fractures of the mandible is a feasible but challenging technique.

Adolescent↗

PubMed1998

Transnasal endoscopic repair of congenital choanal atresia: long-term results.

OBJECTIVE: To evaluate the short- and long-term success of the repair of congenital choanal atresia using the transnasal endoscopic approach with and without power instruments. DESIGN AND SETTING: Retrospective case series in a tertiary care center. PATIENTS: Fifteen patients with either unilateral or bilateral congenital choanal atresia were treated using the transnasal endoscopic approach. Postoperative stenting was used in all 15 patients. INTERVENTIONS: The senior surgeon (C.W.G.) currently uses the transnasal endoscopic drill-out technique. We describe our experience and long-term follow-up of 15 patients (9 with unilateral atresia, 5 with bilateral atresia, and 1 with unilateral stenosis) who were treated with the use of the transnasal endoscopic technique during a 7-year period. In 8 patients, the transnasal endoscopic technique was performed using conventional biting instruments, and in 7 patients, the transnasal endoscopic technique with power instruments was used. MAIN OUTCOME MEASURE: The patency of the surgical repair of congenital choanal atresia by the transnasal endoscopic approach. RESULTS: Of 14 patient procedures, 12 remained patent. One patient required minor debridement of granulation tissue 1 week following stent removal, and 1 patient required surgical transnasal revision 2 months after the primary procedure, with a patent result after the second procedure. Despite patent choanae being achieved, 1 patient died of cardiac anomalies 8 months after the atresia repair. CONCLUSIONS: The transnasal endoscopic route offers excellent visualization of the posterior choana and, hence, the ability to open the defect widely with a high surgical success rate. Newer powered instrumentation further enhances the ability to perform this technique cleanly.

Adolescent↗

PubMed2003

Endoscopic photography: digital or 35 mm?

OBJECTIVE: To compare off-the-shelf digital imaging equipment with a standard single lens reflex 35-mm endoscopic camera in a busy pediatric ears, nose, and throat setting. DESIGN: Two digital cameras with an endoscope adapter and a step-down ring were evaluated to obtain optimal settings for digital endoscopic photography. The equipment was used in various clinical and surgical settings to include otoscopy, sinonasal endoscopy, laryngoscopy, and bronchoscopy. The overall quality, color, brightness, and diagnostic quality of the endoscopic digital photographs were compared with those of the single-lens reflex 35-mm flash-generated photographs by experienced endoscopists. Cost analysis and ease of use were also compared. Subjects Initial digital endoscopic settings were formulated from cadaveric tests. These settings were then studied in multiple patients during endoscopy. RESULTS: Endoscopic digital photography resulted in high-quality images in all settings. Digital images were comparable to 35-mm images. The digital system was easier to use and less expensive than the 35-mm system. CONCLUSIONS: We introduce a simple, inexpensive, and easily available endoscopic digital photography system. Digital photography offers numerous advantages over analog photography in a clinical practice. Digital imaging and archiving is more durable and easier to incorporate into patient records and clinical presentations. As the demand for high-quality digital imaging increases, easy-to-use inexpensive digital endoscopic photography will soon replace 35-mm camera technology.

Endoscopy↗

PubMed2000

Endoscopic mucosectomy: an alternative treatment for superficial esophageal cancer.

Recent trends in the management of superficial esophageal cancer consist of improved detection, pretherapeutic staging and reliable criteria for curative endoscopic therapy. The endoscopic treatment is legitimate when the cancer is at an early stage, intra-epithelial or microinvasive (m1 or m2) and N0. Submucosal cancer should not be treated with a curative intent by endotherapy. Concerning squamous cell cancer, the oriental and occidental pathologists include high-grade dysplasia in the same group as intramucosal cancer. The distinction is however maintained for adenocarcinoma in the Barrett's esophagus. Indications of endoscopic rather than surgical treatment rely on: (1) the small size of the tumor (not more than 2 cm in diameter); (2) the endoscopic morphology in the type 0 of the Japanese classification with the flat subtypes IIa and IIb rather than type IIc--there is high risk of submucosal invasion for the polypoid (type I) or ulcerated superficial cancer (type III); and (3) the endoscopic ultrasound staging, with confirmed integrity of the hyperechoic submucosal layer. The high-frequency (20 MHz) miniprobe is preferred to the standard (7.5 MHz) instrument. The elective procedure for tumor eradication is endoscopic mucosectomy. The technique is associated with a 6.8% risk of severe complications (hemorrhage or perforation) and a recurrence rate of 3%-7%. The 5-year survival rate is similar to that of surgery (over 80%). In the small group of patients with superficial esophageal cancer (less than 10% of the disease) endoscopic treatment may now be proposed in about 30% of cases, surgery is preferred for submucosal cancer and for neoplasia with a large surface. Areas of high-grade dysplasia in the Barrett's esophagus offer a new and increasing sector of indications. The concurrent endoscopic procedure of destruction--photodynamic therapy--is preferred for the destruction of lesions with poorly delineated limits.

Barrett Esophagus↗

PubMed1995

The E.A.E.S. Consensus Development Conferences on laparoscopic cholecystectomy, appendectomy, and hernia repair. Consensus statements--September 1994. The Educational Committee of the European Association for Endoscopic Surgery.

Under the mandate of the Educational Committee of the European Association of Endoscopic Surgery (E.A.E.S.), three consensus development conferences (CDCs) were performed in order to assess the current status of the endoscopic surgical approaches for the treatment of cholelithiasis, appendicitis, and inguinal hernia. Consensus panels for the different disease states (10-13 members each) selected by the education committee on the basis of members' clinical expertise, academic activity, community influence, and geographical location weighed the evidence on the basis of published results according to the criteria for technology assessment: feasibility, efficacy, effectiveness, economy. Draft statements were prepared, discussed by the panels, and presented at plenary sessions of the 2nd European Congress of the E.A.E.S. in Madrid September 15-17, 1994. Following discussions final consensus statements were formulated to provide specific answers for each topic to a minimum of the following questions: 1. What stage of technological development is the endoscopic surgical procedure at (in September 1994)? 2. Is endoscopic surgery safe and feasible? 3. Is it beneficial to the patients? 4. Who should undergo endoscopic surgery? 5. What are the training recommendations? Laparoscopic cholecystectomy is the procedure of choice for symptomatic cholelithiasis. Laparoscopic appendectomy is presently at the efficacy stage of development, because most of the data on feasibility and safety originate from centers with special interest in endoscopic surgery: it is not yet the gold standard for acute appendicitis. Endoscopic hernia repair is presently a feasible alternative for conventional hernia repair if performed by experienced endoscopic surgeons. It appears to be efficacious in the short-term. The full text of the consensus panel's statements is given in this publication.

Appendectomy↗