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PubMed2000

Clinical outcome of endoscopic mucosal resection for superficial GI lesions and the role of high-frequency US probe sonography in an American population.

BACKGROUND: Endoscopic mucosal resection, a major advance in endoscopy, provides an endoscopic option for management of focal and superficial lesions of the gastrointestinal tract. Although popular in the Orient due to the high incidence of superficial neoplasia, there are scant data on its use in the United States. Our aim was to assess the efficacy and safety of endoscopic mucosal resection in our patient population and evaluate whether high-frequency ultrasound (US) probe sonography provides useful information relative to the procedure. METHODS: Endoscopic mucosal resection was performed in 32 of 33 patients referred for endoscopic management of superficial neoplastic or submucosal lesions. High-frequency US probe sonography was performed with a 20 MHz US probe. Endoscopic mucosal resection was performed after submucosal saline solution injection with the strip biopsy technique. RESULTS: Thirty-two superficial lesions were resected. Of 24 epithelial lesions resected, 22 were intramucosal and 2 had early submucosal invasion (SM1); the 2 patients with the latter 2 lesions were poor candidates for surgery. Depth of penetration of 25 of 26 lesions scanned was accurately predicted by high-frequency US probe sonography. Eight lesions raised from the submucosa. Minor complications were limited to the colon. Of the 7 patients with carcinomas, 6 had no evidence of recurrence at a mean follow-up of 12 months; 1 died of a second primary cancer. CONCLUSIONS: Endoscopic mucosal resection provided definitive therapy for 24 early-stage neoplastic lesions and provided a diagnosis in the remaining 8. In our study, the technique proved to be safe with only three minor complications noted. High-frequency US probe sonography accurately delineated the depth of penetration of all lesions scanned, therefore making it an ideal imaging modality for selecting patients who may benefit from endoscopic mucosal resection.

Biopsy↗

PubMed2000

A new endoscopic technique for the removal of gastric phytobezoars.

BACKGROUND: There is no standardized method for the evacuation of gastric phytobezoars. Prior endoscopic attempts have used injected cellulase and various devices to disrupt bezoars. The efficacy of directed, large-channel suction using an endoscope for the removal of large gastric phytobezoars is the subject of this study. METHODS: Three consecutive patients with large gastric bezoars were examined. Phytobezoar removal using a standard endoscope (GIF-100, Olympus) was attempted but unsuccessful. Each phytobezoar was successfully evacuated by directed suction through an endoscope with a large-diameter accessory channel (GIF-XT30, Olympus). Each patient was followed up for bezoar recurrence. RESULTS: Rapid, complete bezoar evacuation was achieved at one session in all patients. Aspirated volumes were 500, 700, and 1000 mL. There were no procedure-related complications. CONCLUSIONS: Endoscopic suction removal of gastric phytobezoars using a large-channel endoscope is efficacious and safe. Coupling directed endoscopic suction with other endoscopic techniques might be efficacious for removal of more complex bezoars.

Adult↗

PubMed2001

Endoscopic screening for early esophageal cancer by iodine staining in patients with other current or prior primary cancers.

BACKGROUND: Although early diagnosis of esophageal carcinoma is an important determinant of outcome, early stage carcinomas are rarely detected on routine endoscopic examination. Iodine staining may be useful in the detection of early stage esophageal carcinoma, especially in high-risk populations. In a prior study, 29.2% (68/233) patients with superficial esophageal carcinoma (SEC) undergoing resection at our hospital had other nonesophageal primary carcinomas, suggesting that patients with nonesophageal primary cancers are at increased risk for the development of esophageal cancer. The aim of the current study was to determine whether endoscopic screening with iodine staining is useful for the detection of SEC in patients with a history of non-esophageal cancers. PATIENTS AND METHODS: In a prospective study, 331 patients with nonesophageal primary cancers were screened for esophageal cancer by endoscopic examination with iodine staining. All patients were men 55 years of age or older. RESULTS: Nine patients (2.7%) with SEC were identified. Among these patients, 7 with mucosal cancer were treated by endoscopic mucosal resection, and 2 with submucosal cancer were treated by surgical resection or radiation therapy. Five patients (1.5%) were found to have cancer confined to the epithelium or the lamina propria. These lesions were difficult to detect by conventional endoscopic screening and were cured by endoscopic mucosal resection. After exclusion of 51 patients with head and neck cancer, the incidence of SEC was still 2.1% (6/280), higher than reported in prior screening studies. CONCLUSIONS: All men with a history of nonesophageal primary cancers should undergo endoscopic screening for esophageal cancer. Endoscopic iodine staining in such patients may be useful in screening for early stage esophageal carcinoma.

Aged↗

PubMed2002

Accuracy of a narrow-diameter battery-powered endoscope in sedated and unsedated patients.

BACKGROUND: Esophagoscopy with a portable battery-powered endoscope could provide a safe, inexpensive, and minimally invasive way to screen for Barrett's esophagus or esophageal varices. The use of such an instrument in an unsedated fashion has not been previously evaluated. METHODS: Patients referred for an EGD were recruited to undergo an additional examination with the battery-powered endoscope before EGD. In phase 1, (n = 42) patients received conscious sedation before the battery-powered endoscopic examination. In phase 2, (n = 56) patients were not sedated and were given the option of a peroral (n = 43) or transnasal (n = 13) endoscopy. Examiners were blinded to patient history and procedure indications. Esophageal findings, ease of intubation, optical quality, and patient comfort for the battery-powered endoscope and standard EGD were recorded by the endoscopist. RESULTS: Ninety-eight patients (60 men, 38 women, mean age 53 years) were recruited. The sensitivity for detecting Barrett's esophagus, esophageal tumors, and esophageal varices was 54.5%, 66.7%, and 80%, respectively. Ease of intubation and patient comfort as perceived by the endoscopist were not significantly different between the battery-powered endoscope and EGD. Optical quality was ranked as less than 4 (on a 5-point scale with 5 = standard EGD and 1 = poor) in 42% of battery-powered endoscopic examinations. There were no complications. CONCLUSION: The accuracy of esophageal examination with a 3.1-mm endoscope is substantially inferior to standard EGD. Thus, the battery-powered endoscope would not be useful for screening patients for Barrett's esophagus or varices unless improvements in optical quality and visualization are made.

Adult↗

PubMed2002

Clinical outcome of endoscopic aspiration mucosectomy for early stage gastric cancer.

BACKGROUND: Endoscopic mucosal resection is an established treatment option for early stage gastric cancer. However, several problems with endoscopic mucosal resection remain to be solved, such as appropriate treatment for recurrence and incomplete tumor resection. The outcome for patients undergoing endoscopic aspiration mucosectomy (endoscopic mucosal resection) by a modification of the cap-fitted technique was evaluated retrospectively to determine factors associated with complete resection and tumor recurrence. METHODS: Endoscopic mucosal resection was performed in 106 patients with early stage gastric cancers up to 20 mm in diameter that were well or moderately differentiated adenocarcinoma. All were superficial lesions without ulceration, distinct signs of submucosal invasion, or a poorly demarcated border. En bloc (tumors <10 mm in diameter) or piecemeal (tumors 10-20 mm in diameter) resection was performed. Follow-up endoscopy was performed at 2, 6, 12, 18, and 24 months and thereafter once per year. Outcome and factors associated with complete resection and tumor recurrence were assessed retrospectively. RESULTS: Sixty-eight patients (64%) underwent en bloc resection and 38 (36%) piecemeal resection. The mean longest dimension (SD) of the resected lesions was significantly greater after piecemeal resection (12.3 [4.0] mm) than after en bloc resection (7.6 [4.0] mm; p < 0.01). In patients with tumors completely resected, there was no recurrence after either en bloc or piecemeal resection. Six of 8 patients found to have submucosal invasion after endoscopic mucosal resection underwent surgery. Patients with incompletely resected intramucosal lesions underwent additional endoscopic treatment. Cancer recurred in 3 patients (2.8%), all of whom had lesions measuring more than 15 mm in diameter. CONCLUSIONS: Endoscopic mucosal resection is safe and useful for the management of early stage gastric cancer. Further improvement in outcome requires more accurate preoperative diagnosis and postoperative histopathologic evaluation. Patients with incompletely resected lesions should undergo aggressive additional treatment.

Adenocarcinoma↗

PubMed2003

Predictors of bleeding after endoscopic mucosal resection of gastric tumors.

BACKGROUND: Endoscopic mucosal resection has been increasingly used to treat gastric tumors. Bleeding is the major complication of endoscopic mucosal resection. This study evaluated risk factors for bleeding associated with endoscopic mucosal resection. METHODS: Four hundred seventy-seven patients who underwent endoscopic mucosal resection of gastric tumors during the past 10 years were studied retrospectively. Bleeding encountered during endoscopic mucosal resection was termed immediate; bleeding after endoscopic mucosal resection was termed delayed. Univariate and multivariate analyses were used for determination of the factors related to delayed bleeding. One case of perforation was excluded. RESULTS: Delayed bleeding occurred in 25 (5.3%) of 476 patients. The only factor found to be significantly different between cases with and without delayed bleeding was the occurrence of immediate bleeding during endoscopic mucosal resection (p < 0.001). Sites where immediate bleeding occurred were not the same as those where delayed bleeding arose. There were no significant differences in other factors. CONCLUSIONS: When immediate bleeding occurs during endoscopic mucosal resection, there is an increased risk of delayed bleeding.

Adenocarcinoma↗

PubMed2003

A prospective randomized trial of two different endoscopic resection techniques for early stage cancer of the esophagus.

BACKGROUND: A variety of different endoscopic resection techniques for early stage cancer of the upper GI tract have been described that are more effective than strip biopsy. However, there is no report of a prospective randomized comparison of different techniques. METHODS: In a prospective randomized study, 100 consecutive endoscopic resections were performed in 72 patients with early stage esophageal cancer. Fifty endoscopic resections were performed with a "suck-and-ligate" device without prior submucosa injection and 50 with the cap technique with prior submucosa injection of a dilute saline solution of epinephrine. The main assessment criteria were maximum diameter of the resection specimen and of the resection area, and the complication rate. RESULTS: No significant differences were observed between the two groups with regard to the maximum diameters and calculated area of the resected specimens (ligation group: 16.4 [4.0] x 11 [3.1] mm/185 [84] mm(2) vs. cap group: 15.5 [4.1] x 10.7 [2.7] mm/168 [83] mm(2)), or the maximum diameters and calculated area of the endoscopic resection ulcers after 24 hours (ligation group: 20.6 [4.8] x 14.3 [4.5] mm/314 [160] mm(2) vs. cap group: 18.9 [5.1] x 12.9 [3.8] mm/260 [145] mm(2)). There was only a slight advantage (greater diameter of resection specimens) for the ligation group in patients who had prior endoscopic treatment. There was one minor episode of bleeding in each group; there was no severe complication. In 41 of 72 patients (57%), further endoscopic therapy after endoscopic resection was necessary because of residual neoplasia at the first follow-up endoscopy after resection (61 of 100 resection specimens [61%] had lateral margins that could not be evaluated because of coagulation artifact or contained malignancy but with the base of the lesion free of tumor). CONCLUSIONS: The cap technique with submucosa injection and the ligation technique without submucosa injection are similar with respect to efficacy and safety for endoscopic resection of early stage esophageal cancers.

Esophageal Neoplasms↗

PubMed2003

Criteria for the diagnosis of dysplasia by endoscopic optical coherence tomography.

BACKGROUND: Endoscopic optical coherence tomography provides images of the GI mucosa and submucosa in microscopic detail. It is unknown whether endoscopic optical coherence tomography can reliably detect dysplasia. Colon polyps were used as a model to determine whether dysplasia in GI tissue has characteristic optical coherence tomography imaging features. METHODS: Endoscopic optical coherence tomography images of colon polyps and normal colon tissue were obtained at colonoscopy. In real time, endoscopists compared tissue organization and light scattering for polyps and normal mucosa with endoscopic optical coherence tomography. Imaged polyps were removed and evaluated histopathologically. Organization and light scattering, as assessed by endoscopic optical coherence tomography at colonoscopy, were compared for adenomas versus hyperplastic polyps. A computer program also quantified and compared the degree of light scattering for hyperplastic polyps and adenomas. RESULTS: A total of 44 polyps were imaged in 24 patients (30 adenomas, 14 hyperplastic polyps). Endoscopic optical coherence tomography images of adenomas had significantly less structure (p = 0.0005) and scattered light to a lesser degree than hyperplastic polyps (p = 0.0007). Hyperplastic polyps were significantly closer in organization (p = 0.0003) and light scattering (p = 0.0006) to normal mucosa as compared with adenomas. By digital image analysis, the light-scattering property of hyperplastic polyps was closer to normal mucosa compared with adenomas (14.86 vs. 45.81; p = 0.0001). CONCLUSIONS: Real-time endoscopic optical coherence tomography imaging differentiated adenomas, hyperplastic polyps, and normal colon tissue. By using the colon adenoma as a model, the endoscopic optical coherence tomography characteristics of dysplasia are loss of tissue organization and reduced light scattering.

Adenoma↗

PubMed2000

Fetal hydrolaparoscopy and endoscopic cystotomy in complicated cases of lower urinary tract obstruction.

OBJECTIVE: Vesicoamniotic shunting may be difficult or impossible in selected cases of fetal lower obstructive uropathy. The purpose of this article is to describe the performance of fetal hydrolaparoscopy and endoscopic fetal cystotomy in two fetuses with complicated lower obstructive uropathy. STUDY DESIGN: Fetal hydrolaparoscopy-endoscopic fetal cystotomy was performed in a patient with a markedly thickened bladder that could not be entered percutaneously. A peritoneoamniotic (bridge) shunt was also placed. Fetal hydrolaparoscopy-endoscopic fetal cystotomy was performed in a second patient with a collapsed bladder from a previous vesicocentesis, because vesicoinfusion resulted in further ascites. Fetal cystoscopy was performed after endoscopic fetal cystotomy, and posterior urethral valves were ablated with neodymium:yttrium-aluminum-garnet laser energy. A vesicoamniotic shunt was left in place. RESULTS: Adequate bladder drainage was obtained in both cases. The first baby required bilateral nephrotomy and a permanent cystotomy at birth and is scheduled for a bladder expansion procedure at the age of year. The second patient had premature rupture of membranes and fetal death from treatment of this complication 5 days after the original procedure. CONCLUSION: Fetal hydrolaparoscopy-endoscopic fetal cystotomy can be performed in complicated cases of lower obstructive uropathy. The procedure involves the creation of a defect in the bladder dome under direct endoscopic visualization within a spontaneous or intentional hydroperitoneum. Peritoneoamniotic shunting, vesicoamniotic shunting, or ablation of posterior urethral valves may then be performed. Fetal hydrolaparoscopy-endoscopic fetal cystotomy should be reserved only for complicated cases of lower obstructive uropathy in which conventional vesicoamniotic shunting is not safely possible. Further experience with fetal hydrolaparoscopy-endoscopic fetal cystotomy is necessary to establish its risks and benefits.

Adult↗

PubMed2002

A prospective randomized trial of endoscopic versus conventional harvesting of the saphenous vein in coronary artery bypass surgery.

OBJECTIVES: Our objectives were (1) to determine whether minimally invasive endoscopic harvesting of the saphenous vein reduces morbidity due to postoperative wound infection and pain with improved cosmetic results and mobilization as compared with the conventional technique and (2) to compare the histologic properties of the saphenous veins harvested conventionally and endoscopically. METHODS: One hundred forty-four patients undergoing coronary artery bypass grafting were randomized to have vein harvesting performed by either the conventional (n = 72) or an endoscopic (n = 72) minimally invasive technique. RESULTS: Vein harvest time (open leg wound time) was significantly reduced in the endoscopic group (27.6 vs 64.4 minutes; P <.0001). The rate of leg wound infection was significantly reduced in the endoscopic group (4.3%) as compared with the conventional group (24.6%), a relative risk reduction of 83% (95% confidence interval: 36%-129%; P =.0006). The majority of infections (84.2%) occurred after hospital discharge. Postoperative leg pain, mobilization, and overall patient satisfaction were also significantly improved in the endoscopic group. Double blinded histologic assessment of harvested vein (n = 28) showed no evidence of any clinically important significant damage to the specimens in either group. CONCLUSIONS: In this prospective randomized trial, endoscopic harvesting of the saphenous vein significantly reduced postoperative leg wound complications, including infection, and improved patient satisfaction as compared with the conventional harvesting technique. There were no significant histologic differences between the conventional and endoscopically harvested saphenous veins.

Coronary Artery Bypass↗

PubMed2006

Endoscopic treatment of gastroesophageal reflux disease: effect of gender on clinical outcome.

OBJECTIVE: Gender differences in gastroesophageal reflux disease have been reported. Higher frequency and severity of symptoms, lower esophageal acid exposure and lower incidence of reflux-related complications have been observed in women. The aim of this study was to determine whether there are any gender differences in clinical presentation, diagnostic evaluations and response to endoscopic therapy in patients with gastroesophageal reflux disease. MATERIAL METHODS: Patients with gastroesophageal reflux disease referred for endoscopic therapy were scored for typical (heartburn and regurgitation) and atypical (chest pain, cough, wheezing, and hoarseness) symptoms at baseline. Upper endoscopy, manometry and pH studies were performed for all patients. Endoscopic treatment consisted of placement of two to three sutures within 2 cm of the squamocolumnar junction. Reflux symptoms were re-scored after endoscopic treatment. RESULTS: Ninety-five patients (37 M, 58 F, mean age 51 years) were included in the analysis. Male and female patients at baseline reported similar severity of typical reflux symptoms as well as comparable prevalence of atypical symptoms. Manometric findings were also comparable between the genders. Endoscopic and ambulatory pH studies revealed a higher incidence of erosive esophagitis and a trend towards higher acid exposures in male patients. The response to endoscopic therapy was similar for men and women. CONCLUSIONS: Apart from a higher incidence of erosive esophagitis in male patients, no major differences were found in endoscopic, manometric, esophageal acid exposure studies and clinical response to endoscopic therapy between the genders.

Endoscopy, Gastrointestinal↗

PubMed2000

Endoscopic transsphenoidal pituitary surgery: various surgical techniques and recommended steps for procedural transition.

Various techniques in pituitary endoscopy are reviewed in the attempt to assemble the transitional steps necessary to take a neurosurgeon from traditional microscopic transsphenoidal surgery to endoscopic endonasal pituitary surgery. The senior author's (HDJ) experiences of endonasal endoscopy in more than 200 operations as well as the reports in the literature on pituitary endoscopy are reviewed. Two distinct advantages that an endoscope has over an operating microscope are its ability to visualize through a narrow surgical corridor and its ability to provide angled, close-up views. An endoscope can be used to assist the operating microscope (endoscope-assisted microsurgery). Endoscopy can also be used for endonasal retractor placement when microscopic surgery is preferred (endoscopic sphenoidotomy). When endonasal endoscopy is chosen, the surgical approach can be made with a deep-transseptal, a paraseptal, a middle turbinectomy or a middle meatal approach (endonasal transsphenoidal endoscopy). Endonasal endoscopy can be performed via either one or two nostrils. Working-channel endoscopy can be performed for restricted purposes. When a neurosurgeon desires to adopt endoscopy into pituitary surgery, the author recommends endoscope-assisted microsurgery as the first step followed by endoscopic sphenoidotomy as a combined effort between an endoscopic rhinologist and the neurosurgeon as the next step leading finally to endonasal pituitary endoscopy. Various methods of transsphenoidal endoscopy and the authors' recommendations for transitional steps are reported based on the authors' personal experience and literature review.

Acromegaly↗

PubMed1995

Mechanical impactor employing Nitinol probes to fragment human calculi: fragmentation efficiency with flexible endoscope deflection.

The Browne Pneumatic Impactor (BPI; Browne Medical Systems, Minneapolis, MN) is a new mechanical lithotripter that relies on a pneumatically driven metal probe. It can be employed through both rigid and actively deflectable flexible endoscopes. Prior in vivo studies have shown excellent fragmentation of hard human calculi while employing the BPI with active endoscope deflection of as much as 45 degrees. In this study, we set out to define the efficiency of stone fragmentation with active endoscope deflection and to quantify the extent of retrograde stone migration that is often noted when mechanical lithotripters are employed. Pressure transducer testing of the BPI revealed an inverse relation between increased deflection of the endoscope and transduced voltage. Calculus fragmentation tests showed that as the endoscope was actively deflected to 90 degrees, the BPI still was able to fragment human calcium oxalate monohydrate calculi into extractable fragments with as few as six pulses. The maximum active endoscope deflection was 95 degrees with the 0.020-inch Nitinol probe passed through the working channel. At this deflection, the BPI was able to fragment an 8 mm pure calcium oxalate monohydrate calculus into two fragments after 14 pulses. Retrograde migration was evaluated by employing the BPI in a simulated ureter in a waterbath. The travel distance of a 5-mm 5-g calculus with one pulse averaged 12.2 mm (range 1-44 mm). Smaller, less dense calculi travelled farther. A rebound effect was occasionally noted, and this was associated with an off-center delivery. In conclusion, the BPI is an efficient mechanical lithotrite able to fragment hard human calculi when employed with active endoscope deflection of as much as 95 degrees. Delivered energy decreased with active endoscope deflection, but this change did not prevent fragmentation. Retrograde migration was an important variable more notable with smaller calculi.

Alloys↗

PubMed1998

Endoscopic-assisted temporoparietal fascial flap dissection and harvesting: a feasibility preliminary cadaveric study.

Endoscopic procedures in plastic surgery have been applied in various aesthetic and reconstructive surgical techniques. The authors describe, in this preliminary report, a new surgical technique of endoscopic dissection of the temporoparietal fascial flap. A series of 6 fresh human cadavers (12 flaps) were dissected endoscopically. The surgical incisions, flap anatomy applicable to endoscopy, endoscopic surgical technique, and type of endoscopic setup is standardized for all flaps, allowing direct identification of the temporoparietal fascial layers and the major vascular pedicle. This endoscopic manipulation of the flap, without the traditional large scalp incision, permits local and free transfer of the temporoparietal fascial flap. Exposure of the flap by means of the conventional T or Y temporal incisions has several possible disadvantages, including an increased risk of blood loss, alopecia, and facial nerve injury. Endoscopic dissection and mobilization of the temporoparietal fascial flap can obviate the direct flap incision and yield a flap accessible to dissection and mobilization for additional clinical applications. This new, innovative, and minimally invasive endoscopic procedure may prove particularly applicable to future clinical applications of this type of fascial flap.

Cadaver↗

PubMed2000

Endoscopic intracranial craniofacial and monobloc osteotomies with the aid of a malleable high-speed pneumatic drill: a cadaveric and clinical study.

Endoscopic techniques are now an accepted part of the surgical armamentarium and are used routinely in a number of aesthetic and reconstructive procedures. Endoscopic techniques are now being used commonly by plastic surgeons in forehead and face lifts. In both craniofacial surgery and in neurosurgery, the application of endoscopy potentially allows the surgical team to perform wide dissection of the dura mater in a minimally invasive fashion, thereby potentially reducing the risk of dural and brain injury. Also reduced by this surgical approach is potential injury to the major venous structures, such as the sagittal sinus, along with overall reduced bleeding. After an extensive laboratory study of 10 cadaveric dissections, the authors have refined a new endoscopic technique for completing an endoscopic intracranial craniofacial osteotomy. This study was conducted in the Department of Pathology at the University of Brno (Czech Republic), and was performed as a cooperative multicenter project between the University of Palermo, the Albert Einstein College of Medicine/ Montefiore Medical Center, the Hospital Infantil de Mexico, "Federico Gomez," and the Medtronic Midas Rex Institute, (Fort Worth, TX). During this cadaveric anatomic study and using small trephinations and skin incisions the authors were able to develop several different craniofacial and endoscopic monobloc procedures. To accomplish intracranial and facial osteotomies, a new malleable high-speed drill was designed for use in the endoscopic craniofacial approach. Using these newly developed cadaveric techniques and instrumentation, the authors performed two intracranial craniofacial procedures on children with congenital craniofacial anomalies. There would appear to be several significant advantages for the craniofacial patient as result of these new techniques: reduced surgical trauma, operative bleeding, surgical time, and hospitalization, along with a reduced risk of infection. It became quickly apparent, as a result of these cadaveric studies, that the learning curve for this endoscopic procedure is quite steep. Tutino M, Chico F, Tutino M, Goodrich JT, Ortiz Monasterio F. Endoscopic intracranial craniofacial and monobloc osteotomies with the aid of a malleable high-speed pneumatic drill: a cadaveric and clinical study.

Aged↗

PubMed2004

Pitfalls of endoscopic ultrasound staging after application of electrocautery.

Patients may be referred for endosonography after endoscopic resection of polyps because of cancer identified in the histologic specimen. To assess the effects of electrocautery-induced tissue changes on tumor staging by endosonography, endosonography findings after endoscopic removal of large polyps were correlated with surgical and endoscopic pathology. Endosonography findings revealed irregular and thickened wall layers, especially in the muscularis propria with pseudopod extensions. Five of 7 patients had evidence of cancer in the endoscopic specimen. However, no residual tumor was found in the surgically resected bowel (2 patients) or in subsequent biopsies of the endoscopic resection site (3 patients). In 2 other patients, no cancer was present in the endoscopic specimen, and follow-up biopsies of the endoscopic resection site were all benign. Electrocautery-induced inflammatory changes create hypoechoic changes within the gut wall that may mimic tumor invasion. Irregularities in the muscularis propria layer cannot be relied upon to diagnose a T2 or T3 lesion by endosonography in this setting. Patients with large polyps greater than 2 cm and other mucosal lesions with malignant potential should undergo endosonography prior to endoscopic resection.

Adenocarcinoma↗

PubMed1997

Percutaneous endoscopic gastrostomy in children and adolescents.

BACKGROUND: Long-term nasogastric tube feeding is often associated with irritation of the hypopharynx or dislocation of the tube. These pitfalls may be circumvented by percutaneous endoscopic gastrostomy. Although frequently used in adults, there is limited experience with the procedure in children. METHODS: A series of 139 patients (aged 3 weeks to 36.5 years, mean age, 4.4 years; weight 3.1-60 kg, mean weight, 15 kg) underwent placement of a percutaneous endoscopic gastrostomy because of central dysphagia (n = 103); general dystrophy caused by chronic renal failure, congenital heart disease, neoplasms, or cystic fibrosis (n = 26); requirement for special diets (n = 7); malnutrition related to respiratory insufficiency (n = 2); and gastric volvulus (n = 1). RESULTS: The percutaneous endoscopic gastrostomy was placed either in the stomach (n = 122) or in the duodenum (n = 15). In two patients a direct percutaneous endoscopic jejunostomy was performed, because duodenal placement proved impossible. Percutaneous endoscopic gastrostomies were placed using intravenous sedation (midazolam, etomidate, or diazepam). None of the patients required general or inhalation anesthesia. We observed 19 complications including: dislocation of the duodenal part into the stomach (n = 5); inflammation at the insertion site (n = 3); perforation of the stomach (n = 2), which healed under conservative treatment; disconnection of the retention disk (n = 4); occlusion of the tube (n = 4), and chronic vomiting (n = 1). Mean lifetime of a percutaneous endoscopic gastrostomy was more than 1 year. CONCLUSIONS: Percutaneous endoscopic gastrostomy provides a major improvement for children requiring long-term tube feeding. High efficacy and low rates of complication suggest that percutaneous endoscopic gastrostomy should be considered more often, even in infants.

Adolescent↗

PubMed2003

Transnasal endoscopic medial maxillectomy for inverting papilloma.

OBJECTIVE: To describe the new technique of transnasal endoscopic medial maxillectomy. STUDY DESIGN: Study design included application of the new technique in the management of five patients with inverting papilloma; retrospective review of five patients who had lateral rhinotomy with medial maxillectomy for inverting papilloma; comparison of transnasal endoscopic medial maxillectomy to open medial maxillectomy for scope of resection, margin control, operative time, and surgical access; and detailed description of transnasal endoscopic medial maxillectomy. METHODS: Charts were reviewed and tabulated for operative time, duration of follow-up, and recurrence. Pathology reports were reviewed for number and orientation of the specimens and for margin control. RESULTS: Operative time was shorter for patients managed with transnasal endoscopic medial maxillectomy. All patients with transnasal endoscopic medial maxillectomy had one large, well-oriented specimen with margin control. There was no recurrence in either group. CONCLUSIONS: Transnasal endoscopic medial maxillectomy providing full access to the maxillary and ethmoid sinuses is described in detail. Transnasal endoscopic medial maxillectomy is an effective, reproducible technique with less operative time and morbidity and, possibly, better pathological tumor mapping than open medial maxillectomy for selected patients. Maxillary sinus involvement with inverting papilloma is not a contraindication for this technique. Strong illumination, superior resolution, and angled visualization, coupled with exact osteotomies, make transnasal endoscopic medial maxillectomy an efficacious technique for inverting papilloma with extension limited to the maxillary and ethmoid sinuses.

Endoscopy↗