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PubMed2000

Reevaluation of duodenal endoscopic markers in the diagnosis of celiac disease.

BACKGROUND: Loss or reduction of duodenal folds, scalloping of Kerkring folds and a micronodular or mosaic duodenal mucosal pattern have been described in celiac disease (CD), endoscopic findings that are considered reliable in the diagnosis of this disorder. However, most data have been obtained in patients with suspected or certain disease. We assessed the accuracy of the above markers in diagnosing CD in patients with nonulcer dyspepsia. METHODS: In this prospective study, in 705 consecutive dyspeptic patients (284 men, 421 women, mean age 51 +/- SD 15.8 years) duodenal biopsies were obtained only in the presence of typical endoscopic markers, whereas in another 517 (207 men, 310 women, mean age 49.9 +/- SD 16 years) duodenal biopsies were done irrespective of macroscopic findings. CD was diagnosed histologically and on the basis of positive antiendomysium antibody. RESULTS: Endoscopic markers were found in 4 patients of the first group but CD was ruled out. In the second group 5 patients had an endoscopic pattern that was consistent and CD was diagnosed in 3, whereas 3 others with normal endoscopic findings were eventually diagnosed as having CD. Endoscopic markers had a sensitivity of 50% and a specificity of 99.6% (95% CI [11.8, 88.2 and 98.6, 99.9], respectively) with positive and negative predictive values of 60% and 99.4%, respectively. CONCLUSION: The accuracy of endoscopic markers in the diagnosis of CD must be reevaluated in relation to the characteristics of the population studied.

Adolescent↗
PubMed2002

High-frequency probe EUS-assisted endoscopic mucosal resection: a therapeutic strategy for submucosal tumors of the GI tract.

BACKGROUND: The aim of this study was to evaluate the efficacy and safety of high-frequency probe EUS (HFPE)-assisted endoscopic mucosal resection in the management of submucosal tumors of the GI tract. METHODS: HFPE-assisted endoscopic mucosal resection was attempted in 28 patients with submucosal tumors less than 2 cm in diameter. HFPE was performed with a 20-MHz "through-the-scope" probe. Saline solution was injected into the submucosa. After confirming detachment of the lesion from the muscularis propria by repeat HFPE, endoscopic mucosal resection was performed with a lift-and-cut or endoscopic mucosal resection cap technique. Follow-up endoscopy was performed in all patients. RESULTS: Submucosal tumors from the following areas were included: esophagus 3, stomach 4, duodenum 3, and colon 18. The submucosal tumors were located in the upper third (n = 3), middle third (n = 18), and lower third (n = 7) of the submucosa. Twenty-one submucosal tumors were removed by the lift-and-cut technique and 6 by the cap method. One patient required surgical resection after unsuccessful endoscopic mucosal resection. The origin and depth of penetration of all lesions was accurately depicted by HFPE. Median tumor diameter was 9 mm (range 3-20 mm). Resection was successful and complete in 93% of the cases. There were no immediate postprocedure complications (exact 95% CI [0%, 12.3%]). During a median follow-up of 21.5 months (range 2-74 months) no recurrence was found. CONCLUSIONS: HFPE-assisted endoscopic mucosal resection is safe and effective for the management of selected submucosal tumors of the GI tract. A management algorithm based on endoscopic and HFPE findings is proposed.

Adult↗
PubMed2002

Endoscopic hemoclip placement and epinephrine injection for Mallory-Weiss syndrome with active bleeding.

BACKGROUND: Mallory-Weiss syndrome with active bleeding requires effective hemostasis. This is an investigation of the respective efficacy and safety of endoscopic hemoclip placement and endoscopic epinephrine injection in Mallory-Weiss syndrome. METHODS: Thirty-five patients with Mallory-Weiss syndrome with spurting vessels or oozing in a university hospital were enrolled prospectively and randomly assigned to endoscopic hemoclip placement (18 patients) or endoscopic epinephrine injection (17 patients) performed by 4 endoscopists with similar clinical experiences. Demographic characteristics, endoscopic variables, and outcome parameters as well as rates of hemostasis and recurrent bleeding were analyzed. RESULTS: The mean (SD) number of hemoclips applied was 2.5 (1.2) and the mean volume of injection was 7.9 (4.3) mL. Primary hemostasis was achieved in all 35 patients. In each group there was 1 case of recurrent bleeding. Secondary hemostasis was achieved by repeating the same procedures as at randomization in both cases. There were no significant differences in age, gender, prior ingestion of alcohol, presenting symptoms, hemoglobin level, shock, comorbid diseases, bleeding stigmata, tear location, blood transfusion, or hospitalization between the groups. There were no procedure-related complications in either group; surgery was not required in any patient. For both groups, there were no second episodes of recurrent bleeding, procedure-related complication, or need of operation. CONCLUSION: Endoscopic hemoclip placement and endoscopic epinephrine injection are equally effective and safe for the management of active bleeding in Mallory-Weiss syndrome, even in patients with shock or comorbid diseases.

Adult↗
PubMed2002

Outcome differences after endoscopic drainage of pancreatic necrosis, acute pancreatic pseudocysts, and chronic pancreatic pseudocysts.

BACKGROUND: Comparative outcomes after endoscopic drainage of specific types of symptomatic pancreatic fluid collections, defined by using standardized nomenclature, have not been described. This study sought to determine outcome differences after attempted endoscopic drainage of pancreatic fluid collections classified as pancreatic necrosis, acute pseudocyst, and chronic pseudocyst. METHODS: Outcomes were retrospectively analyzed for consecutive patients with symptoms caused by pancreatic fluid collections referred for endoscopic transmural and/or transpapillary drainage. RESULTS: Complete endoscopic resolution was achieved in 113 of 138 patients (82%). Resolution was significantly more frequent in patients with chronic pseudocysts (59/64, 92%) than acute pseudocysts (23/31, 74%, p = 0.02) or necrosis (31/43, 72%, p = 0.006). Complications were more common in patients with necrosis (16/43, 37%) than chronic (11/64, 17%, p = 0.02) or acute pseudocysts (6/31, 19%, p = NS). At a median follow-up of 2.1 years after successful endoscopic treatment (resolution), pancreatic fluid collections had recurred in 18 of 113 patients (16%). Recurrences developed more commonly in patients with necrosis (9/31, 29%) than acute pseudocysts (2/23, 9%, p = 0.07) or chronic pseudocysts (7/59, 12%, p = 0.047). CONCLUSIONS: Successful resolution of pancreatic fluid collections may be achieved endoscopically by an experienced therapeutic endoscopist. Outcomes differ depending on the type of pancreatic fluid collection drained. Further studies of endoscopic drainage of pancreatic fluid collections must use defined terminology to allow meaningful comparisons.

Acute Disease↗
PubMed2002

Recurrent bleeding from peptic ulcer associated with adherent clot: a randomized study comparing endoscopic treatment with medical therapy.

BACKGROUND: Endoscopic therapy reduces the recurrence of bleeding from actively bleeding peptic ulcers and those with visible vessels. However, the use of endoscopic therapy for ulcers with adherent clots remains controversial. The purpose of this study was to determine whether removal of clot from an ulcer and endoscopic therapy reduces the frequency of recurrent bleeding. METHODS: Patients with acute upper GI bleeding from peptic ulcers with adherent clots and no active bleeding were enrolled in a multicenter study. At each center patients were stratified for age, use of nonsteroidal anti-inflammatory drugs, and ulcer location, and were randomized to endoscopic or medical management. Endoscopic therapy consisted of injection of the base of the adherent clot with a solution of epinephrine and mechanical removal of the clot. The base of the ulcer and any stigmata of bleeding were then coagulated until cavitation and adequate coagulation were obtained. Patients in both groups received standard medical therapy for peptic ulcer. Patients were evaluated for recurrence of bleeding for 1 month. RESULTS: Fifty-six patients were enrolled. Rates of recurrent bleeding were 34.3% (12/35) in the medical treatment arm versus 4.8% (1/21) in the endoscopic treatment arm (p < 0.02). CONCLUSIONS: In patients with GI bleeding caused by gastric or duodenal ulcers with an adherent clot found on endoscopy, endoscopic therapy with injection of the base of the clot, clot removal, and heat probe coagulation significantly reduces the rate of recurrent bleeding compared with medical therapy alone.

Blood Coagulation↗
PubMed2003

Percutaneous endoscopic cecostomy: a case series.

BACKGROUND: There are few reports of percutaneous endoscopic cecostomy in adult patients. METHODS: All cases of acute colonic pseudo-obstruction (n = 2) and neurogenic bowel (n = 3) in adults in which percutaneous endoscopic cecostomy was performed were reviewed retrospectively. OBSERVATIONS: Percutaneous endoscopic cecostomy was a definitive treatment. In 1 of the 2 patients with acute colonic pseudo-obstruction, the percutaneous endoscopic cecostomy tube was clamped and subsequently removed 10 weeks after placement; in the other patient with acute colonic pseudo-obstruction, the percutaneous endoscopic cecostomy tube remains in place. In 2 of the 3 patients with neurogenic bowel, the percutaneous endoscopic cecostomy tube continues to function well; the third patient did well for 6 months and then died of underlying comorbid disease. There was no mortality or need for surgical intervention for any patient. Complications occurred in 2 patients; 1 developed transient fever and leukocytosis and 1 had self-limited bleeding during anticoagulation. CONCLUSIONS: Percutaneous endoscopic cecostomy is a safe and effective treatment for both acute colonic pseudo-obstruction and neurogenic bowel when aggressive albeit conservative treatment is unsuccessful.

Acute Disease↗
PubMed2001

Totally endoscopic coronary artery bypass on the beating heart.

Our aim was to develop a technique for totally endoscopic coronary artery bypass on the beating heart for patients with coronary artery disease. For this procedure, operations were performed through four thoracoports. The left internal thoracic artery (LITA) was harvested thoracoscopically. The pericardium was then opened and the left anterior descending artery (LAD) identified. The endoscopic stabiliser was inserted and transformed into a coiled ring shape. After suction, sufficient immobilisation of the LAD was achieved. The proximal snare was placed using a 5-0 Prolene suture to give a bloodless field. After blunt dissection of the coronary artery, an arteriotomy was performed with a sharp blade and enlarged with endoscopic Potts scissors. Using an endoscopic needle holder and forceps via two thoracoports at the fourth intracostal space, a conventional end-to-side anastomosis was safely created with an 8-0 Prolene single running suture. Total endoscopic beating-heart bypass grafting, including ITA harvest, stabilisation, arteriotomy and performance of the anastomosis, was performed successfully in three patients. There were no intraoperative arrhythmias, and no postoperative haemorrhage. The patients required no intensive care management postoperatively. All patients were ready for discharge on the fourth postoperative day. Postoperative angiogram revealed that anastomoses are patent. We conclude that the endoscopic stabiliser can sufficiently immobilise the heart to enable endoscopic beating-heart coronary artery bypass grafting by means of an easily controllable instrumentation system.

Journal Article↗
PubMed2001

Endoscopic foraminoplasty: a prospective study on 250 consecutive patients with independent evaluation.

OBJECTIVE: This study focused on the efficacy of endoscopic decompression of the foramen guided by endoscopic aware-state pain source definition. BACKGROUND DATA: Endoscopic foraminoplasty consists of undercutting of the facet joint and endoscopic discectomy, mobilization and neurolysis of the exiting and transiting nerves, and ablation of osteophytes. This study sought the outcome of endoscopic foraminoplasty in 250 consecutive patients followed for a minimum of 2 years, reviewed and assessed by an external independent assessor. It was applied to patients with back pain and sciatica in multilevel degenerative disc disease and also to those with prior surgery. METHODS: A prospective study of endoscopic laser foraminoplasty was performed on 121 males and 129 females with an average age of 48 years (21-86 years), followed for an average period of 30 months (26-43 months). The average preoperative duration of back, buttock, or leg pain was 6.1 years (5-11 years). A total of 30% had undergone prior open spinal surgery. RESULTS: The cohort integrity at follow up was 97%. Outcome was analyzed using the percentage change in Oswestry Disability Scores and visual analogue pain scores. Clinically relevant change in pain and disability was observed in 73%. Using a percentage change in Oswestry Disability Score of 50 or more to determine good and excellent outcomes, 60% of patients exceeded this score. A total of 95% patients required no further surgical intervention. CONCLUSIONS: Endoscopic laser foraminoplasty provides a minimalist means of exploring the extraforaminal zone, the foramen, the disc, and the epidural space and performing discectomy, lateral recess decompression, osteophytectomy, and neural mobilization. Performed in the aware state, it serves to identify and localize precisely the causal source of pain in multilevel disc disease, in revision surgery, and in the infirm and elderly without open fusion or decompression.

Adult↗
PubMed1999

Feasibility of total intravesical endoscopic surgery using mini-instruments in a porcine model.

BACKGROUND AND OBJECTIVES: The aim of minimally invasive approaches to vesicoureteral reflux, such as endoscopic trigonoplasty, is to lower the morbidity of open procedures without compromising the results. Initial successes have not been sustained, mainly because of trigonal splitting, which results in the ureteral orifices returning to their preoperative positions. This study was designed to address trigonal splitting by mobilizing the ureters before repositioning them and to evaluate the feasibility of accomplishing this intravesically with 2- to 3-mm endoscopic mini-instruments. METHODS: Bilateral vesicoureteral reflux was surgically created in 10 minipigs. After radiologic confirmation of success 4 weeks later, modified trigonoplasty was performed by endoscopic intravesical mobilization of both ureters and incision of the trigonal mucosa using 2-mm instruments. The ureteral orifices were then advanced toward the midline and sutured in place. The initial surgical techniques were modified to permit the entire procedure to be performed endoscopically in the last four minipigs. Cystograms and intravenous urograms were obtained 4 weeks later. RESULTS: Two minipigs died postoperatively. Six of the remaining eight had persistent reflux, including three of the four in the group treated completely by endoscopic means. None of the dissected ureters showed evidence of stricture or necrosis. CONCLUSIONS: Although the procedure was not successful in correcting reflux in this model, this study demonstrates the feasibility of endoscopic ureteral mobilization. With current instrumentation, there is no significant technical obstacle to complete intravesical endoscopic surgery, including ureteral reimplantation.

Animals↗
PubMed2005

Endoscopic cross-trigonal ureteral reimplantation under carbon dioxide bladder insufflation: a novel technique.

PURPOSE: To report on a novel technique of endoscopic intravesical ureteral mobilization and cross-trigonal ureteral reimplantation under carbon dioxide insufflation of the bladder (pneumovesicum) for correcting primary vesicoureteral reflux (VUR) in infants and children. PATIENTS AND METHODS: Ten boys and six girls with dilating primary VUR (7 bilateral; 23 refluxing ureters) associated with recurrent urinary-tract infections and multiple pyelonephritic renal scars underwent endoscopic Cohen's cross-trigonal ureteral reimplantation with CO(2) pneumovesicum. Their ages ranged from 10 months to 13 years (mean 4.1 years). The endoscopic procedure was preceded by distention of the bladder with saline and insertion of a 5-mm Step port over the bladder dome under cystoscopic guidance. The bladder was then drained and insufflated with CO(2) to 10 to 12 mm Hg pressure with a suction catheter inserted per urethra to occlude the internal urethral meatus. A 5-mm 30 degrees endoscope was used to provide intravesical vision. Two more 3- to 5-mm working ports were inserted on the lateral bladder wall on either side. Endoscopic intravesical mobilization of the ureter, dissection of a submucosal tunnel, and a Cohen's type of crosstrigonal ureteral reimplantation using interrupted 5-0 monofilament sutures was then performed under videoscopic guidance. Bladder drainage by a urethral catheter was maintained for 24 hours postoperatively. RESULTS: Endoscopic cross-trigonal ureteral reimplantation under CO(2) pneumovesicum was successfully performed in all except one patient, who had displacement of a port into the extravesical space after completion of the ureteral reimplantation necessitating a small vesicotomy for closure of the mucosal defect. The mean operating time was 136 minutes (range 80-230 minutes), being 112 minutes for unilateral cases and 178 minutes for bilateral cases. Two boys developed mild suprapubic and scrotal emphysema postoperatively that subsided spontaneously. All other patients recovered uneventfully and remained well. Follow-up cystograms showed complete resolution of VUR in all except one unit that had persistent grade I reflux, thus giving a success rate of 96%. CONCLUSIONS: This early experience illustrates that endoscopic intravesical ureteral mobilization and crosstrigonal ureteral reimplantation can be performed safely and effectively with routine laparoscopic surgical techniques and instruments under CO(2) insufflation of the bladder, achieving a high success rate in reflux resolution that is equivalent to that obtained with the open technique but with minimal invasiveness and much faster recovery. The longer-term outcome and potential physiological effects of CO(2) pneumovesicum on the bladder and upper-tract function will need to be evaluated further.

Adolescent↗
PubMed2000

Early recovery after endoscopic vs. short-incision open carpal tunnel release.

Endoscopic carpal tunnel release has been claimed to offer improvement in recovery time and postoperative discomfort over open carpal tunnel release. Short-incision open carpal tunnel release has been claimed to offer recoveries comparable with endoscopic techniques. Patients receiving carpal tunnel surgery were randomized to short-incision open release or single-portal endoscopic release. Preoperative and postoperative evaluation included grip and pinch strength measurements and patient completion of a questionnaire regarding symptoms and function. Thirty-six operated hands completed evaluation, including 22 endoscopic and 14 open releases. Early grip and pinch strength after endoscopic carpal tunnel release were improved significantly over short-incision open release (p < 0.05). Subjective evaluation indicated a trend toward improved symptoms and function with endoscopic over short-incision open carpal tunnel release. Endoscopic carpal tunnel release provides faster recovery of strength than short-incision open carpal tunnel release and improves early postoperative comfort and function to a small degree.

Carpal Tunnel Syndrome↗
PubMed2001

Prospective clinical trial of robotically assisted endoscopic coronary grafting with 1-year follow-up.

OBJECTIVE: To follow up in prospective fashion patients with coronary artery anastomoses completed endoscopically with robotic assistance. The robotic system was evaluated for safety and its effectiveness in completing microsurgical coronary anastomoses. SUMMARY BACKGROUND DATA: Recently there has been an interest in using robotics and computers to enhance the surgeon's ability to perform endoscopic cardiac surgery. This interest has stemmed from the rapid advancement of technology and the desire to make cardiac surgery less invasive. Using traditional endoscopic instruments, it has not been possible to perform coronary surgery. METHODS: Nineteen patients underwent robotically assisted endoscopic coronary artery bypass grafting of the left internal thoracic artery (LITA) to the left anterior descending artery (LAD). Two robotic instruments and one endoscopic camera were placed through three 5-mm ports. A robotic system was used to construct the LITA-LAD anastomosis. All other required grafts were completed by conventional techniques. RESULTS: Seventeen LITA-LAD grafts (89%) had adequate intraoperative flow. The mean LITA-LAD graft flow was 38.5 +/- 5 mL/min. At 8 weeks, LITA-LAD grafts were assessed by angiography and showed 100% patency with thrombolysis in myocardial infarction (TIMI) I flow. At a mean follow-up of 17 +/- 4.2 months, all patients were NYHA class I and there were no adverse cardiac events. CONCLUSIONS: The results from the first prospective clinical trial of robotically assisted endoscopic coronary bypass surgery in the United States showed favorable short-term outcomes with no adverse events. Robotic assistance is an enabling technology allowing the performance of endoscopic coronary anastomoses.

Aged↗
PubMed2001

Number of lymph node metastases determined by presurgical ultrasound and endoscopic ultrasound is related to prognosis in patients with esophageal carcinoma.

OBJECTIVE: To analyze the impact on prognosis of the number of lymph node metastases detected by ultrasound and endoscopic ultrasound in patients with esophageal carcinoma. SUMMARY BACKGROUND DATA: Ultrasound and endoscopic ultrasound are useful for diagnosing tumor depth and lymph node metastasis in patients with esophageal carcinoma. However, the clinical significance of the number of lymph node metastases before surgery has not been elucidated. METHODS: The authors evaluated lymph node metastases using preoperative ultrasound and endoscopic ultrasound in 329 consecutive patients who underwent esophagectomy with lymphadenectomy. TNM classification and one-to-one comparison of lymph node metastasis was performed between the preoperative and histologic diagnosis. The number of lymph node metastases was subdivided into four groups: zero, one to three, four to seven, and eight or more. RESULTS: The accuracy of preoperative ultrasound and endoscopic ultrasound diagnosis exceeded 70% in each category of TNM classification. The incidence of lymph node metastasis determined by preoperative and histologic diagnosis was 69.0% (234/339) and 59.3% (201/339), respectively. The correlation between preoperative and histologic diagnosis was significant (P <.0001). According to the subdivision of number of lymph node metastases, the accuracy rates associated with nodal involvement of zero, one to three, four to seven, and eight or more were 83.8%, 59.7%, 43.3%, and 96.0%, respectively. The clinical outcome between ultrasound and endoscopic ultrasound diagnosis and histologic diagnosis in stage grouping was almost similar. The 5-year survival rates of patients with zero, one to three, four to seven, and eight or more lymph node metastases determined by ultrasound and endoscopic ultrasound were 53.3%, 33.8% 17.0%, and 0%, respectively. The differences among groups were statistically significant. The survival curves associated with preoperative and histologic diagnosis were similar. CONCLUSIONS: Not only the stage grouping of TNM classification but also the number of lymph node metastases determined by ultrasound and endoscopic ultrasound before surgery may be useful for predicting prognosis in patients with esophageal carcinoma.

Adult↗
PubMed2004

Approaches to endoscopic ampullectomy.

PURPOSE OF REVIEW: Ampullary tumors, usually adenomas, are often encountered during endoscopic evaluation, especially in patients with familial adenomatous polyposis (FAP). Because of the risk of progression to adenocarcinoma, ampullary adenomas should be treated. Endoscopic therapy is an appropriate option and recent experience highlights the effectiveness and safety of this approach. RECENT FINDINGS: Several authors have published experiences with endoscopic ampullectomy. In the current era, endoscopic ampullectomy is performed like a snare polypectomy using a side-viewing duodenoscope. Tumors are removed either en bloc or in a piecemeal fashion with retrieval of all tissue. Because of the potential for incidental carcinoma when all tissue is removed, complete retrieval is essential. Although initially used as primary therapy, thermal ablation, such as ionized argon coagulation (IAC), is now commonly used as adjunctive therapy. Prophylactic pancreatic or biliary stent placement is also performed to minimize risks of pancreatitis, jaundice, cholangitis, and stenosis. Endoscopic therapy is effective in removing more than 80% of adenomas, though several sessions may be necessary. Complications are reported in 20% of patients from most series and include acute pancreatitis, bleeding, perforation, orifice stenosis, and, rarely death. Recurrence of the adenoma can occur, especially in FAP patients, and warrants periodic surveillance. SUMMARY: Endoscopic ampullectomy appears to be an effective method for treating ampullary tumors. However, complications are significant and only well-trained and experienced endoscopists should perform ampullectomy. Future research should focus on multicenter, randomized clinical trials to determine the best therapeutic approach for patients with ampullary tumors and to determine methods to decrease complication rates associated with endoscopic therapy.

Journal Article↗
PubMed2001

Endoscopic management of 108 sinus mucoceles.

OBJECTIVES/BACKGROUND: Traditional teaching has emphasized the need for complete removal of sinus mucoceles to achieve a cure. However, with the introduction of endoscopic sinus surgical instruments and techniques, there has been a trend toward transnasal endoscopic management of sinus mucoceles. The aim of this study is to establish the efficacy of endoscopic management of sinus mucoceles. STUDY DESIGN: Retrospective review. PATIENTS AND METHODS: Between 1988 and 2000, 103 patients with 108 paranasal sinus mucoceles were treated endoscopically. This series includes 66 frontal and frontoethmoid, 17 ethmoid, 7 sphenoethmoid, 12 sphenoid, and 6 maxillary mucoceles. Ninety patients (83.3%) had intraorbital extension and 85 of them presented with some degree of proptosis or eye displacement. Sixty patients (55.5%) had erosion of the skull base with varying degrees of intracranial extension of the mucocele. Follow- up ranged from 1 to 131/2 years with a median of 4.6 years. INTERVENTION: All patients underwent endoscopic-wide marsupialization of the mucocele cavity. Stents were used in frontal mucoceles only. RESULTS: Recurrence of a frontal mucocele was seen in 1 patient (0.9%). In 5 patients, out of 23 patients who presented with massive pansinus polyposis in addition to the mucocele, recurrent polyposis required revision surgery. However, the mucoceles did not recur in those patients. CONCLUSIONS: There is increasing evidence in the literature that endoscopic management of sinus mucoceles results in long-term control with recurrence rates at or close to 0%. Rhinologic surgeons should consider the endoscopic technique as the surgical treatment of choice.

Adolescent↗
PubMed2002

Endoscopic-assisted transcolumellar approach to the clivus: an anatomical study.

OBJECTIVE: Surgical exposure of the clivus and retroclival region is a challenging problem. Several extracranial and intracranial approaches using microsurgical techniques have been proposed in the search to optimize the exposure of the clival region. The objective of the present study was to develop an endoseopic-assisted transcolumellar approach to the anterior clivus. STUDY DESIGN: Experimental anatomic study. METHODS: The approach was studied in 10 consecutive cadaveric preparations. It included a preliminary external rhinoplasty technique with a septal displacement procedure, which gives a wide intranasal route to the posterior wall of the nasopharynx. By use of a drill system and instruments specially designed for endoscopic sinus surgery, the clivus and retroclival region were appropriately managed. Direct morphometric measurements were obtained during all steps of the procedure. RESULTS: The endoscopic-assisted transcolumellar approach developed in the present experimental study allowed a good exposure of the clivus area and anterior cranial-cervical junction. By performing a preliminary septoplasty, the nostrils were turned into a single passage with adequate space for endoscopic insertion and manipulation of one or two instruments. The authors were able to completely expose the posterior wall of the sphenoid sinus and clival dura after the thick bone of the vomer, the floor of the sphenoid, and the clivus were removed by a drill. Angled endoscopes provided a comprehensive view of the retrosellar area. CONCLUSIONS: The endoscopic-assisted transcolumellar approach, besides offering a wide opening for endoscopic management of the clivus, also allowed the surgeon to perform a double-handed procedure and to associate the use of a microscope if needed. The use of endoscopes, although lacking the three-dimensional view, gave a thorough and closer exposure of the surgical field with the advantage of a multiangled perspective.

Brain↗
PubMed2002

Endoscopic sinus surgery for inflammatory maxillary sinus disease.

OBJECTIVE/HYPOTHESIS: The role of endoscopic sinus surgery for treating chronic maxillary sinusitis is well established. The purpose of the study is to determine the efficacy of endoscopic sinus surgery in the treatment of maxillary sinus inflammatory disease that includes mucoceles, retention cysts, and antrochoanal polyps. STUDY DESIGN: This is a retrospective review of 32 consecutive patients who underwent endoscopic sinus surgery for mucoceles (n = 21), retention cysts (n = 5), or antrochoanal polyps (n = 6). METHODS: The medical records were reviewed for patient demographics, presenting symptoms, and type of operation. Surgical outcome was determined by resolution of symptoms, recurrence of disease, and need for revision or additional surgery. RESULTS: Ethmoidectomy with middle meatal antrostomy was performed in all patients; 28 patients had additional middle turbinectomy. Postoperative follow-up ranged from 6 months to 4 years. The operation resulted in resolution of symptoms and a patent antrostomy on long-term follow-up in all cases of mucoceles. No case required revision surgery. On the other hand, the disease recurred in three patients (60%) with retention cysts and three patients (50%) with antrochoanal polyps despite patent antrostomies. The recurrences occurred 3 to 6 months after the surgery. The recurrent cases of antrochoanal polyps required Caldwell Luc procedures. The three failures in cases of retention cysts were successfully managed with repeated office endoscopic marsupialization through a patent antrostomy. CONCLUSIONS: Endoscopic sinus surgery is an effective treatment for mucoceles, with favorable long-term outcome. Maxillary retention cysts commonly recur after endoscopic sinus surgery. However, the recurrence can be managed in the office through a patent antrostomy. Endoscopic sinus surgery may be offered as initial surgical treatment for antrochoanal polyps, but a Caldwell Luc operation may be needed for recurrent disease.

Adult↗
PubMed2004

Endoscopic surgery for recurrent inverted papilloma.

OBJECTIVES/HYPOTHESIS: Inverted papilloma of the nose and paranasal sinuses is noted for its high rate of recurrence. The feasibility of endoscopic treatment for inverted papilloma has been shown in the literature; however, reports discussing the efficacy of endoscopic surgery for recurrent diseases are rare. The study determined the effectiveness of endoscopic surgery for recurrent inverted papilloma and described when endoscopic medial maxillectomy was indicated. STUDY DESIGN: Retrospective. METHODS: Seventeen patients with recurrent inverted papilloma were treated over a 10-year period. Krouse's staging system was used for tumor grading. Because of the extent of the tumor in the majority (70.6%) of the patients, en bloc resection could not be regularly achieved; therefore, sequential segmental endoscopic surgery was the chosen treatment. Some diseases that extensively involved the maxillary sinus were treated by the combination of endoscopic medial maxillectomy (EMM) and sequential segmental surgery (SSES) to extirpate the whole disease. RESULTS: Efficacy was evaluated strictly by radiographic study. Successful treatment was accomplished in 14 (82.4%) patients. Three (17.6%) patients had residual disease; each required one revision surgery. None of the patients had recurrence at the time of writing. There were no major complications or associated malignancies encountered in the patients. CONCLUSION: Endoscopic surgery is an effective treatment for recurrent inverted papilloma. Precise determination of the sites of tumor origin and attachment during the operation is the key to the successful treatment. Recurrent inverted papilloma tends to behave more aggressively and has a higher postoperative recurrence rate than the primary lesion. Stage III disease had a higher recurrence rate (27.3%) than that of other stages (0%).

Endoscopy↗