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PubMed2004

Endoscopic biliary drainage for severe acute cholangitis in biliary obstruction as a result of malignant and benign diseases.

BACKGROUND AND AIMS: Endoscopic biliary drainage is an established mode of biliary decompression in patients with acute cholangitis as a result of biliary obstruction secondary to stones and benign strictures. However, there are no reports on endoscopic management of severe acute cholangitis caused by malignant conditions. We prospectively compared the efficacy of the endoscopic drainage for severe acute cholangitis in biliary obstruction as a result of malignant and benign diseases. METHODS: Forty-three patients with severe acute cholangitis requiring urgent biliary drainage were included. Sixteen patients (mean age 58.2 +/- 9.3 years; seven men, nine women) had biliary obstruction as a result of malignant diseases and 27 had benign biliary diseases (mean age 41.6 +/- 14.3 years; nine men, 18 women). Indications for urgent drainage included any one of the following: temperature >38 degrees C (n = 21), septic shock with systolic blood pressure <100 mmHg (n = 9), localized peritonism (n = 21), impaired consciousness (n = 6) and failure to improve within 72 h of conservative management (n = 13). After successful bile duct cannul degrees ation, patients received either a nasobiliary catheter (n = 38) or an in-dwelling stent (n = 5) with or without sphincterotomy for biliary drainage. Outcome measures included complications and clinical response. RESULTS: Endoscopic drainage was established successfully in all the patients in both the groups. Clinical improvement after biliary drainage occurred in 94% patients (15/16) in the malignant group compared with 96% patients (26/27) in the benign group (P = not significant [NS]). Fever subsided at a median of 2.2 days in the malignant group and at 1 day in the benign group (P = NS). Normalization of leukocyte count was seen at a median of 6 days (range 1-17) and 2 days (range 1-5) days in the malignant group and the the benign group, respectively (P = NS). There were no endoscopic retrograde cholangiopancreatography-related complications. The mortality rate as a result of cholangitis was 4.6%, that is two of 43 patients (6.2% of the malignant group vs 3.7% of the benign group; P = NS). CONCLUSIONS: Endoscopic biliary drainage is equally effective in patients with severe acute cholangitis caused by either malignant or benign biliary diseases.

Acute Disease↗
PubMed1998

The benefits of endoscopic nasobiliary drainage without sphincterotomy for acute cholangitis.

OBJECTIVE: Endoscopic nasobiliary drainage for acute cholangitis is performed with or without endoscopic sphincterotomy. However, sphincterotomy carries a small but important risk of complications. We evaluated the benefits of endoscopic nasobiliary drainage without sphincterotomy for acute cholangitis. METHODS: A total of 166 patients underwent endoscopic nasobiliary drainage with sphincterotomy (73 patients, sphincterotomy group) or without (93 patients, nonsphincterotomy group). The indications were acute cholangitis due to choledocholithiasis (120 patients) or benign (10 patients) or malignant (36 patients) biliary stricture. Patient backgrounds were similar in the two groups. The outcomes of nasobiliary drainage were compared between the groups. RESULTS: Nasobiliary drainage was successful in 69 patients (95%) in the sphincterotomy group and in 89 (96%) in the nonsphincterotomy group. Efficient drainage was achieved in 67 patients (92%) in the sphincterotomy group and in 87 (94%) in the nonsphincterotomy group. Procedure-related complications developed in eight sphincterotomy-group patients (hemorrhage in three, acute cholecystitis in three, acute pancreatitis in one, catheter withdrawal in one) and in two nonsphincterotomy patients (pancreatitis in one, catheter withdrawal in one) (11% vs 2%; p < 0.05). There were no deaths. CONCLUSIONS: Endoscopic nasobiliary drainage without endoscopic sphincterotomy is a simple, safe, and effective treatment for acute cholangitis. This procedure is especially useful for critically ill patients and those with coagulopathy.

Acute Disease↗
PubMed1999

Efficacy of endoscopic clipping for bleeding gastroduodenal ulcer: comparison with topical ethanol injection.

OBJECTIVE: Although endoscopic clipping is used widely for the treatment of bleeding gastroduodenal ulcers, clinical trials on its efficacy are scarce. The aim of this study is to assess the efficacy and safety of endoscopic clipping for hemostasis from bleeding gastroduodenal ulcers. METHODS: The present study was designed as a retrospective study using historical controls. One hundred consecutive patients with bleeding gastroduodenal ulcers were treated by endoscopic clipping. The preceding 91 consecutive patients treated by endoscopic pure ethanol injection were regarded as controls. Forty-nine of the clipping group and 41 of the ethanol group had lesions at sites difficult to perform endoscopic manipulation. Hemostatic rates, rebleeding rates, amounts of blood transfusion, and durations of hospital stay were analyzed. RESULTS: The hemostatic rate was 96% in both clipping and ethanol groups, whereas the rebleeding rate was lower (15% vs 29%, p = 0.023) in the former than the latter. In technically difficult cases, the hemostatic rate was comparable (96 vs 90%). CONCLUSION: In patients with bleeding gastroduodenal ulcers, endoscopic clipping may be a choice of therapy because of a low rebleeding rate compared with pure ethanol injection.

Ethanol↗
PubMedDate not supplied

Endoscopic ultrasonography of the pancreas in the dog.

Endoscopic ultrasonography was done in 12 normal adult dogs to investigate its efficacy in visualization of the pancreas. The endoscopic ultrasonographic device used in the present study had a curved-array ultrasound transducer mounted in front of the objective lens. The tip of the ultrasonic endoscope was inserted into the stomach, and all examinations of the pancreas were performed from within the stomach. Endoscopic ultrasonography provided good images of most parts of the pancreas except for the ends of each lobe. Useful information about the pancreatic parenchyma, including pancreatic lobular structure, pancreatic duct, and vessels of the pancreas was obtained by endoscopic ultrasonography. Blood flow within vessels was detected using color Doppler and pulsed-wave Doppler examination. These results suggest that endoscopic ultrasonography is available as an effective diagnostic modality in small animal practice.

Animals↗
PubMedDate not supplied

Methods and application areas of endoscopic optical coherence tomography.

We review the current state of research in endoscopic optical coherence tomography (OCT). We first survey the range of available endoscopic optical imaging techniques. We then discuss the various OCT-based endoscopic methods that have thus far been developed. We compare the different endoscopic OCT methods in terms of their scan performance. Next, we examine the application range of endoscopic OCT methods. In particular, we look at the reported utility of the methods in digestive, intravascular, respiratory, urinary and reproductive systems. We highlight two additional applications--biopsy procedures and neurosurgery--where sufficiently compact OCT-based endoscopes can have significant clinical impacts.

Endoscopes↗
PubMed1986

Tumours and pseudotumours of the region of the ampulla of Vater: an endoscopic, clinical and pathological study.

From a large series of patients referred for endoscopic retrograde cholangiopancreatography to one endoscopist, 49 patients had the duodenoscopic appearance of a periampullary tumour. Thirty eight of these lesions were neoplastic, but the remaining 11 patients had inflammatory non-neoplastic lesions (pseudotumours). These could not be distinguished from the neoplasms on endoscopic appearances. The cholangiopancreatograms were similar except that the diameter of the pancreatic duct tended to be higher in the tumour group and gall stones were present significantly more often in the patients with pseudotumour. Endoscopic biopsy correctly diagnosed 28 of 34 ampullary carcinomas. Two of the 11 pseudotumour patients were subjected to surgical excision biopsy because of suspicious histological features of endoscopic biopsy. In the neoplastic group 19 patients underwent Whipple's procedure, seven surgical bypass, seven endoscopic sphincterotomy only and five died without successful biliary drainage. The overall one year survival was 44.7%. By contrast, the patients with pseudotumours were clinically well at a median follow up 24 months (range 12-41 months), after endoscopic sphincterotomy except for one 89 year old patient who died 22 months later from unrelated causes.

Adult↗
PubMed1996

Longterm effects of endoscopic sphincterotomy on gall bladder motility.

BACKGROUND: Some of patients with an intact gall bladder develop acute cholecystitis or have gall bladder stone formation after endoscopic sphincterotomy. Endoscopic sphincterotomy may affect gall bladder motility. AIMS: To prospectively evaluate longterm effect of endoscopic sphincterotomy on gall bladder motility. PATIENTS: Thirty two patients with an intact gall bladder (15 with and 17 without gall bladder stones) who underwent endoscopic sphincterotomy for choledocholithiasis. METHODS: Gall bladder function was examined before and at from seven days to five years after sphincterotomy. Gall bladder volume, at fasting and after caerulein administration, was determined by ultrasonography. RESULTS: After endoscopic sphincterotomy, the enlarged orifice remained patent during a five year follow up period. One patient with gall bladder stones subsequently developed acute cholecystitis, the remaining being asymptomatic. In the patients before sphincterotomy, particularly in those with gall bladder stones, the gall bladder showed larger fasting volume and lower caerulein stimulated maximum contraction than normal controls. Throughout five years after sphincterotomy, fasting volume of the gall bladder decreased and its maximum contraction increased, regardless of gall bladder stones; significantly different from the values before sphincterotomy (p < 0.05). CONCLUSIONS: Endoscopic sphincterotomy decreases fasting volume of the gall bladder and increases its contraction ability for a long period. These changes may rather decrease the risk of future acute cholecystitis or gall stone formation.

Adult↗
PubMed1997

Endoscopic management of Mirizzi's syndrome.

BACKGROUND: The accepted management of Mirizzi's syndrome is surgical, but endoscopic and percutaneous management have been described. AIM: To review our experience of endoscopic intervention for Mirizzi's syndrome. PATIENTS AND METHODS: ERCP reports of patients presenting for endoscopic management of choledocholithiasis between March 1989 and June 1995 were reviewed. Those with cholangiographic evidence of Mirizzi's syndrome were selected for study. Patient records and cholangiograms were reviewed and follow up was recorded from the notes or by telephone contact with patients, their relatives, or doctors. RESULTS: Twenty five patients had Mirizzi's syndrome. Sixteen were female and their median age was 67 years (range 28-91). Ten presented with painless jaundice, nine with painful jaundice, four with cholangitis, and two had pain as their only symptom. Twelve were referred for surgery and 11 of these had preliminary endoscopic therapy. Thirteen have been treated solely with endoscopic therapy. Treatment in this group was aimed at relieving jaundice and removing stones. Stones were completely removed in three patients. Nine patients have been treated with long term stents, and one awaits extracorporeal shockwave lithotripsy of the gall bladder. Complications of treatment occurred in four of 25 after ERCP. CONCLUSIONS: Endoscopic treatment of Mirizzi's syndrome is effective as a temporising measure before surgery and can be definitive treatment for unsuitable surgical candidates.

Adult↗
PubMed2004

Endoscopic therapy of chronic pancreatitis.

We present an overview of endoscopic therapies for chronic pancreatitis (CP) and its associated conditions. It is evident that endoscopy can be a definite therapy for pancreatic pseudocysts, pancreatic ascites and pancreatic duct (PD) disruption. Endoscopic therapy has also been useful in the short-term and medium therapy of common bile duct strictures due to CP, the best results being obtained if there are no calcifications in the head of the pancreas. Although most experts agree that obstruction to the outflow of pancreatic juice and the resulting increased pressure within the main PD is one of the major factors contributing to pain and that endoscopic therapy has been proven effective to remove stones as well as to dilate PD strictures and place stents across the PD, there is no convincing evidence from randomized trials that the patient's dominant symptom of CP, i.e. pain, is resolved in an appropriate and long-term fashion. We believe that there are other factors which are important in the etiology of chronic pain such as pancreatic inflammation and peripancreatic fibrosis with resulting nerve entrapment around the gland. The reader is reminded that endoscopic therapy is associated with significant and important complications, therefore appropriate patient selection and patient information are of paramount importance. Nevertheless, it is important to consider that one advantage of endoscopic management of CP is that it is less invasive as compared with surgery, often effective for years, does not hinder further surgery, and can be repeated. Finally we want to emphasize that there are many valid surgical, radiological and endoscopic techniques to treat the complications of CP. Therefore, the approach to CP and its complications should be by a multidisciplinary team of gastroenterologists, surgeons, radiologists, endoscopists and pain specialists.

Chronic Disease↗
PubMed2006

Technical innovations and the evolution of endoscopic sinus surgery.

Since the introduction of endoscopic sinus surgery, a number of significant technological advances, as well as an improved understanding of disease pathogenesis and management, have enabled major evolutions in surgical techniques. Modifications to surgical instruments, imaging, the development of the microdebrider, and other newer instrumentation have all contributed to the current level of patient success associated with endoscopic intranasal techniques. At the same time, it has become evident that anatomic variations are less important in the pathogenesis of chronic rhinosinusitis than was previously thought, and that ventilation alone is insufficient to resolve well-established disease. This paper reviews the changes that have occurred in endoscopic sinus surgery over the past 20 years since the techniques were first introduced into the United States, and the technologies that have enabled these changes and the development of extended endoscopic techniques. Continuing developments of interactive computer-guided surgery, endoscopic 3-dimensional imagery, robotics, and improved adjunctive therapies will further extend the role of endoscopic transnasal approaches to an expanded number of skull base and intracranial lesions.

Debridement↗
PubMed2004

Percutaneous endoscopic cellular transplantation into the lower lumbar spinal cord.

OBJECTIVE: To explore the feasibility of performing percutaneous endoscopic cellular transplantation into the lumbar spinal cord of pigs to create intramedullary cellular trails. METHODS: The lumbar subarachnoid space was accessed using a 10-gauge needle inserted between L5 and L6. A 12.5-French flexible introducer sheath was fed over the needle into the subarachnoid space. A 3.2-mm-diameter flexible, steerable endoscope was then directed intradurally through the sheath. The thecal space was distended by saline infusion. A microcatheter with an attached needle then was advanced through the working channel into the dorsal surface of the lumbar spinal cord. Five microliters of Hoechst-labeled fibroblasts were injected while the catheter was withdrawn slowly to create a trail of cells within the spinal cord. The spinal canal then was perfused with fixative. The injected spinal cord segment was removed and studied histologically. Endoscopic video was analyzed offline. RESULTS: The endoscope could be navigated under visual guidance. The sacral and lumbar rootlets, the spinal cord, and associated vessels were visualized. In fixed sagittal sections, a linear trail of fluorescent fibroblasts could be seen within the lumbar spinal cord in each specimen. CONCLUSION: Percutaneous endoscopic cellular injection may be useful for cellular transplantation, may reduce surgical and anesthetic time, may be compatible with local anesthesia, may eliminate the need to disrupt spinal instrumentation and bone grafts, and may allow greater flexibility in the respective timing of spinal fixation and cellular transplantation after spinal cord injury. This is the first report of the use of endoscopic intraspinal cellular transplantation.

Animals↗
PubMed2002

Endoscopic visualization of the submarginal gingiva dental sulcus and tooth root surfaces.

BACKGROUND: Direct, real-time visualization of the hard and soft tissues within the gingival sulcus may aid the clinician in diagnosis and therapy of periodontal disease. This report describes an endoscope specifically designed for this purpose and the interpretation of dental endoscopic images. METHODS: Medical endoscope technology was modified for application in the dental environment. A fixed, fused fiber optic bundle, less than 1 millimeter in diameter, was coupled to an active matrix LCD-TFT flat panel video monitor for viewing by the clinician. A bilumen sheath was designed to provide irrigation of the sulcus and a sterile barrier between the patient and the fiber bundle. Standard dental curets and ultrasonic scalers were adapted for instrumentation aided by the endoscope. RESULTS: Endoscope technology has been successfully adapted for use in periodontal diagnosis and therapy. Techniques for identification and interpretation of the hard and soft tissue images, as well as the location of root deposits and caries, have been developed. CONCLUSIONS: The dental endoscope gives the clinician direct, real-time visualization and magnification of the subgingival tooth root surface, aiding in the location of deposits on the tooth root. The subgingival soft tissue, including the gingival attachment, sulcus wall, and sulcus contents, can be assessed. Identification and location of subgingival caries, root fractures, tooth root deposits, post perforations, and open restoration margins may aid the clinician in diagnosis and therapy.

Computer Terminals↗
PubMed2005

Ergonomics in endoscopic sinus surgery: systematic review of the literature.

OBJECTIVE: To conduct a systematic review of reports on the ergonomic posture of the surgeon during endoscopic sinus surgery. STUDY DESIGN: Literature review. METHODS: Systematic review of the French- and English-language literature using PubMed from January 1970 to March 2004. Articles were divided into four categories: visualization through an endoscope or a videoendoscope, monitor position, sitting or standing position, and arm support. RESULTS: Endoscopic sinus surgery with direct vision through the endoscope is associated with faulty neck positioning and does not appear to bring any advantages in terms of surgical performance compared with vision via a video monitor. Low back pain and lower extremity complaints are commonly associated with the standing position. Spinal flexion seems more harmful than a straight posture. The preferred viewing angle for video monitors is a few degrees below the horizontal gaze line. An arm support can be beneficial because it is associated with minimization of neck, shoulder, and lumbar stress. CONCLUSION: We recommend (1) visualization via a television monitor instead of direct vision through an endoscope, (2) positioning the screen in direct axis with the surgeon's body and a few degrees below the horizontal line of gaze, (3) surgery in the seated position instead of the standing position, and (4) the use of an elbow support for the arm holding the endoscope.

Endoscopes↗
PubMedDate not supplied

Transnasal endoscopic approach to the sella turcica.

The transseptal/transsphenoidal approach to the pituitary gland has been the most commonly used approach for resection of pituitary adenomas for the last 50 years. This procedure has a low morbidity and provides direct midline access to the sella and pituitary gland. Recent advancements in endoscopic surgery, however, suggest that a lower morbidity approach to the sella would be possible via transnasal endoscopic route. Prior reports have confirmed effectiveness of this approach to the pituitary gland and we report here an early series of endoscopic transnasal pituitary surgery from our institution. We report seven cases of transnasal endoscopic pituitary surgery. Our technique consists of endoscopic exposure of the sphenoid ostium unilaterally, excision of the posterior septum anterior to the rostrum of the sphenoid sinus with resection of the sphenoid rostrum for bilateral exposure of the sphenoid sinus. A specially designed nasal speculum is positioned to displace the posterior septum and lateralize the middle turbinates, permitting direct midline exposure of the sphenoid sinus and sella. We have progressively modified the technique over the seven cases that we present and will discuss our specific instrumentation, indications, and technique for this procedure. We have encountered one cerebrospinal fluid leak in this series. Patient satisfaction has been high and hospitalization is less than with the conventional transseptal approach, averaging 1 day. Our impression is that the transnasal endoscopic approach to pituitary adenomas is a safe technique with reduced morbidity permitting shortened hospital stay.

Adenoma↗
PubMed2000

A transparent sheath for endoscopic surgery and its application in surgical evacuation of spontaneous intracerebral hematomas. Technical note.

The authors advocate the use of a transparent sheath for guiding an endoscope, a simple and unique tool for endoscopic surgery, and describe preliminary results of its application in the evacuation of hypertensive intracerebral hematomas. This sheath is a 10-cm-long tube made of clear acrylic plastic, which greatly improves visualization of the surgical field through a 2.7-mm nonangled endoscope inserted within. Between April 1997 and December 1998, the authors performed endoscopic evacuation of intracerebral hematomas by using this sheath inserted into the patients' heads through a burr hole. In nine consecutive cases in which the hematoma was larger than 40 ml in volume, nearly complete evacuation (86-100%) of the lesion was achieved without complication. Excellent visualization of the border between the brain parenchyma and the hematoma facilitated accurate intraoperative orientation, and also allowed easy identification of the bleeding point. Thus, this combination of sheath and endoscope achieves both minimal invasiveness and the maximum extent of hematoma removal with secure hemostasis. This tool will reduce the inherent disadvantage of endoscopic procedures and may expand their application in other areas of neurosurgical management.

Aged↗
PubMed2004

[Significance of working environment improvement based on determination of source of harmful substance--example of an endoscope syringe room using glutaraldehyde].

Because a worker complained of irritated eyes and throat due to glutaraldehyde (GA) in an endoscope syringe room, the automated endoscope washers and GA liquid stored in reserve were isolated in a separate room. A ventilation system was installed in this room, and the packing of the automated endoscope washers was changed. However, since the obnoxious smell of GA still remained in the endoscope syringe room, we had to determine the source of the smell. A plastic bucket with a cap was found to be filled with GA for disinfection of the endoscope apparatus. GA had evaporated when dispersed around the bucket, resulting in the obnoxious smell. The plastic bucket was replaced with a different type of container. Moreover, GA from the separate room did not affect the concentration of GA in the working area because the separate room for the automated endoscope washers had twice the ventilation volume proposed by the guidelines of the Society of Gastroenterology Nurses and Associates of the USA and the Healthcare Engineering Association of Japan. Consequently, we reconfirmed the significance of working environment improvement after clarifying the source of the harmful substance.

Disinfectants↗
PubMed1999

Endoscopic endonasal transsphenoidal approach to the sellar region: technical evolution of the methodology and refinement of a dedicated instrumentation.

BACKGROUND: Endoscopic treatment of hydrocephalus has in time acquired a primary position in Neurosurgery. Today endoscopy can be employed in the vast majority of neurosurgical procedures in the realization of the so-called endoscope-assisted microneurosurgery. On the basis of the encouraging results obtained by Jho and Carrau, the authors report the pros and cons of the new endoscopic endonasal technique. METHODS: An endoscopic endonasal transsphenoidal approach to the sella was performed in 50 patients: 33 females and 17 males, of age included between 16 and 76 years; 45 were affected by pituitary adenomas (9 micro and 36 macro; 10 were recurrences), 3 by craniopharyngiomas, 2 by clival chordomas. The new instrumentation was realized through straight devices with a handle shifted 10-30 degrees horizontally. The possible danger to the nasal structures is reduced not only by the elimination of the bayonet-like shape but also by hiding the cutting extremity in the handle. RESULTS: The advantages of this technique have been represented by an easier access to the lesion, especially in recurrent tumors, a more complete excision of voluminous neoplasms, a decrease of ENT post-surgical complications and a reduction of hospitalization times and costs. The main limits have been the reduction of field depth and the lack of adequate instrumentation. CONCLUSIONS: In this peculiar surgery the absence of proper instruments has to be overcome because: a) there is less room to work, b) a conflict between the hands of the surgeon and the endoscope may occur, c) the blind introduction of the instruments in the nostril may cause damage to the nasal structures. The secret for the success of the endoscopic endonasal transsphenoidal technique is to create the optimal conditions, in order to avoid improper manoeuvres that may cause potential dangers.

Adenoma↗
PubMedDate not supplied

[Shadow optic. An endoscope with optimized ligth].

Modern endoscopes use a single mid-frontal illumination source that yields an unnatural flat image. At the University of Tübingen, in collaboration with Gimmi GmbH (Tuttlingen, Germany), a new concept endoscope has been developed with an additional light source: the shadow optic. With the aid of a secondary light source along the axis of the endoscope, a shadow is obtained which gives an impression of spatial depth. The aim of the study was to assess this new endoscope objectively, focusing on the speed and safety of the surgical act. The shadow optic was used in an experimental setting by 20 probands, each of whom performed five different standardized procedures of increasing difficulty five times, with and without shadow optic in randomized sequence, making a total of 1000 experiments. The procedures consisted in spatial orientation tests, structure-surrounding maneuvers, tissue clamping, needle puncture and suturing. The evaluation criteria were the time required to perform the procedures and the number of predefined errors as determined by electronic control. In each procedure, the time needed to perform the experiments was shorter with the shadow optic, reductions of up to 18% being recorded, and the number of errors was up to 54% lower compared to the experiments conducted with the traditional endoscope. The results of the study demonstrate that, as a result of the more natural spatial view conditions, the procedures were performed faster and with greater precision when the shadow optic was used. The endoscopic imaging with the shadow optic makes for better spatial orientation and a more natural and manageable image.

Endoscopes↗