Eosinophilic oesophagitis: relationship of quality of life with clinical, endoscopic and histological activity.

BACKGROUND Knowledge about determinants of quality of life (QoL) in eosinophilic oesophagitis (EoO) patients helps to identify patients at risk of experiencing poor QoL and to tailor therapeutic interventions accordingly. AIM To evaluate the impact of symptom severity, endoscopic and histological activity on EoE-specific QoL in adult EoE patients. METHODS Ninety-eight adult EoE patients were prospectively included (64% male, median age 39 years). Patients completed two validated instruments to assess EoE-specific QoL (EoO-QoL-A) and symptom severity (adult EoE activity index patient-reported outcome) and then underwent esophagogastroduodenoscopy with biopsy sampling. Physicians reported standardised information on EoE-associated endoscopic and histological alterations. The Spearman's rank correlation coefficient was calculated to determine the relationship between QoL and symptom severity. Linear regression and analysis of variance was used to quantify the extent to which variations in severity of EoE symptoms, endoscopic and histological findings explain variations in QoL. RESULTS Quality of life strongly correlated with symptom severity (r = 0.610, P < 0.001). While the variation in severity of symptoms, endoscopic and histological findings alone explained 38%, 35% and 22% of the variability in EoE-related QoL, respectively, these together explained 60% of variation. Symptom severity explained 18-35% of the variation in each of the five QoL subscale scores. CONCLUSIONS Eosinophilic oesophagitis symptom severity and biological disease activity determine QoL in adult patients with eosinophilic oesophagitis. Therefore, reduction in both eosinophilic oesophagitis symptoms as well as biological disease activity is essential for improvement of QoL in adult patients. Clinicaltrials.gov number, NCT00939263.

The Rendez-vous technique for treatment of caesarean scar defects: a novel combined endoscopic approach.

BACKGROUND A caesarean scar defect is a late complication of caesarean birth with a wide range of prevalence between 56 and 84 % depending on which diagnostic tool and which definition is used [1]. The referred symptoms which include postmenstrual spotting and infertility are fortunately rare. Moreover, severe complications such as caesarean scar pregnancy and uterine rupture in the following pregnancy may occur. Given the increasing incidence of caesarean births, the potential morbidity associated with caesarean scars is likely to become more important. Recently, a few repair techniques were described in the literature including the hysteroscopic resection of scarred tissue or the laparoscopic repair with or without robotic assistance [2, 3]. METHODS Between June 2009 and February 2014, 21 women with caesarean scar defects were operated with the Rendez-vous technique, a minimally invasive surgery combining the laparoscopic and hysteroscopic approach. Data were retrospectively collected. The indications for this surgery included secondary infertility, previous caesarean scar pregnancy, recurrent miscarriage and postmenstrual spotting. Prior to operation, a transvaginal ultrasound was performed to examine the uterine wall defect. RESULTS The patient characteristics are provided in Table 1. In all cases, the operation was successfully completed laparoscopically. The median operation time was 125 min. One case was complicated by recurrence of the scar defect 6 weeks after the operation. No other intra- or post-operative complications were observed, and the median in-patient stay was 3 days. CONCLUSIONS The benefits of the technique include the feasibility and safety of the procedure, the "Halloween sign" (Fig. 1) which indicates the exact extent and localization of the scar defect and the immediate assessment of repair through the hysteroscopy at the end of the surgery. However, before further studies evaluate the efficacy of this method, the routine repair of caesarean scar defects cannot be recommended. A video of the technique is presented.

Endoscopic Biopsy for Intra- and Paraventricular Tumors: Rates of Complications, Mortality, and Tumor Cell Dissemination

Background and Study Aim Intra- and paraventricular tumors are frequently associated with cerebrospinal fluid (CSF) pathway obstruction. Thus the aim of an endoscopic approach is to restore patency of the CSF pathways and to obtain a tumor biopsy. Because endoscopic tumor biopsy may increase tumor cell dissemination, this study sought to evaluate this risk. Patients, Materials, and Methods Forty-four patients who underwent endoscopic biopsies for ventricular or paraventricular tumors between 1993 and 2011 were included in the study. Charts and images were reviewed retrospectively to evaluate rates of adverse events, mortality, and tumor cell dissemination. Adverse events, mortality, and tumor cell dissemination were evaluated. Results Postoperative clinical condition improved in 63.0% of patients, remained stable in 30.4%, and worsened in 6.6%. One patient (2.2%) had a postoperative thalamic stroke leading to hemiparesis and hemineglect. No procedure-related deaths occurred. Postoperative tumor cell dissemination was observed in 14.3% of patients available for follow-up. Conclusions For patients presenting with occlusive hydrocephalus due to tumors in or adjacent to the ventricular system, endoscopic CSF diversion is the procedure of first choice. Tumor biopsy in the current study did not affect safety or efficacy.

Long-term results of endoscopic third ventriculostomy: an outcome analysis.

OBJECT Endoscopic third ventriculostomy (ETV) is the procedure of choice in the treatment of obstructive hydrocephalus. The excellent clinical and radiological success rates are well known. Nevertheless, very few papers have addressed the very long term outcomes of the procedure in very large series. The authors present a large case series of 113 patients who underwent 126 ETVs, and they highlight the initial postoperative outcome after 3 months and long-term follow-up with an average of 7 years. METHODS All patients who underwent ETV at the Department of Neurosurgery, Mainz University Hospital, between 1993 and 1999 were evaluated. Obstructive hydrocephalus was the causative pathology in all cases. RESULTS The initial clinical success rate was 82% and decreased slightly to 78% during long-term follow-up. Long-term success was analyzed using Kaplan-Meier curves. Overall, ETV failed in 31 patients. These patients underwent a second ETV or shunt treatment. A positive impact on long-term success was seen for age older than 6 months, and for obstruction due to cysts or benign aqueductal stenosis. The complication rate was 9% with 5 intraoperative and 5 postoperative events. CONCLUSIONS The high clinical success rate in short-term and long-term follow-up confirms ETV's status as the gold standard for the treatment of obstructive hydrocephalus, especially for distinct pathologies. The patient's age and underlying pathology may influence the outcome. These factors should be considered carefully preoperatively by the surgeon.

Intensity-modulated radiotherapy for a rendu-osler-weber disease patient with recurrent severe epistaxis: a case report

We present a case of a Rendu-Osler-Weber disease patient with recurrent life threatening epistaxis demanding multiple blood transfusions despite of repetitive endoscopic laser and electrocoagulations, endovascular embolisation, septodermoplasty, and long-term intranasal dressings. As alternative treatment modalities repeatedly failed and the patient became almost permanently dependent on nasal dressing, we performed a highly conformal intensity-modulated radiotherapy of the nasal cavity; a total dose of 50 Gy in 2 Gy single fractions was applied. The therapy was very well tolerated, no acute toxicities occurred. Two weeks after the last radiation dose had been applied, the nasal dressing could be removed without problems. Endoscopical control revealed an almost avascular white mucosa without any trace of bleeding spots; previously existing hemangiomas and crusts had disappeared. After a 1-year-follow up, the patient had no significant recurrent epistaxis.

Outcome of computer-assisted surgery in patients with chronic rhinosinusitis

To compare the complication rates and outcome of computer-assisted versus non-computer-assisted functional endoscopic sinus surgery.

A new tool for frameless stereotactic placement of ventricular catheters

The accurate position of the ventricular catheter inside the frontal horn of the lateral ventricle is essential to prevent proximal failure in shunt surgery. For optimal placement, endoscopic- and image-guided techniques are available.

Limitations of balloon sinuplasty in frontal sinus surgery

Balloon sinuplasty is a tool that is used to treat selected patients with paranasal sinus pathologies. No studies have investigated the aetiology of failed access to the frontal sinus. The aim of our study was to specify the intraoperative technical failure rate and to analyse the aetiology of the failed access to predict potential technical difficulties before surgery. We retrospectively analysed the charts of patients who underwent balloon sinuplasty from November 2007 to July 2010 at three different ENT-Centres. CT-analysis of the patients with failed access was performed. Of the 104 frontal sinuses, dilation of 12 (12%) sinuses failed. The anatomy of all failed cases revealed variations in the frontal recess (frontoethmoidal-cell, frontal-bulla-cell or agger-nasi-cell) or osteoneogenesis. In one patient, a lymphoma was overlooked during a balloon only procedure. The lymphoma was diagnosed 6 months later with a biopsy during functional endoscopic sinus surgery. In complex anatomical situations of the frontal recess, balloon sinuplasty may be challenging or impossible. In these situations, it is essential to have knowledge of classical functional endoscopic sinus surgery of the frontal recess area. The drawbacks of not including a histopathologic exam should be considered in balloon only procedures.

Obesity and GERD: pathophysiology and effect of bariatric surgery

Epidemiologic, endoscopic, and pathophysiologic studies document the relationship between obesity and gastroesophageal reflux disease (GERD). Increased body mass index and accumulation of visceral fat are associated with a two- to threefold increased risk of developing reflux symptoms and esophageal lesions. Given this association, many studies were designed to evaluate the outcome of reflux symptoms following conventional and surgical treatment of obesity. Among bariatric procedures, gastric sleeve and banded gastroplasty were shown to have no effect or even worsen reflux symptoms in the postoperative setting. Gastric banding improves reflux symptoms and findings (endoscopic and pH-measured distal esophageal acid exposure) in many patients, but is associated with de novo reflux symptoms or lesions in a considerable proportion of patients. To date, Roux-en-Y gastric bypass is the most effective bariatric procedure that consistently leads to weight reduction and improvement of GERD symptoms in patients undergoing direct gastric bypass and among those converted from restrictive bariatric procedures to gastric bypass.

Therapy options and long-term results of sinonasal malignancies

Nasal and paranasal sinus malignancies are rare. The most common lesions are located in the nasal cavity and the maxillary sinus, although they also occur in the ethmoid, sphenoid and frontal sinuses. Treatment often combines surgery, radiotherapy and chemotherapy. Endoscopic surgical approaches are increasingly used in order to reduce the morbidity associated with standard open resection. The aim of our study was to analyse the long-term treatment results of sinonasal malignancies (SNM), with a special focus on surgical approaches.

Alternating one lung ventilation using a double lumen endobronchial tube and providing CPAP to the non-ventilated lung in a dog

INTRODUCTION: This case report describes the anaesthetic management of exploratory thoracoscopy and alternating one lung ventilation (OLV) in a dog with a pulmonary bulla, and the application of continuous positive airway pressure (CPAP) to the non-ventilated lung for preventing and treating hypoxia. CASE HISTORY: A 6-year-old, male castrated Border collie was scheduled for exploratory thoracoscopy to investigate spontaneous pnemothorax that had not resolved with repeated suction. Specific requirements for the thoracoscopy were alternating OLV to allow the surgical access to the right middle lobe and its removal, and the examination of the left hemithorax to rule out the presence of other lesions. DIAGNOSIS AND MANAGEMENT: Selective lung ventilation was performed with a double lumen endobronchial tube (DLT), inserted under endoscopic guidance. After a short period of two lung ventilation during preparation of the surgical field, alternating OLV was performed, combining CPAP, provided to the non-ventilated lung via a Mapleson D breathing system, and positive end-expiratory pressure (PEEP) applied to the ventilated lung. Left OLV occurred first and resection of the right middle pulmonary lobe was successfully performed; right OLV followed to allow the examination of the left hemithorax. DISCUSSION AND CONCLUSIONS: The combination of CPAP and PEEP resulted in a satisfactory intra-operative management of hypoxemia. Alternating OLV can be performed successfully by using a DLT. CPAP, commonly employed in human medicine, should be considered an important tool in the anaesthetic management of OLV in small animals.

Tenovaginoscopic approach to the common digital flexor tendon sheath of adult cattle: technique, normal findings and preliminary results in four clinical cases

The aim of this study was to describe the tenovaginoscopic approach to the bovine common digital flexor tendon sheath (CDFTS). A comparative anatomical, ultrasonographic and endoscopic study was undertaken using 26 healthy cadaver feet from adult dairy cows. Tenovaginoscopy was performed using a rigid, 30 degrees arthroscope (length 18 cm; outer diameter 4mm) enabling a direct view of the synovial cavity and the following structures: digital flexor tendons, digital annular ligaments, lateral and medial pouches, three mesotendons, the vinculum of the superficial digital flexor tendon, and a slot-shaped opening in the manicaflexoria of the hind feet. Additionally, four clinical cases of septic tenosynovitis treated with lavage under tenovaginoscopic control were examined. Tenovaginoscopy represents a feasible, minimally invasive method for the diagnosis and treatment of septic tenosynovitis of the CDFTS, which allows the degree of alterations of the normal structures to be evaluated.