Anatomical landmarks for transnasal endoscopic skull base surgery.

Resection of midline skull base lesions involve approaches needing extensive neurovascular manipulation. Transnasal endoscopic approach (TEA) is minimally invasive and ideal for certain selected lesions of the anterior skull base. A thorough knowledge of endonasal endoscopic anatomy is essential to be well versed with its surgical applications and this is possible only by dedicated cadaveric dissections. The goal in this study was to understand endoscopic anatomy of the orbital apex, petrous apex and the pterygopalatine fossa. Six cadaveric heads (3 injected and 3 non injected) and 12 sides, were dissected using a TEA outlining systematically, the steps of surgical dissection and the landmarks encountered. Dissection done by the "2 nostril, 4 hands" technique, allows better transnasal instrumentation with two surgeons working in unison with each other. The main surgical landmarks for the orbital apex are the carotid artery protuberance in the lateral sphenoid wall, optic nerve canal, lateral optico-carotid recess, optic strut and the V2 nerve. Orbital apex includes structures passing through the superior and inferior orbital fissure and the optic nerve canal. Vidian nerve canal and the V2 are important landmarks for the petrous apex. Identification of the sphenopalatine artery, V2 and foramen rotundum are important during dissection of the pterygopalatine fossa. In conclusion, the major potential advantage of TEA to the skull base is that it provides a direct anatomical route to the lesion without traversing any major neurovascular structures, as against the open transcranial approaches which involve more neurovascular manipulation and brain retraction. Obviously, these approaches require close cooperation and collaboration between otorhinolaryngologists and neurosurgeons.

Prise en charge des troubles oculomoteurs après effraction iatrogène de l'orbite au cours d'interventions sinusiennes endoscopiques [Management of motility disorders secondary to iatrogenic orbital fracture during endoscopic sinus surgery.]

PURPOSE: Orbital wall fracture may occur during endoscopic sinus surgery, resulting in oculomotor disorders. We report the management of four cases presenting with this surgical complication. METHODS: A non-comparative observational retrospective study was carried out on four patients presenting with diplopia after endoscopic ethmoidal sinus surgery. All patients underwent full ophthalmologic and orthoptic examination as well as orbital imaging. RESULTS: All four patients presented with diplopia secondary to a medial rectus lesion confirmed by orbital imaging. A large horizontal deviation as well as limitation of adduction was present in all cases. Surgical management consisted of conventional recession-resection procedures in three cases and muscle transposition in one patient. A useful field of binocular single vision was restored in two of the four patients. CONCLUSION: Orbital injury may occur during endoscopic sinus surgery and cause diplopia, usually secondary to medial rectus involvement due to the proximity of this muscle to the lamina papyracea of the ethmoid bone. Surgical management is based on orbital imaging, duration of the lesion, evaluation of anterior segment vasculature, results of forced duction testing and intraoperative findings. In most cases, treatment is aimed at the symptoms rather than the cause, and the functional prognosis remains guarded.

Endoscopic mucosal resection in the esophagus with a new rigide device : an animal study

Résumé: Introduction : L'utilisation de méthodes endoscopiques peu invasives est en constante augmentation pour le traitement des lésions tumorales précoces de l'oesophage. Le but du traitement comprend l'éradication complète de tous les foyers de dysplasie ou de carcinome in situ, notamment dans les métaplasies intestinales de l'oesophage de Barrett, qui peuvent dégénérer en adénocarcinome. Plusieurs techniques d'ablation de la muqueuse oesophagienne (laser, argon plasma, electrocoagulation, photothérapie dynamique, résection endoscopique) ont été utilisées jusqu'à présent, mais aucune n'a vraiment donné entière satisfaction. Les techniques actuelles de résections endoscopiques par fibroscopie sont entre autres limitées par le grand nombre de séances nécessaires à l'éradication complète de la lésion et par la petite taille des fragments de muqueuse obtenus, ce qui rend l'analyse histologique difficile. Dans notre étude animale, nous avons évalué la faisabilité, l'efficacité et la sécurité d'une méthode de résection endoscopique à l'aide d'un nouvel oesophagoscope rigide. Matériel et méthode : Le résectoscope est formé d'un oesophagoscope rigide avec une fenêtre distale transparente à travers laquelle la muqueuse et une partie de la sous-muqueuse sont aspirées et ensuite réséquées avec une anse thermique. Les diverses fenêtres utilisées ont une taille comprise entre 2.2 et 4.4 cm. Le mouton a été choisi en raison de la ressemblance de son oesophage avec celui de l'humain en ce qui concerne l'épaisseur de son oesophage et sa structure histologique. Nous avons effectué 55 résections hémi-circonférentielles sur 21 animaux et 11 résections circonférentielles sur 11 autres. La Mitomycine-C, une substance qui inhibe la prolifération fibroblastique, a été utilisée dans 8 résections circonférentielles à différents intervalles de temps afin d'empêcher la survenue de sténoses oesophagiennes. Résultats : Toutes les résections hémi-circonférentielles ont permis d'obtenir des fragments compacts de tissu avec des bords nets, ce qui permet une excellente étude histologique. La surface du tissu prélevé était en corrélation avec la taille de la fenêtre du resectoscope. Nous avons ainsi pu obtenir des fragments avec des dimensions comprises entre 6 et 12 cm2. Pour les résections circonférentielles, les tissus étaient obtenus en 2 parties, en inversant de 180° la position de l'appareil. La profondeur de la résection a été optimale dans 58 cas sur 65 avec une découpe précise au niveau de la sous-muqueuse sans lésion de la couche musculaire sous- jacente. Il n'y a pas eu de complications après les résections hémi-circonférentielles. Les complications engendrées par les résections circonférentielles (sténose, perforation) n'ont plus été rencontrées après application locale de Mitomycine-C administrée à des intervalles de temps bien précis. Conclusion : Notre méthode de résection endoscopique de la muqueuse oesophagienne offre une nouvelle approche très prometteuse par rapport aux options déjà disponibles. Elle apparaît supérieure en ce qui concerne la taille de tissu prélevé, la précision et régularité de la profondeur de résection, ainsi que la facilité et sûreté du diagnostic histologique et des marges de sécurité. Les résections hémi-circonférentielles se sont révélées sûres chez le modèle animal. Cette nouvelle technique mérite de plus amples investigations pour les résections circonférentielles avant son utilisation chez l'humain. Abstract: Background and Study Aims: We undertook this retrospective study to evaluate the frequency and prognosis of endoscopic treatment of laterally spreading tumors (LSTs) in the rectum. The recurrence rate for lesions of the lower rectum was compared with that of the upper rectum. Patients and Methods: During the period from July 1989 to June 2002, a total of 1237 rectal tumors were detected. LSTs accounted for 6.9% (85/1237) of all rectal tumors. A total of 224 tumors of the lower rectum were detected among the 1237 rectal tumors. LSTs accounted for 16.1 % (36/224) of all the lower rectal tumors. From 85 LST lesions, 67 were evaluated for their prognosis after endoscopic mucosal resection (EMR). Patients whose LSTs had been resected were followed up by endoscopy at the following frequencies: once 15 (22.4%); twice (more than 1 year), 20 (29.9%); three times (more than 3 years), 21(31.3%); and four times or more (more than 5 years), 11 (16.4%). Results: A total of 67 patients with endoscopically treated LSTs were followed up by endoscopy. We observed recurrences in two lesions of the upper rectum (2/38, 5.3%) and five lesions of the lower rectum (5/29, 17.2%) (P = 0.2364); all seven lesions were resected piecemeal. LSTs whose horizontal margin reached the pectinate line frequently recurred in the lower rectum, at a rate of 80% (4/5). However, all patients were completely cured by additional endoscopic resections, the greatest number of treatments being four. Conclusion: For early detection of recurrence and successful endoscopic cure, further colonoscopic examination within a few months after the first treatment is necessary.

Fecal calprotectin more accurately reflects endoscopic activity of ulcerative colitis than the Lichtiger Index, C-reactive protein, platelets, hemoglobin, and blood leukocytes.

BACKGROUND: The correlation between noninvasive markers with endoscopic activity according to the modified Baron Index in patients with ulcerative colitis (UC) is unknown. We aimed to evaluate the correlation between endoscopic activity and fecal calprotectin (FC), C-reactive protein (CRP), hemoglobin, platelets, blood leukocytes, and the Lichtiger Index (clinical score). METHODS: UC patients undergoing complete colonoscopy were prospectively enrolled and scored clinically and endoscopically. Samples from feces and blood were analyzed in UC patients and controls. RESULTS: We enrolled 228 UC patients and 52 healthy controls. Endoscopic disease activity correlated best with FC (Spearman's rank correlation coefficient r = 0.821), followed by the Lichtiger Index (r = 0.682), CRP (r = 0.556), platelets (r = 0.488), blood leukocytes (r = 0.401), and hemoglobin (r = -0.388). FC was the only marker that could discriminate between different grades of endoscopic activity (grade 0, 16 [10-30] μg/g; grade 1, 35 [25-48] μg/g; grade 2, 102 [44-159] μg/g; grade 3, 235 [176-319] μg/g; grade 4, 611 [406-868] μg/g; P < 0.001 for discriminating the different grades). FC with a cutoff of 57 μg/g had a sensitivity of 91% and a specificity of 90% to detect endoscopically active disease (modified Baron Index ≥ 2). CONCLUSIONS: FC correlated better with endoscopic disease activity than clinical activity, CRP, platelets, hemoglobin, and blood leukocytes. The strong correlation with endoscopic disease activity suggests that FC represents a useful biomarker for noninvasive monitoring of disease activity in UC patients.

Transanal endoscopic microsurgery resection of rectal tumors: outcomes and recommendations.

PURPOSE: Transanal endoscopic microsurgery provides a minimally invasive alternative to radical surgery for excision of benign and malignant rectal tumors. The purpose of this study was to review our experience with transanal endoscopic microsurgery to clarify its role in the treatment of different types of rectal pathology. METHODS: A prospective database documented all patients undergoing transanal endoscopic microsurgery from October 1996 through June 2008. We analyzed patient and operative factors, complications, and tumor recurrence. For recurrence analysis, we excluded patients with fewer than 6 months of follow-up, previous excisions, known metastases at initial presentation, and those who underwent immediate radical resection following transanal endoscopic microsurgery. RESULTS: Two hundred sixty-nine patients underwent transanal endoscopic microsurgery for benign (n = 158) and malignant (n = 111) tumors. Procedure-related complications (21%) included urinary retention (10.8%), fecal incontinence (4.1%), fever (3.8%), suture line dehiscence (1.5%), and bleeding (1.5%). Local recurrence rates for 121 benign and 83 malignant tumors were 5% for adenomas, 9.8% for T1 adenocarcinoma, 23.5% for T2 adenocarcinoma, 100% for T3 adenocarcinoma, and 0% for carcinoid tumors. All 6 (100%) recurrent adenomas were retreated with endoscopic techniques, and 8 of 17 (47%) recurrent adenocarcinomas underwent salvage procedures with curative intent. CONCLUSIONS: Transanal endoscopic microsurgery is a safe and effective method for excision of benign and malignant rectal tumors. Transanal endoscopic microsurgery can be offered for (1) curative resection of benign tumors, carcinoid tumors, and select T1 adenocarcinomas, (2) histopathologic staging in indeterminate cases, and (3) palliative resection in patients medically unfit or unwilling to undergo radical resection.

Choledocholithiasis: repetitive thick-slab single-shot projection magnetic resonance cholangiopancreaticography versus endoscopic ultrasonography.

This prospective study compares repetitive thick-slab single-shot projection magnetic resonance cholangiopancreatography (MRCP) with endoscopic ultrasonography (EUS) for the detection of choledocholithiasis. Fifty-seven consecutive patients (36 women, mean age 61) referred for suspected choledocholithiasis underwent MRCP, followed by EUS. Each procedure was performed by different operators blinded to the results of the other investigation. MR technique included a turbo spin-echo T2-weighted axial sequence with selective fat saturation (SPIR/TSE, TE=70 ms, TR=1,600 ms), followed by coronal dynamic MRCP. The same thick-slab slice was sequentially acquired 12 times as breath-hold single-shot projection imaging (SSh, TE=900 ms, TE=8,000 ms) centred on the common bile duct (CBD). Two experienced radiologists independently and blindly evaluated MR images for the detection of CBD stones. Their inter-observer agreement kappa was determined. Secondly, the two observers read MR images in consensus again. CBD stones were demonstrated in 18 out of 57 patients (31.6 %) and confirmed by endoscopic retrograde cholangiography (ERCP, n=17) or intraoperative cholangiography (n=1). Clinical follow-up served as the "gold standard" in patients with negative results without following invasive procedure (n=28). Sensitivity, specificity, accuracy, positive and negative predictive value for MRCP resulting from consensus reading were 94.9%, 94.4%, 94.7%, 97.4% and 89.5%, respectively. Corresponding values of EUS were 97.4%, 94.4%, 96.5%, 97.4% and 94.4%. Inter-observer agreement kappa was 0.81. Repetitive thick-slab single-shot projection MRCP is an accurate non-invasive imaging modality for suspected choledocholithiasis and should be increasingly used to select those patients who require a subsequent therapeutic procedure, namely ERCP.

Helicobacter pylori in dyspeptic children and adults: endoscopic, bacteriologic and histologic correlations

Using different bacteriological (urease test, Gram staining and culture) and histological (Steiner staining and modified Giemsa staining) techniques, we searched for the presence of Helicobacter pylori in the gastric antrum of 200 dyspeptic Brazilian patients (106 females and 94 males aged 19 days to 81 years). The presence of bacteria was then correlated with the endoscopic and histological findings. H. pylori was present in 59.5 of the population studied. In Brazil, colonization occurs early, involving 37 of the dyspeptic population by 20 years of age. The presence of H. pylori in the gastric antrum was strongly associated with duodenal ulcer (P < 0.001) and a normal endoscopic examination did not exclude the possibility of colonization of the gastric antrum by H. pylori. The most sensitive test was the preformed urease test (89). We conclude that more than one diagnostic method should preferably be used for the detection of H. pylori and that the presence of H. pylori is closely correlated with active chronic gastritis (P < 0.001).

Fibrin sealant for mesh fixation in endoscopic inguinal hernia repair: is there enough evidence for its routine use?

Fibrin sealing has recently evolved as a new technique for mesh fixation in endoscopic inguinal hernia repair. A comprehensive Medline search was carried out evaluating fibrin sealant for mesh fixation, and finally 12 studies were included (3 randomized trials, 3 nonrandomized trials, and 6 case series). The trials were assessed for operative time, seroma formation, recovery time, recurrence rate, and acute and chronic pain.There was a trend toward decreased operative times for fibrin sealing compared with mechanical stapling; however, the results for seroma formation remained contradictory. The most important finding was the reduced postoperative pain. Recovery times were lower after fibrin sealing and the recurrence rates showed no differences.Fibrin sealing for mesh fixation in the endoscopic inguinal hernia surgery is a promising alternative to mechanical stapling, which can be safely applied. As the overall quality of published data remains poor, further well-designed studies are needed until fibrin sealing can replace mechanical stapling as a new standard for mesh fixation.

Fecal calprotectin more accurately reflects endoscopic activity of ulcerative colitis than the Lichtiger Index, CRP, or blood leukocytes

Background: Mucosal healing in ulcerative colitis (UC) is reported to be associated with favourable clinical outcomes such as reduced hospitalization and surgery rates. Activity monitoring by endoscopy has its shortcomings due to invasiveness, costs, and potential patient discomfort. Data on the correlation of noninvasive biomarkers with endoscopic severity in UC are scarce. Aim: to evaluate the correlation between endoscopic activity according to the modified Baron Index and fecal calprotectin, C-reactive protein (CRP), blood leukocytes, and the Lichtiger Index (clinical score). Methods: UC patients with leftsided and extensive colitis undergoing complete colonoscopy were prospectively enrolled and scored clinically and endoscopically. Fecal and blood samples were analyzed in UC patients (in a blinded fashion) and controls. The modified Baron score describes the following 5 endoscopic conditions: 0 = normal, 1 = granular mucosa, edema, 2 = friable mucosa but no spontaneous bleeding, 3 = microulcerations with spontaneous bleeding, 4 = gross ulceration, denuded mucosa. Results: We enrolled 228 UC patients (mean age 41 ± 13 years, 39 female) and 52 healthy controls. Disease was located in 40% in the left colon, 21% had an extensive and 39% a pancolitis. Endoscopic disease activity correlated best with fecal calprotectin (Spearman's rank correlation coefficient r = 0.821), followed by the Lichtiger Index (r = 0.682), CRP (r = 0.556), and blood leukocytes (r = 0.401). Fecal calprotectin was the only marker that could discriminate between different grades of endoscopic activity (grade 0, 25 ± 11 μg/g; grade 1, 44 ± 34 μg/g; grade 2, 111 ± 74 μg/g; grade 3, 330 ± 332 μg/g; grade 4, 659 ± 319 μg/g; P = 0.002 for discriminating grade 0 vs. 1, and P < 0.001 for discriminating grade 1 vs. 2, grade 2 vs. 3, and grade 3 vs. 4). Fecal calprotectin had the highest overall accuracy (91%) to detect endoscopically active disease (modified Baron Index ≥ 2), followed by the Lichtiger Index score of ≥ 4 (77%), CRP > 5 mg/L (69%) and blood leukocytosis (58%). Conclusions: Fecal calprotectin better correlated with endoscopic disease activity than clinical activity, CRP, and blood leukocytes. The strong correlation with endoscopic disease activity suggests that FC represents a useful biomarker for noninvasive monitoring of disease activity in UC patients.

Purely Endoscopic Keyhole Supraorbital Approaches for Anterior and Middle Skull Base Tumors

Anterior and middle skull base tumors, mainly meningiomas, are usually operated on using a sub-frontal route with a microscope. With modern radiotherapy, the goal of skull base surgery moves from a radical surgery with high rate of side effect to a functional concept that aims to remove as much as possible of the tumor without compromising the neurological status of patients. Minimally skull base surgery benefits from keyhole and endoscopy techniques. For 3 2 decades, the development of endoscopy helps to imagine innovative approaches for skull base tumors such as the endonasal route. Nonetheless, CSF leak issue and the absence of direct control of the tumor margins may limit the interest of such a route. Keyhole craniotomies have been developed with microscope but vision issue limits their use. Combining advantages of both techniques appears therefore natural and gave birth to intracranial assisted and more recently to fully endoscopic keyhole surgery. For anterior or middle skull base tumors, Keyhole supraorbital approaches can be done either by a trans-eyebrow or trans-eyelid routes. A step-by-step description of these fully endoscopic alternative routes summarizing advantages and drawbacks compared to others (traditional sub-frontal or more recent endonasal approaches) is reported in this chapter by the authors.

Serum ficolin-2 correlates worse than fecal calprotectin and CRP with endoscopic Crohn's disease activity.

BACKGROUND AND AIMS: Ficolin-2 is an acute phase reactant produced by the liver and targeted to recognize N-acetyl-glucosamine which is present in bacterial and fungal cell walls. We recently showed that ficolin-2 serum levels were significantly higher in CD patients compared to healthy controls. We aimed to evaluate serum ficolin-2 concentrations in CD patients regarding their correlation with endoscopic severity and to compare them with clinical activity, fecal calprotectin, and CRP. METHODS: Patients provided fecal and blood samples before undergoing ileo-colonoscopy. Disease activity was scored clinically according to the Harvey-Bradshaw Index (HBI) and endoscopically according to the simplified endoscopic score for CD (SES-CD). Ficolin-2 serum levels and fecal calprotectin levels were measured by ELISA. RESULTS: A total of 136 CD patients were prospectively included (mean age at inclusion 41.5±15.4 years, 37.5% females). Median HBI was 3 [2-6] points, median SES-CD was 5 [2-8], median fecal calprotectin was 301 [120-703] μg/g, and median serum ficolin-2 was 2.69 [2.02-3.83] μg/mL. SES-CD correlated significantly with calprotectin (R=0.676, P<0.001), CRP (R=0.458, P<0.001), HBI (R=0.385, P<0.001), and serum ficolin-2 levels (R=0.171, P=0.047). Ficolin-2 levels were higher in CD patients with mild endoscopic disease compared to patients in endoscopic remission (P=0.015) but no difference was found between patients with mild, moderate, and severe endoscopic disease. CONCLUSIONS: Ficolin-2 serum levels correlate worse with endoscopic CD activity when compared to fecal calprotectin or CRP.