Endoscopic off-pump aortic valve replacement: does the pericardial cuff improve the sutureless closure of left ventricular access?

OBJECTIVE: Off-pump trans left ventricular approach provides more precise deployment of stented aortic valve of any size with respect to the endovascular replacement. One of the key steps of this procedure is the ventricle repair after catheter withdrawing. We designed an animal study to compare the consistency of a sutureless repair of the left ventricle access using nitinol occluder with and without pericardial cuff on the ventricular side. METHODS: Material description: The Amplatz-nitinol occluder consists of two square heads squeezing ventricle wall in between them, sealing the defect. To improve its sealing property, a pericardial patch was sutured to the ventricular head of the occluder. Animal study setup: In adult pigs, a 30F sheath was inserted into the epigastric area through the cardiac apex, up to the left ventricle, simulating the approach for off-pump aortic valve replacement. The sheath was then removed and the ventricle closed with standard occluder in half of the animals, and cuffed occluder in the other half. Animals were followed-up for 3h, collecting haemodynamics data and pericardial bleeding. RESULTS: Device was successfully deployed in 12 animals in less than 1min. In the group where the standard occluder was used, bleeding during the deployment was 80+/-20ml and after the deployment was 800+/-20ml over 3h. In the group where the cuffed occluder was used, bleeding during the deployment was 85+/-20ml and after the deployment was 100+/-5ml over 3h. In the cuffed group, bleeding was significantly lower than the standard group, p-value being <0.001. CONCLUSIONS: The occluder is easy to use and the pericardial cuff dramatically increases its efficacy as demonstrated by a significant reduction of blood loss. The cuffed occluder opens the way for endoscopic, off-pump, transventricular aortic valve replacement.

Endoscopic low-coherence topography measurement for upper airways and hollow samples.

To evaluate the severity of airway pathologies, quantitative dimensioning of airways is of utmost importance. Endoscopic vision gives a projective image and thus no true scaling information can be directly deduced from it. In this article, an approach based on an interferometric setup, a low-coherence laser source and a standard rigid endoscope is presented, and applied to hollow samples measurements. More generally, the use of the low-coherence interferometric setup detailed here could be extended to any other endoscopy-related field of interest, e.g., gastroscopy, arthroscopy and other medical or industrial applications where tri-dimensional topology is required. The setup design with a multiple fibers illumination system is presented. Demonstration of the method ability to operate on biological samples is assessed through measurements on ex vivo pig bronchi.

Combined laparoscopic-endoscopic method using an omental plug for therapy of gastroduodenal ulcer perforation.

BACKGROUND: Laparoscopic techniques have been proposed as an alternative to open surgery for therapy of peptic ulcer perforation. They provide better postoperative comfort and absence of parietal complications, but leakage occurs in 5% of cases. We describe a new method combining laparoscopy and endoluminal endoscopy, designed to ensure complete closure of the perforation. METHODS: Six patients with anterior ulcer perforations (4 duodenal, 2 gastric) underwent a concomitant laparoscopy and endoluminal endoscopy with closure of the orifice by an omental plug attracted into the digestive tract. RESULTS: All perforations were sealed. The mean operating time was 72 minutes. The mean hospital stay was 5.5 days. There was no morbidity and no mortality. At the 30-day evaluation all ulcers but one (due to Helicobacter pylori persistence) were healed. CONCLUSIONS: This method is safe and effective. Its advantages compared with open surgery or laparoscopic patching as well as its cost-effectiveness should be studied in prospective randomized trials.

Endoscopic subureteral collagen injection for the treatment of vesicoureteral reflux in infants and children.

Between June 1988 and September 1994, 100 girls and 32 boys 2 months to 15.5 years old (average 4.9 years) with 204 refluxing ureteral units were treated by endoscopic subureteral collagen injection. The collagen injected was of bovine origin and cross-linked with glutaraldehyde (Zyplast*). Followup ranged from 3 to 75 months (mean 33). Reflux was absent in 62.7% of cases 3 months after 1 endoscopic subureteral injection. Improvement to reflux grades I and II, generally not requiring further treatment, occurred in a further 15.2% of cases. A total of 66 ureters was injected twice. The overall cure rate after 1 or 2 injections was 79.4% 3 months after injection. There was no correlation between the risk of recurrent reflux and initial degree of reflux. Late recurrence of reflux following a reflux-free period occurred in 11.3% of the 204 units during the observation period, which varied from 3 months to 6 1/4 years. Reflux was absent after 1 or 2 injections, including late recurrence, in 70.6% of cases and in an additional 13.2% recurrent reflux was grade I or II, not necessitating any further treatment. Considering these results, subureteral collagen injection remains an adequate method of treatment for vesicoureteral reflux in children.

Multifocalité du carcinome épidermoïde sur les voies digestive supérieure et respiratoire distale : technicité du diagnostic endoscopique [Multiple squamous cell carcinoma of the upper digestive and lower respiratory tracts : methodology of endoscopic screening]

L'étude porte sur 951 porteurs d'un cancer primaire bucco-pharyngo-laryngé, et révèle un taux de multifocalité du carcinome épidermoïde sur les voies digestive supérieure (bouche-pharynx-oesophage) et aérienne distale (larynx-trachée-bronches) s'élevant à 14,5 %. Les secondes localisations peuvent être simultanées (6,4 %) ou successives (8,1 %) à la découverte du premier cancer: dès la deuxième année du follow-up leur incidence dépasse celle des récidives. Elles se localisent tant au niveau ORL (8,5 %) qu'oesophagien (3 %) ou bronchique (3 %). Le cancer du voile présente un taux de multifocalité particulièrement élevé (51 %). Les auteurs décrivent un type d'endoscopie de dépistage (bucco-pharyngo-oesophago-laryngo-trachéobronchoscopie) dont la fiabilité repose sur une technicité spécifique d'une part, et sur la connaissance des caractéristiques propres aux secondes localisations d'autre part. Ce dépistage systématique permet de détecter les tumeurs secondaires à un stade le plus souvent précoce et encore asymptomatique.

La nouvelle classification de Savary des oesophagites de reflux [Savary's new endoscopic classification of reflux oesophagitis]

Comme la classification de Savary-Miller dont elle adopte l'essentiel, la classification de l'oesophagite par refluxen 5 types de Savary-Monnier repose sur une analyse rigoureuse et précise des lésions endoscopiques. Ses principales qualités sont d'être simple, complète, logique et souple. Son impact sur la pratique est certain puisqu'elle a une excellente valeur pronostique et qu'elle permet de choisir la bonne stratégie thérapeutique. De plus, en isolant les cicatrices cylindriques (seules précancéroses à surveiller à long terme) elle permet de les utiliser pour préciser la topographie des oesophagites de reflux.

Intraepithelial carcinoma of the oesophagus: endoscopic morphology.

The endoscopic detection of 18 "early" hypopharyngo-oesophageal carcinomas, has allowed us to perform a detailed study of the morphological correlation between endoscopy and histology (in 10 cases). We have thus defined 4 different endoscopic types of intraepithelial carcinomas; their morphology, mapping and evolution are greatly variable. In high risk groups (heavy smoking and alcohol consumption, ENt-cancer) the multicentricity of intraepithelial carcinomas (80%) entails a thorough endoscopic screening of the upper digestive tract (mouth, pharynx, oesophagus) and of the lower respiratory tract (larynx, trachea and bronchi).

Monitoring inflammatory bowel disease activity: clinical activity is judged to be more relevant than endoscopic severity or biomarkers.

BACKGROUND: There is increasing evidence for the clinical relevance of mucosal healing (MH) as therapeutic treatment goal in inflammatory bowel disease (IBD). We aimed to investigate by which method gastroenterologists monitor IBD activity in daily practice. METHODS: A questionnaire was sent to all board-certified gastroenterologists in Switzerland to specifically address their strategy to monitor IBD between May 2009 and April 2010. RESULTS: The response rate was 57% (153/270). Fifty-two percent of gastroenterologists worked in private practice and 48% worked in hospitals. Seventy-eight percent judged clinical activity to be the most relevant criterion for monitoring IBD activity, 15% chose endoscopic severity, and 7% chose biomarkers. Seventy percent of gastroenterologists based their therapeutic decisions on clinical activity, 24% on endoscopic severity, and 6% on biomarkers. The following biomarkers were used for IBD activity monitoring: CRP, 94%; differential blood count, 78%; fecal calprotectin (FC), 74%; iron status, 63%; blood sedimentation rate, 3%; protein electrophoresis, 0.7%; fecal neutrophils, 0.7%; and vitamin B12, 0.7%. Gastroenterologists in hospitals and those with ≤ 10 years of professional experience used FC more frequently compared with colleagues in private practice (P=0.035) and those with > 10 years of experience (P<0.001). CONCLUSIONS: Clinical activity is judged to be more relevant for monitoring IBD activity and guiding therapeutic decisions than endoscopic severity and biomarkers. As such, the accumulating scientific evidence on the clinical impact of mucosal healing does not yet seem to influence the management of IBD in daily gastroenterologic practice.

Endoscopic Approach and Management of Parasellar Lesions

The parasellar region is the location of a wide variety of inflammatory and benign or malignant lesions. A pathological diagnostic strategy may be difficult to establish relying solely on imaging data. Percutaneous biopsy through the foramen ovale using the Hartel technique has been developed for decision-making process. It is an accurate diagnostic tool allowing pathological diagnosis to determine the best treatment strategy. However, in some cases, this procedure may fail or may be inappropriate particularly for anterior parasellar lesions. Over these past decades, endoscopy has been widely developed and promoted in many indications. It represents an interesting alternative approach to parasellar lesions with low morbidity when compared to the classic microscopic sub-temporal extradural approach with or without orbito-zygomatic removal. In this chapter, we describe our experience with the endoscopic approach to parasellar lesions. We propose a complete overview of surgical anatomy and describe methods and results of the technique. We also suggest a model of a decision-making tree for the diagnosis and treatment of parasellar lesions.