Conventional versus biological therapy for prevention of postoperative endoscopic recurrence in patients with Crohn's disease: an international, multicenter, and observational study

Postoperative endoscopic recurrence (PER) occurs in nearly 80% of patients 1 year after ileocecal resection in patients with Crohn's disease (CD). Biological agents were more effective in reducing the rates of PER in comparison with conventional therapy, in prospective trials. The aim of this study was to compare the PER rates of biological versus conventional therapy after ileocecal resections in patients with CD in real-world practice. The MULTIPER (Multicenter International Postoperative Endoscopic Recurrence) database is a retrospective analysis of PER rates in CD patients after ileocecal resection, from 7 referral centers in 3 different countries. All consecutive patients who underwent ileocecal resections between 2008 and 2012 and in whom colonoscopies had been performed up to 12 months after surgery, were included. Recurrence was defined as Rutgeerts' score ≥i2. The patients were allocated to either biological or conventional therapy after surgery, and PER rates were compared between the groups. Initially, 231 patients were evaluated, and 63 were excluded. Of the 168 patients in the database, 96 received anti-tumor necrosis factor agents and 72 were treated with conventional therapy after resection. The groups were comparable regarding age, gender, and perianal disease. There was longer disease duration, more previous resections, and more open surgical procedures in patients on biologicals postoperatively. PER was identified in 25/96 (26%) patients on biological therapy and in 24/72 (33.3%) patients on conventional therapy (P=0.310). In this retrospective observational analysis from an international database, no difference was observed between biological and conventional therapy in preventing PER after ileocecal resections in CD patients.

Morphometric endoscopic study of the pharynx in patients with sleep apnea

Purpose: The aims of the study were to measure endoscopically the retrolingual pharynx during wakefulness and sleep before and after maxillomandibular advancement surgery and to quantify the changes observed. Materials and Methods: Eighteen patients with mild to severe grade obstructive sleep apnea hypopnea were evaluated during wakefulness while sitting and lying down and during induced sleep in dorsal decubitus while breathing naturally. Images of the retrolingual region of the pharynx were captured with a nasofibroscope and recorded on a DVD using the Sony Vegas 8.0 software (Sony Creative Software, Madison, WI). The images captured in greater and smaller aperture were measured with the Image J software (produced by Wayne Rasband, United States National Institutes of Health, Bethesda, MD) in linear anteroposterior and linear laterolateral areas. A correction factor was then applied to equalize the size of the images and thus compare them to one another. Results: The postoperative dimensions of the pharynx always increased significantly in all measurements compared with the preoperative ones. During induced sleep in dorsal decubitus, there was a greater gain in the area of smaller aperture (201.33%). Conclusions: The proposed method showed that the dimensions of the pharynx always increased significantly after surgery for maxillomandibular advancement, although the gain was not homogeneous in all dimensions and also varied according to state of consciousness. The greatest gain was observed in the area of smaller aperture with the patient in induced sleep, thus reducing the collapse of the pharynx. (C) 2012 Elsevier Inc. All rights reserved.

Endoscopic Laser Thyroarytenoid Myoneurectomy in Patients with Adductor Spasmodic Dysphonia: A Pilot Study on Long-Term Outcome on Voice Quality

Objectives. Adductor spasmodic dysphonia (ADSD) is a focal laryngeal dystonia, which compromises greatly the quality of life of the patients involved. It is a severe vocal disorder characterized by spasms of laryngeal muscles during speech, producing phonatory breaks, forced, strained and strangled voice. Its symptoms result from involuntary and intermittent contractions of thyroarytenoid muscle during speech, which causes vocal fold to strain, pressing each vocal fold against the other and increasing glottic resistance. Botulinum toxin injection remains the gold-standard treatment. However, as injections should be repeated periodically leading to voice quality instability, a more definitive procedure would be desirable. In this pilot study we report the long-term vocal quality results of endoscopic laser thyroarytenoid myoneurectomy. Study Design. Prospective study. Methods. Surgery was performed in 15 patients (11 females and four males), aged between 29 and 73 years, diagnosed with ADSD. Voice Handicap Index (VHI) was obtained before and after surgery (median 31 months postoperatively). Results. A significant improvement in VHI was observed after surgery, as compared with baseline values (P = 0.001). The median and interquartile range for preoperative VHI was 99 and 13, respectively and 24 and 42, for postoperative VHI. Subjective improvement of voice as assessed by the patients showed median improvement of 80%. Conclusions. Because long-term follow-up showed significant improvement of voice quality, this innovative surgical technique seems a satisfactory alternative treatment of ADSD patients who seek a definite improvement of their condition.

The use of Mitomycin-C to reduce synechia in middle meatus in sinus surgery: preliminary results

Synechia is the most frequent complication after sinus surgery and has been reported in up to 36% of cases. Several types of materials have been used to reduce the incidence of synechia, including Mitomycin C (MMC). Objective: This prospective study aimed to assess the effectiveness of topical MMC in the prevention of synechia after sinus surgery in humans. Methods: At the end of surgery, MMC solution (1.0 mg/ml) was topically applied randomly to one of the middle meatuses (MMC group) of 14 patients while saline solution was applied to the contralateral meatus (control group). The author remained blind to the medicated side. Synechiae were classified as partial or total. Results: Three patients had middle meatus synechia in the MMC group (21.43%) versus nine (64.29%) in the control group (p = 0.054). In the MMC group, all three middle meatus synechia were partial, while in the control group there were four partial (28.57%) and five total (35.71%) cases of synechia (p = 0.025). Conclusions: Mitomycin C was not effective in preventing middle meatus synechia, but reduced the probability of total synechia formation.

A novel approach for the treatment of pelvic abscess: transrectal endoscopic drainage facilitated by transanal endoscopic microsurgery access

Postoperative pelvic abscesses in patients submitted to colorectal surgery are challenging. The surgical approach may be too risky, and image-guided drainage often is difficult due to the complex anatomy of the pelvis. This article describes novel access for drainage of a pelvic collection using a minimally invasive natural orifice approach. A 37 year-old man presented with sepsis due to a pelvic abscess during the second postoperative week after a Hartmann procedure due to perforated rectal cancer. Percutaneous drainage was determined by computed tomography to be unsuccessful, and another operation was considered to be hazardous. Because the pelvic fluid was very close to the rectal stump, transrectal drainage was planned. The rectal stump was opened using transanal endoscopic microsurgery (TEM) instruments. The endoscope was advanced through the TEM working channel and the rectal stump opening, accessing the abdominal cavity and pelvic collection. The pelvic collection was endoscopically drained and the local cavity washed with saline through the scope channel. A Foley catheter was placed in the rectal stump. The patient's recovery after the procedure was successful, without the need for further intervention. Transrectal endoscopic drainage may be an option for selected cases of pelvic fluid collection in patients submitted to Hartmann's procedure. The technique allows not only fluid drainage but also visualization of the local cavity, cleavage of multiloculated abscesses, and saline irrigation if necessary. The use of TEM instrumentation allows safe access to the peritoneal cavity.

In Vitro Macroscopic and Endoscopic Analysis of Three-Rooted Maxillary Premolars and Two-Rooted Mandibular Premolars in the Same Individual: a Case Report

The recent addition of endoscopy in dental practice has enabled clinicians to have an excellent view of the operative field, yielding highly successful visualization of anatomical structures that are difficult to access, both in oral surgery and endodontics. The purpose of this report is to provide an in vitro macroscopic, radiographic, and endoscopic description of the anatomic variation of the roots of maxillary and mandibular first premolars in the same patient. A 22-year-old patient was referred by an orthodontist for the extraction of all the first premolars. Once extracted, the premolars were examined macroscopically and then analyzed radiographically after trepanation and filled root canal systems. Subsequently, a diaphanization process was carried out and the samples were sectioned at the middle and apical third for observation by endoscope. It was found that both the maxillary first premolars had three roots, and mandibular first premolars had two roots, all with complete root formation. Apical deltas or accessory canals were not identified in the radiographic images; however, through endoscope at the middle third, it was possible to observe an accessory canal to the first maxillary and mandibular right premolars. Thus, it can be concluded that the view through the endoscope allows better identification of accessory canals than X-rays.

Endonasal endoscopic exposure of the internal carotid artery: An anatomical study

Objectives/Hypothesis: The aim of this work was to define the anatomical landmarks, limitations, and difficulties of obtaining internal carotid artery (ICA) exposure via endonasal endoscopic approaches (EEA).

Evaluation of quality of life over time among 453 patients with hyperhidrosis submitted to endoscopic thoracic sympathectomy

Objectives: Current data do not provide enough information on how quality of life (QoL) evolves over time in cases of endoscopic thoracic sympathectomy (ETS). The purpose of this study was to ascertain whether the immediate improvement in QoL after the surgery was sustained until the fifth postoperative year. Methods: This was a prospective, nonrandomized and uncontrolled study. From March 2001 to December 2003, 475 consecutive patients with hyperhidrosis submitted to ETS were included. A QoL questionnaire was applied at the preoperative day, around the 30th postoperative day, and after the fifth year. Results: After excluding 22 patients who did not answer all the questions, we analyzed 453 patients. Their ages ranged from 11 to 57 years old, with a mean of 25.3 + 7.9 years, including 297 female patients (65.6%). All patients were assessed on three occasions: before surgery, around the 30th postoperative day, and after the fifth postoperative year. The QoL before surgery was considered to be poor or very poor for all patients. The QoL around 30 days after surgery was better in 412 patients (90.9%), the same in 27 patients (6.0%), and worse in 14 patients (3.1%). After 5 years, 409 patients (90.3%) were better, 27 (6.0%) were the same, and 14 (3.1%) were worse. There were no differences between these postoperative times according to the McNemar statistical test. Conclusion:The patients had an immediate improvement in QoL after ETS, and this improvement was sustained until the fifth postoperative year. (J Vase Surg 2012;55:154-6.)

A randomized controlled trial of fetal endoscopic tracheal occlusion versus postnatal management of severe isolated congenital diaphragmatic hernia

Objective Severe pulmonary hypoplasia and pulmonary arterial hypertension are associated with reduced survival in congenital diaphragmatic hernia (CDH). We aimed to determine whether fetal endoscopic tracheal occlusion (FETO) improves survival in cases of severe isolated CDH. Methods Between May 2008 and July 2010, patients whose fetuses had severe isolated CDH (lung-to-head ratio < 1.0, liver herniation into the thoracic cavity and no other detectable anomalies) were assigned randomly to FETO or to no fetal intervention (controls). FETO was performed under maternal epidural anesthesia supplemented with fetal intramuscular anesthesia. Tracheal balloon placement was achieved with ultrasound guidance and fetoscopy between 26 and 30 weeks of gestation. All cases that underwent FETO were delivered by the EXIT procedure. Postnatal therapy was the same for both treated fetuses and controls. The primary outcome was survival to 6 months of age. Other maternal and neonatal outcomes were also evaluated. Results Twenty patients were enrolled randomly to FETO and 21 patients to standard postnatal management. The mean gestational age at randomization was similar in both groups (P = 0.83). Delivery occurred at 35.6 +/- 2.4 weeks in the FETO group and at 37.4 +/- 1.9 weeks in the controls (P < 0.01). In the intention-to-treat analysis, 10/20 (50.0%) infants in the FETO group survived, while 1/21 (4.8%) controls survived (relative risk (RR), 10.5 (95% CI, 1.5-74.7), P < 0.01). In the receivedtreatment analysis, 10/19 (52.6%) infants in the FETO group and 1/19 (5.3%) controls survived (RR, 10.0 (95% CI, 1.4-70.6) P < 0.01). Conclusion FETO improves neonatal survival in cases with isolated severe CDH. Copyright (C) 2011 ISUOG. Published by John Wiley & Sons, Ltd.

Accuracy of endoscopic ultrasound-guided fine-needle aspiration in the suspicion of pancreatic metastases

Abstract Background Metastases to the pancreas are rare, and usually mistaken for primary pancreatic cancers. This study aimed to describe the histology results of solid pancreatic tumours obtained by endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) for diagnosis of metastases to the pancreas. Methods In a retrospective review, patients with pancreatic solid tumours and history of previous extrapancreatic cancer underwent EUS-FNA from January/1997 to December/2010. Most patients were followed-up until death and some of them were still alive at the end of the study. The performance of EUS-FNA for diagnosis of pancreatic metastases was analyzed. Symptoms, time frame between primary tumour diagnosis and the finding of metastases, and survival after diagnosis were also analyzed. Results 37 patients underwent EUS-FNA for probable pancreas metastases. Most cases (65%) presented with symptoms, especially upper abdominal pain (46%). Median time between detection of the first tumour and the finding of pancreatic metastases was 36 months. Metastases were confirmed in 32 (1.6%) cases, 30 of them by EUS-FNA, and 2 by surgery. Other 5 cases were non-metastatic. Most metastases were from lymphoma, colon, lung, and kidney. Twelve (32%) patients were submitted to surgery. Median survival after diagnosis of pancreatic metastases was 9 months, with no difference of survival between surgical and non-surgical cases. Sensitivity, specificity, positive and negative predictive values, and accuracy of EUS-FNA with histology analysis of the specimens for diagnosis of pancreatic metastases were, respectively, 93.8%, 60%, 93.8%, 60% and 89%. Conclusion EUS-FNA with histology of the specimens is a sensitive and accurate method for definitive diagnosis of metastatic disease in patients with a previous history of extrapancreatic malignancies.

Percutaneous endoscopic gastrostomy in head and neck cancer patients: indications, techniques, complications and results

The aim of this study was to review our experience in percutaneous endoscopic gastrostomy (PEG) performed in patients with cancer of the upper aerodigestive tract. Descriptive retrospective study of 142 patients (115 males, 27 females), mean age 62.4 years (25-84 years), with head and neck or esophageal cancer, who underwent PEG tube insertion between January 2006 and December 2008. The studied parameters were indications, success rate, rate and type of complications, and their management. Percutaneous endoscopic gastrostomy was inserted before chemoradiation therapy in 80% and during or after cancer treatment in 20% of the patients. PEG placement was possible in 137 patients (96%). Major complications were observed in 9 (7%) and minor complications in 22 (17%) of the 137 patients. Seven of the 9 patients with a major complication needed revision surgery. The mortality directly related to the procedure was 0.7%. Percutaneous endoscopic gastrostomy tube insertion has a high success rate. In patients with upper aerodigestive tract cancer, PEG should be the first choice for enteral nutrition when sufficient oral intake is not possible. Although apparently easy, the procedure may occasionally lead to severe complications. Therefore, a strict technique and knowledge of clinical signs of possible complications are mandatory.

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.

TAPP or TEP? Population-based analysis of prospective data on 4,552 patients undergoing endoscopic inguinal hernia repair

Whether total extraperitoneal inguinal hernia repair (TEP) is associated with worse outcomes than transabdominal preperitoneal inguinal hernia repair (TAPP) continues to be a matter of debate. The objective of this large cohort study is to compare outcomes between patients undergoing TEP or TAPP.

Endoscopic resection of laryngeal and tracheal lesions using the microdebrider

CONCLUSION: Endoscopic resection of laryngeal and tracheal lesions using the microdebrider is a safe, accurate and reliable method. OBJECTIVE: The microdebrider is an important tool for endoscopic nasal and sinus surgery and over the last few years a powered blade with a long shaft has been developed for endoscopic laryngeal and tracheal surgery. The aim of this non-randomized prospective study was to determine the advantages and disadvantages of the microdebrider for treating patients with different laryngeal and tracheal pathologies. MATERIAL AND METHODS: The laryngeal microdebrider was used under endoscopic control in 37 patients. In 29 cases a benign laryngeal lesion was removed endoscopically. In four patients debulking of a malignant obstructive endolaryngeal tumor was performed in order to avoid a tracheotomy. In four cases a bulky obstructing endotracheal lesion was removed. RESULTS: All laryngotracheal lesions could be removed, and this was facilitated by the use of angled rigid telescopes and the laryngeal blade. No traumatic lesions to normal laryngeal tissue occurred as a result of use of the microdebrider and no postoperative endolaryngeal bleeding was observed. The histological diagnosis of the biopsies taken with the microdebrider was accurate in every case. In three of the four cases with obstructive laryngeal malignancies, a tracheotomy was avoided until definitive therapy was undertaken. Normal breathing was restored in all patients with endotracheal lesions.