Video versus Direct Laryngoscopy for Urgent Intubation of Newborn Infants.

BACKGROUND: Repeated attempts at endotracheal intubation are associated with increased adverse events in neonates. When clinicians view the airway directly with a laryngoscope, fewer than half of first attempts are successful. The use of a video laryngoscope, which has a camera at the tip of the blade that displays a view of the airway on a screen, has been associated with a greater percentage of successful intubations on the first attempt than the use of direct laryngoscopy in adults and children. The effect of video laryngoscopy among neonates is uncertain. METHODS: In this single-center trial, we randomly assigned neonates of any gestational age who were undergoing intubation in the delivery room or neonatal intensive care unit (NICU) to the video-laryngoscopy group or the direct-laryngoscopy group. Randomization was stratified according to gestational age (<32 weeks or ≥32 weeks). The primary outcome was successful intubation on the first attempt, as determined by exhaled carbon dioxide detection. RESULTS: Data were analyzed for 214 of the 226 neonates who were enrolled in the trial, 63 (29%) of whom were intubated in the delivery room and 151 (71%) in the NICU. Successful intubation on the first attempt occurred in 79 of the 107 patients (74%; 95% confidence interval [CI], 66 to 82) in the video-laryngoscopy group and in 48 of the 107 patients (45%; 95% CI, 35 to 54) in the direct-laryngoscopy group (P<0.001). The median number of attempts to achieve successful intubation was 1 (95% CI, 1 to 1) in the video-laryngoscopy group and 2 (95% CI, 1 to 2) in the direct-laryngoscopy group. The median lowest oxygen saturation during intubation was 74% (95% CI, 65 to 78) in the video-laryngoscopy group and 68% (95% CI, 62 to 74) in the direct-laryngoscopy group; the lowest heart rate was 153 beats per minute (95% CI, 148 to 158) and 148 (95% CI, 140 to 156), respectively. CONCLUSIONS: Among neonates undergoing urgent endotracheal intubation, video laryngoscopy resulted in a greater number of successful intubations on the first attempt than direct laryngoscopy. (Funded by the National Maternity Hospital Foundation; VODE ClinicalTrials.gov number, NCT04994652.).

Video-Assisted Telescope Operating Monitor 3D System in Microsurgical Varicocelectomy: A Preliminary Report.

INTRODUCTION: Video-assisted telescope operating monitor (VITOM®) with 3D Visualization technology was developed and has been used with favorable results by several surgical specialties. Our study aims to be a preliminary report for initial experience using the VITOM® 3D system for microsurgical varicocelectomy on varicocele patients. METHODS: We performed 35 microsurgical varicocelectomy procedures using the VITOM® 3D system on varying types and grades of varicoceles. The surgeon had the option of using either a 2.5 or 3.5 magnifying loupe in addition to the exoscope for each operation evaluated. The exoscope is a standalone camera head with an integrated 3D telescope and remote control with zoom and focus functions. It is connected to the 3D monitor via a mechanical holding arm. During the procedure, surgeons, assistants, and observers were able to view the 3D high-definition stream displayed on a 26-inch 3D monitor at a convenient viewing angle and distance. The varicocele ligation was performed using a Carl Zeiss Meditec AG microscope. RESULTS: There were 35 patients with varicocele aged 31.51 years old on average, which were included in this report. Most patients had grade 3 bilateral varicocele (n = 13, 37.1%). All procedures were performed without any intraoperative complications. After the procedures, only a few patients suffered from postoperative complications. Three patients suffered scrotal edema (8.6%), while another had hydrocele (2.9%). The postoperative pain results were also very minimal from .89 1 day after the operation to .26 3 days after the operation. CONCLUSION: The VITOM® 3D system showed promise in microsurgical varicocelectomy.

Video laryngoscopic oral intubation in rats: a simple and effective method.

Endotracheal intubation is a vital component of many rat in vivo experiments to secure the airway and allow controlled ventilation. Even in the hands of experienced researchers, however, the procedure remains technically challenging. The safest and most reliable way for human intubation is by video laryngoscopy. Previous attempts to apply this technique in rodents have been complicated and expensive. We, hereby, describe a novel, noninvasive method to safely intubate rats orally by video laryngoscopy, thus avoiding the need for a surgical tracheostomy. By repurposing a commercially available ear wax removal device, visualization of the rat larynx can be significantly enhanced. Because of its small diameter, integrated illumination, and a powerful camera with adequate focal length, the device has all of the necessary properties for exploring the upper airway of a rat. After identifying the vocal cords by video laryngoscopy, the insertion of an endotracheal tube (a 14G intravenous catheter) into the trachea under constant visual control is facilitated by using PE50 polyethylene tubing as a stylet (Seldinger technique). The procedure has been performed more than 60 times in our laboratory; all intubations were successful on the first attempt, and no adverse events were observed. We conclude that the described procedure is a simple and effective way to intubate a rat noninvasively, using inexpensive and commercially available equipment.

3D Versus 4K Display System - Influence of "State-of-the-art"-Display Technique on Surgical Performance (IDOSP-study) in Minimally Invasive Surgery: A Randomized Cross-over Trial.

OBJECTIVE: To evaluate if "state-of-the-art" 3D- versus 4K-display techniques could influence surgical performance. BACKGROUND: High quality minimally invasive surgery is challenging. Therefore excellent vision is crucial. 3D display technique (3D) and 2D-4K technique (4K) are designed to facilitate surgical performance, either due to spatial resolution (3D) or due to very high resolution (4K). METHODS: In randomized cross-over trial the surgical performance of medical students (MS), non-board certified surgeons (NBC), and board certified surgeons (BC) was compared using 3D versus 4K display technique at a minimally invasive training Parkour. RESULTS: One hundred twenty-eight participants were included (February 2018 through October 2019, 49 MS, 39 NBC, 40 BC). The overall Parkour time (s) 3D versus 4K was 712.5 s ± 17.5 s versus 999.5 s ±â€Š25.1 s (P < 0.001) for all levels of experience. It was (3D vs 4K) for MS (30 tasks) 555.4 s ±â€Š28.9 s versus 858.7 s ±â€Š41.6 s, (P < 0.0001), for NBC (42 tasks) 935.9 s ±â€Š31.5 s versus 1274.1 s ±â€Š45.1 s (P =< 0.001) and for BC (42 task) 646.3 s ±â€Š30.9 s versus 865.7 s ±â€Š43.7 s (P < 0.001). The overall number of mistakes was (3D vs 4K) 10.0 ±â€Š0.5 versus 13.3 ±â€Š0.7 (P < 0.001), for MS 8.9 ±â€Š0.9 versus 13.1 ±â€Š1.1 (P < 0.001), for NBC 12.45 ±â€Š1.0 versus 16.7 ±â€Š1.2 (P < 0.001) and for BC 8.8 ±â€Š1.0 versus 10.0 ±â€Š1.2 (P = 0.18). MS, BC, and NBC showed shorter performance time in 100% of the task with 3D (significantly in 6/7 tasks). For number of mistakes the effect was less pronounced for more experienced surgeons. The National Aeronautics and Space Administration-task load index was lower with 3D. CONCLUSION: 3D laparoscopic display technique optimizes surgical performance compared to the 4K technique. Surgeons benefit from the improved visualization regardless of their individual surgical expertise.

Integrating the MasSpec Pen to the da Vinci Surgical System for In Vivo Tissue Analysis during a Robotic Assisted Porcine Surgery.

Minimally invasive robotic-assisted surgeries have been increasingly used as a first-line of treatment for patients undergoing oncologic surgeries. In-situ tissue identification is critical to guide tissue resection and assist decision-making. Traditional intraoperative histopathologic analysis of frozen tissue sections can be time-consuming and present logistical challenges which interrupt surgical workflows. We report the development and implementation of a laparoscopic, drop-in version of the MasSpec Pen device integrated into the da Vinci Xi Surgical system for in vivo tissue analysis in a robotic-assisted porcine surgery. We evaluated the performance of the drop-in MasSpec Pen during surgery by introducing the device into the animal upper gastrointestinal system and performing in vivo analyses of the stomach and liver, including charred and bloody tissues after electrocauterization. The molecular profiles obtained included ions tentatively identified as metabolites and lipids typically observed with MasSpec Pen analysis, without causing observable tissue damage. Statistical classifiers built to distinguish porcine liver and stomach tissues using the in vivo data yielded an overall tissue identification accuracy of 98% (n = 53 analyses). The results provide evidence that the drop-in MasSpec Pen developed can be used to acquire mass spectra in vivo during a robotic-assisted surgery and might be used as an in vivo tissue assessment tool to help guide surgical resections and streamline surgical workflows.

McGrath Video Laryngoscope Versus Macintosh Direct Laryngoscopy for Intubation of Morbidly Obese Patients: A Randomized Trial.

BACKGROUND: Two-thirds of the US population is considered obese and about 8% morbidly obese. Obese patients may present a unique challenge to anesthesia clinicians in airway management. Videolaryngoscopes may provide better airway visualization, which theoretically improves intubation success. However, previous work in morbidly obese patients was limited. We therefore tested the primary hypothesis that the use of McGrath video laryngoscope improves visualization of the vocal cords versus Macintosh direct laryngoscopy (Teleflex, Morrisville, NC) in morbidly obese patients. METHODS: We enrolled 130 surgical patients, aged 18-99 years, with a body mass index ≥40 kg/m and American Society of Anaesthesiologists (ASA) physical status I-III. Patients were randomly allocated 1:1-stratified for patient's body mass index ≥50 kg/m-to McGrath video laryngoscope versus direct laryngoscopy with a Macintosh blade. The study groups were compared on glottis visualization, defined as improved Cormack and Lehane classification, with proportional odds logistic regression model. RESULTS: McGrath video laryngoscope provided significantly better glottis visualization than Macintosh direct laryngoscopy with an estimated odds ratio of 4.6 (95% confidence interval [CI], 2.2-9.8; P < .01). We did not observe any evidence that number of intubation attempts and failed intubations increased or decreased. CONCLUSIONS: McGrath video laryngoscope improves glottis visualization versus Macintosh direct laryngoscopy in morbidly obese patients. Large clinical trials are needed to determine whether improved airway visualization with videolaryngoscopy reduces intubation attempts and failures.

Randomized crossover trial comparing cervical spine motion during tracheal intubation with a Macintosh laryngoscope versus a C-MAC D-blade videolaryngoscope in a simulated immobilized cervical spine.

BACKGROUND: Maintaining cervical immobilization is essential during tracheal intubation in patients with unstable cervical spines. When using the Macintosh laryngoscope for intubation in patients with cervical immobilization, substantial neck extension is required for visualization of the glottis. However, the C-MAC D-Blade videolaryngoscope may require less neck extension due to its acute angulation. We hypothesized that C-MAC D-Blade videolaryngoscopic intubation would result in less cervical spine movement than Macintosh laryngoscopic intubation. We compared the effects of C-MAC D-Blade videolaryngoscopic intubation and Macintosh laryngoscopic intubation in terms of cervical spine motion during intubation in patients with simulated cervical immobilization. METHODS: In this randomized crossover study, the cervical spine angle was measured at the occiput-C1, C1-C2, and C2-C5 segments before and during tracheal intubation with either a C-MAC D-Blade videolaryngoscope or Macintosh laryngoscope in 20 patients, with application of a neck collar for simulated cervical immobilization. Cervical spine motion was defined as the change in angle measured before and during tracheal intubation. RESULTS: The cervical spine motion at the occiput-C1 segment was measured at 12.1 ± 4.2° and 6.8 ± 5.0° during Macintosh laryngoscopic and C-MAC D-blade videolaryngoscopic intubation, respectively, corresponding to a 44% reduction in cervical spine motion when using the latter device (mean difference, - 5.3; 98.33% CI: - 8.8 to - 1.8; p = 0.001). However, there was no significant difference between the two intubation devices at the C1-C2 segment (- 0.6; 98.33% CI: - 3.4 to 2.2; p = 0.639) or C2-C5 segment (0.2; 98.33% CI: - 6.0 to 6.4; p = 0.929). CONCLUSIONS: The C-MAC D-Blade videolaryngoscope causes less upper cervical spine motion than the Macintosh laryngoscope during tracheal intubation of patients with simulated cervical immobilization. TRIAL REGISTRATION: This study was registered at ClinicalTrials.gov on June 26, 2018 ( NCT03567902 ).

Upgraded bidirectional approach video-assisted neck surgery (BAVANS) using a rigid endoscope with variable viewing direction for advanced endoscopic lymph node dissection in thyroid cancer patients.

In 2011, we developed bidirectional approach video-assisted neck surgery (BAVANS) for endoscopic thyroid cancer surgery. BAVANS combines two different approach pathways at 180 degrees to the cervical lesion for endoscopic thyroidectomy and complete cervical lymphadenectomy. We reported previously that the cranio-caudal approach is extremely useful for endoscopic complete lymph node dissection around the trachea. In 2014, we upgraded the initial BAVANS for better maneuverability and quality of lymph node dissection. A new high-tech rigid endoscope with a variable viewing direction (EndoCAMeleon™), has enabled us to reduce the camera port in the anterior neck while keeping the easy maneuverability and the same quality of central lymph node dissection (LND) as with the initial BAVANS. Endoscopic thyroid cancer surgery is now evolving concurrently with new visual technology.

Validation of a 2-mm videoendoscope for the evaluation of the paranasal sinuses with a minimally invasive technique.

OBJECTIVE: To describe the technique, experience, and limitations of using a 2-mm flexible endoscope to perform standing minimally invasive sinoscopy. STUDY DESIGN: In phases 1 and 2, we used cadaveric heads (ex vivo). In phase 3, we used unaffected horses (in vivo). ANIMALS: Five cadaveric equine skulls in phase 1 and 10 cadaveric equine skulls in phase 2. Six horses older than 5 years in phase 3. METHODS: In phase 1, the specimens were used to determine the suitability of the endoscope for sinoscopy and the ideal landmarks to approach the paranasal sinuses through minisinusotomies performed with a 14 gauge needle. In phase 2, a nonblinded evaluation of the visualization of the different sinus compartments was performed, and a score was attributed to each structure. Procedures were video recorded and compared with direct visualization of the sinuses after performing frontal and maxillary flaps. In phase 3, the technique was validated in healthy horses under sedation. RESULTS: The landmarks determined in phase 1 allowed a thorough exploration of the sinuses in phases 2 and 3. Sinoscopy findings were confirmed after direct visualization of the sinuses via frontal and maxillary bone flaps in phase 2. The procedure was well tolerated by all horses. CONCLUSION: Minimally invasive sinoscopy was readily performed without relevant complications in standing horses. A thorough evaluation of most sinus structures was obtained only using the frontal and the rostral maxillary portals. CLINICAL SIGNIFICANCE: Minimally invasive sinoscopy offers an alternative diagnostic tool to veterinarians. A specialized endoscope and appropriate training are required to perform this minimally invasive procedure.

10-mm Laparo-Endoscopic Single-Site Cholecystectomy Using Multiple Magnetically Anchored and Controlled Instruments.

BACKGROUND: To study the feasibility of laparo-endoscopic single-site (LESS) cholecystectomy through a 10-mm incision using a miniature magnetically anchored and controlled laparoscopy system and a grasper system. METHODS: The miniature magnetically anchored and controlled laparoscopy system consisted of a miniature magnetically anchored camera (MMAC), an external magnetic anchoring unit, and a vision output device. The camera weighed 9.8 g and measured Φ10 mm × 50 mm. The magnetically anchored and controlled grasper system consisted of a magnetically anchored grasper (MAG), an external magnetic anchoring unit, and a push-pull device. The MAG had a titanium alloy clip head and a magnetic tail. The laparoscopy system and grasper system were used simultaneously to perform LESS cholecystectomy through a single 10-mm incision in model canines. RESULTS: LESS cholecystectomy through a 10-mm incision using the MMAC and MAG was attempted in six dogs. The mean operative time was 85.75 ± 7.14 min. The operation was completed successfully in four cases, with failure occurring in one case due to gallbladder rupture and in another due to bile duct injury. The MMAC provided clear imaging, and the MAG provided sufficient exposure to perform the cholecystectomy. The use of multiple magnetically anchored and controlled instruments did not result in notable collisions. CONCLUSIONS: The designed MMAC and MAG system could be easily maneuvered. LESS cholecystectomy may be feasible through a single 10-mm incision with the simultaneous use of multiple magnetically anchored and controlled instruments.

Is Tube Thermosoftening Helpful for Videolaryngoscope-Guided Nasotracheal Intubation?: A Randomized Controlled Trial.

BACKGROUND: Thermosoftening of the endotracheal tube (ETT) and telescoping the ETT into a rubber catheter have been suggested as a method for reducing epistaxis during nasotracheal intubation (NTI). However, thermosoftening technique is known to make it difficult to navigate the ETT into trachea without the use of Magill forceps during NTI. The cuff inflation technique has been suggested as an effective alternative to the use of Magill forceps to improve the oropharyngeal navigation of the ETT, irrespective of their stiffness, during direct laryngoscope-guided NTI. We evaluated whether thermosoftening of the ETT telescoped into rubber catheters has an additional benefit in reducing nasal injury. Simultaneously, we also evaluated whether thermosoftening of the ETT worsened orotracheal navigability during cuff inflation-supplemented videolaryngoscope-guided NTI. METHODS: One hundred forty patients were randomly assigned to 1 of the 2 groups depending on whether the ETT was softened by warming or not. The primary outcome was the incidence of epistaxis during NTI. The secondary outcome was nasotracheal navigability of the ETT, assessed by navigation grade and time required for insertion of ETT in each phase (from nose to oropharynx, from oropharynx to glottic inlet aided by cuff inflation if needed, and from glottic inlet to trachea). RESULTS: The ETTs were successfully inserted through the selected nostril of all 140 patients. In the thermosoftening group, the incidence and severity of epistaxis was significantly lower (7% vs 51%; difference of 44.2%; 95% confidence interval, 29.9%-56.2%; P < .001), and the ETT passed through the nasal cavity with lower resistance (P = .001) and less time (P < .001) when compared to the control group. No difference was found in the ease of ETT insertion (navigation grade and time required) from the oropharynx to the glottic inlet (P > .99 and P = .054, respectively) and from the glottic inlet to the trachea (P > .99 and P = .750, respectively) between the 2 groups. In both groups, all ETTs could be navigated into the trachea without the use of Magill forceps. CONCLUSIONS: Supplemented with cuff inflation during videolaryngoscope-guided NTI, thermosoftening of the ETT telescoped into rubber catheters has a substantial benefit because it significantly reduces the incidence of epistaxis without worsening the oropharyngeal navigability of the ETT.

Intubation of non-difficult airways using video laryngoscope versus direct laryngoscope: a randomized, parallel-group study.

BACKGROUND: The video laryngoscope is recommended for intubating difficult airways. The present study aimed to determine whether the video laryngoscope can further improve intubation success rates compared with the direct laryngoscope in patients with non-difficult airways. METHODS: In total, 360 patients scheduled for elective abdominal surgeries were randomly assigned to undergo intubation using either a video laryngoscope (n = 179) or a direct laryngoscope (n = 181). The following parameters were measured: mouth opening; thyromental distance; sternomental distance; shape angle of the tracheal catheter; and glottic exposure grade. RESULTS: The percentage of patients with level I-II of total glottic exposure in the video laryngoscope group was 100% versus 63.5% in the direct laryngoscope group (P < 0.001). The one-attempt success rate of intubation was 96.1% using a video laryngoscope versus 90.1% using a direct laryngoscope (P = 0.024). The intubation success rate using a video laryngoscope was 100% versus 94.5% using a direct laryngoscope (P = 0.004). Immediate oropharyngeal injury occurred in 5.1% of patients intubated using a direct laryngoscope versus 1.1% using a video laryngoscope (P = 0.033). On postoperative day 1, obvious hoarseness was exhibited by 7.9% of patients intubated using a direct laryngoscope versus 2.8% using a video laryngoscope (P = 0.035). The grade of glottic exposure and catheter shape angle were independent risk factors for tracheal intubation failure. Thyromental distance, shape angle, glottic exposure time, and surgical position were independent risk factors for postoperative complications. Thyromental distance and glottic exposure time were independent risk factors for complications lasting > 2 days. CONCLUSIONS: Intubation using a video laryngoscope yielded significantly higher intubation success rates and significantly fewer postoperative complications than direct laryngoscopy in patients with non-difficult airways. TRIAL REGISTRATION: Chinese Clinical Trial Registry. No: ChiCTR-IOR-16009023 . Prospective registration.

Measurement of forces applied using a Macintosh direct laryngoscope compared with a Glidescope video laryngoscope in patients with predictors of difficult laryngoscopy: A randomised controlled trial.

BACKGROUND: In patients with predictive features associated with easy direct laryngoscopy, videolaryngoscoy with the GlideScope has been shown to require less force when compared with Macintosh direct laryngoscopy. OBJECTIVE: The aim of this study was to compare forces applied with Glidescope vs. Macintosh laryngoscopes in patients with predictive features associated with difficult direct laryngoscopy. DESIGN: A randomised study. SETTING: Toronto General Hospital, a university tertiary centre in Canada. PATIENTS: Forty-four patients aged over 18 years, with one or more features of difficult intubation, undergoing elective surgery requiring single-lumen tracheal intubation. INTERVENTION: We measured the force applied to oropharyngeal tissues by attaching three FlexiForce Sensors (A201-25) to the concave surface of Macintosh and GlideScope laryngoscope blades.Anaesthetists or experienced anaesthesia residents performed laryngoscopies with both devices in a randomised sequence. MAIN OUTCOME MEASURES: The primary outcome was peak force. The secondary outcomes were average force and impulse force. The latter is the integral of the force over the time during which the force acted. RESULTS: Complete data were available for 40 individuals. Peak and average forces decreased with GlideScope (17 vs. 21 N, P = 0.03, and 6 vs. 11 N, P < 0.001, respectively). Laryngoscopy time increased with the GlideScope (30 vs. 18 s, P < 0.001), resulting in similar median impulse forces (206 vs. 175 N, P = 0.92). CONCLUSION: GlideScope laryngoscopy resulted in reduced peak and average forces, but as the laryngoscopy duration increased, the product of force and time (impulse force) was similar with both devices. TRIAL REGISTRATION: Clinicaltrials.gov Identifier: NCT01814176.

A comparison of two hyperangulated video laryngoscope blades to direct laryngoscopy in a simulated infant airway: a bicentric, comparative, randomized manikin study.

BACKGROUND: In infants, securing the airway is time-critical because of anatomical and physiological differences related to airway management in children less than 1 year old. The aim of this study was to compare the time to ventilation using two different hyperangulated video laryngoscope blades with the time to ventilation via conventional direct laryngoscopy in a normal airway [NA] and in a simulated difficult airway [DA]. METHODS: This study was a comparative, bicentric, open-label, randomized controlled evaluation. An infant high-fidelity simulator (SimBaby™; Laerdal® Medical, Stavanger, Norway) was used, and two scenarios were proposed, as follows: NA and DA evoked with tongue edema and cervical collar. After theoretical and practical briefing, each participant compared in the two airway scenarios the novel King Vision™ Pediatric aBlade (KV) (Ambu® A/S, Bad Nauheim, Germany) video laryngoscope and the C-MAC™ D-blade Ped (DB) (Karl Storz® SE & Co. KG, Tuttlingen, Germany) video laryngoscope to conventional laryngoscopy using the Miller Blade (MiB) and the Macintosh Blade (MaB) in a random sequence. RESULTS: Eighty physicians (65 AN and 15 PCCM staff) were included. In the NA scenario, the median [IQR] time to successful time to ventilation (TTV) was significantly shorter for the KV at 13 s [12-15 s] than for the MaB at 14.5 s [13-16 s], DB at 14.5 s [13-16] and MiB at 16 s [14-19] (p < 0.001). In DA, the KV also shortened TTV to 14 s [13-16], whereas TTV was 23 s with the MaB [20-26], 19 s with the DB [16-21], and 27 s with the MiB [22-31] (p < 0.001). There were no differences in first-pass intubation success rates (FPAs) between hyperangulated blades and direct laryngoscopes in NA. In DA, the hyperangulated blades enabled 92 (DB) to 100% (KV) FPAs compared with 65 (MiB) to 76% (MaB) for conventional laryngoscopy (p < 0.001). CONCLUSION: Video laryngoscopes with hyperangulated blades were associated with shorter TTV in normal and difficult infant airway situations. The higher FPAs of hyperangulated blades in DA may avoid desaturations and decrease adverse events in pediatric airway management.

A Randomized Controlled Trial Comparing the Utility of Lighted Stylet and GlideScope for Double-Lumen Endobronchial Intubation.

OBJECTIVE: To compare GlideScope and lighted stylet for double-lumen endobronchial tube (DLT) intubation in terms of intubation time, success rate of first attempt at intubation, difficulty in DLT advancement toward the glottis, and postoperative sore throat and hoarseness. DESIGN: A prospective, randomized study. SETTING: Medical center governed by a university hostpial. PARTICIPANTS: Sixty-two adult patients undergoing thoracic surgery using DLT intubation. INTERVENTION: After the induction of anesthesia, DLT intubation was performed using GlideScope (n = 32) or lighted stylet (n = 32). MEASUREMENTS AND MAIN RESULTS: Number of intubation attempts, difficulty of DLT advancement toward the glottis, time taken for DLT intubation, and the incidence and severity of postoperative sore throat and hoarseness at 1 and 24 hours after surgery were evaluated. Time taken for DLT intubation was shorter in the lighted stylet group compared with the GlideScope group (30 [28-32] s v 45 [38-53] s, median [interquartile range], respectively; p < 0.001). DLT advancement toward the glottis was easier in the lighted stylet group than in the GlideScope group (p = 0.016). The success rate of DLT intubation in the first attempt (96.9% v 90.6% for lighted stylet and GlideScope, respectively), and the incidence and severity of postoperative sore throat and hoarseness were not different between the two groups. CONCLUSIONS: The use of lighted stylet allowed easier advancement of the DLT toward the glottis in the oropharyngeal space and reduced time for achieving DLT intubation compared with GlideScope.

IONM and minimally invasive videoassisted thyroidectomy.

BACKGROUND: We know that benefits of MIVAT are related to a better cosmetic result and lower post-operative pain in comparison to CT. The incidence of nerve cold palsy is related to a correct identification of the recurrent laringeal nerve (RLN) as standard procedure in thyroid surgery. From September 2014 we have introduced the use of intraoperative neural monitoring(I-IONM) in all thyroidectomies in the Unit of General Surgery of University Hospital of Parma, including in MIVAT. PATIENTS AND METHODS: We have considered all patients treated from September 2014 to September 2017 for thyroid diseases using MIVAT and IONM. Intermittent neuromonitoring with NIM-3.0 equipment (Medtronic, Jacksonville, FL, USA) was used during all operations. We have recorded all data about age, sex, diagnosis, surgical time, i-IONM signal, postoperative pain, postoperative hypocalcemia after 24 hours, haematoma and vocal cord palsy. The mean hospital stay was collected from surgical procedure to hospital discharge. We have considered vocal dysfunctions that persist six months after surgery as permanent. RESULTS: From September 2014 to September 2017 we treated consecutively with both MIVAT and i-IONM 100 patients. Considering the extent of surgery, 26 pts underwent to hemithyroidectomy and 74 pts to total thyroidectomy. The mean surgical time was 61.8 minutes. In 7 cases the patients were affected by preoperative clinical dysphonia. Using I-IONM during thyroidectomy, we recorded in 5 cases (5%) a loss of signal; in two cases (2%) we experienced a temporary postoperative vocal cord palsy. DISCUSSION: In our experience the use of IONM has improved the safety during thyroidectomy because precision that can be achieved by endoscopic procedures is further improved by complementary use of IONM. The costs associated to a potential reduction of medical litigation have not been investigated.

Prospective clinical study of endoscopic ultrasound-guided biliary drainage using novel balloon catheter (with video).

BACKGROUND AND AIM: On endoscopic ultrasound (EUS)-guided biliary drainage, fistula dilation may be accompanied by leakage of bile juice, potentially along with bacteria or air, so this procedure should be kept as simple and short as possible. To date, various techniques to dilate the fistula have been reported. This prospective, single-center, single-arm study evaluated the technical feasibility and safety of EUS-guided biliary drainage using novel balloon catheters. METHODS: Tip of novel balloon catheters is only 3 Fr and tapered, and the catheters also show favorable push ability. First, biliary tract was punctured using 19-G fine needle aspiration needle. Next, we immediately inserted the novel balloon catheter, and the biliary tract and intestinal wall were dilated. Then, we performed metallic stent placement without any dilation fistula. RESULTS: A total of 20 patients were prospectively enrolled in this study. Technical success rate was 100%. Eleven patients underwent EUS-guided choledochoduodenostomy, and nine patients underwent EUS-guided hepaticogastrostomy. Median procedure time was only 11 min (range, 8-16 min) for EUS-guided choledochoduodenostomy and 14 min (range, 11-18 min) for EUS-guided hepaticogastrostomy. Adverse events were seen in 15% (3/20; self-limited abdominal pain n = 2, peritonitis n = 1). CONCLUSIONS: Although additional cases and a randomized controlled comparison with another dilation technique such as the graded dilation or cystotome dilation technique are needed, our technique may be helpful for EUS-guided biliary drainage.