Use of topical methylene blue to image nuclear morphometry with a low-cost scanning darkfield microendoscope.

Significance: Fiber-optic microendoscopy is a promising approach to noninvasively visualize epithelial nuclear morphometry for early cancer and precancer detection. However, the broader clinical application of this approach is limited by a lack of topical contrast agents available for in vivo use. Aim: The aim of this study was to evaluate the ability to image nuclear morphometry in vivo with a novel fiber-optic microendoscope used together with topical application of methylene blue (MB), a dye with FDA approval for use in chromoendoscopy in the gastrointestinal tract. Approach: The low-cost, high-resolution microendoscope implements scanning darkfield imaging without complex optomechanical components by leveraging programmable illumination and the rolling shutter of the image sensor. We validate the integration of our system and MB staining for visualizing epithelial cell nuclei by performing ex vivo imaging on fresh animal specimens and in vivo imaging on healthy volunteers. Results: The results indicate that scanning darkfield imaging significantly reduces specular reflection and resolves epithelial nuclei with enhanced image contrast and spatial resolution compared to non-scanning widefield imaging. The image quality of darkfield images with MB staining is comparable to that of fluorescence images with proflavine staining. Conclusions: Our approach enables real-time microscopic evaluation of nuclear patterns and has the potential to be a powerful noninvasive tool for early cancer detection.

Endoscopy mitigation strategy with telemedicine and low-cost device use for COVID-19 prevention: A fourth-level Colombian center experience.

BACKGROUND AND STUDY AIMS: The COVID-19 outbreak has reorganized surgical team conditions regarding endoscopy. The number of interventions has been reduced, the number of healthcare professionals must be limited, and both the patients and physicians are more protected than ever. PATIENTS AND METHODS: In the highest peak of contagion in Colombia, endoscopy, colonoscopy, and esophagogastroduodenoscopy were performed using a low-cost disposable device. A total of 1388 procedures were performed. Every patient was assessed for symptoms via a telephone call, at the health center, and after the procedure, following specific attention routes. RESULTS: After procedure follow-up, no positive cases of COVID-19 were noted. CONCLUSION: The methodology reduced the risk of infection during the COVID-19 pandemic.

Learning From Those who Learned: A Survey of Fellowship Trained HoLEP Surgeons and Their Current Practice Patterns.

OBJECTIVE: To gain insight from the experience of learning Holmium laser enucleation of the prostate (HoLEP), teaching HoLEP, and the current HoLEP practice patterns of fellowship-trained endourologists. METHODS: Surveys were electronically distributed to United States (U.S.) practicing urologists who completed American Endourology fellowships (that included HoLEP) within the past 6 years. Questions focused on HoLEP training and current practice patterns. RESULTS: As of September 2019, 12% (6/49) of U.S. endourology fellowships reported including HoLEP as a component of training. With a 73% response rate (16 of 22), 81% participated in over 20 cases during training, while 50% participated in over 50. A total of 25% independently completed over 50 cases from start to finish. At training completion, most (80%) felt comfortable/somewhat comfortable completing an entire HoLEP independently and managing post-op complications. Seventy-five percent practice HoLEP currently, and 25% teach to trainees. When asked "What is most challenging about HoLEP in current practice?" common responses were: efficiency/profitability concerns, poor reimbursement, educating OR/hospital staff, establishing case volume, minimizing sphincter trauma, and large glands (>200gm). CONCLUSION: With diverse exposure in fellowship, most incorporate HoLEP into their practice after training. Aspects of the procedure remain challenging after several years of experience. Profitability/reimbursement concerns should be further explored to increase HoLEP adoption.

Cost-effectiveness of palliative emergent surgery versus endoscopic stenting for acute malignant colonic obstruction.

BACKGROUND: Endoscopic stenting has demonstrated value over emergent surgery as a palliative intervention for patients with acute large bowel obstruction due to advanced colorectal cancer. However, concerns regarding high reintervention rates and the risk of perforation have brought into question its cost-effectiveness. METHODS: A decision tree analysis was performed to analyze costs and survival in patients with unresectable or metastatic colorectal cancer who present with acute large bowel obstruction. The model was designed with two treatment arms: self-expanding metallic stent (SEMS) placement and emergent surgery. Costs were derived from medicare reimbursement rates (US$), while effectiveness was represented by quality-adjusted life years (QALYs). The primary outcome measure was the incremental cost-effectiveness ratio (ICER). The model was tested for validation using one-way, two-way, and probabilistic sensitivity analyses. RESULTS: Endoscopic stenting resulted in an average cost of $43,798.06 and 0.68 QALYs. Emergent surgery cost $5865.30 more, while only yielding 0.58 QALYs. This resulted in an ICER of - $58,653.00, indicating that SEMS placement is the dominant strategy. One-way and two-way sensitivity analyses demonstrated that emergent surgery would require an improved survival rate in comparison to endoscopic stenting to become the favored treatment modality. In 100,000 probabilistic simulations, endoscopic stenting was favored 96.3% of the time. CONCLUSIONS: In patients with acute colonic obstruction in the presence of unresectable or metastatic disease, endoscopic stenting is a more cost-effective palliative intervention than emergent surgery. This recommendation would favor surgery over SEMS placement with improved surgical survival, or if the majority of patients undergoing stenting required reintervention.

Comparative study of endoscopic and microscopic tympanoplasty performed by a single experienced surgeon.

PURPOSE: The use of endoscopes in otologic procedures has been increasing worldwide. This study aimed to compare the efficacy of microscopic tympanoplasty (MT) and endoscopic tympanoplasty (ET) for tympanic membrane and middle ear surgery. MATERIALS AND METHODS: We retrospectively analyzed 81 patients who underwent MT (n = 44) and ET (n = 37) for chronic otitis media with tympanic membrane perforation performed by a single surgeon between January 2013 and September 2019. The hearing outcomes, graft success rate, complications, operation time and hospital stay, and cost-effectiveness were recorded and compared between groups. Hearing outcomes were determined by pure tone audiometry. Cost-effectiveness was determined by the operation cost and total cost. RESULTS: There was no significant difference between the MT and ET groups regarding demographic characteristics, with the exception of the male:female ratio. There was no significant difference in the pre- and postoperative air conduction, bone conduction thresholds, and air-bone gap values between the two groups, but a significant audiologic improvement was observed in both groups (p < 0.05). In terms of recurrence of tympanic membrane perforation, postoperative otorrhea, and discomfort symptoms, there was no significant difference between groups (p > 0.05). The operation time and hospital stay were shorter in the ET group than in the MT group (p < 0.05). There were no significant differences in operation cost between the two groups (p > 0.05), but the total cost was significantly lower in the ET group than the MT group (p < 0.05). CONCLUSION: ET is as safe and medically efficacious as conventional MT, shortens the operation time and hospital stay, and is cost-effective.

Early Career Challenges in Setting Up an Endoscopic Spine Surgery Practice.

After the completion of an endoscopic spinal surgery fellowship, the next challenge for the newly minted consultant is to set up a viable and sustainable endoscopic practice. A successful practice of endoscopic spine surgery is dependent on several factors, such as anesthetic support; surgical expertise; support for provision and maintenance of endoscopic equipment; cost of equipment; administrative and nursing support; postoperative care services to optimize patients' outcome and satisfaction; patients' ideas, concerns, and expectations, as well as continuing medical education. In this article, a perspective is given on the early career challenges that a fellowship-trained endoscopic surgeon may encounter in the period leading to first successful endoscopic spinal surgery.

En bloc MoLEP (MOSES HoLEP) with early apical dissection and preservation of the sphincter's mucosa. Surgical technique and technology developments that allow a new paradigm of endoscopic prostate enucleation. / MoLEP (MOSES HoLEP) en bloque con liberación apical precoz y preservación de la mucosa esfinteriana. Evolución de la técnica quirúrgica y la tecnológica que permiten un nuevo paradigma de enucleación endoscópica anatómica de próstata.

Endoscopic enucleation of the prostate was first described by Hiraoka in 1986, using a monopolar resectoscope. His contribution was largely ignored until Gilling and Fraundorfer published their three-lobe enucleation technique with the Holmium laser in 1998 ,that ended establishing itself as a reliable option for the treatment of HBP, backed by ample scientific evidence. Later on, enucleation performed with other lasers, as well as bipolar energy, have shown concordance in their clinical results. As a result, the term AEEP (anatomic endoscopic enucleation of the prostate) emerged to encompass all these techniques. During the last few years there have been significant advances in two areas: first, technology, with the development of pulse modulation for Holmium generators (MOSES) as well as high-speed morcellators. Second, the development of new surgical techniques that recognize the importance of the early release of the sphincter from the apex of the adenoma during the operation as well as the careful preservation of the external sphincter's mucosa, to avoid early stress incontinence. In this paper,we review the recent evolution of both technology and surgical technique. AEEP has been risen to a new level, reducing operative time significantly, usually under one hour, and radically reducing the incidence of early temporary stress incontinence, and maybe also facilitating the learning curve of AEEP.

La enucleación endoscópica de próstata fue descrita por primera vez por Hiraoka en 1986, usando un resector monopolar. Su aportación pasó desapercibida hasta que Gilling y Fraundorfer publicaron su técnica de enucleación en tres lóbulos con láser de Holmio en 1998, que se estableció como una opción de tratamiento de la obstrucción prostática benigna ampliamente respaldada por la evidencia científica. Posteriormentes e ha estudiado el uso de otros láseres así como de la energía bipolar para realizar enucleación  endoscópica y se ha observado una concordancia en los resultados de estas técnicas, independientemente de la fuente de energía utilizada, que ha conducido a englobarlas bajo el acrónimo EEAP (enucleación endoscópica anatómica de próstata). En los últimos años se han producido avances muy relevantes en dos ámbitos: Uno, el ámbito tecnológico, con el desarrollo de la tecnología de modulación del pulso del láser de Holmio (MOSES) y de los morceladores de alto rendimiento. Otro, el desarrollo de nuevas técnicas quirúrgicas, que reconocen la importancia de liberar precozmente el esfínter del ápex del adenoma en la intervención y de preservar escrupulosamente la mucosa del esfínter externo, para evitar la incontinencia urinaria precoz postoperatoria. En este artículo se revisa la evolución reciente de la tecnología y de la técnica quirúrgica que han elevado a la enucleación endoscópica de próstata a otro nivel, reduciendo significativamente el tiempo operatorio, normalmente inferior a una hora, disminuyendo radicalmente la incontinencia precoz postoperatoria y probablemente, facilitando el aprendizaje de la técnica.

Impacto de las nuevas tecnologías en la endoscopía diagnóstica y terapéutica / Impact of new technologies in diagnostic and therapeutic endoscopy

El desarrollo y aplicación de la tecnología en la medicina ha creado dilemas éticos para los galenos, al tener que definir hasta qué punto es ético someter a un paciente a una técnica quirúrgica o un procedimiento endoscópico que presente una alta incidencia de complicaciones cuando pueden existir otros con mejores resultados. En este trabajo se analizan los efectos beneficiosos y nocivos de los adelantes tecnológicos para las ciencias médicas, de ahí que el objetivo fue identificar la influencia de la revolución científico técnica en el desarrollo de la cirugía endoscópica endoluminal. Se analiza cómo el médico debe mantener un equilibrio entre la ciencia y la ética, que le permita, además de ser acertado en el diagnóstico y el tratamiento, ser más humano y comprensivo con sus pacientes. Se concluye que la revolución científica técnica de hoy, que integra conocimientos y experiencia, ha dado solidez al cómo hacer y por qué. Sin embargo, los recursos en ocasiones pueden ser limitados. Ello significa que no siempre se puede realizar todo lo que es técnicamente factible. Las buenas prácticas médicas deben acompañar a todos los galenos a sabiendas de que es la vida de un ser humano que ha confiado en sus capacidades intelectuales y buen poder de decisión(AU)

The development and application of technology in medicine has created ethical dilemmas for physicians to define to what extent it is ethical to subject a patient to a surgical technique or an endoscopic procedure that presents a high incidence of complications when there may be others with best results. In this work the beneficial and harmful effects of the technological advancements for the Medical Sciences are analyzed, for that reason the objective of the same one was to identify the influence of the Technical Scientific Revolution in the development of the Endoluminal Endoscopic Surgery. It is analyzed how the doctor must maintain a balance between science and ethics, which allows him, in addition to being successful in diagnosis and treatment, to be more human and understanding with his patients. It is concluded that the technical scientific revolution of today, which integrates knowledge and experience, has given solidity to how to do and why. However, resources can sometimes be limited. This means that everything that is technically feasible cannot always be done. Good medical practices should accompany all physicians knowing that it is the life of a human being who has relied on their intellectual abilities and good decision-making power(AU)

A handheld flexible manipulator system for frontal sinus surgery.

PURPOSE: Draf drainage is the standard treatment procedure for frontal sinus diseases. In this procedure, rigid angled endoscopes and rigid curved instruments are used. However, laterally located pathologies in the frontal sinus cannot be reached with rigid instrumentation. In order to assist surgeons with such complicated cases, we propose a novel handheld flexible manipulator system. METHODS: A cross section of 3 mm × 4.6 mm enables transnasal guiding of a flexible endoscope with 1.4 mm diameter and a standard flexible surgical instrument with up to 1.8 mm diameter into the frontal sinus with increased reachability. The developed system consists of an electrical discharge-machined flexure hinge-based nitinol manipulator arm and a purely mechanical handheld control unit. The corresponding control unit enables upward and left-right bending of the manipulator arm, translation, rolling, actuation and also quick exchange of the surgical instrument. In order to verify the fulfillment of performance requirements, tests regarding reachability and payload capacity were conducted. RESULTS: Reachability tests showed that the manipulator arm can be inserted into the frontal sinus and reach its lateral regions following a Draf IIa procedure. The system can exert forces of at least 2 N in the vertical direction and 1 N in the lateral direction which is sufficient for manipulation of frontal sinus pathologies. CONCLUSION: Considering the fact that the anatomical requirements of the frontal sinus are not addressed satisfactorily in the development of prospective flexible instruments, the proposed system shows great potential in terms of therapeutic use owing to its small cross section and dexterity.

A Novel Robotic Endoscopic Device Used for Operative Hysteroscopy.

To trial the use of a novel endoscopic robot that functions using concentric tube robots, enabling 2-handed surgery in small spaces, in a bioengineering laboratory. This was a feasibility study of the endoscopic robot for hysteroscopic applications, including removal of a simulated endometrial polyp. The endoscopic robot was successfully used to resect a simulated endometrial polyp from a porcine uterine tissue model in a fluid environment. The potential advantages of this platform to the surgeon may include improved exposure, finer dissection capability, and use of a 2-handed surgical technique. Further study regarding the safe, efficient, and cost-effective use of the endoscopic robot in gynecology is needed.

Comparison of adenoid assessment by flexible endoscopy and mirror exam.

OBJECTIVE: Assessment of adenoid hypertrophy can be completed through various methods including flexible endoscopy and intraoperative mirror exam. The objective of this study was to compare the effect of adenoid size on the accuracy of these techniques. METHODS: Patients younger than 18 years old who underwent adenoidectomy at Boston Medical Center from October 2012 to December 2018 and had documented preoperative and intraoperative adenoid sizes were included. Cases were identified through Current Procedural Terminology (CPT) codes 42,830 and 42,831 with exclusion of CPT 42820 for tonsillectomy and adenoidectomy. Patients who had less obstruction (75% or less obstruction) and more obstruction (>75%) were compared using Chi-square analysis and t-tests. RESULTS: Of 276 patients who underwent adenoidectomy from October 2012 to December 2018, 84 patients had adenoid size determined both preoperatively by flexible endoscopy and intraoperatively. Thirty-eight (45.2%) patients had intraoperative adenoids that were characterized as less obstructive hypertrophy and 46 (54.8%) had intraoperative adenoids that were characterized as more obstructive hypertrophy. In patients with less obstruction, the mean preoperative adenoid obstruction size of 72% was significantly higher than the mean intraoperative adenoid obstruction size of 63% (p = 0.0212). However, in patients with more obstruction, the mean preoperative adenoid size of 86% was not significantly different from the mean intraoperative adenoid size of 90% (p = 0.1237). CONCLUSION: Adenoid assessment by flexible endoscopy and intraoperative mirror exam may not correlate as closely in patients who have less obstructive hypertrophy.

Assessment of Factors Associated With Internal Carotid Injury in Expanded Endoscopic Endonasal Skull Base Surgery.

Importance: Injury to the internal carotid artery (ICA) during endoscopic endonasal skull base surgery does not typically occur as an isolated circumstance but often is the result of multiple factors. Objective: To assess the factors associated with ICA injury in an effort to reduce its occurrence. Design, Setting, and Participants: This quality improvement study used a multicenter root cause analysis of ICA injuries sustained during endoscopic endonasal skull base surgery performed at 11 tertiary care centers across 4 continents (North America, South America, Europe, and Asia) from January 1, 1993, to December 31, 2018. A fishbone model was built to facilitate the root cause analysis. Patients who underwent an expanded endoscopic endonasal approach that carried a substantial potential risk of an ICA injury were included in the analysis. A questionnaire was completed by surgeons at the centers to assess relevant human, patient, process, technique, instrument, and environmental factors associated with the injury. Main Outcomes and Measures: Root cause analysis of demographic, human, patient, process, technique, instrument, and environmental factors as well as mortality and morbidity data. Results: Twenty-eight cases of ICA injury occurred during 7160 expanded endoscopic endonasal approach procedures (incidence of 0.4%). The mean age of the patients was 49 years, with a female to male predominance ratio of 1.8:1 (18 women to 10 men). Anatomical (23 [82%]), pathological (15 [54%]), and surgical resection (26 [93%]) factors were most frequently reported. The surgeon's mental or physical well-being was reported as inadequate in 4 cases (14%). Suboptimal imaging was reported in 6 cases (21%). The surgeon's experience level was not associated with ICA injury. The ICA injury was associated with use of powered or sharp instruments in 20 cases (71%), and use of new instruments or technology in 7 cases (25%). Two patients (7%) died in the operating room, and 3 (11%) were alive with neurological deficits. Overall, patient-related factors were the most frequently reported risk factors (in 27 of 28 cases [96%]). Factors associated with ICA injury catalyzed a list of preventive recommendations. Conclusions and Relevance: This study found that human factors were associated with intraoperative ICA injuries; however, they were usually accompanied by other deficiencies. These findings suggest that identifying risk factors is crucial for preventing such injuries. Preoperative planning and minimizing the potential for ICA injury also appear to be essential.

Operating Costs of Full-endoscopic Lumbar Spine Surgery in Japan.

For full-endoscopic lumbar discectomy, operating costs are also important because expensive equipment are necessary. We surveyed the operating costs of surgical equipment necessary for full-endoscopic surgery together with surgical procedure reimbursement fees. A total of 295 cases of full-endoscopic surgery via a transforaminal approach were retrospectively analyzed. We calculated the frequency of damage and the unit purchase price of devices such as endoscopes, and surgical instruments such as grasping forceps for nucleotomy, high-speed drill bar, and bipolar forceps, and examined the operating costs in Japanese yen against the procedure fee per case. Endoscope breakage occurred seven times, and a payment of ¥760,000 was necessary for trade-in and purchase of a new endoscope. The total breakage number of grasping forceps was 58, and the purchase price per unit was ¥116,000. Therefore, a total of ¥12,020,000 was required for the 295 cases, and the calculated operating cost that accompanies equipment breakage was ¥40,000 per case. In addition, about ¥118,000 was required for disposable bipolar forceps and high-speed drill bar to be used intraoperatively for each case. Thus, for one case it is calculated that total ¥158,000 is utilized for equipment from the surgical reimbursement fee per case specified by the Japanese Ministry of Health being ¥303,900. Minimally invasive procedures provide great benefit to patients; however, the eventual contribution to hospital profits is small and may not be sufficient. To resolve this issue, the cost of surgical equipment should be lowered and/or the surgical reimbursement fee of the full-endoscopic surgery should be raised.

Low-Computational Cost Stitching Method in a Three-Eyed Endoscope.

Aortic valve replacement is the only definitive treatment for aortic stenosis, a highly prevalent condition in elderly population. Minimally invasive surgery brought numerous benefits to this intervention, and robotics recently provided additional improvements in terms of telemanipulation, motion scaling, and smaller incisions. Difficulties in obtaining a clear and wide field of vision is a major challenge in minimally invasive aortic valve surgery: surgeon orientates with difficulty because of lack of direct view and limited spaces. This work focuses on the development of a computer vision methodology, for a three-eyed endoscopic vision system, to ease minimally invasive instrument guidance during aortic valve surgery. Specifically, it presents an efficient image stitching method to improve spatial awareness and overcome the orientation problems which arise when cameras are decentralized with respect to the main axis of the aorta and are nonparallel oriented. The proposed approach was tested for the navigation of an innovative robotic system for minimally invasive valve surgery. Based on the specific geometry of the setup and the intrinsic parameters of the three cameras, we estimate the proper plane-induced homographic transformation that merges the views of the operatory site plane into a single stitched image. To evaluate the deviation from the image correct alignment, we performed quantitative tests by stitching a chessboard pattern. The tests showed a minimum error with respect to the image size of 0.46 ± 0.15% measured at the homography distance of 40 mm and a maximum error of 6.09 ± 0.23% at the maximum offset of 10 mm. Three experienced surgeons in aortic valve replacement by mini-sternotomy and mini-thoracotomy performed experimental tests based on the comparison of navigation and orientation capabilities in a silicone aorta with and without stitched image. The tests showed that the stitched image allows for good orientation and navigation within the aorta, and furthermore, it provides more safety while releasing the valve than driving from the three separate views. The average processing time for the stitching of three views into one image is 12.6 ms, proving that the method is not computationally expensive, thus leaving space for further real-time processing.

Low-risk assessment of swallowing impairment using flexible endoscopy without food or liquid.

OBJECTIVES/HYPOTHESIS: Flexible endoscopic evaluation of swallowing (FEES) is a relatively safe procedure to determine the safety of oral feeding, and consists of the introduction of food and liquid as well as a sensitivity test. However, the introduction of food and liquid can cause pneumonia or suffocation secondary to aspiration. To solve this problem, we investigated the possibility of performing FEES without introduction of food or liquid (referred to hereafter as FEES screen) to assess swallowing impairment severity. STUDY DESIGN: Retrospective study. METHODS: A total of 106 subjects with swallowing impairment underwent conventional FEES, and both their salivary pooling degree and larynx sensitivity were analyzed to detect swallowing impairment without the introduction of food or liquid. The subjects were divided into two groups: an undetectable swallowing impairment (USI) group and a detectable swallowing impairment (DSI) group. The general characteristics, functional impairment status, and clinical assistance requirements of the two groups were investigated and compared. RESULTS: The numbers of subjects in the USI and DSI groups were 64 and 42, respectively. The DSI group showed a significantly higher prevalence of aspiration during FEES, and their required levels of care were also significantly higher. Additionally, their levels of consciousness, oral intake ability, and activities of daily living were significantly low compared to the USI group. CONCLUSIONS: This study demonstrated the feasibility of FEES screen for assessment of swallowing impairment severity. Using our low-risk assessment, we were able to identify subjects with low oral intake ability as well as those who required intervention. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:2249-2252, 2019.

Utilization and reimbursements for sinus procedures: A five-year analysis.

OBJECTIVES/HYPOTHESIS: Balloon sinuplasty has become an increasingly popular option for patients undergoing surgical treatment of sinusitis. This study analyzes utilization and growth of these procedures across a large cohort of patients over a 5-year period. STUDY DESIGN: Retrospective data review. METHODS: This was a retrospective review of Medicare utilization and billing data. Utilization and payment values were obtained from Medicare claims data using Centers for Medicare and Medicaid Services datasets. All Medicare claims were analyzed from 2012 to 2016. Data were extracted for balloon sinuplasty and endoscopic sinus surgery claims. Procedure location, total submitted claims, charges, and payments were compared. RESULTS: From 2012 to 2016, the number of balloon procedures increased from 5,603 to 25,640. Traditional endoscopic sinus surgery procedures increased from 15,509 to 18,164. Aggregate Medicare payments to otolaryngologists for endoscopic sinus surgery have remained relatively stable, whereas there has been a 450% increase in total payments to providers of balloon sinuplasty. In 2016, total payments to providers of balloon procedures ($40.5 million) were substantially higher than payments to providers of non-balloon-based endoscopic sinus surgery ($4.7 million). The number of providers performing balloon procedures has increased 277% versus 17% for traditional sinus surgery. CONCLUSIONS: There has been a rapid expansion in the number of sinus procedures in the Medicare population from 2012 to 2016. Office-based balloon procedures account for the overwhelming majority of the increases in procedures and payments. Per procedure and aggregate payments are now higher for sinuplasty procedures than for traditional sinus surgery. LEVEL OF EVIDENCE: NA Laryngoscope, 129:2224-2229, 2019.

Endoscopic vacuum assisted wound closure (EVAC) device to treat esophageal and gastric leaks: assessing time to proficiency and cost.

BACKGROUND: Endoluminal vacuum therapy (EVAC) is an emerging procedure used to treat anastomotic leaks and/or perforations that would otherwise require surgery. The aim of this study was to determine time to proficiency in EVAC and the cost effectiveness of the procedure. METHODS: We retrospectively reviewed a prospectively maintained IRB approved database for all patients undergoing EVAC after esophageal and gastric complications between October 2013 and December 2017. Proficiency was determined by obtaining predicted estimates and analyzing the point at which average procedure time plateaued based on case volume. Total cost was calculated based on supplies and location where the procedure was performed. RESULTS: There were 50 patients (17 males, 33 female), with a mean age of 52.1 years. EVAC was placed in 23 (46%) patients with esophageal injuries and 28 (56%) with gastric injuries. Two advanced endoscopists performed all EVAC procedures in this study (1 surgeon, 1 gastroenterologist). The average procedure time for all patients was 43.5 min and the average wheel in/wheel out time for all patients was 75.6 min. Analysis of the trend based on average procedure times for EVAC revealed that proficiency was obtained after 10 cases. Total cost of the procedure is significantly lower in the GI lab compared to the operating room ($4528 vs. $11889). The majority of EVAC were performed in the GI lab (62%) compared to the operating room (38%). CONCLUSION: Successful outcomes in managing anastomotic leaks or intestinal perforations non-operatively has led to an increased interest in EVAC. For advanced endoscopists, time to proficiency is approximately 10 cases. Performing the procedure in the GI lab has a 2.5 reduction in total cost compared to the operating room.

Radiation-Associated Chronic Dysphagia Assessment by Flexible Endoscopic Evaluation of Swallowing (FEES) in Head and Neck Cancer Patients: Swallowing-Related Structures and Radiation Dose-Volume Effect.

PURPOSE: We aimed to restore dose-volume parameters of swallowing-related structures (SRSs) by evaluating long-term swallowing dysfunctions after radiotherapy (RT) in head and neck cancer patients (HNCPs). MATERIALS AND METHODS: Head and neck cancer patients whose pharyngeal region was involved in RT portal and treated with definitive RT/chemoradiotherapy (CRT) were included in the analyses. Patients underwent objective swallowing assessment by flexible endoscopic evaluation of swallowing (FEES). Volumes of SRSs that received 55 Gy (V55) (mean dose [Dmean]) were evaluated according to the dose-volume histograms of each patient. For every SRS, optimal dose-volume cut-off values were determined by receiver operating characteristic curve analysis. RESULTS: Fifty-five patients at a median 20 months (range, 12-26 months) after their treatments were evaluated. There was a strong negative correlation between FEES scores and dose-volume parameters of SRS ( r ⩽ -0.5, P < .0001). According to our results, middle pharyngeal constrictor (MPC) and inferior pharyngeal constrictor (IPC) had a Dmean > 57 Gy, base of tongue (BOT) Dmean > 50 Gy, supraglottic larynx (SGL) and glottic larynx (GL) Dmean > 55 Gy, and cervical esophagus (CE) Dmean > 45 Gy. MPC V55 > 70%, IPC V55 > 50%, BOT V55 > 65%, CE V55 > 40%, and SGL and GL V55 > 50% were significant predictors for dysphagia. CONCLUSION: It was found that dysphagia correlates strongly with dose-volume parameters of SRSs. IPC, SGL, and CE were found to be structures significantly associated with dysphagia.