PERORAL ENDOSCOPIC MYOTOMY FOR ACHALASIA: SAFETY PROFILE, COMPLICATIONS AND RESULTS OF 94 PATIENTS.

BACKGROUND: Achalasia is an esophageal motility disorder, with clinical presentation of dysphagia and regurgitation. This is a chronic condition with no cure. Current treatment options aim to reduce lower esophageal sphincter tone by pharmacological, endoscopic or surgical means, with the aim of improving patients' symptoms. Peroral endoscopic myotomy (POEM) is an alternative endoscopic surgery to Heller cardiomyotomy, in which the procedure is performed orally, by endoscopy, offering efficacy comparable to surgical myotomy, with relative ease and minimal invasion, without external incisions. AIMS: To study the safety of POEM by analyzing its results, adverse events and perioperative complications and the main ways to overcome them, in addition to evaluating the effectiveness of the procedure and the short-term postoperative quality of life. METHODS: A qualitative and quantitative, observational and cross-sectional study that analyzed patients who underwent the POEM in a reference center, from December 2016 to December 2022, maintaining the technical standard of pre-, peri- and postoperative protocol. RESULTS: A total of 94 patients were included in the study, and only three had postoperative complications. The average early postoperative Eckardt score was 0.93 and the late 1.40, with a mean improvement of 7.1 in early results and 6.63 in late results (p<0.05). CONCLUSIONS: POEM can be reproduced with an excellent safety profile, significant relief of symptoms and improvement in esophageal emptying, and in quality of life.

Successful Design and Implementation of a POEM Program for Achalasia in an Integrated Healthcare System.

BACKGROUND: Per Oral Endoscopic Myotomy (POEM) is a minimally invasive treatment for achalasia with results comparable to laparoscopic Heller myotomy (LHM). Studies have described the development of proficiency for endoscopists learning to perform POEM, and societies have defined educational and technical objectives for advanced endoscopy fellows in training. However, there is limited guidance on the organizational strategy and educational plan necessary to develop an achalasia service with POEM expertise. AIMS: We aim to outline the steps for design and implementation of a successful POEM program. METHODS: We reported our experience developing a multi-disciplinary clinical program for POEM and the steps taken to achieve procedural proficiency. We also reported our technical success (successful tunneling into the gastric cardia and myotomy of LES muscle fibers) and clinical success (post-procedure Eckardt score ≤ 3) at 3-6 months and 12 months post-procedure. Adverse events were classified per the ASGE lexicon for endoscopic adverse events. RESULTS: After creating a multi-disciplinary clinical program for achalasia and completing procedural proficiency for POEM, our technical success rate was 100% and clinical success rate 90% for the first 41 patients. One adverse event (2.4%) occurred, moderate in severity per the American Society of Gastrointestinal Endoscopy (ASGE) lexicon for adverse endoscopic events. CONCLUSION: In this study, we outlined the steps involved to establish a POEM service in a large integrated healthcare system. Prior competency in interventional endoscopy, procedural training models, POEM observation and education, proctorship, and interdisciplinary patient care are recommended.

Oxigenoterapia hiperbárica como tratamiento complementario en mucormicosis asociada a COVID-19: a propósito de dos casos / Hyperbaric oxygen therapy as an adjunctive treatment for COVID-19-associated mucormycosis: a report of two cases

Reportamos los dos primeros casos, en Perú, sobre el uso del tratamiento con oxigeno hiperbárico coadyuvante (TOHC) en pacientes con mucormicosis asociado a COVID-19 (MAC). El primer caso es una mujer de 41 años, con dolor en hemicara y región palatina izquierdas con rinorrea purulenta de un mes de evolución. Al examen físico, solo evidencia fístula oroantral. El segundo caso se trata de un varón de 35 años, con disminución de agudeza visual izquierda y dolor palatino con fístula que drena secreción purulenta de cuatro meses de evolución. Ambos pacientes tienen el antecedente de diabetes, tuvieron COVID-19 moderado cuatro meses antes del ingreso, y recibieron corticoterapia por este diagnóstico. Ambos pacientes tuvieron una evaluación tomográfica que mostró compromiso del seno maxilar y tejido óseo circundante, con endoscopia nasal diagnóstica y terapéutica para desbridamiento. Se obtuvieron muestras compatibles con mucormicosis en estudio histológico. Los pacientes fueron tratados con limpieza quirúrgica y anfotericina B desoxicolato, sin embargo, presentaron evoluciones tórpidas. Por lo tanto, se adicionó la TOHC y mostraron una mejoría evidente tras cuatro semanas de tratamiento con controles subsiguientes sin presencia de mucormicosis. Resaltamos la evolución de estos pacientes con TOHC, en una enfermedad con importante morbimortalidad, que ha sido emergente durante la pandemia.

We present the first two cases reported in Peru of the use of adjuvant hyperbaric oxygen therapy (HBOT) in patients with COVID-19-associated mucormycosis (CAM). The first case is a 41-year-old woman, with pain in the left side of the face and palatine region with purulent rhinorrhea for a month. Only an oroantral fistula was found during physical examination. The second case is a 35-year-old male, with decreased left visual acuity and palatal pain with a fistula, draining purulent secretion for four months. Both patients have history of diabetes, had moderate COVID-19 four months prior to admission, and received corticosteroid therapy for this diagnosis. Tomographic evaluation of both patients showed involvement of the maxillary sinus and surrounding bone tissue; both received diagnostic and therapeutic nasal endoscopy for debridement. Histological analysis showed that the samples were compatible with mucormycosis. The patients underwent debridement and were treated with amphotericin B deoxycholate; however, they presented torpid evolution. Then, HBOT was added and the patients showed an evident improvement after four weeks of treatment with subsequent controls without the presence of mucormycosis. We highlight the favorable evolution of these patients while receiving HBOT as treatment for a disease with high morbimortality, which emerged during the pandemic.

Treatment with endoscopic transnasal resection of hypothalamic pilocytic astrocytomas: a single-center experience.

BACKGROUNDS: Pilocytic astrocytomas (PAs) are World Health Organization (WHO) grade I tumors, which are relatively common, and are benign lesions in children. PAs could originate from the cerebellum, optic pathways, and third ventricular/hypothalamic region. Traditional various transcranial routes are used for hypothalamic PAs (HPAs). However, there are few studies on hypothalamic PAs treated through the endoscopic endonasal approach (EEA). This study reports the preliminary experience of the investigators and results with HPAs via expanded EEAs. METHODS: All patients with HPAs, undergone EEA in our hospital from 2017 to 2019, were retrospectively reviewed. The demographic data, clinical symptoms, complications, skull base reconstruction, prognosis, and endocrinological data were all recorded and analyzed in detail. RESULTS: Finally, five female patients were enrolled. The average age of patients was 28.6 ± 14.0. All patients had complaints about their menstrual disorder. One patient had severe bilateral visual impairment. Furthermore, only one patient suffered from severe headache due to acute hydrocephalus, although there were four patients with headache or dizziness. Four cases achieved gross-total resection, and one patient achieved subtotal resection. Furthermore, there was visual improvement in one patient (case 5), and postoperative worsening of vision in one patient (case 4). However, only one patient had postoperative intracranial infection. None of the patients experienced a postoperative CSF leak, and in situ bone flap (ISBF) techniques were used for two cases for skull base repair. In particular, ISBF combined with free middle turbinate mucosal flap was used for case 5. After three years of follow-up, three patients are still alive, two patients had no neurological or visual symptoms, or tumor recurrence, and one patient had severe hypothalamic dysfunction. Unfortunately, one patient died of severe postoperative hypothalamus reaction, which presented with coma, high fever, diabetes insipidus, hypernatremia and intracranial infection. The other patient died of recurrent severe pancreatitis at one year after the operation. CONCLUSION: Although the data is still very limited and preliminary, EEA provides a direct approach to HPAs with acceptable prognosis in terms of tumor resection, endocrinological and visual outcomes. ISBF technique is safe and reliable for skull base reconstruction.

Comparison of Objective Intermediate-Term Outcomes Between per-Oral Endoscopic Myotomy and Laparoscopic Heller Myotomy Show Equivalence.

INTRODUCTION: The surgical gold standard for esophageal motility disorders is laparoscopic Heller myotomy (LHM). Per-oral endoscopic myotomy (POEM) is a less invasive flexible endoscopic alternative. We compare their intermediate-term outcomes. METHODS: Data were collected on consecutive LHM and POEM patients treated for esophageal motility disorders from January 2015 to December 2019. All patients were invited for a comprehensive workup between 6 and 12 months post-myotomy including symptom evaluation, pH testing off medications, manometry, and esophagogastroduodenoscopy (EGD). Primary outcomes include swallowing function and development of postoperative gastroesophageal reflux disease (GERD). RESULTS: There were 100 patients (46 LHM and 54 POEM). Patient demographics and presenting symptoms were comparable. Follow-up data were obtained from 49% of patients. Average length of follow-up for all patients was 10 months. Mean Eckardt scores for LHM decreased from 6.6 to 2.4 (P < .05) and from 7.06 to 2.2 for POEM (P < .05). Mean integrated relaxation pressure decreased from 22.8 preoperatively to 11 postoperatively in LHM patients and from 24.6 to 11.5 in POEM patients. POEM patients had a lower incidence of objective postoperative GERD with lower average DeMeester scores (20 vs 29.4) and a higher percentage of patients with a normal DeMeester score (47% vs 31%) compared to LHM patients. However, postoperative GERD health related quality of life scores (11.7 vs 14.1), the percent of patients on proton pump inhibitors (PPIs) (40% vs 53%), and frequency of grade C/D esophagitis (4.3% vs 5.6%) were lower in LHM patients. CONCLUSIONS: Intermediate-term symptom resolution and esophageal physiology are improved equally with both procedures. The development of postoperative GERD is equivalent.

Hypothalamic injury patterns after resection of craniopharyngiomas and correlation to tumor origin: A study based on endoscopic observation.

The precise understanding of hypothalamic injury (HI) patterns and their relationship with different craniopharyngioma (CP) classifications remains poorly addressed. Here, four HI patterns after CP resection based on endoscopic observation were introduced. A total of 131 CP cases treated with endoscopic endonasal approach (EEA) were reviewed retrospectively and divided into four HI patterns: no-HI, mild-HI, unilateral-HI and bilateral-HI, according to intraoperative findings. The outcomes were evaluated and compared between groups in terms of weight gain, endocrine status, electrolyte disturbance and neuropsychological function before and after surgery. A systematic correlation was found between CP origin and subsequent HI patterns. The majority of intrasellar and suprasellar stalk origins lead to a no-HI pattern, the central-type CP mainly develops a mild or bilateral HI pattern, and the majority of tumors with hypothalamic stalk origins result in unilateral HI and sometimes bilateral HI patterns. The proportion of tumors with a maximum diameter >3 cm in the no-HI group was higher than that in the mild-HI group, BMI and quality of life in the no-HI group showed better results than those in the other groups. The incidence of new-onset diabetes insipidus in the bilateral-HI group was significantly higher than that in the other groups. Memory difficulty was observed mainly in the unilateral-HI and bilateral-HI groups. However, the outcomes of electrolyte disturbance, sleep, and cognitive disorder in the unilateral-HI group were significantly better than those in the bilateral-HI group. This study suggests the possibility of using pre- and intraoperative observation of CP origin to predict four HI patterns and even subsequent outcomes after tumor removal.

Safety and Feasibility of Per-Oral Pyloromyotomy as Augmentative Therapy after Prior Gastric Electrical Stimulation for Gastroparesis.

BACKGROUND: For medically refractory diabetic or idiopathic gastroparesis, gastric electrical stimulation (GES) is an excellent option for symptom control; however, a small subset of patients may develop recurrent or persistent symptoms. Per-oral pyloromyotomy (POP, also described by some authors as gastric per-oral endoscopic myotomy or G-POEM) is an emerging therapy for medically refractory gastroparesis. This study investigated the safety and feasibility of POP after previous GES for recurrent or persistent gastroparesis. STUDY DESIGN: We retrospectively identified all patients undergoing POP between January 2016 and December 2017, with GES in situ. Patient characteristics, gastroparesis etiology, and procedural data were collected. Symptoms were assessed with the Gastroparesis Cardinal Symptom Index (GCSI) both before and 30 to 90 days after POP. Standard pre- and post-procedure 4-hour gastric emptying tests were obtained when available. RESULTS: There were 22 patients who met inclusion criteria (81.8% female, mean age 42.3 ± 12.4 years). Causes of gastroparesis were diabetes in 38.1%, and idiopathic in 61.9%. The average time since GES insertion was 3.45 years. Mean preoperative 4-hour gastric retention was 50.1%. Most POP procedures were performed in the operating room (90.9%), with mean operative time of 40 minutes and a 1.4-day length of stay. There were 4 readmissions within 30 days, but no POP-related complications. Overall, GCSI improved by an absolute reduction of 1.63 points (p = 0.002), with significant improvements in all sub-scores. Of 11 patients with post-procedural motility or emptying studies available, 7 were normal. CONCLUSIONS: Per-oral pyloromyotomy appears to be safe and feasible for patients with recurrent gastroparesis symptoms after GES. Both symptoms and motility significantly improved in the short-term. These data replicate similar data suggesting laparoscopic pyloroplasty as an effective augmentative therapy after GES, but may provide a less invasive option for patients.

Preservation of Hypothalamic Function with Endoscopic Endonasal Resection of Hypothalamus-Invaded Craniopharyngiomas.

OBJECTIVE: To analyze the preservation of hypothalamic function using the endoscopic endonasal approach (EEA) in a single-center clinical series of patients with hypothalamus-invaded craniopharyngioma (CP) and compare this series with reported cases by the open transcranial approach (TCA). METHODS: A retrospective review of hypothalamus-invaded CP surgical cases treated with EEA was performed. Hypothalamic damage was evaluated in terms of the body mass index (BMI), endocrine status, and quality of life before and after surgery. A review of the available literature reporting the use of EEA and TCA over the last decade was performed for comparison. RESULTS: In total, 63 cases amenable to EEA were investigated. The elevation in BMI was substantial and an increase in BMI greater than 9% was observed in 22 patients (34.92%). Most patients exhibited a BMI gain >9% within 3 months postoperatively. A total of 16 of the 19 patients who had normal anterior pituitary function preoperatively worsened after surgery. Of the 27 cases reporting preoperative partial hypopituitarism, 16 cases worsened postoperatively and 11 cases remained unchanged. All 9 cases with preoperative panhypopituitarism remained unchanged postoperatively. A total of 40 new cases developed diabetes insipidus, and 3 of the 10 patients with preoperative diabetes insipidus exhibited resolved at the latest follow-up. The quality of life showed no significant difference. CONCLUSIONS: EEA can achieve greater gross total resection than TCA when performed by an experienced surgeon. Combined with the reduced postoperative hypothalamic damage in our patients with only hypothalamus-invaded CP, especially the shortened time horizons of hypothalamic obesity development and reduced percentage of patients with obesity, the EEA technique should be a preferred alternative over TCA.

Pediatric pituitary adenomas.

BACKGROUND: Pediatric pituitary adenomas are a rare medical entity that makes up a small portion of intracranial tumors in children and adolescents. Although benign, the majority of these lesions are secreting functional tumors with the potential for physiological sequela that can profoundly affect a child's development. FOCUS OF REVIEW: In this review, we discuss the medical and surgical management of these tumors with a focus on clinical presentation, diagnostic identification, surgical approach, and associated adjuvant therapies. We will also discuss our current treatment paradigm using endoscopic, open, and combined approaches to treat these tumors. The management of pituitary tumors requires a multidisciplinary team of surgeons, endocrinologists, and neuroanesthesiologists as well as neurocritical care specialists to deliver comprehensive care.

Feasibility of transnasal flexible carbon dioxide laser surgery for laryngopharyngeal lesions.

OBJECTIVE: The fiber-guided carbon dioxide (CO2) laser is a useful device for laryngopharyngeal surgery. The flexible CO2 wave-guide laser has been developed and commercially available for several years. However, the transnasal use of CO2 flexible wave-guided laser surgery through the instrument channel of a flexible endoscope (CO2 TNFLS) is not permitted in Japan. This feasibility study aimed to assess the value and the safety of an in-office CO2 TNFLS procedure. METHODS: Patients with small laryngopharyngeal diseases were enrolled from June 2015. Eligible patients had indications with lesions generally localized superficial lesions such as the benign tumor, leukoplakia, and premalignant lesion-like carcinoma in situ (CIS). Patients were locally well anesthetized using xylocaine. After removing as much of the lesion(s) as possible with flexible forceps, the remainder of the lesions were evaporated using CO2 TNFLS through the instrument channel of a flexible endoscope under local anesthesia. RESULTS: Eighteen surgeries involving 13 patients, including 9 papilloma (7 recurrent respiratory papilloma [RRP]), 2 carcinoma in situ, 1 leukoplakia, and 1 large epiglottic cyst), were performed. Four patients with RRP required multiple surgeries. Except for 3 patients with RRP, all patients achieved disease control without additional intervention. All procedures were completed with no severe adverse events. CONCLUSION: Office-based CO2 TNFLS is safe and feasible for patients with laryngopharyngeal pathologies. It is especially valuable for RRP patients with small lesions to avoid surgery under general anesthesia.

Transoral robotic surgery versus upper airway stimulation in select obstructive sleep apnea patients.

OBJECTIVES: Transoral robotic surgery (TORS) has been used to treat obstructive sleep apnea (OSA) since 2009, with recent meta-analysis showing an average reduction of apnea-hypopnea index (AHI) from 44.3 to 17.0. In 2014, upper airway stimulation surgery (UAS) was approved for OSA treatment, with results showing an average AHI reduction from 32.0 to 15.3. Given there was a period when TORS was available and UAS was not, we looked at a subset of patients treated with TORS but who could have qualified for UAS and compared their outcomes to patients who received UAS. METHODS: This is a retrospective chart review comparing TORS to UAS in treatment of OSA performed by a single surgeon between 2011 and 2016. Inclusion criteria were a body mass index less than 35 and AHI between 20 and 65 consistent with criteria for UAS implantation. Patients who received TORS and met the inclusion criteria had their preoperative drug-induced sleep endoscopy recordings re-evaluated. Patients with anteroposterior retropalatal collapse that would have qualified them for UAS had their outcomes compared to patients who received UAS. RESULTS: Results between TORS and UAS showed an average AHI reduction of 12.7 and 33.3, respectively. Overall cure rate, defined as AHI < 5, was 10.0% and 70.3%, respectively. CONCLUSION: Results of this study indicate that, when met with criteria for both TORS and UAS, patients receiving UAS had greater improvement in several objective measures of OSA. Studies like this may help direct future treatment algorithms for surgical management of OSA. LEVEL OF EVIDENCE: 4 Laryngoscope, 129:256-258, 2019.

Efficacy of Laparoscopic Nissen Fundoplication vs Transoral Incisionless Fundoplication or Proton Pump Inhibitors in Patients With Gastroesophageal Reflux Disease: A Systematic Review and Network Meta-analysis.

BACKGROUND & AIMS: The effects of transoral incisionless fundoplication (TIF) and laparoscopic Nissen fundoplication (LNF) have been compared with those of proton pump inhibitors (PPIs) or a sham procedure in patients with gastroesophageal reflux disease (GERD), but there has been no direct comparison of TIF vs LNF. We performed a systematic review and network meta-analysis of randomized controlled trials to compare the relative efficacies of TIF vs LNF in patients with GERD. METHODS: We searched publication databases and conference abstracts through May 10, 2017 for randomized controlled trials that compared the efficacy of TIF or LNF with that of a sham procedure or PPIs in patients with GERD. We performed a network meta-analysis using Bayesian methods under random-effects multiple treatment comparisons. We assessed ranking probability by surface under the cumulative ranking curve. RESULTS: Our search identified 7 trials comprising 1128 patients. Surface under the cumulative ranking curve ranking indicated TIF had highest probability of increasing patients' health-related quality of life (0.96), followed by LNF (0.66), a sham procedure (0.35), and PPIs (0.042). LNF had the highest probability of increasing percent time at pH <4 (0.99), followed by PPIs (0.64), TIF (0.32), and the sham procedure (0.05). LNF also had the highest probability of increasing LES pressure (0.78), followed by TIF (0.72) and PPIs (0.01). Patients who underwent the sham procedure had the highest probability for persistent esophagitis (0.74), followed by those receiving TIF (0.69), LNF (0.38), and PPIs (0.19). Meta-regression showed a shorter follow-up time as a significant confounder for the outcome of health-related quality of life in studies of TIF. CONCLUSIONS: In a systematic review and network meta-analysis of trials of patients with GERD, we found LNF to have the greatest ability to improve physiologic parameters of GERD, including increased LES pressure and decreased percent time pH <4. Although TIF produced the largest increase in health-related quality of life, this could be due to the shorter follow-up time of patients treated with TIF vs LNF or PPIs. TIF is a minimally invasive endoscopic procedure, yet based on evaluation of benefits vs risks, we do not recommend it as a long-term alternative to PPI or LNF treatment of GERD.

Transrectal rigid-hybrid NOTES cholecystectomy can be performed without peritoneal contamination: a controlled porcine survival study.

BACKGROUND AND STUDY AIMS: The risk of infectious complications due to peritoneal contamination is a major concern and inhibits the widespread use of transrectal NOTES. A standardized rectal washout with a reversible colon occlusion device in situ has previously shown potential in reducing peritoneal contamination. The aim of this study was to compare the peritoneal contamination rate and inflammatory reaction for transrectal cholecystectomy after ideal rectal preparation (trCCE) and standard laparoscopic cholecystectomy (lapCCE) in a porcine survival experiment. METHODS: Twenty pigs were randomized to trCCE (n = 10) or lapCCE (n = 10). Before trCCE, rectal washout was performed with saline solution. A colon occlusion device was then inserted and a second washout with povidone-iodine was performed. The perioperative course and the inflammatory reaction (leukocytes, C-reactive protein) were compared. At necropsy, 14 days after surgery the abdominal cavity was screened for infectious complications and peritoneal swabs were obtained for comparison of peritoneal contamination. RESULTS: Peritoneal contamination was lower after trCCE than after lapCCE (0/10 vs. 6/10; p = 0.003). No infectious complications were found at necropsy in either group and postoperative complications did not differ (p = 1.0). Immediately after the procedure, leukocytes were higher after lapCCE (17.0 ± 2.7 vs. 14.6 ± 2.3; p = 0.047). Leukocytes and C-reactive protein showed no difference in the further postoperative course. Intraoperative complications and total operation time (trCCE 114 ± 32 vs. 111 ± 27 min; p = 0.921) did not differ, but wound closure took longer for trCCE (31.5 ± 19 vs. 13 ± 5 min; p = 0.002). CONCLUSIONS: After standardized rectal washout with a colon occlusion device in situ, trCCE was associated without peritoneal contamination and without access-related infectious complications. Based on the findings of this study, a randomized controlled clinical study comparing clinical outcomes of trCCE with lapCCE should be conducted.

Palatoglossus coupling in selective upper airway stimulation.

OBJECTIVES/HYPOTHESIS: Selective upper airway stimulation (sUAS) of the hypoglossal nerve is a useful therapy to treat patients with obstructive sleep apnea. Is it known that multiple obstructions can be solved by this stimulation technique, even at the retropalatal region. The aim of this study was to verify the palatoglossus coupling at the soft palate during stimulation. STUDY DESIGN: Single-center, prospective clinical trail. METHODS: Twenty patients who received an sUAS implant from April 2015 to April 2016 were included. A drug-induced sedated endoscopy (DISE) was performed before surgery. Six to 12 months after activation of the system, patients' tongue motions were recorded, an awake transnasal endoscopy was performed with stimulation turned on, and a DISE with stimulation off and on was done. RESULTS: Patients with a bilateral protrusion of the tongue base showed a significantly increased opening at the retropalatal level compared to ipsilateral protrusions. Furthermore, patients with a clear activation of the geniohyoid muscle showed a better reduction in apnea-hypopnea index. CONCLUSIONS: A bilateral protrusion of the tongue base during sUAS seems to be accompanied with a better opening of the soft palate. This effect can be explained by the palatoglossal coupling, due to its linkage of the muscles within the soft palate to those of the lateral tongue body. LEVEL OF EVIDENCE: 4 Laryngoscope, 127:E378-E383, 2017.

Endonasal endoscopic reoperation for residual or recurrent craniopharyngiomas.

OBJECTIVE Craniopharyngiomas can be difficult to remove completely based on their intimate relationship with surrounding visual and endocrine structures. Reoperations are not uncommon but have been associated with higher rates of complications and lower extents of resection. So radiation is often offered as an alternative to reoperation. The endonasal endoscopic transsphenoidal approach has been used in recent years for craniopharyngiomas previously removed with craniotomy. The impact of this approach on reoperations has not been widely investigated. METHODS The authors reviewed a prospectively acquired database of endonasal endoscopic resections of craniopharyngiomas over 11 years at Weill Cornell Medical College, NewYork-Presbyterian Hospital, performed by the senior authors. Reoperations were separated from first operations. Pre- and postoperative visual and endocrine function, tumor size, body mass index (BMI), quality of life (QOL), extent of resection (EOR), impact of prior radiation, and complications were compared between groups. EOR was divided into gross-total resection (GTR, 100%), near-total resection (NTR, > 95%), and subtotal resection (STR, < 95%). Univariate and multivariate analyses were performed. RESULTS Of the total 57 endonasal surgical procedures, 22 (39%) were reoperations. First-time operations and reoperations did not differ in tumor volume, radiological configuration, or patients' BMI. Hypopituitarism and diabetes insipidus (DI) were more common before reoperations (82% and 55%, respectively) compared with first operations (60% and 8.6%, respectively; p < 0.001). For the 46 patients in whom GTR was intended, rates of GTR and GTR+NTR were not significantly different between first operations (90% and 97%, respectively) and reoperations (80% and 100%, respectively). For reoperations, prior radiation and larger tumor volume had lower rates of GTR. Vision improved equally in first operations (80%) compared with reoperations (73%). New anterior pituitary deficits were more common in first operations compared with reoperations (51% vs 23%, respectively; p = 0.08), while new DI was more common in reoperations compared with first-time operations (80% vs 47%, respectively; p = 0.08). Nonendocrine complications occurred in 2 (3.6%) first-time operations and no reoperations. Tumor regrowth occurred in 6 patients (11%) over a median follow-up of 46 months and was not different between first versus reoperations, but was associated with STR (33%) compared with GTR+NTR (4%; p = 0.02) and with not receiving radiation after STR (67% vs 22%; p = 0.08). The overall BMI increased significantly from 28.7 to 34.8 kg/m2 over 10 years. Six months after surgery, there was a significant improvement in QOL, which was similar between first-time operations and reoperations, and negatively correlated with STR. CONCLUSIONS Endonasal endoscopic transsphenoidal reoperation results in similar EOR, visual outcome, and improvement in QOL as first-time operations, with no significant increase in complications. EOR is more impacted by tumor volume and prior radiation. Reoperations should be offered to patients with recurrent craniopharyngiomas and may be preferable to radiation in patients in whom GTR or NTR can be achieved.

Artery of Percheron infarction after endoscopic pituitary surgery.

Infarction in the artery of Percheron territory is a rare phenomenon in which occlusion of an unpaired perforating artery arising from the P1 segment on one side results in infarcts in the bilateral paramedian thalami with or without midbrain infarcts. We describe the case of a 40-year-old male who developed this complication following re-exploratory trans-sphenoidal surgery for a pituitary adenoma. In this first report of its kind in endoscopic pituitary surgery, the pathogenesis and clinico-radiological features of this rare vascular event are discussed.

Avoiding allogenic blood transfusions in endoscopic angiofibroma surgery.

BACKGROUND: Surgical approaches for many tumours are often limited by blood loss, exposure and risk to vital anatomical structures. Therefore, the standard of care for certain skull base tumours has become endoscopic transnasal resection. Other surgical disciplines often use cell salvage techniques, but review of the otolaryngology literature revealed very few case reports. This study investigated the value and safety of salvage-type autologous blood transfusion during the endoscopic resection of juvenile nasopharyngeal angiofibromas (JNA). METHODS: JNA is a rare vascular nasal tumour and the study extended over a 3-year period to obtain adequate patient numbers. All patients undergoing endoscopic resection during this period were included in the population sample. Ten patients with JNA were identified and underwent embolization prior to the endoscopic resection. In all cases the intraoperative blood salvage apparatus was used. Close post-operative monitoring was performed. RESULTS: Homologous blood transfusion could be avoided in all cases. Postoperative monitoring revealed transient bacteraemia in two cases where the leukocyte filter was not used, but no evidence of septicaemia. CONCLUSIONS: Perioperative cell saver and autologous blood transfusion in endonasal JNA surgery is safe. Homologous blood transfusion can be avoided by using this technique. The use of cell salvage allows for single stage surgery without the need to abandon surgery due to excessive blood loss and its future use is promising.

Transoral incisionless fundoplication: current status.

PURPOSE OF REVIEW: Transoral incisionless fundoplication (TIF) performed with the EsophyX device (Redmond, Washington, USA) is a totally endoscopic procedure with the objectives to mechanically repair a defective gastroesophageal valve and to reduce small hiatal hernias. The recent publication of randomized controlled trials and long-term follow-up data offers the opportunity to reevaluate this treatment modality and its role in the management of patients with chronic gastroesophageal reflux disease (GERD). RECENT FINDINGS: Randomized controlled trials have confirmed the ability of TIF to eliminate troublesome GERD symptoms, heal esophagitis, and improve distal esophageal acid exposure in appropriately selected patient populations. These studies establish TIF's superiority to conventional medical therapy, especially in clinical scenarios where proton-pump inhibitors fail to provide complete symptom relief across the spectrum of classic and atypical GERD manifestations, including regurgitation and laryngopharyngeal reflux. Long-term data indicate sustained positive outcomes and durability up to 6 years after procedure. These results were achieved with a low rate of serious adverse events and usually without introducing troublesome dysphagia, gas bloat, or flatulence. SUMMARY: Based on the most recent data, TIF appears to be a valuable treatment alternative for the management of appropriately selected patients with moderate to severe chronic GERD symptoms.

Salivary gland function after sialendoscopy for treatment of chronic radioiodine-induced sialadenitis.

BACKGROUND: The purpose of this study was to determine whether sialendoscopy could ameliorate radioactive iodine-induced obstructive sialadenitis and restore the salivary gland dysfunction in recalcitrant radioactive iodine sialadenitis. METHODS: Ten patients with 15 parotid glands of chronic radioactive iodine sialadenitis who did not respond to medical treatment were enrolled in this prospective study. We assessed subjective symptom scores and evaluated the objective salivary gland functions before and 3 months after sialendoscopy. RESULTS: The post-sialendoscopic obstructive symptoms were significantly improved relative to pre-sialendoscopy (p = .009). Xerostomia-related symptom scores post-sialendoscopy did not differ significantly from the pre-sialendoscopy scores. Stimulated salivary flow rate post-sialendoscopy tended to increase relative to pre-sialendoscopy. No pre-sialendoscopic parameters associated with salivary uptake and secretion by salivary gland scintigraphy were significantly improved post-sialendoscopy. CONCLUSION: These results show that sialendoscopy can improve obstructive symptoms; however, it seems to have some limitations for relief of xerostomia and improvement of salivary gland dysfunctions in recalcitrant chronic radioactive iodine sialadenitis.