Survival Benefits and Disparities in Adjuvant Radiation Therapy for Patients with Pancreatic Cancer.

BACKGROUND: The effects of adjuvant radiation therapy on pancreatic cancer outcomes after resection are not well defined in the literature. METHODS: We abstracted data from the Surveillance, Epidemiology, and End Result (SEER) database to explore the impact of adjuvant radiation on cancer-specific survival in pancreatic cancer patients who received surgical resection. RESULTS: A total of 10,224 patients met our inclusion criteria with 6768 (66.2%) patients treated with surgery only and 3456 (33.8%) treated with surgery plus adjuvant radiation. Surgery followed by adjuvant radiation was associated with significantly improved survival (HR: 0.753, CI: 0.718-0.789, p<0.001). Additionally, female gender and married status were both independently associated with better survival (p<0.05), while advanced age, Caucasian race, higher TNM stage, and higher grade had worse survival outcomes (p<0.05) Asian and Spanish-Hispanic-Latino patients were less likely to receive adjuvant radiotherapy (p<0.05). CONCLUSION: Adjuvant radiation was associated with significantly improved survival after resection for pancreatic cancer. There are significant differences in the patient populations who receive adjuvant radiation.

Infantile haemangioendothelioma of the parotid gland: Case report and review of literature.

Haemangioendotheliomas (HAE), although rare but are the most common parotid gland tumours in children. We report a 4-month-old girl who presented with a progressively enlarging right sided facial swelling overlying the angle of the mandible. An Ultrasound of the lesion and a computed tomography (CT) scan of the head and neck was carried out which revealed a large lesion within the right parotid gland. CT scan further demonstrated a direct communication with the right external carotid artery and external jugular vein. Considering the clinical course and radiological findings, there was sufficient evidence to avoid any invasive testing. Due to the self-limiting nature of the disease, patient was managed expectantly.

Non O1, non O139 Vibrio cholerae bacteraemia in an infant; case report and literature review.

Non 01, Non O139 Vibrio cholerae bacteraemia is a rare but potentially fatal occurrence. There have been very few incidents of this infection from around the world. The treatment regimen of antibiotics also varies in literature. We present a case of bacteraemia caused by Non O1, Non O139 Vibrio cholerae along with associated risk factors, disease manifestations, laboratory diagnosis and treatment regimen. This serves to add additional information regarding symptoms and signs of this infection along with management of patient. Knowledge regarding this topic shall be highly useful to professionals if further cases are detected. In the discussion section, a review of literature of previous cases is also presented.

Lobectomy Demonstrates Superior Survival Than Segmentectomy for High-Grade Non-Small Cell Lung Cancer: The National Cancer Database Analysis.

BACKGROUND: Current recommendations for segmentectomy for non-small cell lung cancer (NSCLC) include size ≤2 cm, margins ≥ 2 cm, and no nodal involvement. This study further stratifies the selection criteria for segmentectomy using the National Cancer Database (NCDB). METHODS: The NCDB was queried for patients with high-grade (poorly/undifferentiated) T1a/b peripheral NSCLC (tumor size ≤2 cm), who underwent either lobectomy or segmentectomy. Patients with pathologic node-positive disease or who received neoadjuvant/adjuvant treatments were excluded. Propensity score analysis was used to adjust for differences in pretreatment characteristics. RESULTS: 11 091 patients were included with 10 413 patients (93.9%) treated with lobectomy and 678 patients (6.1%) underwent segmentectomy. In a propensity matched pair analysis of 1282 patients, lobectomy showed significantly improved median survival of 88.48 months vs 68.30 months for segmentectomy, P = .004. On multivariate Cox regression, lobectomy was associated with significantly improved survival (hazard ratio (HR): .81, 95% CI .72-.92, P = .001). Subgroup analysis of propensity score matched patients with a Charlson-Deyo comorbidity score (CDCC) of 0 also demonstrated a trend of improved survival with lobectomy. DISCUSSION: Lobectomy may confer significant survival advantage over segmentectomy for high-grade NSCLC (≤2 cm). More work is needed to further stratify various NSCLC histologies with their respective grades allowing more comprehensive selection criteria for segmentectomy.

Increasing Time-to-Treatment for Lung Cancer: Are We Going Backward?

BACKGROUND: Treatment delays in lung cancer care in the United States may be attributable to a diverse range of patient, provider, and institutional factors, the precise contributions of which remain unclear. The objective of our study was to use the National Cancer Database to investigate specific predictors of increased time-to-treatment initiation. METHODS: We identified 567 783 patients undergoing treatment for stage I to stage IV non-small cell lung cancer during 2010 to 2018. Time-to-treatment initiation was defined as the number of days from radiologic diagnosis to initiation of first treatment. We used mixed effect negative binomial regression to determine predictors of time-to-treatment initiation. RESULTS: We noted a steady rise in the overall mean time-to-treatment initiation interval from 33 days (2010) to 39 days (2018; P < .01). Black race, a later year at diagnosis, nonprivate insurance, and diagnosis and treatment at different facilities were independent predictors of increased time-to-treatment initiation, irrespective of disease stage. Compared with White race, Black race corresponded to a 15% to 20% increase in time-to-treatment initiation, depending on disease stage (P < .01). For stages I and II, radiation as first course of therapy corresponded with a 69% and 33% increase in time-to-treatment initiation, respectively, compared with surgery (P < .01). CONCLUSIONS: Lung cancer treatment initiation times have seen an upward trajectory in recent years. Black patients encountered significantly longer treatment initiation times, regardless of treatment modality or disease stage. Prolonged initiation times appear to contribute to existing health care disparities by disproportionately affecting medically underserved communities.

Anastomotic stenosis of bioengineered trachea grafts is driven by transforming growth factor ß1-induced signaling, proinflammatory macrophages, and delayed epithelialization.

Objective: Anastomotic stenosis caused by hypertrophic granulation tissue often develops in response to orthotopically implanted bioengineered tracheal grafts. To determine mechanisms responsible for the development and persistence of this granulation tissue, we looked for changes in gene expression from tissue specimens from the graft-native interface. Methods: RNA was isolated from paraffin-embedded tissue samples of the anastomotic sites of orthotopically implanted bioengineered tracheal grafts of 9 animals. Tissue samples were binned into 3 groups based on degree of stenosis: no stenosis (<5%), mild stenosis (25%-50%), and moderate and severe stenosis (≥75%). Sections of healthy trachea tissue were used as control. The expression levels of ∼200 genes related to wound healing, plus several endogenous controls, were measured with a pathway-focused predesigned primer array. Results: Expression of ARG2, IL4, RPL13 A, TGFBR3, and EGFR decreased, whereas expression of RUNX2 was increased in stenotic wounds compared with nonstenotic tissue. Based on the cell types present in the trachea and wound healing, this expression profile indicates a lack of M2 anti-inflammatory macrophages, absent epithelial cells, and transforming growth factor ß1-induced signaling. Conclusions: These findings represent a significant step for tracheal tissue engineering by identifying several key mechanisms present in stenotic granulation tissue. Further research must be conducted to determine what modifications of the graft substrate and which coadministered therapeutics can be used to prevent the development of hypertrophic granulation tissue.

Social determinants and facility type impact adherence to best practices in operable IIIAN2 lung cancer.

OBJECTIVES: We aimed to identify patient- and facility-specific predictors of collective adherence to 4 recommended best treatment practices in operable IIIAN2 non-small-cell lung cancer (NSCLC) and test the hypothesis that collective adherence is associated with superior survival. METHODS: We queried the National Cancer Database for clinical stage IIIAN2 NSCLC patients undergoing surgery during 2010-2015. The following best practices were examined: performance of an anatomic resection, performance of an R0 resection, examination of regional lymph nodes and administration of induction therapy. Multivariable regression models were fitted to identify independent predictors of guideline-concordance. RESULTS: We identified 7371 patients undergoing surgical resection for IIIAN2 lung cancer, of whom 90.8% underwent an anatomic resection, 88.2% received an R0 resection, 92.5% underwent a regional lymph node examination, 41.6% received induction therapy and 33.7% received all 4 best practices. Higher income, private insurance and treatment at an academic facility were independently associated with adherence to all 4 best practices (P < 0.01). A lower level of education and residence in a rural county were associated with a lack of adherence (P < 0.05). Adherence to all 4 practices correlated with improved survival (P < 0.01). CONCLUSIONS: National adherence to best treatment practices in operable IIIAN2 lung cancer was variable as evidenced by the majority of patients not receiving recommended induction therapy. Socioeconomic factors and facility type are important determinants of guideline-concordance. Future efforts to improve outcomes should take this into account since guideline concordance, in the form of collective adherence to all 4 best practices, was associated with improved survival.

Travelling to a High-Volume Center Confers Improved Survival in Stage I Non-small Cell Lung Cancer.

BACKGROUND: The association of hospital volume with outcomes has been assessed previously for patients with non-small cell lung cancer (NSCLC), but there are limited data on the cumulative effect of travel burden and hospital volume on treatment decisions and survival outcomes. We used the National Cancer Database to evaluate this relationship in early-stage NSCLC. METHODS: Outcomes of interest were compared between 2 propensity-matched groups with stage I NSCLC: patients in the bottom quartile of distance travelled who underwent surgery at low-volume centers (Local) and those in the top quartile of distance travelled who received surgery at high-volume centers (Distant). Outcomes included type of resection (anatomic or nonanatomic), time to resection (< or ≥8 weeks), number of lymph nodes examined (< or ≥10 nodes) and R0 resection. RESULTS: We identified 3325 Local patients who travelled 2.3 miles (interquartile range [IQR]: 1.4-3.3 miles) to centers that treated 10.5 (IQR: 6.5-16.5) stage I NSCLCs/year and 3361 Distant patients who travelled 40.0 miles (IQR: 29.1-63.4 miles) to centers treating 56.9 (IQR: 40.1-84.7) stage I NSCLCs/year. Local patients were less likely to receive surgery <8 weeks post-diagnosis, have ≥10 lymph nodes examined during surgery, and undergo an R0 resection (all P < .01). Distant patients had shorter hospital stays and superior median survival, both P < .01. CONCLUSIONS: Patients travelling longer distances to high-volume centers receive better and more timely surgical care, leading to shorter hospital stays and improved survival outcomes. Regionalization of lung cancer care by improving travel support to larger treatment facilities may help improve early-stage NSCLC outcomes.

Robotic-assisted thoracoscopic surgery demonstrates a lower rate of conversion to thoracotomy than video-assisted thoracoscopic surgery for complex lobectomies.

OBJECTIVES: Locally advanced lung cancers present a significant challenge to minimally invasive thoracic surgeons. An increasing number of centres have adopted robotic-assisted thoracoscopic surgeries for these complex operations. In this study, we compare surgical margins achieved, conversion rates to thoracotomy, perioperative mortality and 30-day readmission rates for robotic and video-assisted thoracoscopic surgery (VATS) lobectomy for locally advanced lung cancers. METHODS: Using the National Cancer Database, we identified patients with non-small-cell lung cancer who received neoadjuvant chemotherapy/radiotherapy, had clinical N1/N2 disease or in the absence of these 2 features had a tumour >5 cm treated with either robotic or VATS lobectomy between 2010 and 2016. Perioperative outcomes and conversion rates were compared between robotic and VATS lobectomy. RESULTS: A total of 9512 patients met our inclusion criteria with 2123 (22.3%) treated with robotic lobectomy and 7389 (77.7%) treated with VATS lobectomy. Comparable R0 resections, 30- and 90-day mortality and 30-day readmission rates were observed for robotic and VATS lobectomy while a higher rate of conversion to thoracotomy was observed for VATS (aOR = 1.99, 95% confidence interval = 1.65, 2.39, P < 0.001). CONCLUSIONS: Our analysis of the National Cancer Database suggests that robotic lobectomy for complex lung resections achieves similar perioperative outcomes and R0 resections as VATS lobectomy with the exception of a lower rate of conversion to thoracotomy.

Patient-specific 3-dimensional lung modelling: next-generation imaging helps guide precise surgical resection.

Recent strides have allowed the consolidation of routine imaging modalities with highly accurate reconstruction software to aid the operating surgeon generate patient-specific three-dimensional models. In this preliminary report, we describe our initial experience using a patient-specific reconstruction software to guide surgical resection for 2 patients with non-small-cell lung cancer. Digital imaging and communications in medicine data from patient chest CT scans was configured into IQQA BodyImaging Lung software to generate highly accurate maps of airways, vessels and segments as well as estimates of lung volumes. Models generated aided us in planning appropriate lung cancer resection procedures.

Successes and Failures in Tracheal Bioengineering: Lessons Learned.

BACKGROUND: Controversy in tracheal reconstruction using grafts and bioengineered constructs highlights the importance of animal studies before human application. Small animal models help to refine designs but do not adequately model sizes relevant to human anatomy. We have conducted extensive large animal studies and summarize our findings in 26 consecutive transplants. METHODS: We pooled 26 large animal studies together to investigate common elements related to successes and failures. In general the engineered tracheal graft consisted of a decellularized extracellular matrix surgical patch supported by a 3-dimensional-printed plastic polymer scaffold. Circumferential graft coverage ranged from 50% to 100%, spanning the length of 4 to 6 tracheal rings. Some grafts included embedded stem cells. Control grafts were fabricated without the support scaffold. At death grafts were harvested and examined grossly and through histology. RESULTS: The support scaffold prevented graft malacia and collapse. Luminal epithelialization was most extensive in grafts with smaller circumferential coverage. Smaller circumferential coverage was also associated with longest animal survival. Chondrogenesis was only observed in grafts with embedded stem cells. Survival time was shortest in 100% circumferential grafts. Granulation tissue was an issue for all graft designs. CONCLUSIONS: Large animal models capture challenges and complexities relevant to human anatomy. Development of granulation tissue remains a challenge, especially in circumferential grafts. Significant additional research is needed to investigate granulation tissue formation and to provide actionable insight into its management.

Novel composite trachea grafts using 3-dimensional printing.

Objective: Porcine-derived small intestine submucosa (SIS) extracellular matrix (ECM) surgical patches claim to have greater regenerative properties compared with dermal extracellular matrices. We hypothesized that using SIS-ECM in a bioengineered composite tracheal graft would allow better incorporation into the native tissue. Methods: Two types of size-matched polycaprolactone support scaffolds were designed: rigid and flexible. The SIS-ECM was wrapped around the polycaprolactone supports lining the inside and outside of the graft. The grafts were implanted in 4 Yorkshire pigs, replacing an ∼2 cm segment of native trachea. Airway patency was evaluated with computed tomography scans and explanted grafts were examined grossly and histologically. Results: All animals survived through the immediate postoperative period. Generally, extraluminal examination showed a smooth transition between native and graft without significant volumetric loss. Animals that received the flexible design survived ∼10 days longer than those that received the rigid design; however, severe perianastomotic intraluminal granulation tissue was observed. The rigid design had less significant intraluminal granulation tissue development at the distal anastomosis, but partial dehiscence had occurred at the proximal anastomosis interrupting graft incorporation. Conclusions: The generally good extraluminal graft incorporation in our composite tracheal graft highlights some increased regenerative capabilities of SIS-ECM. However, the presence of intraluminal granulation tissue indicates that its use as an off-the-shelf, unaltered substrate in an airway graft is still not ideal. Further research must be conducted to determine whether a modification of the substrate is possible to enhance luminal airway incorporation and to exert control over the mechanisms responsible for granulation tissue development.

Anatomic resection has superior long-term survival compared with wedge resection for second primary lung cancer after prior lobectomy.

OBJECTIVES: The extent of surgical resection for early-stage second primary lung cancer (SPLC) in patients with a previous lobectomy is unclear. We sought to compare anatomic lung resections (lobectomy and segmentectomy) and wedge resections for small peripheral SPLC using a population-based database. METHODS: The Surveillance, Epidemiology and End Results database was queried for all patients with ≤2 cm peripheral SPLC diagnosed between 2004 and 2015 who underwent prior lobectomy for the first primary and surgical resection only for the SPLC. American College of Chest Physicians guidelines were used to classify SPLC. Kaplan-Meier analysis and multivariable Cox regression were used to compare overall survival. RESULTS: A total of 356 patients met the inclusion criteria with 203 (57%) treated with wedge resection and 153 (43%) treated with anatomic resection. Significantly better median survival was observed with anatomic resection than with wedge resection using a Kaplan-Meier analysis (124 vs 63 months; P < 0.001). With multivariable Cox regression, improved long-term survival was observed for anatomic resection (hazard ratio: 0.44, confidence interval: 0.27-0.70; P = 0.001). Improvement in survival was demonstrated with wedge resection when lymph node sampling was done. Lastly, we calculated the average treatment effect on the treated with inverse probability weighting for a subgroup of patients and found that those with wedge resection and lymph node sampling had shorter long-term survival times. CONCLUSIONS: Anatomic resections may provide better long-term survival than wedge resections for patients with early-stage peripheral SPLC after prior lobectomy. Significant improvement in survival was observed with wedge resection for SPLC when adequate lymph node dissection was performed.

Use of Platelet-Rich Plasma in Treating Low Back Pain: A Review of the Current Literature.

Low back pain (LBP) is a common problem encountered by physicians. It is a considerable cause of morbidity and socioeconomic loss and is one of the most expensive musculoskeletal disorders. Conventional treatments include bed rest, analgesics, therapeutic exercises, lumbar or caudal epidural corticosteroids, and surgery. Several new biological therapies are being investigated for use in LBP and one of these is platelet-rich plasma (PRP). In this article, we summarize the current literature published on PRP concerning its composition, classification, and application in LBP. We believe our review will prove useful to clinicians and academics alike, interested in new developing therapies for LBP.

Invasive thymoma - Which patients benefit from post-operative radiotherapy?

BACKGROUND: The aim of this study is to identify patients with thymoma who should receive post-operative radiotherapy. METHODS: The Surveillance, Epidemiology, and End Results database was queried for stage IIB-IV thymoma patients diagnosed during 1988-2015. We analyzed the prognostic implications of various clinical-pathological factors by comparing the outcomes of those who received surgery with and without post-operative radiotherapy. RESULTS: A total of 1120 patients were identified; 62% received post-operative radiotherapy and 38% underwent surgery alone. In a propensity-matched cohort of 812 patients, no survival difference was seen in World Health Organization A, AB, B1, B2, or B3 tumors with the addition of post-operative radiotherapy to surgery (p>0.05). Post-operative radiotherapy also did not improve survival over surgery alone for tumors ≥ or < less than the 4 cm, 7 cm, 10 cm, and 13 cm cutoffs, all p>0.05. Post-operative radiotherapy was an independent, positive prognostic indicator only in the subgroup with stage III disease and in those receiving chemotherapy in addition to post-operative radiotherapy, both p<0.05. CONCLUSIONS: Patients with stage III thymoma are most likely to benefit from the addition of post-operative radiotherapy to surgical treatments. Tumor size or World Health Organization histology alone should not be criteria for determining the need for post-operative radiotherapy in locally advanced thymoma. Masaoka-Koga stage, which has traditionally been used to help make such decisions, appears to be the most reliable determinant of the use of post-operative radiotherapy.

Lobectomy is superior to segmentectomy for peripheral high grade non-small cell lung cancer ≤2 cm.

BACKGROUND: Current practice guidelines recommend the following criteria for segmentectomy for non-small cell lung cancer (NSCLC): size ≤2 cm, margins ≥2 cm and no lymph node involvement. We sought to further stratify the selection criteria for segmentectomy for small peripheral high-grade tumors. METHODS: This retrospective database study was conducted using the Surveillance, Epidemiology and End Results (SEER) database. We queried for patients with high-grade (poorly differentiated/undifferentiated) pathological (p)T1a/b peripheral NSCLC (tumor size ≤2 cm), who underwent either lobectomy or segmentectomy between 2004 and 2015. Patients with node-positive disease or those who received any form of induction or adjuvant treatments were excluded. RESULTS: A total of 4,332 patients met the inclusion criteria, with 3,977 patients (91.8%) treated with lobectomy and 355 patients (8.2%) who underwent segmentectomy. In a propensity matched pair analysis of 640 patients, lobectomy (n=320) showed significantly improved 5-year survival of 45.9% vs. 33.8% for segmentectomy (n=320), P<0.01. In a multivariate Cox regression analysis, lobectomy was associated with significantly improved survival (HR: 0.84, 95% CI: 0.714-0.989, P=0.036). Interestingly, married status, adenocarcinoma histology, number of lymph nodes sampled were associated with better survival (P<0.05), while advanced age and male gender had worse survival outcomes (P<0.05). CONCLUSIONS: For small peripheral NSCLC ≤2 cm and high grades of tumor differentiation, lobectomy is associated with better long-term survival outcomes as compared to segmentectomy. Additional data is needed to further stratify various NSCLC histologies with their respective grades to allow for better selection for segmentectomy.

Prophylactic Mesh Placement for the Prevention of Incisional Hernia in High-Risk Patients After Abdominal Surgery: A Systematic Review and Meta-Analysis.

Background and objectives In high-risk populations, the efficacy of mesh placement in incisional hernia (IH) prevention after elective abdominal surgeries has been supported by many published studies. This meta-analysis aimed at providing comprehensive and updated clinical implications of prophylactic mesh placement (PMP) for the prevention of IH as compared to primary suture closure (PSC). Materials and methods PubMed, Science Direct, Cochrane, and Google Scholar were systematically searched until March 3, 2020, for studies comparing the efficacy of PMP to PSC in abdominal surgeries. The main outcome of interest was the incidence of IH at different follow-up durations. All statistical analyses were carried out using Review Manager version 5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, 2014) and Stata 11.0 (Stata Corporation LP, College Station, TX). The data were pooled using the random-effects model, and odds ratio (OR) and weighted mean differences (WMD) were calculated with the corresponding 95% confidence interval (CI). Results A total of 3,330 were identified initially and after duplicate removal and exclusion based on title and abstract, 26 studies comprising 3,000 patients, were included. The incidence of IH was significantly reduced for PMP at follow-up periods of one year (OR= 0.16 [0.05, 0.51]; p=0.002; I2=77%), two years (OR= 0.23 [0.12, 0.45]; p<0.0001; I2=68%), three years (OR= 0.30 [0.16, 0.59]; p=0.0004; I2= 52%), and five years (OR=0.15 [0.03, 0.85]; p=0.03; I2=87%). However, PMP was associated with an increased risk of seroma (OR=1.67 [1.10, 2.55]; p= 0.02; I2=19%) and chronic wound pain (OR=1.71 [1.03, 2.83]; p= 0.04; I2= 0%). No significant difference between the PMP and PSC groups was noted for postoperative hematoma (OR= 1.04 [0.43, 2.50]; p=0.92; I2=0%), surgical site infection (OR=1.09 [0.78, 1.52]; p= 0.62; I2=12%), wound dehiscence (OR=0.69 [0.30, 1.62]; p=0.40; I2= 0%), gastrointestinal complications (OR= 1.40 [0.76, 2.58]; p=0.28; I2= 0%), length of hospital stay (WMD= -0.49 [-1.45, 0.48]; p=0.32; I2=0%), and operating time (WMD=9.18 [-7.17, 25.54]; p= 0.27; I2=80%). Conclusions PMP has been effective in reducing the rate of IH in the high-risk population at all time intervals, but it is associated with an increased risk of seroma and chronic wound pain. The benefits of mesh largely outweigh the risk, and it is linked with positive outcomes in high-risk patients.

Ossification of the Cruciform Ligament of Atlas; a Rare Cause of Cervical Myelopathy: Case Report and Review of Literature.

We present a case of cervical myelopathy secondary to ossification of the cruciform ligament (also known as cruciate ligament). This is a rare phenomenon that, to the best of our knowledge, has only been reported 16 times previously in literature. We have added a review of literature after our case presentation. We hope that by doing so, we may aid clinicians reach early diagnosis so as to be able to better manage this rare disease.

Perianal Necrotizing Fasciitis with Retroperitoneal Extension: A Case Report from Pakistan.

Necrotizing fasciitis is a rare but potentially fatal condition. It is defined as a rapidly spreading infection of the subcutaneous soft tissue. Extension into the retroperitoneum may further complicate this deadly condition. We report a case of a 45-year-old gentleman who presented to our institute with perianal necrotizing fasciitis with extension into the retroperitoneum. He was managed with antibiotics and prompt surgical debridement. Our patient had a positive outcome which may be due to the fact that we had a high clinical suspicion, on the basis of which we opted for early operative management rather than delaying definitive treatment by obtaining imaging.

Endoscopic Transsphenoidal Surgery for Cushing's Disease: A Review.

Ever since the 1960s, transsphenoidal surgery has been the modality of choice for treating Cushing's disease. Subsequent visualization of the pituitary fossa and sphenoid sinus may be done either with the operating microscope or with the relatively new endoscope. The endoscope due to its panoramic view allows greater visualization as compared to the operating microscope. It confers greater access to the cavernous sinus, sella, suprasellar, and parasellar regions and accommodates higher magnifications. It is bi-dimensional, however as opposed to the operating microscope that provides a three-dimensional view and allows greater depth perception. This article provides a comprehensive review of the advantages and disadvantages of the endoscope and compares it to the operating microscope. We hope this article will prove useful to both clinicians and academicians alike in their approach and management of Cushing's disease.