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.

Improving nuclear morphometry imaging with real-time and low-cost line-scanning confocal microendoscope.

Fiber-optic endomicroscopy is a minimally invasive tool to probe disease progression with subcellular resolution. In this Letter, we demonstrate a low-cost and compact fluorescence microendoscope capable of line-scanning confocal imaging by synchronizing a digital light projector with a CMOS camera. We present the digital aperture design to enable real-time confocal imaging, and we implement parallel illumination to improve the optical sectioning performance. Furthermore, we show that the confocal microendoscope can enhance visualization of disease-associated features when imaging highly scattering esophageal specimens.

Clinical and cost utility of an intraoperative endoscopic second look in cholesteatoma surgery.

OBJECTIVE/HYPOTHESIS: This study aimed to determine the clinical and cost-effectiveness of endoscopes during cholesteatoma surgery. More specifically, this study hypothesized that endoscope use would reduce cholesteatoma recurrence rates and cost. STUDY DESIGN: Case series involving the prospective enrollment of 110 consecutive cholesteatoma patients over a 2-year period. METHODS: Patients underwent cholesteatoma surgery with microscopy. During dissection, the location of the cholesteatoma was assessed. At the end of dissection and before reconstruction, the same subunits were visualized with straight and angled endoscopes for residual cholesteatoma. Hearing was analyzed before surgery and at the last possible examination. Costs were analyzed using Medicare reimbursement rates from the Centers for Medicare and Medicaid Services. RESULTS: Intraoperative endoscopic surveillance was able to detect residual cholesteatoma in 18 patients. With a 0° endoscope, residual cholesteatoma was noted in the epitympanum (two patients), sinus tympani (one patient), and the supratubal air cells (one patient). With a 45° endoscope, residual cholesteatoma was noted in the epitympanum (three patients), sinus tympani (nine patients), the supratubal air cells (two patients), and the mesotympanum (two patients). From a cost analysis, endoscopic surveillance ($6110.36 per patient) are less expensive than second look surgeries ($11,829.83 per patient), observation ($7097.20 per patient), and observation with annual magnetic resonance imaging studies ($9891.95 per patient). The patients hearing improved after surgery, consistent with previous studies. No complications were noted from the use of endoscopes. CONCLUSIONS: Intraoperative endoscopic surveillance reduced recurrence in our series of 110 patients. Endoscopes are particularly useful in evaluating the epitympanum, mesotympanum, sinus tympani, and supratubal air cells. Moreover, endoscopic surveillance is cost-effective. LEVEL OF EVIDENCE: 4 Laryngoscope, 128:2867-2871, 2018.

Building an Oral Endoscope for Use in Equine Oral Examination and Treatment.

The use of oral endoscopy can be very beneficial in that it helps the clinician to perform a more thorough oral examination. However, due to the high cost, most commercially available equine oral endoscopy systems have been out of reach for clinicians who practice equine dentistry outside a large hospital setting. This article details how to set up an oral endoscopy system that can be used on equine patients either in an ambulatory practice or in a hospital setting. The system is more cost-effective than most other systems currently on the market without sacrificing functionality or image quality. The oral endoscope can be wirelessly integrated with a handheld tablet device or larger monitor for real-time viewing of images. It also has the ability to obtain high-resolution digital images and videos that can be easily incorporated into the patient's medical record. Incorporation of this system into equine practices has the potential to provide improved care for dental patients and to help overcome some of the inherent challenges of equine dentistry.

Evaluation of the economic and clinical feasibility of introducing rigid endoscopy and laparoscopy to a small animal general practice.

OBJECTIVE To evaluate the economic and clinical feasibility of introducing rigid endoscopy and laparoscopy to a small animal general practice. DESIGN Prospective study. SAMPLE A single 2-veterinarian small animal practice in southern California. PROCEDURES In early 2012, endoscopic equipment was purchased, and both veterinarians in the practice undertook training in rigid endoscopic and laparoscopic procedures. Subsequently, information for client-owned animals that underwent endoscopic and laparoscopic procedures during a 12-month period (2012 to 2013) was collected. Cost of equipment and training, revenue generated, specific procedures performed, surgery time, complications, and client satisfaction were evaluated. RESULTS 78 endoscopic procedures were performed in 73 patients, including 71 dogs, 1 cat, and 1 rabbit. Cost of endoscopic and laparoscopic equipment and training in the first year was $14,809.71; most equipment was financed through a 5-year lease at a total cost of $57,507.70 ($ 10,675.20/y). Total revenue generated in the first year was $50,423.63. The most common procedures performed were ovariectomy (OVE; n = 49), prophylactic gastropexy (6), and video otoscopy (12). Mean ± SD surgery times for OVE (n = 44) and for OVE with gastropexy (5) were 63.7 ± 19.7 minutes and 73.0 ± 33.5 minutes; respectively. Twelve of 54 patients undergoing laparoscopic procedures experienced minor intraoperative complications. Conversion to laparotomy was not required in any patient. There were no major complications. All 49 clients available for follow-up were satisfied. CONCLUSIONS AND CLINICAL RELEVANCE With appropriate training and equipment, incorporation of basic rigid endoscopy and laparoscopy may be feasible in small animal general practice. However, results of the present study are not applicable to all veterinarians and practice settings, and patient safety considerations should always be paramount.

Echoendoscopes.

Advances in echoendoscopes and their processors have significantly expanded the role of EUS and its clinical applications.The diagnostic and therapeutic capabilities of EUS continue to evolve and improve. EUS has made a large impact on patient care but comes with significant startup and maintenance costs. As improved technology continues to enhance image resolution while decreasing the size of EUS processors, use of endosonography will become more widespread. EUS will continue to be a vital part of patient care and complement currently available cross-sectional imaging.

Towards automated visual flexible endoscope navigation.

BACKGROUND: The design of flexible endoscopes has not changed significantly in the past 50 years. A trend is observed towards a wider application of flexible endoscopes with an increasing role in complex intraluminal therapeutic procedures. The nonintuitive and nonergonomical steering mechanism now forms a barrier in the extension of flexible endoscope applications. Automating the navigation of endoscopes could be a solution for this problem. This paper summarizes the current state of the art in image-based navigation algorithms. The objectives are to find the most promising navigation system(s) to date and to indicate fields for further research. METHODS: A systematic literature search was performed using three general search terms in two medical-technological literature databases. Papers were included according to the inclusion criteria. A total of 135 papers were analyzed. Ultimately, 26 were included. RESULTS: Navigation often is based on visual information, which means steering the endoscope using the images that the endoscope produces. Two main techniques are described: lumen centralization and visual odometry. Although the research results are promising, no successful, commercially available automated flexible endoscopy system exists to date. CONCLUSIONS: Automated systems that employ conventional flexible endoscopes show the most promising prospects in terms of cost and applicability. To produce such a system, the research focus should lie on finding low-cost mechatronics and technologically robust steering algorithms. Additional functionality and increased efficiency can be obtained through software development. The first priority is to find real-time, robust steering algorithms. These algorithms need to handle bubbles, motion blur, and other image artifacts without disrupting the steering process.

Endockscope: using mobile technology to create global point of service endoscopy.

BACKGROUND AND PURPOSE: Recent advances and the widespread availability of smartphones have ushered in a new wave of innovations in healthcare. We present our initial experience with Endockscope, a new docking system that optimizes the coupling of the iPhone 4S with modern endoscopes. MATERIALS AND METHODS: Using the United States Air Force resolution target, we compared the image resolution (line pairs/mm) of a flexible cystoscope coupled to the Endockscope+iPhone to the Storz high definition (HD) camera (H3-Z Versatile). We then used the Munsell ColorChecker chart to compare the color resolution with a 0° laparoscope. Furthermore, 12 expert endoscopists blindly compared and evaluated images from a porcine model using a cystoscope and ureteroscope for both systems. Finally, we also compared the cost (average of two company listed prices) and weight (lb) of the two systems. RESULTS: Overall, the image resolution allowed by the Endockscope was identical to the traditional HD camera (4.49 vs 4.49 lp/mm). Red (ΔE=9.26 vs 9.69) demonstrated better color resolution for iPhone, but green (ΔE=7.76 vs 10.95), and blue (ΔE=12.35 vs 14.66) revealed better color resolution with the Storz HD camera. Expert reviews of cystoscopic images acquired with the HD camera were superior in image, color, and overall quality (P=0.002, 0.042, and 0.003). In contrast, the ureteroscopic reviews yielded no statistical difference in image, color, and overall (P=1, 0.203, and 0.120) quality. The overall cost of the Endockscope+iPhone was $154 compared with $46,623 for a standard HD system. The weight of the mobile-coupled system was 0.47 lb and 1.01 lb for the Storz HD camera. CONCLUSION: Endockscope demonstrated feasibility of coupling endoscopes to a smartphone. The lighter and inexpensive Endockscope acquired images of the same resolution and acceptable color resolution. When evaluated by expert endoscopists, the quality of the images overall were equivalent for flexible ureteroscopy and somewhat inferior, but still acceptable for flexible cystoscopy.

[Cost analysis comparing single-use (Ambu® aScope™) and conventional reusable fiberoptic flexible scopes for difficult tracheal intubation]. / Analyse de coût comparant les fibroscopes à usage unique (Ambu®aScope™) et les fibroscopes réutilisables pour l'intubation difficile.

OBJECTIVE: Recommendations on difficult tracheal intubation constrain each surgical block to have a fiberscope available. Reusable fiberscope presents the problem of availability, the risk of non-conventional infections transmission and the cost. Single-use fiberscopes are presently available (Ambu® aScope™). This medico-economic study aims to assess the cost of using a reusable fiberscope as compared to the single use fiberscope. STUDY DESIGN: Cost minimization analysis. MATERIAL: Reusable fiberscope Pentax® FB 15P (Pentax France, Argenteuil) and single-use fiberscope Ambu® aScope™ (Ambu A/S, Ballerup, Denmark). METHOD: Minimization-cost analysis conducted between 2006 and 2012. The amortization cost per utilization for two reusable fiberscopes took into account the acquisition and maintenance costs, as well as the costs related to disinfection. The cost of the single use fiberscope was calculated according to its acquisition cost. RESULTS: The total cost of the reusable material was 55,874€ over 6years, corresponding to a unitary cost of 206€ per fiberscopy. During this period, 780 sterilizations were carried out for a total cost of 32,611€. Acquisition and maintenance costs were respectively 18,382€ and 4880€. The cost of the single use fiberscope is of 200€ per fiberscopy. CONCLUSION: This medico-economic evaluation shows that the utilization cost of single use and reusable fiberscopes are very close. This should be analyzed at the light of some benefits of using single use devices for the difficult tracheal intubation.

Empirical evidence of the continuing improvement in cost efficiency of an endoscopic surveillance programme for gastric cancer in Singapore from 2004 to 2010.

BACKGROUND: Endoscopic surveillance has been proven effective in prolonging the survival of gastric cancer (GC) patients. However, there is limited evidence on the cost efficiency of delivering this intervention, especially on a national level in spite of cost efficiency being a major determinant of the actual cost-effectiveness of a cancer prevention programme. The Singapore Gastric Cancer Epidemiology Clinical and Genetic Programme (GCEP) is a demonstration project offering scheduled endoscopy to the Chinese population aged 50 years or older in Singapore. By assessing the cost efficiency of the GCEP, this study aimed to provide empirical evidence on the cost structure and mechanisms underlying cost generation in conducting GC surveillance, thus informing resource allocation and programme budgeting for the Singapore government. METHODS: From a societal perspective, we reported on the direct cost (resource consumption) of conducting endoscopic surveillance through the GCEP network. We retrospectively collected individual-level data of 216 subjects recruited at the National University Hospital, Singapore from 01/04/2004 to 31/10/2010. The Overall Cost, Clinical Cost, GCEP Cost and Personal Cost incurred in serving one subject was computed and discounted as 2004 US dollar (US$) per capita for every year. The Generalized Estimation Equation (GEE) was used to model the data. RESULTS: All cost indices continuously declined over the 6.5-year costing period. For the total sample, Overall Cost, Clinical Cost, GCEP Cost and Personal Cost declined by 42.3%, 54.1%, 30% and 25.7% respectively. This downward trend existed for age and gender subgroups and the high risk group only with cost reductions varying between 3.5% and 58.4%. The GEE models confirmed statistical significance of the downward trend and of its association with risk profile, where the moderate risk group had cost indices at most 77% of the high risk group. CONCLUSIONS: Our study offered empirical evidence of improved cost efficiency of a surveillance programme for GC in the early phase of programme implementation. Mechanisms such as economies of scale and self-learning were found to be involved in the cost reduction. Our findings highlighted the importance of assessing the cost efficiency and offered valuable insights for future programme budgeting and policy making.

Automated high-level disinfection of nonchanneled flexible endoscopes: duty cycles and endoscope repair.

PURPOSE: Guidelines issued by the Association of Operating Room Nurses and the Association of Professionals in Infection Control and Epidemiology recommend high-level disinfection (HLD) for semicritical instruments, such as flexible endoscopes. We aim to examine the durability of endoscopes to continued use and automated HLD. We report the number of duty cycles a flexible endoscope can withstand before repairs should be anticipated. METHODS: Retrospective review. RESULTS: A total of 4,336 endoscopic exams and subsequent disinfection cycles were performed with 60 flexible endoscopes in an outpatient tertiary pediatric otolaryngology practice from 2005 to 2009. All endoscopes were systemically cleaned with mechanical cleansing followed by leak testing, enzymatic cleaning, and exposure to Orthophthaldehyde (0.55%) for 5 minutes at a temperature of at least 25°C, followed by rinsing for 3 minutes. A total of 77 repairs were performed, 48 major (average cost $3,815.97), and 29 minor (average cost $326.85). On average, the 2.2-mm flexible endoscopes were utilized for 61.9 examinations before major repair was needed, whereas the 3.6 mm endoscopes were utilized for 154.5 exams before needing minor repairs. No major repairs have been needed to date on the 3.6-mm endoscopes. CONCLUSIONS: Automated endoscope reprocessor use for HLD is an effective means to disinfect and process flexible endoscopes. This minimizes variability in the processing of the endoscopes and maximizes the rate of successful HLD. Even when utilizing standardized, automated HLD and limiting the number of personnel processing the endoscopes, smaller fiberoptic endoscopes demonstrate a shortened time interval between repairs than that seen with the larger endoscopes. Laryngoscope, 2010.

[Evaluation of a daily used navigation system for FESS]. / Untersuchungen zur Effizienz eines Navigationssystems für die HNO-Chirurgie: Auswertungen von 300 Patienten.

PROBLEM: The aim of this study is to proof the clinical efficiency by using a modern navigation system for Functional Endoscopic Sinus Surgery (FESS). MATERIAL AND METHODS: An optical navigation system was used in clinical routine of 300 patients. Two groups with 150 patients each were examined. Group A was treated with navigation assistance (Karl Storz Navigation Panel Unit NPU), Group B was treated without navigation by conventional FESS. Examination period was limited to 12 months. Median follow-up is 22 and 26 weeks. Perioperative, intraoperative and postoperative parameters were recorded by workflow-analysis, clinical and radiological findings and standardized questionnary. RESULTS: Application of the navigation system needs 1.1 min additional perioperative time in average. Intraoperative time reduction by the navigation system was about 10 min per case (Group A 32.6 (SD 11.2) min, Gruppe B 42.7 (SD 9.5) min). Specific information by the navigation system was evaluated in all surgical areas as usefull and additional to a-priori-knowledge. Postoperatively patients from group A (10/89) show lower rate of re-polyposis then in group B (24/71). Fenestration of the sphenoid sinus were sufficient by CT-evaluation in 100% (group A) and 23% (group B). CONCLUSIONS: The advantages of the examined navigation system in comparison to the gold standard of FESS are proven. Navigation assistance led to an reduced intraoperative time consumption, increased postoperative results and lowered the workload of the surgeons.

A simplified method for anal ultrasonography: preliminary report.

BACKGROUND: Anal endosonography (AES) is able to reliably visualize and identify anal sphincter abnormalities. However, dedicated probes are quite expensive. AIM: We describe a simple and less costly method to perform AES in a unit that already has echoendoscopes available by inserting the endoscope through a disposable anoscope filled with standard ultrasound gel. PATIENTS: Subjects without anal abnormalities and patients with anal disease (abscesses, fistulas) were evaluated. RESULTS: Good-quality images were obtained in both controls and patients, with optimal visualization of the anatomic structures and pathologic features. The latter (abscesses, fistulas) were always confirmed by magnetic resonance imaging. CONCLUSIONS: This simple and less costly method allows to perform good-quality AES in units having echoendoscopes availability, without the need of a more expensive dedicated probe.

A low-cost and simple imaging technique of the anterior and posterior segments: eye fundus, ciliary bodies, iridocorneal angle.

PURPOSE: The authors recently used topical endoscopy to image the mouse eye fundus. Here, they widened the field of application for this ophthalmologic tool, imaging both the posterior and the anterior eye segments in larger animals commonly encountered in research laboratories and veterinary clinics. METHODS: Pupils were dilated, and local anesthetic and gel were applied to the animal cornea. The endoscopic probe was placed in contact with the cornea of conscious rats, sedated cats and dogs, anesthetized sheep, and nonhuman primates. RESULTS: High-resolution digital images of the eye fundus were obtained in all investigated animals using the endoscopic probe along the eye axis. Arteriovenous filling time was monitored with fluorescein angiography in pigmented rats. The retinal periphery and ciliary bodies could be visualized with the probe placed at an oblique angle. The probe was inclined further to observe the iridocorneal angle such that the pectinate ligaments could be seen at high resolution in cats. The authors used the probe on eyes with retinal detachment, luxation of a cataractous lens, and pigment infiltration in the iridocorneal angle, demonstrating its potential use in eye diseases. CONCLUSIONS: This topical endoscopic technique provides a unique tool for single eye examinations. The authors obtained a circular view of the anterior (iridocorneal angle) and the posterior (fundus) eye segments from all animal species studied. This technique is inexpensive and easy to use. It can be easily moved to the eye of the patient who cannot move to stand in front of classic apparatus, offering new opportunities in ophthalmology.