Application of enhanced recovery after surgery for oral dryness prevention after endoscopic sinus surgery.

OBJECTIVE: To investigate the efficacy of cluster nursing intervention based on Enhanced Recovery After Surgery (ERAS) for xerostomia in chronic rhinosinusitis after nasal endoscopic surgery. METHODS: A total of 80 patients with chronic rhinosinusitis who underwent functional nasal endoscopic surgery between January 2020 and December 2021 were selected and randomly divided into a control group (n = 40) and an experimental group (n = 40). Patients in the control group were treated with general nursing, while ERAS-based cluster nursing intervention was adopted for the experimental group, in addition to general nursing. Xerostomia stage and comfort level were observed at 2 h, 6 h, 24 h and 48 h after surgery; negative emotions before and after nursing were also observed. RESULTS: After the intervention, the xerostomia stage and comfort level at 6, 24 and 48 after surgery were higher in the experimental group (p < 0.05). Negative emotions in the experimental group were lower after nursing (p < 0.001). The self-rating depression scale and self-rating anxiety scale scores increased after nursing in both two groups (p < 0.05). CONCLUSION: Enhanced recovery after surgery-based cluster nursing intervention can alleviate xerostomia, improve patients' comfort levels, reduce their negative emotions and accelerate postoperative recovery.

Involvement of IL17A and IL17RA variants in interleukin-17A levels and disease activity in ulcerative colitis.

Ulcerative colitis (UC) is characterized by chronic inflammation of the large intestine with involvement of Th17 cells and interleukin (IL)-17A. The role of IL17A and IL17A receptor (IL17RA) variants in pathophysiology of UC still remains inconclusive. The aim was to evaluate the association between IL17A and IL17RA variants with susceptibility, IL-17A plasma levels, and endoscopic activity in UC. The study included 104 patients with UC and 213 controls. Patients were divided according to endoscopic activity (remission/mild and moderate/severe). The IL17A rs3819024 A>G and rs3819025 G>A, and IL17RA rs2241043 C>T, rs2241049 A>G, and rs6518661 G>A variants were genotyped using real time polymerase chain reaction. IL-17A plasma levels were determined using immunofluorimetric assay. Neither IL17A nor IL17RA variants were associated with UC susceptibility. The IL17A rs3819024 AG genotype was associated to high levels of IL-17 only in patients. Patients with the G allele of IL17RA rs2241049 showed 2.944 more chance of developing moderate/severe disease. The haplotype analysis showed that IL17RA rs2241049 and rs6518661 was not associated with UC susceptibility and haplotypes constituted with G allele of these variants were not associated with disease severity (p = 0.09). In conclusion, the IL17A rs3819024 AG genotype was associated with elevated IL-17A plasma levels in patients with UC but not in controls and the IL17RA rs2241049 AG+GG genotypes were associated to severity of UC. These results suggest a possible hidden interaction between the IL17A rs3819024 variant and other genetic, environmental, and epigenetic factors in the IL-17A expression that is present only in patients with UC.

Reducing local tension to repair nasal septal deviation and spur.

OBJECTIVES: To introduce our method managing nasal septal spurs during endoscopic septoplasty. METHODS: We conducted a prospective study of cases treated with endoscopic septoplasty between March 2022 and June 2023. We innovated a surgical method to reduce the local mucosal tension at the spur by cutting the spur above and below the bony connection, and reducing the chance of mucosal tear and loss during dissection. The authors performed these cases at the First Affiliated Hospital of Fujian Medical University, where 40 surgeries were performed with regular postoperative follow-ups for 6-12 months. RESULTS: All patients' clinical symptoms improved significantly after surgery. After 2-4 weeks of follow-up, the mucosa could recover to the preoperative state on both sides of the nasal septum. CONCLUSION: This surgical method is suitable for most patients with nasal septal deviation, especially those with a spur, which can effectively reduce the chance of nasal septal mucosa tear and accelerate postoperative recovery. LEVEL OF EVIDENCE: Ⅳ.

Endoscopic Calcaneoplasty in Haglund Disease: Surgical Technique, Clinical and Subjective Outcomes.

BACKGROUND: During the last decade, arthroscopic procedures have been replacing open techniques in Haglund disease treatment because of their considerable advantages. Endoscopic calcaneoplasty is a technique that allows resection of posterosuperior calcaneal exostosis and retrocalcaneal bursitis. The objective of this article was to describe this technique and report its clinical and subjective outcome. METHODS: A retrospective study was performed of consecutive patients undergoing endoscopic Haglund resection surgery between July 2014 and March 2020 at a single academic institution. All patients were surveyed in person about the level of pain (visual analog scale), its location (central, lateral, medial or diffuse), its relation with rest, or physical activity. Clinical evaluation was assessed using the hindfoot scale designed by the American Orthopedics Foot & Ankle Society AOFAS. RESULTS: In this study, 14 endoscopic calcaneoplasties were performed in 14 patients, with an average follow-up of 40 months. The visual analog scale score improved from a preoperative average value of 9.07 to 1.8 after surgery (P > .0001). The AOFAS scale rose from 38.7 before surgery to 94.6 postoperative (P > .0001). Good subjective results were observed in 12 patients (85.7%), and all of them would have surgery again. There were no wound complications or infections. No patient required reoperation. CONCLUSION: In this relatively small cohort, we found that endoscopic calcaneoplasty was associated with good clinical and subjective results with few complications.

Fiberoptic Endoscopy Evaluation of Swallowing (FEES) Findings Associated with High Pneumonia Risk in a Cohort of Patients at Risk of Dysphagia.

Aspiration detected in the fiberoptic endoscopy evaluation of swallowing (FEES) has been inconsistently associated with pneumonia, with no evidence of the risk of pneumonia from other alterations in swallowing safety detected in FEES. We conducted a dynamic, ambidirectional cohort study involving 148 subjects at risk of dysphagia in a tertiary university hospital. Our aim was to determine the risk of pneumonia attributed to alterations in swallowing safety detected during FEES. We used multivariate negative binomial regression models to adjust for potential confounders. The incidence density rate (IR) of pneumonia in patients with tracheal aspiration of any consistency was 26.6/100 people-years (RR 7.25; 95% CI: 3.50-14.98; P < 0.001). The IR was 19.7/100 people-years (RR 7.85; 95% CI: 3.34-18.47; P < 0.001) in those with laryngeal penetration of any consistency and 18.1/100 people-years (RR 6.24; 95% CI: 2.58-15.09; P < 0.001) in those with pharyngeal residue of any consistency. When adjusted for aspiration, the association of residue and penetration with pneumonia disappeared, suggesting that their risk of pneumonia is dependent on the presence of aspiration and that only aspiration is independently associated with pneumonia. This increased risk of pneumonia was significant in uni- and multivariate negative binomial regression models. We found an independently increased risk of pneumonia among patients with dysphagia and aspiration detected during FEES. Alterations in the oral and pharyngeal phases of swallowing, without aspiration, did not increase the risk of pneumonia.

Anatomical Measurement as a Reference for Functional Endoscopic Sinus Surgery Based on CT Scans and Dissections.

Introduction Diseases of the paranasal sinuses, nasal cavities, and those related to the skull base can be treated with nasal endoscopic surgery. Anatomical references are essential to safely perform these surgeries. Objective To measure and compare the distance from the posterior wall of the maxillary sinus to the anterior skull base in cadavers and on computed tomography (CT) scans to determine a measurement as an anatomical reference in imaging exams for sinus and anterior skull base surgery. Methods In dissections and CT scans, we took measurements from the most upper and medial point of the posterior wall of the maxillary sinus (point A) to the point where the skull base deflects and the anterior sphenoid wall is formed (Δ 90°; point B), in the right and left nasal cavities. We used 51 cadavers aged ≥ 18 years in the present research. Results The measurements obtained from CT scans and dissections were greater than 1.5 cm in all cadavers, and they were positively correlated. The 1-cm increase in the AB-tomography measurement corresponded to the 1.08-cm increase to the right and 1.07-cm to the left in the AB-dissection measurement. Conclusion The CT measurements may be considered a reliable tool to promote safe and effective access to the paranasal sinuses, matching the distance that should be dissected until the anterior base of the skull.

Invasive Therapeutic Strategies for Stricturing Crohn's Disease in Childhood: A Systematic Review and Meta-Analysis.

BACKGROUND: Crohn's disease (CD) is a chronic inflammatory condition of the gastrointestinal tract. Current drugs are not effective for treating the primary fibrotic component of CD. Recommended invasive treatments include endoscopic balloon dilation, surgery with resection, or strictureplasty. This meta-analysis compared invasive treatment techniques for CD-related strictures in the pediatric population. METHODS: The MEDLINE, EMBASE, and LILACS databases were searched from inception to December 2023. This meta-analysis was performed as per the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines. The outcome was measured by the rate of stenosis recurrence and the adverse events of the techniques. Eligibility criteria were studies that involved the analysis of the recurrence rate of stenosis in pediatric patients with CD requiring surgical intervention after undergoing any of the previously proposed therapies. Additionally, adverse events were analyzed. RESULTS: Three studies comprising a total of 106 endoscopic balloon dilations demonstrated a combined rate of stricture recurrence in patients with CD requiring surgical intervention of 0.171 (95% confidence interval [CI], 0.110-0.255). Three studies comprising a total of 49 surgical resections demonstrated a pooled event rate of 0.100 (95% CI, 0.038-0.240). Finally, 2 studies comprising a total of 38 strictureplasties demonstrated a pooled event rate of 0.347 (95% CI, 0.070-0.789). Concerning adverse events, the most common occurrences were found after surgical resection. CONCLUSIONS: Surgical resection is the best option for treating strictures in pediatric CD patients in terms of recurrence rate, compared with endoscopic balloon dilation and strictureplasty. Nevertheless, surgical resection is associated with more adverse events.

This meta-analysis compares techniques for pediatric Crohn's disease­related strictures. Surgical resection, compared with balloon dilation or strictureplasty, is the best option for treating strictures in these patients in terms of recurrence rate but is associated with more adverse events.

Endoscopic surgery for craniosynostosis: a bibliometric analysis of primary studies.

INTRODUCTION: Bibliometrics, a statistical method assessing the influence of scholarly works, was employed to analyze the evolution of endoscopic surgery for craniosynostosis. METHODS: This comprehensive review followed PRISMA guidelines, sourcing data from PubMed, Embase, and Web of Science, focusing on clinical and surgical outcomes up to December 2023. We identified 1409 records, with 83 papers meeting inclusion criteria. RESULTS: The majority of studies originated from the Americas (79%), predominantly from the United States (75.9%). The typical study design was retrospective cohort studies (62%), involving a total of 8,175 patients with median research duration of 8 years. Citation metrics indicated an average count of 38.9 per paper, with notable contributions from several key authors. A distinct increase in research was observed in recent years, particularly from 2011 onwards, peaking in 2022 and 2023. The top 10 most cited papers, largely emanating from the U.S., had a higher median patient number (103) compared to the overall median (53), suggesting their significant impact. These papers were primarily published in journals with higher impact factors and citation indicators. The most cited research was notably published in the Journal of Neurosurgery-Pediatrics. CONCLUSION: This analysis provides a comprehensive view of the field, highlighting the growing trend and clinical importance of endoscopic approaches in craniosynostosis, offering a valuable resource for future research and clinical practice.

Prognostic factors for endoscopic third ventriculostomy success in hydrocephalus with myelomeningocele.

PURPOSE: Myelomeningocele (MMC) is a prevalent neural tube closure defect often associated with hydrocephalus, necessitating surgical intervention in a significant proportion of cases. While ventriculoperitoneal shunting (VPS) has been a standard treatment approach, endoscopic third ventriculostomy (ETV) has emerged as a promising alternative. However, factors influencing the success of ETV in MMC patients remain uncertain. This retrospective observational study aimed to identify clinical and radiological factors correlating with a higher success rate of ETV in MMC patients. METHODS: Medical records of MMC patients who underwent ETV at a tertiary care center between 2015 and 2021 were reviewed. Demographic, clinical, and radiological data were analyzed. ETV success was defined as the absence of further hydrocephalus treatment during follow-up. RESULTS: Of 131 MMC patients, 21 met inclusion criteria and underwent ETV. The overall success rate of ETV was 57.1%, with a six-month success rate of 61.9%. Age ≤ 6 months was significantly associated with lower ETV success (25%) compared to older patients (76.9%) (OR: 0.1; 95% CI 0.005-2.006; p = 0.019). Radiological factors, including posterior fossa dimensions and linear indices, did not exhibit statistically significant associations with ETV success. CONCLUSION: Age emerged as a significant factor affecting ETV success in MMC patients, with younger patients exhibiting lower success rates. Radiological variables did not significantly influence ETV outcomes in this study. Identifying predictors of ETV success in MMC patients is crucial for optimizing treatment strategies and improving patient outcomes.

Fecal calprotectin and endoscopic scores: The cornerstones in clinical practice for evaluating mucosal healing in inflammatory bowel disease.

Managing inflammatory bowel disease (IBD) is becoming increasingly complex and personalized, considering the advent of new advanced therapies with distinct mechanisms of action. Achieving mucosal healing (MH) is a pivotal therapeutic goal in IBD management and can prevent IBD progression and reduce flares, hospitalization, surgery, intestinal damage, and colorectal cancer. Employing proactive disease and therapy assessment is essential to achieve better control of intestinal inflammation, even if subclinical, to alter the natural course of IBD. Periodic monitoring of fecal calprotectin (FC) levels and interval endoscopic evaluations are cornerstones for evaluating response/remission to advanced therapies targeting IBD, assessing MH, and detecting subclinical recurrence. Here, we comment on the article by Ishida et al Moreover, this editorial aimed to review the role of FC and endoscopic scores in predicting MH in patients with IBD. Furthermore, we intend to present some evidence on the role of these markers in future targets, such as histological and transmural healing. Additional prospective multicenter studies with a stricter MH criterion, standardized endoscopic and histopathological analyses, and virtual chromoscopy, potentially including artificial intelligence and other biomarkers, are desired.

Congenital diaphragmatic hernia treated via fetal endoscopic tracheal occlusion improves outcome in a middle-income country.

OBJECTIVES: A recent European randomized trial - Tracheal Occlusion To Accelerate Lung Growth - demonstrated that fetoscopic endoluminal tracheal occlusion (FETO) is associated with increased postnatal survival among infants with severe congenital diaphragmatic hernia (CDH). However, this differs in middle-income countries such as Brazil, where abortion is illegal and neonatal intensive care is inadequate. This study evaluated the effects of FETO on improving the survival of infants with moderate-to-severe CDH in isolated and non-isolated cases. METHODS: This retrospective cohort study selected 49 fetuses with CDH, a normal karyotype, and a lung-to-head ratio (LHR) of <1 from a single national referral center for fetal surgery in São Paulo, Brazil, between January 2016 and November 2019. FETO was performed between 26 and 29 weeks of gestation. The primary outcomes were infant survival until discharge from the neonatal intensive care unit and survival until six months of age. RESULTS: Forty-six women with singleton fetuses having severe CDH underwent prenatal intervention with FETO. Infant survival rates until discharge and at six months of age were both 38 %. The observed-to-expected LHR increased by 25 % after FETO in neonates who survived until discharge. Spontaneous intrauterine death occurred in four growth-restricted fetuses after FETO. Preterm birth in <37 weeks and preterm rupture of membranes in <34 weeks occurred in 56.5 % (26) and 26 % (12) cases, respectively. CONCLUSIONS: FETO may increase neonatal survival in fetuses with severe CDH, particularly in countries with limited neonatal intensive care.

Scissor-assisted vs. conventional endoscopic submucosal dissection for colorectal lesions: Systematic review and meta-analysis.

OBJECTIVES: Colorectal endoscopic submucosal dissection (ESD) is a technically complex procedure. The scissor knife mechanism may potentially provide easier and safer colorectal ESD. The aim of this meta-analysis is to evaluate the efficacy and safety of scissor-assisted vs. conventional ESD for colorectal lesions. METHODS: A search strategy was conducted in MEDLINE, Embase, and Lilacs databases from January 1990 to November 2023 according to PRISMA guidelines. Fixed and random-effects models were used for statistical analysis. Heterogeneity was assessed using I2 test. Risk of bias was assessed using the ROBINS-I and RoB-2 tools. Quality of evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation tool. RESULTS: A total of five studies (three retrospective and two randomized controlled trials, including a total of 1575 colorectal ESD) were selected. The intraoperative perforation rate was statistically lower (risk difference [RD] -0.02; 95% confidence interval [CI] -0.04 to -0.01; P = 0.001; I2 = 0%) and the self-completion rate was statistically higher (RD 0.14; 95% CI 0.06, 0.23; P = 0.0006; I2 = 0%) in the scissor-assisted group compared with the conventional ESD group. There was no statistical difference in R0 resection rate, en bloc resection rate, mean procedure time, or delayed bleeding rate between the groups. CONCLUSION: Scissor knife-assisted ESD is as effective as conventional knife-assisted ESD for colorectal lesions with lower intraoperative perforation rate and a higher self-completion rate.

Non-Invasive Prediction of Choledocholithiasis Using 1D Convolutional Neural Networks and Clinical Data.

This paper introduces a novel one-dimensional convolutional neural network that utilizes clinical data to accurately detect choledocholithiasis, where gallstones obstruct the common bile duct. Swift and precise detection of this condition is critical to preventing severe complications, such as biliary colic, jaundice, and pancreatitis. This cutting-edge model was rigorously compared with other machine learning methods commonly used in similar problems, such as logistic regression, linear discriminant analysis, and a state-of-the-art random forest, using a dataset derived from endoscopic retrograde cholangiopancreatography scans performed at Olive View-University of California, Los Angeles Medical Center. The one-dimensional convolutional neural network model demonstrated exceptional performance, achieving 90.77% accuracy and 92.86% specificity, with an area under the curve of 0.9270. While the paper acknowledges potential areas for improvement, it emphasizes the effectiveness of the one-dimensional convolutional neural network architecture. The results suggest that this one-dimensional convolutional neural network approach could serve as a plausible alternative to endoscopic retrograde cholangiopancreatography, considering its disadvantages, such as the need for specialized equipment and skilled personnel and the risk of postoperative complications. The potential of the one-dimensional convolutional neural network model to significantly advance the clinical diagnosis of this gallstone-related condition is notable, offering a less invasive, potentially safer, and more accessible alternative.

Fetoscopic Tracheal Occlusion for Isolated Severe Left Diaphragmatic Hernia: A Systematic Review and Meta-Analysis.

Background: We aimed to conduct a systematic review and meta-analysis to evaluate the fetoscopic tracheal occlusion in patients with isolated severe and left-sided diaphragmatic hernia. Methods: Cochrane Library, Embase, and PubMed (Medline) databases were searched from inception to February 2024 with no filters or language restrictions. We included studies evaluating the outcomes of fetoscopic intervention compared to expectant management among patients with severe congenital diaphragmatic hernia exclusively on the left side. A random-effects pairwise meta-analysis was performed using RStudio version 4.3.1. Results: In this study, we included 540 patients from three randomized trials and five cohorts. We found an increased likelihood of neonatal survival associated with fetoscopic tracheal occlusion (Odds Ratio, 5.07; 95% Confidence Intervals, 1.91 to 13.44; p < 0.01) across general and subgroup analyses. Nevertheless, there were higher rates of preterm birth (OR, 5.62; 95% CI, 3.47-9.11; p < 0.01) and preterm premature rupture of membranes (OR, 7.13; 95% CI, 3.76-13.54; p < 0.01) in fetal endoscopic tracheal occlusion group compared to the expectant management. Conclusions: Our systematic review and meta-analysis demonstrated the benefit of fetoscopic tracheal occlusion in improving neonatal and six-month postnatal survival in fetuses with severe left-sided CDH. Further studies are still necessary to evaluate the efficacy of tracheal occlusion for isolated right-sided CDH, as well as the optimal timing to perform the intervention.

Evaluation of the endoscopic cure criteria in patients undergoing surgery for early gastric cancer.

BACKGROUND AND OBJECTIVES: Gastric cancer (GC) prognosis is influenced by the extent of the tumor, lymph node involvement (LNM), and metastasis. Endoscopic resection (ER) or gastrectomy with lymphadenectomy are standard treatments for early GC (EGC). This study evaluated LNM frequency according to eCura categories, clinicopathological characteristics, disease-free (DFS), and overall (OS) survival rates. METHODS: We included EGC patients who underwent curative gastrectomy between 2009 and 2020 from our single-center database. Anatomopathological and clinical reports were reviewed to analyze eCura categories. RESULTS: We included 160 EGC patients who underwent gastrectomy with eCura categories A, B, and C, comprising 26.3%, 13.8%, and 60%, respectively. Baseline clinical characteristics showed no intergroup disparities. LNM incidence for A, B, and C was 4.8%, 18.2%, and 19.8%. When evaluating the criteria for ER and its association with eCura categories, we found that 95.2% of eCura A and 100% of eCura B patients had classic or expanded criteria for ER. On the other hand, 97.9% of eCura C patients were referred to surgical resection. Multivariate analysis demonstrated that lymphatic (OR = 5.57, CI95% = 1.45-21.29, p = 0.012) and perineural (OR = 15.8, CI95% = 1.39-179.88, p = 0.026) invasions were associated with a higher risk of LNM. No significant differences in DFS or OS were found among eCura categories. CONCLUSION: The eCura categories were associated with the occurrence of LNM. In most patients, those with classic and expanded indication criteria for ER were classified as eCura A and B.

Combined open maxillectomy and endoscopic endonasal resection of a giant V2 trigeminal schwannoma.

BACKGROUND: Trigeminal schwannoma is a rare type of tumor that arises from the Schwann cells of the trigeminal nerve. METHOD: We present a case of a patient with a giant V2 trigeminal schwannoma with painful swelling in the left maxilla. A complete resection using a combined open maxillectomy and endoscopic endonasal approach was performed. CONCLUSION: This case highlights the importance of a multidisciplinary approach to perform a combined open and endoscopic approach for safe resection while preserving adequate speech and swallowing.

Shaping the curve from the microscopic transsphenoidal to the endoscopic endonasal approach for the sellar region.

OBJECTIVE: This study aimed to investigate the limitations, barriers, and complications in the early transition from the microscopic transsphenoidal approach (MTA) to the endonasal endoscopic approach (EEA) to the skull base in our institution. METHODS: Technical challenges, as well as clinical features and complications, were compared between MTA, EEA, and mixed cases during the early surgical curve. RESULTS: The period from the early learning curve was 1 year until the EEA protocol was used routinely. A total of 34 patients registered a resection using a transsphenoidal approach. Eighteen patients underwent EEA, 11 underwent MTA, and five underwent a mixed endonasal and microscopic approach. Non-significant differences were found in endocrine outcomes between the three groups. Patients with unchanged or improved visual function were higher in the EEA group (p = 0.147). Non-significant differences were found in terms of the extent of resection (EOR) between groups (p = 0.369). Only 1 (2.9%) patient in the whole series developed a post-operative CSF leaking that resolved with medical management, belonging to the EEA group (5.5%). CONCLUSIONS: The early phase of the learning curve did not affect our series significantly in terms of the EOR, endocrine status, and visual outcomes.

OBJETIVO: Investigar las limitaciones, las barreras y las complicaciones en la transición del abordaje transesfenoidal microscópico (ATM) al abordaje endonasal endoscópico (AEE) para la base del cráneo en nuestra institución. MÉTODO: Se compararon las características clínicas y las complicaciones entre ATM, AEE y casos mixtos durante la curva quirúrgica temprana. RESULTADOS: El periodo desde la curva de aprendizaje inicial fue de 1 año hasta que se utilizó el protocolo AEE de forma sistemática. Un total de 34 pacientes tuvieron una resección por vía transesfenoidal. A 18 pacientes se les realizó AEE, a 11 ATM y a 5 abordaje mixto endonasal y microscópico. Se encontraron diferencias no significativas en los resultados endocrinos entre los tres grupos. Los pacientes con función visual sin cambios o mejorada fueron más en el grupo AEE (p = 0.147). No se encontraron diferencias significativas respecto a la extensión de la resección (p = 0.369). Solo 1 (2.9%) paciente desarrolló una fístula de líquido cefalorraquídeo que se resolvió con manejo médico, perteneciente al grupo AEE (5.5%). CONCLUSIONES: La fase inicial de la curva de aprendizaje no afectó significativamente a nuestra serie en términos de extensión de la resección, estado endocrino y resultados visuales.

Local Control of Distal Cholangiocarcinoma With Radiofrequency Ablation at Endoscopic Retrograde Cholangiopancreatography.

Distal cholangiocarcinoma (CCA) can pose diagnostic and therapeutic challenges, often leading to a poor prognosis. While curative resection is viable for a minority in the early stage, we report a case of successful endoscopic therapy. A 79-year-old patient, diagnosed with early-stage extrahepatic CCA, opted out of surgery and chemotherapy. Instead, he pursued a treatment strategy involving serial radiofrequency ablation with stent exchange at endoscopic retrograde cholangiopancreatography. The patient achieved remission, showcasing the potential for local control of distal CCA through radiofrequency ablation and covered self-expanding metal stents. This alternative becomes particularly relevant for patients unsuitable for surgery or chemotherapy and those who decline it.

The endoscopic transcanal approach to the internal auditory canal: an anatomic study.

PURPOSE: The internal auditory canal (IAC) plays a key role in lateral skull base surgery. Although several approaches to the IAC have been proposed, endoscope-assisted transcanal corridors to the IAC have rarely been studied. We sought to provide a step-by-step description of the transcanal transpromontorial approach to the IAC and analyze anatomic relationships that might enhance predictability and safety of this approach. METHODS: Ten cadaveric specimens were dissected and the extended transcanal transpromontorial approach to the IAC was established. Various morphometric measurements and anatomic landmarks were reviewed and analyzed. RESULTS: The proposed technique proved feasible and safe in all specimens. There was no inadvertent injury to the jugular bulb or internal carotid artery. The chorda tympani, a key landmark for the mastoid segment of the facial nerve, was identified in all dissections. The spherical recess of the vestibule and middle turn of cochlea are important landmarks for identification of the labyrinthine segment of the facial nerve. Identification of all boundaries of the working area is also essential for safe access. Among various morphometric measurements, the modiolus-IAC angle (≈ 150°) proved particularly consistent; given its ease of use and low variability, we believe it could serve as a landmark for identification and subsequent dissection of the IAC. CONCLUSIONS: The extended transcanal transpromontorial approach to the IAC is feasible and safe. Relying on anatomic landmarks to ensure preservation of the involved neurovascular structures is essential for a successful approach. The modiolus-IAC angle is a consistent, reproducible landmark for IAC identification and dissection.

Validation of a synthetic simulation model of endoscopic rectus sheath plication.

PURPOSE: Literature reviews outline minimally invasive approaches for abdominal diastasis in patients without skin excess. However, few surgeons are trained in endoscopic rectus sheath plication, and no simulated training programs exist for this method. This study aimed to develop and validate a synthetic simulation model for the training of skills in this approach under the Messick validity framework. METHODS: A cross-sectional study was carried out to assess the participants' previous level of laparoscopic/endoscopic skills by a questionnaire. Participants performed an endoscopic plication on the model and their performance was evaluated by one blinded observer using the global rating scale OSATS and a procedure specific checklist (PSC) scale. A 5-level Likert survey was applied to 5 experts and 4 plastic surgeons to assess Face and Content validity. RESULTS: Fifteen non-experts and 5 experts in abdominal wall endoscopic surgery were recruited. A median OSATS score [25 (range 24-25) vs 14 (range 5-22); p < 0.05 of maximum 25 points] and a median PSC score [11 (range 10-11) vs 8 (range 3-10); p < 0.05 of maximum 11 points] was significantly higher for experts compared with nonexperts. All experts agreed or strongly agreed that the model simulates a real scenario of endoscopic plication of the rectus sheath. CONCLUSION: Our simulation model met all validation criteria outlined in the Messick framework, demonstrating its ability to differentiate between experts and non-experts based on their baseline endoscopic surgical skills. This model stands as a valuable tool for evaluating skills in endoscopic rectus sheath plication.