Collaborative Human-Computer Vision Operative Video Analysis Algorithm for Analyzing Surgical Fluency and Surgical Interruptions in Endonasal Endoscopic Pituitary Surgery: Cohort Study.

BACKGROUND: The endonasal endoscopic approach (EEA) is effective for pituitary adenoma resection. However, manual review of operative videos is time-consuming. The application of a computer vision (CV) algorithm could potentially reduce the time required for operative video review and facilitate the training of surgeons to overcome the learning curve of EEA. OBJECTIVE: This study aimed to evaluate the performance of a CV-based video analysis system, based on OpenCV algorithm, to detect surgical interruptions and analyze surgical fluency in EEA. The accuracy of the CV-based video analysis was investigated, and the time required for operative video review using CV-based analysis was compared to that of manual review. METHODS: The dominant color of each frame in the EEA video was determined using OpenCV. We developed an algorithm to identify events of surgical interruption if the alterations in the dominant color pixels reached certain thresholds. The thresholds were determined by training the current algorithm using EEA videos. The accuracy of the CV analysis was determined by manual review, and the time spent was reported. RESULTS: A total of 46 EEA operative videos were analyzed, with 93.6%, 95.1%, and 93.3% accuracies in the training, test 1, and test 2 data sets, respectively. Compared with manual review, CV-based analysis reduced the time required for operative video review by 86% (manual review: 166.8 and CV analysis: 22.6 minutes; P<.001). The application of a human-computer collaborative strategy increased the overall accuracy to 98.5%, with a 74% reduction in the review time (manual review: 166.8 and human-CV collaboration: 43.4 minutes; P<.001). Analysis of the different surgical phases showed that the sellar phase had the lowest frequency (nasal phase: 14.9, sphenoidal phase: 15.9, and sellar phase: 4.9 interruptions/10 minutes; P<.001) and duration (nasal phase: 67.4, sphenoidal phase: 77.9, and sellar phase: 31.1 seconds/10 minutes; P<.001) of surgical interruptions. A comparison of the early and late EEA videos showed that increased surgical experience was associated with a decreased number (early: 4.9 and late: 2.9 interruptions/10 minutes; P=.03) and duration (early: 41.1 and late: 19.8 seconds/10 minutes; P=.02) of surgical interruptions during the sellar phase. CONCLUSIONS: CV-based analysis had a 93% to 98% accuracy in detecting the number, frequency, and duration of surgical interruptions occurring during EEA. Moreover, CV-based analysis reduced the time required to analyze the surgical fluency in EEA videos compared to manual review. The application of CV can facilitate the training of surgeons to overcome the learning curve of endoscopic skull base surgery. TRIAL REGISTRATION: ClinicalTrials.gov NCT06156020; https://clinicaltrials.gov/study/NCT06156020.

A comparison of endoscopic procedures performed at a tertiary care hospital before and during the SARS-CoV-2 pandemic.

INTRODUCTION AND AIM: SARS-CoV-2 emerged in 2019 and had a huge impact on the world. The area of endoscopy suffered great changes, causing a reduction in the number of procedures and its indications. The aim of our study was to compare the quantity, indication, and type of procedures in 2019 with those in 2020. METHOD: A retrospective, observational, analytic, and cross-sectional study was conducted, obtaining information from the endoscopy registry. The STROBE checklist was employed. STATISTICAL ANALYSIS: The quantitative variables were analyzed with descriptive statistics (measures of central tendency and dispersion) and the categorical variables with frequencies and percentages. The quantitative variables were compared, using the Student's t test/Mann-Whitney U test, and the categorical variables with contingency tables, using the Fisher's exact test. RESULTS: In 2019, a total of 277 procedures were performed, compared with 139 in 2020. Mean patient age was 98.53 months (61.46 SD) in 2019 and 77.02 months (59.81 SD) in 2020; 352 diagnostic procedures and 136 therapeutic procedures were carried out in 2019, compared with 51 diagnostic procedures and 88 therapeutic procedures in 2020. The number of diagnostic and therapeutic procedures were inverted (72.1%-36.7% and 27.9%-63.3%, respectively) (p<0.0001). Esophageal varices, upper gastrointestinal bleeding (UGIB), and foreign body extraction were the indications, in order of predominance in 2019, compared with foreign body extraction (p<0.05), UGIB, and esophageal varices in 2020. There were no differences regarding colonoscopy. CONCLUSION: There was a clear difference in indication and type of procedure, with an increase in foreign body extraction in preschoolers.

Surgical Advances in Treating Benign Prostatic Hyperplasia in Africa: What About the Endoscopic Approach?

OBJECTIVE: To assess the practices, trends, and challenges associated with the use of endoscopic techniques in Africa related to the surgical treatment of benign prostatic hyperplasia METHODS: The questionnaire, which was based on Google Forms, assessed several points related to the surgical management of benign prostatic hyperplasia. RESULTS: In 67.4% of the centers, BPH was the primary pathology requiring surgical management. In all 43 centers, approximately 1/3 of the urologists (n = 41) are able to perform an endoscopic procedure for the management of prostatic hypertrophy. Of the 43 centers, 30 had a block equipped with endourology equipment, and 56.6% (n = 17) performed endourological surgery exclusively for the surgical management of BPH. TURP is the most widely used endoscopic technique. Open prostatectomy was the only surgical technique used in 14 centers (32.5%). In the remaining centers, both procedures (endoscopy and open surgery) were used depending on the surgeon's skills. Twenty-six (60.5%) centers expressed the need for training in endoscopic management of BPH. CONCLUSION: The main challenges encountered relate to the lack of competent personnel, the unavailability of equipment and materials, and the high cost to patients. It is essential to develop modern urology in Africa, particularly in terms of endourological practices.

Intervention for reducing the overuse of upper endoscopy in patients <45 years: a protocol for a stepwise intervention programme.

Utilisation rates for healthcare services vary widely both within and between nations. Moreover, healthcare providers with insurance-based reimbursement systems observe an effect of social determinants of health on healthcare utilisation rates and outcomes. Even in countries with publicly funded universal healthcare such as Norway, utilisation rates for medical and surgical interventions vary between and within health regions and hospitals.Most interventions targeting overuse and high utilisation rates are based on the assumption that knowledge of areas of unwarranted variation in healthcare automatically will lead to a reduction in unwarranted variation. Recommendations regarding how to reduce this variation are often not very detailed or prominent.This paper describes a protocol for reducing the overuse of upper endoscopy in a Norwegian health region. The protocol uses a combination of digital tools and psychological methods targeting behavioural change in order to alter healthcare workers' approach to patient care.The aim of the planned intervention is to evaluate the effectiveness of a multifaceted set of interventions to reduce the overuse of upper endoscopy in patients under 45 years. A secondary aim is to evaluate the specific effect of the various parts of the intervention.

Multi-Institutional Analysis of Insurance Denial Patterns Within Rhinology.

BACKGROUND: Obtaining insurance approval is a necessary component of healthcare in the United States and denials of these claims have been estimated to result in a loss of 3% to 5% of revenue. OBJECTIVE: Examine the trends in insurance denials for rhinological procedures. METHODS: A retrospective review of deidentified financial data of patients who were treated by participating physicians across 3 institutions from January 1, 2021, to June 30, 2023. The data was queried for rhinological and non-rhinological procedures via CPT codes. Cumulative insurance denials were calculated and stratified by procedure and insurance type. Write-offs were dollar amounts associated with final denials. RESULTS: A sample of 102,984 procedures and visits revealed a final denial rate between 2.2% and 2.9% across institutions (p = .72). The top three rhinological procedures for final write-offs were: nasal endoscopy (16.24%, $111,836.87), nasal debridement or polypectomy (6.48%, $79,457.51), and destruction of intranasal lesion (2.11%, $56,932.20). The write-off percentage for each procedure was highest among commercial insurance payers as opposed to Medicare or Medicaid. CONCLUSION: Final denial rates of rhinology procedures ranged between 2% and 3%. Common procedures such as nasal endoscopy and nasal debridement are among the highest written-off procedures. Insurance denials can lead to notable revenue loss. Rhinology practices must continue to remain knowledgeable of the changes and effects of insurance reimbursement on their practice.

Effect of Hormone Replacement Therapy on Chronic Rhinosinusitis Management.

OBJECTIVES: To investigate whether hormone replacement therapy (HRT) impacts health care resource utilization in the management of chronic rhinosinusitis (CRS) in older women. METHODS: Using the TriNetX US health record database, women 55 years or older with a diagnosis of CRS were included and followed for 3 years. The cohort was stratified into two groups: women who received HRT at the beginning of the study were compared to women who did not receive HRT. The groups were matched by age, race, ethnicity, history of asthma, and history of nasal polyps. Outcomes included whether the patient underwent endoscopic sinus surgery (ESS) and frequency of antibiotic use. Measures of association, Kaplan-Meier analysis, and cohort descriptive statistics were calculated. RESULTS: Of the 65,400 women included, the mean age was 66.9 years. 27.0% and 3.6% of patients had a history of asthma or nasal polyps, respectively. Overall, 2.0% of CRS patients underwent ESS, with the HRT group less likely to undergo ESS [OR: 0.28; 95% CI: (0.25-0.32)] compared to patients who did not receive HRT. When stratified by polyp status, HRT patients with nasal polyps had a greater decrease in ESS rates compared to control than HRT patients without nasal polyps. The HRT group had a higher mean number of antibiotic prescriptions compared to the non-HRT group. CONCLUSION: HRT is associated with decreased utilization of ESS to treat CRS, with a greater effect size for ESS among CRSwNP patients. However, HRT was associated with higher antibiotic utilization. LEVEL OF EVIDENCE: 3 Laryngoscope, 134:3921-3926, 2024.

A Proof-of-Concept Computer Vision Approach for Measurement of Tympanic Membrane Perforations.

OBJECTIVE: Size, an important characteristic of a tympanic membrane perforation (TMP), is commonly assessed with gross estimation via visual inspection, a practice which is prone to inaccuracy. Herein, we demonstrate feasibility of a proof-of-concept computer vision model for estimating TMP size in a small set of perforations. METHODS: An open-source deep learning architecture was used to train a model to segment and calculate the area of a perforation and the visualized tympanic membrane (TM) in a set of endoscopic images of mostly anterior and relatively small TMPs. The model then computed relative TMP size by calculating the ratio of perforation area to TM area. Model performance on the test dataset was compared to ground-truth manual annotations. In a validation survey, otolaryngologists were tasked with estimating the size of TMPs from the test dataset. The primary outcome was the average absolute error of model size predictions and clinician estimates compared to sizes determined by ground-truth manual annotations. RESULTS: The model's average absolute error for size predictions was a 0.8% overestimation for all test perforations. Conversely, among the 38 survey respondents, the average clinician error was a 11.0% overestimation (95% CI, 5.2-16.7%, p = 0.003). CONCLUSIONS: In a small sample of TMPs, we demonstrated a computer vision approach for estimating TMP size is feasible. Further validation studies must be done with significantly larger and more heterogenous datasets. LEVEL OF EVIDENCE: N/A Laryngoscope, 134:2906-2911, 2024.

Trends in Endoscopic and Microscopic Approaches to Transsphenoidal Pituitary Surgery in the US.

OBJECTIVES: Among the transsphenoidal (TSS) approaches to pituitary tumors, the microscopic approach (MA) has historically been the predominant technique with the increasing adoption of the endoscopic approach (EA). This study investigates national trends in TSS approaches and postoperative outcomes for MA and EA through 2021. METHODS: The TriNetX database was queried for patients undergoing TSS (MA and EA) between 2010 and 2021. Data were collected on demographics, geographic distribution of surgical centers, postoperative complications, stereotactic radiosurgery (SRT), repeat surgery, and postoperative emergency department (ED) visits. RESULTS: 8644 TSS cases were queried between 2010 and 2021. MA rates were highest until 2013 when rates of EA (52%) surpassed MA (48%) and continued to increase through 2021 (81%). From 2010 to 2015 EA had higher odds of a postoperative CSF leak (OR 3.40) and diabetes insipidus (DI (OR 2.30)) versus MA (p < 0.05); from 2016 to 2021 differences were not significant. Although there was no significant difference among approaches from 2010 to 2015 for syndrome of inappropriate antidiuretic hormone (SIADH), hyponatremia, or bacterial meningitis, from 2016 to 2021 EA had lower odds of SIADH (OR 0.54) and hyponatremia (OR 0.71), and higher odds of meningitis (OR 1.79) versus MA (p < 0.05). EA had higher odds of additional surgery (either EA or MA) after initial surgery from 2010 to 2021. From 2010 to 2015 EA had lower odds of postoperative SRT compared to MA, whereas in 2016-2021 there was no statistical difference among approaches. CONCLUSION: This study demonstrates increasing EA adoption for TSS in the United States since 2013. Complication rates have overall improved for EA compared to MA, potentially as a result of improving surgeon familiarity and experience. LEVEL OF EVIDENCE: 4 Laryngoscope, 133:2135-2140, 2023.

Risk factors for ninety-day readmissions following full-endoscopic transforaminal lumbar discectomy for 1542 patients in the biggest spine institutes in Korea.

INTRODUCTION: Endoscopic techniques are becoming popular among spine surgeons because of their advantages. Though the advantages of endoscopic spine surgery are evident and patients can be discharged home within hours of surgery, readmissions can be sought for incomplete relief of leg pain, recurrent disc herniation, and recurrent leg pain. We aim to find out the factors related to the readmission of patients treated for lumbar pathologies. MATERIALS AND METHODS: This is a retrospective analysis of the data between the time duration of 2012 and 2022. Patients in the age group of 18-85 years, with lumbar disc herniation treated by transforaminal endoscopic lumbar procedures, were included. The patients who were readmitted within 90 days were included in the R Group and those who were not were included in the NR group. Univariable and multivariable logistic regression analyses were used to find the risk factors for 90-day readmission. RESULTS: There were a total of 1542 patients enrolled in this study. Sex, number of episodes before admission, hypertension, smoking, BMI, migration, disc height, disc height index, spondylolisthesis, instability, pelvic tilt (PT), and disc cross-sectional area (CSA) were found significant on univariable analysis. Age, spondylolisthesis, instability and muscle CSA were the only variables that were found to be statistically significant on multivariable analysis. CONCLUSIONS: This study shows that the elderly age group, presence of spondylolisthesis, segmental instability and decreased muscle cross-sectional area are independent risk factors for 90-day hospital readmissions. Patients having the above risk factors should be carefully counseled regarding the possibility of readmission in the future.

COVID-19 y cirugía. Impacto en los volúmenes de atención, complicaciones posoperatorias y mortalidad. Resultados después de un año de pandemia / COVID-19 and surgery. Impact on volumes of care, postoperative complications and mortality. Results after one year of the pandemic

RESUMEN Antecedentes: la pandemia por COVID-19 generó importantes cambios en la atención y tratamiento de los pacientes quirúrgicos. Objetivo: los objetivos de este estudio fueron comparar los volúmenes de prestaciones realizadas durante un año de pandemia con un período igual sin pandemia, proyectar su impacto asistencial e institucional, y comparar pacientes COVID+ versus COVID- para determinar complicaciones posoperatorias, mortalidad y los factores de riesgo asociados a estos eventos. Material y métodos: estudio observacional y retrospectivo. Comparamos el volumen de prestaciones realizadas entre el 19/3/20 y el 18/3/21 con idéntico período de 2019/20. Efectuamos un estudio de cohorte emparejada (2:1) entre los pacientes con COVID-19 y sin él y se analizaron las complicaciones posoperatorias, la mortalidad, y doce variables objetivas como factores de riesgo asociados. Resultados: todas las variables prestacionales analizadas disminuyeron, pero solo las internaciones programadas y las cirugías y endoscopias no urgentes cayeron significativamente. De los 979 ingresos, 41 casos fueron COVID+ (4,1%). La mortalidad fue del 29,2% en COVID+ (12/41) vs. 7,3% en COVID- (6/82) P = 0,021. Los factores de riesgo significativos asociados a mortalidad fueron: edad ≥ 75 años, hombres, COVID+, urgencias, neumonía, requerimiento de UTI y ARM. Los pacientes operados presentaron una tasa significativamente mayor de neumonías. El análisis de regresión logística (COVID+ vs. -) mostró que por ser COVID+ y registrar la necesidad de ARM, como variables determinantes, en los COVID+ solo la ARM fue determinante en la mortalidad. Conclusión: la pandemia por COVID-19 disminuyó la actividad prestacional y aumentó la mortalidad de los afectados por la virosis.

ABSTRACT Background: The COVID-19 pandemic produced significant changes in the care and treatment of surgical patients. Objectives: The aims of this study were to compare the volume of services provided during a year of pandemic with an equal period without pandemic, estimate its impact on health care and institutional care, and compare COVID-positive versus COVID-negative patients to determine postoperative complications, mortality and risk factors associated with these events. Material and methods: We conducted an observational and retrospective study, comparing the volume of services performed between March 19, 2020, and March 18, 2021, with the same period in 2019/2020. We performed a matched cohort study (in a 2:1 ratio) between patients with and without COVID-19 and analyzed the postoperative complications, mortality, and twelve objective variables as associated risk factors. Results: There was a significant decrease in planned hospitalizations and non-urgent surgeries and endoscopies, while all the other variables showed a non-significant reduction. Of the 979 admissions, 41 corresponded to COVID-positive patients (4.1%). Mortality was 29.2% in COVID-positive patients (12/41) vs. 7.3%% in those COVID negative (p = 0.021). The significant risk factors associated with mortality were age ≥75 years, male sex, COVID+, emergencies, pneumonia, requirement of ICU and MV. Patients operated on had a significantly higher rate of pneumonia. Logistic regression analysis between COVID+ patients and COVID- patients showed that COVID+ and need for MV were predictors of mortality. In COVID+ patients, only MV was a determinant of mortality. Conclusion: The COVID-19 pandemic reduced healthcare services and increased mortality in patients infected with the virus.

Removal of Small, Asymptomatic Kidney Stones and Incidence of Relapse.

BACKGROUND: The benefits of removing small (≤6 mm), asymptomatic kidney stones endoscopically is unknown. Current guidelines leave such decisions to the urologist and the patient. A prospective study involving older, nonendoscopic technology and some retrospective studies favor observation. However, published data indicate that about half of small renal stones left in place at the time that larger stones were removed caused other symptomatic events within 5 years after surgery. METHODS: We conducted a multicenter, randomized, controlled trial in which, during the endoscopic removal of ureteral or contralateral kidney stones, remaining small, asymptomatic stones were removed in 38 patients (treatment group) and were not removed in 35 patients (control group). The primary outcome was relapse as measured by future emergency department visits, surgeries, or growth of secondary stones. RESULTS: After a mean follow-up of 4.2 years, the treatment group had a longer time to relapse than the control group (P<0.001 by log-rank test). The restricted mean (±SE) time to relapse was 75% longer in the treatment group than in the control group (1631.6±72.8 days vs. 934.2±121.8 days). The risk of relapse was 82% lower in the treatment group than the control group (hazard ratio, 0.18; 95% confidence interval, 0.07 to 0.44), with 16% of patients in the treatment group having a relapse as compared with 63% of those in the control group. Treatment added a median of 25.6 minutes (interquartile range, 18.5 to 35.2) to the surgery time. Five patients in the treatment group and four in the control group had emergency department visits within 2 weeks after surgery. Eight patients in the treatment group and 10 in the control group reported passing kidney stones. CONCLUSIONS: The removal of small, asymptomatic kidney stones during surgery to remove ureteral or contralateral kidney stones resulted in a lower incidence of relapse than nonremoval and in a similar number of emergency department visits related to the surgery. (Funded by the National Institute of Diabetes and Digestive and Kidney Diseases and the Veterans Affairs Puget Sound Health Care System; ClinicalTrials.gov number, NCT02210650.).

Clinical outcomes, complications and fusion rates in endoscopic assisted intraforaminal lumbar interbody fusion (iLIF) versus minimally invasive transforaminal lumbar interbody fusion (MI-TLIF): systematic review and meta-analysis.

This meta-analysis aims to determine the clinical outcomes, complications, and fusion rates in endoscopic assisted intra-foraminal lumbar interbody fusion (iLIF) and minimally invasive transforaminal lumbar interbody fusion (MI-TLIF) for lumbar degenerative diseases. The MEDLINE, Embase, and Cochrane Library databases were searched. The inclusion criteria were: five or more consecutive patients who underwent iLIF or MI-TLIF for lumbar degenerative diseases; description of the surgical technique; clinical outcome measures, complications and imaging assessment; minimum follow-up of 12 months. Surgical time, blood loss, and length of hospital stay were extracted. Mean outcome improvements were pooled and compared with minimal clinically important differences (MCID). Pooled and direct meta-analysis were evaluated. We identified 42 eligible studies. The iLIF group had significantly lower mean intra-operative blood loss, unstandardized mean difference (UMD) 110.61 mL (95%CI 70.43; 150.80; p value < 0.0001), and significantly decreased length of hospital stay (UMD 2.36; 95%CI 1.77; 2.94; p value < 0.0001). Visual analogue scale (VAS) back, VAS leg and Oswestry disability index (ODI) baseline to last follow-up mean improvements were statistically significant (p value < 0.0001), and clinically important for both groups (MCID VAS back > 1.16; MCID VAS leg > 1.36; MCID > 12.40). There was no significant difference in complication nor fusion rates between both cohorts. Interbody fusion using either iLIF or MI-TLIF leads to significant and clinically important improvements in clinical outcomes for lumbar degenerative diseases. Both procedures provide high rates of fusion at 12 months or later, without significant difference in complication rates. iLIF is associated with significantly less intraoperative blood loss and length of hospital stay. Study registration: PROSPERO international prospective register of systematic reviews: Registration No. CRD42020180980, accessible at https://www.crd.york.ac.uk/prospero/ April 2020.

Endoscopic Management of Low-Grade Upper Tract Urothelial Carcinoma: Characterizing the Long-term Burden of Care in Comparison to Radical Nephroureterectomy.

OBJECTIVE: To compare procedure burden, oncologic, surgical and renal-function outcomes between patients with low-grade upper urothelial cancer (UTUC) who were referred for either radical management (RM) or kidney-sparing endoscopic management (EM). PATIENTS AND METHODS: We retrospectively reviewed data of all patients treated for UTUC at our tertiary medical center between 2000 and 2018 and selected patients diagnosed with unilateral low-grade UTUC. RESULTS: Twenty-four patients were treated with EM and 37 with RM. Surgical and oncologic risk factors were similar between the arms except for tumor size. Mean follow-up was 4.9 ± 3.4 years. The 5-year overall-survival rate was 85% with EM and 84% with RM (P = .707). Metastasis-free and cancer-specific survival were also similar (P = .994, P = .960). End-of-follow-up average glomerular filtration rates were 58.7 ± 21.5 and 49.2 ± 22.1 mL/min/1.73 m2, respectively (P = .12). Ninety-two percent of patients managed endoscopically had local recurrences, with an average of 3.2 recurrences per patient. Four (17%) patients underwent salvage radical nephroureterectomy. Procedure burden was higher with EM, having 6.5 ± 4.4 operations and 344 ± 272 minutes under anesthesia compared with 1.9 ± 0.4 operations (P <.0001) and 213 ± 84 minutes under anesthesia (P = .031) with RM. Cost-of-care analysis revealed higher costs for EM in both private and publicly funded medical insurance plans. CONCLUSION: Patients undergoing endoscopic management had an 83% chance of preserving their kidney and an 81% chance of 5-year metastasis-free survival at a cost of 6.5 ± 4.4 operations during a mean follow-up of 4.9 ± 3.4 years. Our findings support EM for low-grade UTUC as a valid option from oncological aspects but highlight the associated costs.

Impact of COVID-19 Pandemic on Gastroenterology Fellowship Training in Turkey: A Prospective Nationwide Survey Study.

BACKGROUND: The Coronavirus-2019 disease (COVID-19) pandemic has markedly restricted endoscopic and clinical activities in gastroenterology (GI), with a negative impact on trainee education. We aimed to inve stigate how and to what extent has GI trainees in Turkey are affected by the current pandemic in terms of general, psychological, and educational status. METHODS: We conducted a web-based survey sent electronically to 103 official GI trainees in Turkey from 37 centers. The 32-item survey included questions to capture demographic (5-questions), endoscopic (7-questions), personal protective equipment (PPE) (3-questions), psychological and general well-being (11-questions), and educational (6-questions) data. RESULTS: Ninety-six (93.2%) trainees completed the survey, of which 56.3% (n = 54) reported a decrease in independently performed endoscopic procedures. Due to pandemic, 91.7% of standard diagnostic endoscopic procedures, 57.2% of standard therapeutic procedures, and 67.7% of advanced endoscopic procedures were decreased. Out of 96 respondents, we detected signs of anxiety in 88.5%, exposure concern in 92.7%, concerns for prolongation of training period in 49%, loss of concentration and interest in 47.9%, and burnout syndrome in 63.5%. Female gender (odds-ratio: 3.856, 95% confidence interval: 1.221-12.174, P = .021) was the only independently associated factor with pandemic-related anxiety. CONCLUSIONS: COVID-19 pandemic has led to high amounts of anxiety and non-negligible rates of burnout syndrome among GI trainees, with a significant reduction in endoscopic activities. More effort and novel strategies are required to deliver sufficient competence and general-psychological well-being to GI trainees.

Mandibular Subcondylar Fracture: Improved Functional Outcomes in Selected Patients with Open Treatment.

BACKGROUND: Subcondylar fractures represent 25 to 35 percent of all mandibular fractures, yet the treatment paradigm has remained controversial. Closed treatment relies on the plasticity of the condyle head during recovery, whereas open treatment is challenging and risks facial nerve injury. Perioperative, functional, and patient-reported outcomes were measured to compare methods of open versus closed treatment of subcondylar fractures. METHODS: Selected displaced subcondylar fracture cases with open (open reduction and internal fixation of subcondylar fracture with maxillomandibular fixation) versus closed (maxillomandibular fixation) treatment were compared (n = 60). Demographics, perioperative data, complications, persistent symptoms, chin deviation, malocclusion, change in mouth opening, functional scores, and FACE-Q patient satisfaction were recorded. RESULTS: Open versus closed groups had similar demographics and perioperative data, except the open group had longer operating room time (76.39 minutes versus 56.15 minutes). In long-term follow-up, open-treated patients had fewer symptoms (9 percent versus 67 percent), less chin deviation (0 percent versus 40 percent), a less restricted mouth opening (3mm versus 5mm), and better functional scores (1.92 versus 0.861). Transient facial nerve weakness was seen in 6 percent of open cases. CONCLUSION: For selected subcondylar fracture patients, open treatment with endoscopic assistance, nerve monitoring, and specialized plates provides superior long-term results compared to closed treatment when considering symptoms and functional parameters. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, II.

Treatment outcomes in patients with laryngotracheal lesions and compromised airway during and prior to the coronovirus disease 2019 pandemic: a tertiary institution's experience.

OBJECTIVE: This study aimed to compare treatment outcomes in patients with laryngeal and tracheal stenosis treated during and prior to the coronavirus disease 2019 pandemic period. METHOD: Patients treated for laryngotracheal lesions with impending airway compromise during the active pandemic period were matched with those treated for similar lesions in the preceding years in a monocentric tertiary hospital setting. RESULTS: During the pandemic period of 55 days, 31 patients underwent 47 procedures. Seven patients (2 children, 5 adults) had open airway surgery, and one had an operation-specific complication. Twenty-four patients (10 children, 14 adults) underwent 40 endoscopic interventions without any complications. Operation specific results during and prior to the pandemic were comparable. CONCLUSION: The management strategy in patients with laryngotracheal lesions and impending airway compromise should not be altered during periods of risk from coronavirus disease 2019. Avoiding a tracheostomy by performing primary corrective surgery or proceeding with a definitive decannulation would be beneficial in these patients to reduce the risk of contagion.

Effects of general anesthesia on quality of recovery after transaxillary endoscopic breast augmentation: A randomized controlled trial.

BACKGROUND: Types of general anesthesia may affect the quality of recovery, but few studies have investigated the quality of postoperative recovery, and none has focused on patients undergoing breast augmentation. METHODS: This prospective, parallel, randomized controlled study enrolled 104 patients undergoing transaxillary endoscopic breast augmentation. Eligible patients were randomly assigned to receive inhalation anesthesia (IH, n = 52) or total intravenous anesthesia (TIVA, n = 52). Quality of recovery was assessed on the first and on the second postoperative days using the 15-item Quality of Recovery questionnaire (QoR-15). Baseline demographic, clinical characteristics, and operative data were also collected. RESULTS: The IH and TIVA groups had similar QoR-15 total scores on the first postoperative day (P = .921) and on the second postoperative day (P = .960), but the IH group had a significantly higher proportion of patients receiving antiemetics than the TIVA group (53.6% vs 23.1%, P = .002). Multivariate analysis revealed that the type of general anesthesia was not significantly associated with QoR-15 total scores on the first postoperative day (ß = 0.68, P = .874) and with QoR-15 total scores on the second postoperative day (ß = 0.56, P = .892), after adjusting for age, BMI, operation time, steroids use, and antiemetics use. CONCLUSION: For the patients undergoing transaxillary endoscopic breast augmentation, the type of general anesthesia did not significantly impact the quality of recovery. Both IH or TIVA could provide good quality of recovery demonstrated by high QoR-15 total scores. The results suggested that the type of general anesthesia may not be the most critical factors of quality of recovery in the patients undergoing transaxillary endoscopic breast augmentation.

Comparison of the clinical efficacy of percutaneous transforaminal endoscopic discectomy and traditional laminectomy in the treatment of recurrent lumbar disc herniation.

ABSTRACT: A few years ago, percutaneous transforaminal endoscopic discectomy (PTED) began to prevail in clinical treatment of recurrent lumbar disc herniation (RLDH), whereas traditional laminectomy (TL) was treated earlier in RLDH than PTED. This study aimed to compare the clinical efficacy of PTED and TL in the treatment of RLDH.Between November 2012 and October 2017, retrospective analysis of 48 patients with RLDH who were treated at the Cancer Hospital, Chinese Academy of Sciences, Hefei and Department of Orthopaedics, Second Affiliated Hospital of Anhui Medical University. Perioperative evaluation indicators included operation time, the intraoperative blood loss, length of incision and hospitalization time. Clinical outcomes were measured preoperatively, and at 1 days, 3 months, and 12 months postoperatively. The patients' lower limb pain was evaluated using Oswestry disability index (ODI) and visual analog scale (VAS) scores. The ODI is the most widely-used assessment method internationally for lumbar or leg pain at present. Every category comprises 6 options, with the highest score for each question being 5 points. higher scores represent more serious dysfunction. The VAS is the most commonly-used quantitative method for assessing the degree of pain in clinical practice. The measurement method is to draw a 10 cm horizontal line on a piece of paper, 1 end of which is 0, indicating no pain, which the other end is 10, which means severe pain, and the middle part indicates different degree of pain.Compared with the TL group, the operation time, postoperative bed-rest time, and hospitalization time of the PTED group were significantly shorter, and the intraoperative blood loss was also reduced. These differences were statistically significant (P < .01). There were no significant differences in VAS or ODI scores between the two groups before or after surgery (P > .05).PTED and TL have similar clinical efficacy in the treatment of RLDH, but PTED can shorten the operation time, postoperative bed-rest time and hospitalization time, and reduce intraoperative blood loss, so the PTED is a safe and effective surgical method for the treatment of RLDH than TL, but more randomized controlled trials are still required to further verify these conclusions.

Utility of sleep nasendoscopy versus microlaryngotracheobronchoscopy in the diagnosis of paediatric upper airway obstruction.

OBJECTIVE: To describe the utility of sleep nasendoscopy in determining the level of upper airway obstruction compared to microlaryngotracheobronchoscopy. METHODS: A retrospective observational study was conducted at a tertiary level paediatric hospital. Patients clinically diagnosed with upper airway obstruction warranting surgical intervention (i.e. with obstructive sleep apnoea or laryngomalacia) were included. These patients underwent sleep nasendoscopy in the anaesthetic room; microlaryngotracheobronchoscopy was subsequently performed and findings were compared. RESULTS: Twenty-seven patients were included in the study. Sleep nasendoscopy was able to induce stridor or stertor, and to detect obstruction at the level of palate and pharynx, including tongue base collapse, that was not observed with microlaryngotracheobronchoscopy. Only 47 per cent of patients who had prolapse or indrawing of arytenoids on sleep nasendoscopy had similar findings on microlaryngotracheobronchoscopy. However, microlaryngotracheobronchoscopy was better in diagnosing shortened aryepiglottic folds. CONCLUSION: This study demonstrates the utility of sleep nasendoscopy in determining the level and severity of obstruction by mimicking physiological sleep dynamics of the upper airway.