A Comparative Study of Surgical Outcomes in Children with Cochlear Implantation Using Posterior Tympanotomy & Modified Veria Technique.

Purpose: To compare the two common approaches of cochlear implantations i.e., mastoidectomy with posterior tympanotomy approach (MPTA) and modified veria technique and to know whether veria technique and its later modifications are as efficacious as the classic approach in terms of duration of procedure, gain in hearing and acquisition and incidence of complications if any. Methods: A prospective comparative study was undertaken at a tertiary care teaching institute. 30 children were selected and randomised into 2 groups who then underwent surgery from the same surgeon after proper evaluation but with 2 different approaches. Their outcomes were then observed and compared in terms of surgical technique and complications and hearing outcomes. Results: 30 children were operated with 15 in each group. In the study, patients under Group A (MPTA) had mean surgical duration of 139.67 ± 16.53 min while Group B (modified Veria) had of 84.67 ± 11.72 min, which was statistically significant (p < 0.05). 1 patient in Group A suffered House Brackman grade 4 facial nerve injury that recovered over 3 months and another had discolouration of the skin flap. No complications were observed in group B. During follow-up CAP and SIR scores were compared and were found to be statistically non-significant between the 2 groups (p value > 0.05), but the paired differences within each group showed statistical significance (P value- <0.001). Conclusion: Veria Technique (and its later modifications) for cochlear implantation is a simple, safe and easy procedure, which is as efficacious as MPTA with added benefits of consuming lesser surgical duration. Supplementary Information: The online version contains supplementary material available at 10.1007/s12070-022-03399-1.

Lateral Skull Base Lesions: Our Experience of 15 Years.

To analyse and report various aspects of lateral skull base surgery by describing the incidence and demographic variables, diagnostic and management challenges, surgical choices along with complications and their management and the long term morbidity and survival outcomes in our experience of 15 years. Retrospective review of complete records of all cases operated for lateral skull base tumors at a tertiary care teaching institution in India between timespan of 15 years from 2003 to 2018 was undertaken. 53 cases were selected and analysed. Those having follow up of less than 6 months were excluded. Outcomes were assessed in terms of incidence of types of tumors, benign or malignant, age and sex variation of the patients, staging status at presentation, status of facial and other lower cranial nerves pre-operatively, surgical techniques with complications if any, recurrences and survival. Of 35 benign tumors, tympanojugular paragangliomas were most common. Average age for these was 53 years with 19 females and 14 males. All were non-functional. Tinnitus and hearing loss were most common presentations. Class B2 and C1 tumors were most commonly encountered and the ITF A approach was most commonly used. Hearing loss and Facial palsy were commonest complication post-operatively. There were 2 recurrences. 18 malignancies were observed. Most were stage IV at presentation. Otorrhea and otalgia were most common presenting symptoms followed by hearing loss. 5 year survival was 55%. Successful treatment of lateral skull base lesions requires a multimodality therapy with team approach. Surgical resection is the primary management choice with variable approaches. ICA status related to the tumor is the most important consideration. Malignancies require more aggressive treatment for obtaining clear margins along with pre/post-op chemoradiation. Good results with acceptable complications can be obtained even with advanced tumors.

Sublabial Approach Versus Modified Denker's Procedure: A Comparative Study of Pre-maxillary Tissue Clearance in Covid-Associated Mucormycosis.

To compare the efficacy of the sublabial and modified Denker's procedure in clearance of fungal disease from the anterior wall of maxilla and the pre-maxillary area i.e. the difficult areas of maxillary sinus. A prospective observational study was conducted over a period of 2 months (April 21-June 21) in the ENT department of Sawai Man Singh hospital, Jaipur. All the patients with clinical involvement of the premaxilla or the cheek abutting the anterior wall of maxilla were included in the study population. Cases matched in both groups were subjected to debridement either by the sublabial or the modified denker's approach. Outcomes were measured by assessing the daily CRP values, post-operative DNE every 3 days after pack removal, and imaging at the end of 1 month. Repeat biopsies were performed in patients that still had persistent symptoms after getting operated on. 16 of the 60 patients (26.6%) operated on by the endoscopic approach showed evidence of residual disease on follow-up whereas only 5 patients (9.6%) in the other category had a similar outcome. Most of the recidivism was seen in the anterior maxilla. Lower rates of complications were found following debridement by the sublabial approach. Since the sublabial approach is the most direct approach for the key areas of fungal involvement of maxillary sinus, it is recommended over the modified Denker's procedure for disease clearance from pre maxilla and the anterior wall of maxillary sinus. This view is also supported by the lower rates of complications encountered following the former.

Diagnostic Efficacy of Thyrotropin to Thyroglobulin Ratio in Correlation with Histopathology of Euthyroid Patient Having Solitary Thyroid Nodule.

In patients with solitary thyroid nodules, the first course of action is to determine whether the nodule is benign or malignant. Many investigations are used to differentiate between benign and malignant nodules so as to avoid surgery in those who don't need it. Among these, FNAC and USG are commonly used in association with clinical features but there are drawbacks of each technique. The present study was undertaken to assess the diagnostic effectivity of thyrotropin (also known as TSH) to thyroglobulin ratio in correlation with histopathology in euthyroid patients having solitary thyroid nodule. This is a prospective study carried out on 48 euthyroid cases of solitary thyroid nodule. All patients subjected to FNAC, USG, thyrotropin and thyroglobulin assay. Then, they underwent surgery and histopathological examination (HPE) of the specimens done. Finally, the histopathology reports were correlated with the thyrotropin to thyroglobulin ratio in order to evaluate their sensitivity and specificity by statistical methods. The sensitivity and specificity of thyrotropin to thyroglobulin ratio was 100% and 100% respectively. All malignant lesions according to thyrotropin to thyroglobulin ratio were confirmed by histopathology indicating its excellence. Therefore, TSH to thyroglobulin ratio helps in planning the correct management and avoids second surgery. It was found that serum TSH:Tg is a safe, reliable and effective diagnostic modality with a high sensitivity and specificity and is the single best investigation for preoperative evaluation of solitary thyroid nodule to differentiate between benign and malignant nodules.

An Observational Study Depicting Role of p16 in Detecting Human Papilloma Virus in Oral and Oropharyngeal Cancer and Associated Factors.

The longstanding phrase, traditional risk factors like-smoking, tobacco and alcohol are the only causative agents of oral and oropharyngeal squamous cell carcinoma (SCC) is changing now. Etiological divergence is taking place which we have to know to reach upon an exact cause of the disease. Human papilloma virus (HPV) infection is a well-established cause of oral cancer. Escalating incidence of HPV associated cancer has a strong impact on its management. So, a concern clinician needs to get aware for it. Among various types of HPV, HPV-16 is more frequently associated with oral cancers. HPV detection will become a game changer in management of oral cancers. HPV infection and p16 protein expression has a strong and consistent correlation. Therefore, immunohistochemical analysis of p16 protein can be a surrogate biomarker in high risk groups. This hospital based prospective observational study recruited 180 subjects of oral and oropharyngeal SCC. We underwent immunohistochemical analysis of p16 in biopsy specimen of subjects and studied HPV status and associated environmental, clinical and behavioral factors. We observed 9.4% (17/180) incidence of p16 positivity with female predominance. Our observations showed that its prevalence was higher in urban patients who were non tobacco users, had sexually transmitted disease, early stage (T1-T2), poorly differentiated SCC with nodal metastasis. We conclude that keeping in mind HPV as a cause of oral and oropharyngeal SCC, p16 should be use as a biomarker for its detection in high risk cases.

Role of Vimentin and E-cadherin Expression in Premalignant and Malignant Lesions of Oral Cavity.

To determine the role of Vimentin and E-cadherin expression in oral premalignant and malignant lesions. 68 histopathologically confirmed cases of premalignant and malignant oral cavity lesions enrolled. Biopsy specimens were taken from lesion of all cases and subjected to immunohistochemical evaluation of expression of E-cadherin and Vimentin. We examined the relationships between the expression of these markers and specific clinicopathological features were analyzed. Out of 68 cases 28 showed high vimentin expression (3 + and 4 + grade) and 40 showed low vimentin expression (1 + and 2 + grade). 20 cases out of 68 presented with high E-cadherin expression (3 + and 4 +) and rest 48 with low expression (1 + and 2 +) of the same. Smoking and tobacco chewing reflected non-significant association with their expression. In this study all 28 patients (100%) with high vimentin expression had malignant lesions and 17 (60.7%) presented with metastatic lymph nodes Out of 20 patients with high E-cadherin expression 8(40.0%) had malignant lesions and 12 (60.0%) had pre malignant lesions and 4 (20%) showed nodal metastasis. As tumor stage (TNM) progresses, it showed increased vimentin and decreased E-cadherin expression and vice versa. We concluded that increased vimentin and decreased E-cadherin expression in oral cancers are associated with metastasis and disease progression in terms of upstaging of disease. We can use cellular expression of vimentin and E-cadherin for early diagnosis of disease.

Invasive Fungal Infections in Dengue Recovered Patients: A New Phenomenon in the Covid-19 Era.

Invasive fungal rhinosinusitis was seen to rise to epidemic levels after the 2nd wave of ongoing Covid pandemic, especially in tropical countries, maximally in India. A similar trend is being observed for cases who have recently recovered from dengue virus infection. Post dengue invasive fungal infection is a new presentation and any associations between it and Covid pandemic need to be studied in detail to help prepare for any complications. 3 patients presented to the out-patient department of E.N.T at a tertiary level teaching hospital in East India with complains similar to rhinosinusitis. These patients were then evaluated and diagnosed to be infected from Mucormycosis and Aspergillosis fungal sinusitis after which they were managed with surgical debridement and systemic antifungal therapy. All had a recent history of recovery from Dengue virus infection and a possible association could be suspected. 3 patients presented with complains of pain over upper jaw with orbital swelling and loss of vision developing over a period of 24 days. Two of them had ulceration of hard palate. They were then subjected to Contrast MRI along with CT scan of the Paranasal sinuses which depicted pansinus involvement with intracranial extension in two patients. These were then planned for diagnostic nasal endoscopies along with biopsies which turned out to be Invasive fungal sinusitis in the form of Aspergillosis and Mucormycosis. All the 3 patients had recent history of recovery from Dengue virus infection and did not have any other co-morbidities. Covid Associated Mucormycosis (CAM) is a well-known entity now but no reports of Dengue associated Invasive fungal sinusitis are yet reported. Whether this new phenomenon has anything to do with the interactions between dengue virus and coronavirus is not known at present and needs to be studied in detail so appropriate management protocols can be formulated.

Otology Training in India: Is It Up to the Mark?

Different studies have shown that a significant number of medical graduates do not achieve the necessary preparedness for delivery of effective health care in a safe and acceptable manner. Various studies have been undertaken to explore the competencies of surgical residents in otorhinolaryngology. This study was carried out to find out the status of training in otology being provided across different institutions in India. This is a cross sectional study undertaken at All India Institute of Medical Sciences (AIIMS), Jodhpur. An online survey questionnaire enquiring about different aspects of otologic training being followed at various centres was developed and was sent online to all prospective responders. Out of the 217 responders, 88 were faculty members and 129 residents. 62% of the faculty members and 56.5% of residents mentioned that their centre has a temporal bone dissection lab. 64.7% of the faculty members and 58.2% of the residents responded that temporal bone dissection is mandatory before live surgeries. 44% residents have their thesis topic related to otology. About 79% of faculty members and residents are not happy with the the training module being followed in their centre and feel it needs improvement. There needs to be a standardized curriculum that is followed all over the country for teaching the residents during their residency. Increase in existing centers with well equipped staff and facilites is required to provide the residents with opportunities to hone and refine their surgical skills during their training period. Supplementary Information: The online version contains supplementary material available at (10.1007/s12070-021-02485-0).

Encapsulated Follicular Variant of Papillary Thyroid Carcinoma: A review on Surgical Treatment.

Differentiated thyroid carcinoma is one of the commonest malignancies in head and neck region. Among differentiated thyroid carcinoma, papillary carcinoma is the commonest. Encapsulated follicular variant of papillary thyroid carcinoma tumors are very indolent tumors which behave like benign tumors. Many tumors have been over diagnosed and over treated in spite of their indolent nature. We aimed to find out if total thyroidectomy is really required for very low grade tumors like encapsulated FVPTC. We operated 672 patients of thyroid disease during 2012 to 2020 in SMS Medical College, Jaipur. Out of 256 patients, 199 patients (78%) had papillary carcinoma of thyroid. Classical variant was present in 40% and follicular variant was present in 35% (N-69). Out of 69 patients with follicular variant of PTC, 59 patients had well encapsulated type of follicular variant of PTC while 10 patients had invasive type of follicular variant of PTC. Encapsulated FVPTC are less aggressive and indolent tumors. They should be treated more conservatively. Hemithyroidectomy is sufficient treatment for its complete cure. Out of 69 patients with Follicular variant of PTC, 59 patients had encapsulated disease. Out of 59 patients, 14 (24%) had bilateral nodular disease. 45 (77%) patients had unilateral disease; multicentric in one lobe in 9 (15%) patients and unicentric in 36 (61%) patients. However, encapsulated FVPTC was only found in predominant lobe and the non dominant lobe had benign disease.

Spontaneous Esophageal Perforation in an Infant: A Rare Case.

Spontaneous perforation of the esophagus is an emergency that requires early diagnosis and management. It may be fatal and delay in treatment can cause an increase in morbidity and mortality. Despite of being very rare in infants, we have to be watchful whenever we encounter signs and symptoms related to it. Only 7 cases of spontaneous esophageal perforation in infants have been report in the literature to the best of our knowledge. Here we are reporting a rare case of spontaneous esophageal rupture in an infant.

Vertical Strut Ossiculoplasty: A Versatile Alternate to Conventional Techniques-A Randomized study.

INTRODUCTION: Various ossicular reconstruction materials and techniques have been described in literature using autologous ossicle, cortical bone, autologous cartilage, synthetic materials and implants like total/partial ossicular replacement prosthesis (TORP/PORP) etc., but it has always been a topic of controversy in terms of the efficacy, longevity and complications of the material or method used. MATERIAL AND METHODS: This is a prospective, interventional, comparative, double-blind randomized control study which was done at a tertiary care center to compare outcomes of conventional and carved conchal cartilage (vertical strut) type III Tympanoplasty in terms of graft uptake and hearing gain. A total number of 52 cases were enrolled, randomized and allocated to 2 groups (26 each) i.e. group A (conventional type III) and group B (vertical strut technique). RESULTS: Graft uptake was seen in 25 (96.16%) patients in group B while it was observed in 23 (88.5%) cases in group A. Hearing gains were also better in group B. CONCLUSION: This study suggests that Vertical Strut technique can be studied further as it gives better gains in Air Conduction threshold and A-B Gap along with graft uptake as it provides better middle ear space and ossicular / tympanic membrane interface resulting in better hearing.

The diagnostic and prognostic utility of insulin growth factor of squamous cell carcinoma in oral cavity.

OBJECTIVE: The present study was conducted to find the utility of insulin growth factors (IGFs) as diagnostic and prognostic biochemical parameters in patients suffering from squamous cell carcinoma of oral cavity. MATERIALS AND METHODS: A total of 360 male and female patients diagnosed with precancerous conditions (PCC) and oral squamous cell carcinoma (OSCC) of Stage I to IV were selected for the present study. Patients were interviewed using a structured questionnaire to ascertain their demographic and medical history. After completing the history and physical examination, patients were subjected to routine blood investigations along with determining insulin growth factor (IGF-1, IGFBP-3) levels. The data obtained were then subjected to statistical analysis using SPSS 20.0 version. RESULTS: The mean values of IGF-1, insulin-like growth factor-binding protein-3 (IGFBP-3), and ratio of IGF-1 and IGFBP-3 were obtained. The intergroup comparison was done between PCC and all the stages of OSCC for all the IGFs. The result obtained was found to be statistically significant (P < 0.05). CONCLUSION: The present study concluded that a positive correlation was observed for various insulin growth factors (IGF-1, IGFBP-3; and ratio of IGF-1 and IGFBP-3) between OSCC and PCC such as erythroplakia and oral submucous fibrosis. Thus, the study highlighted the use of IGFs as diagnostic and prognostic parameters in patients suffering from cancerous conditions.

Is It Wise to Wait for Ear to Become Dry in Indian Scenario?

Tympanoplasty is the standard and well-established procedure for closure of tympanic membrane perforations. Tympanoplasty in wet ear is still a topic of debate among ENT surgeons. This study discusses the balance between wait and watch policy and early intervention in wet ear. It also compares the rate of graft uptake and hearing improvement in Type I tympanoplasty in dry and wet ears. This is a hospital based, observational, descriptive and comparative study. Total 246 patients enrolled in the study. Two groups were created with 123 patients in each group. One included dry ears and another included wet ears. All patients had mucosal type of chronic otitis media. They all underwent Type I tympanoplasty. Graft uptake rate and hearing was compared between both groups. The overall success rate (graft uptake) was 91.06% (224). The success rate in dry ear group was 93.50% (115) and in wet ear group it was 88.62% (109). This study concluded that there is no added advantage of drying the ear rather the delay in treatment increases morbidity and drop outs in Indian scenario.

Modified Veria Technique for Cochlear Implantation by Postaural Approach.

There are various surgical techniques for cochlear implantation, classical one being mastoidectomy and posterior tympanotomy which has some disadvantages and complications like extensive bone work, violation of mastoid air cell system and fear of injury to vital structures like facial nerve. To minimize these problems, various modifications in cochlear implantation surgery has been done which includes introduction of Veria technique which also has certain disadvantages like extensive dissection and prolonged surgical time. In this article we are introducing an innovative technique of cochlear implantation where we have modified the pre-existing Veria technique that has been described in detail in the coming sections. Total 9 cases have been done so far with this modified Veria technique. This technique includes postaural approach with minimal soft tissue and bone work, making the cochlear implantation simple, easily doable, with less operating time, with minimal morbidity, faster healing due to smaller incision and avoiding facial nerve injury.

Is thyroid excision mandatory with laryngectomy in carcinoma larynx?

BACKGROUND: Advanced stage operable cancers of larynx are treated with total laryngectomy including thyroid resection in most of the cases, which may expose patient to hypothyroidism and hypoparathyroidism. The requirement of thyroidectomy during Total Laryngectomy is controversial. METHODS: A cross sectional observational study was set out to review preoperative clinical and radiological assessment; intraoperative and histopathological findings; and follow-up data to predict thyroid gland invasion in the setting of squamous cell carcinoma of the Larynx. RESULTS: 11 (16%) out of 69 patients had thyroid gland involvement on histopathological examination with mean age 63 years. Out of these 11 cases, 8 (72%) underwent primary total laryngectomy. 90% patients with thyroid gland involvement were male. 9 cases with thyroid gland involvement were staged as T4a preoperatively. CONCLUSION: Invasion of thyroid gland by laryngeal cancer is uncommon. Unnecessary hemithyroidectomies lead to hypothyroidism and hypoparathyroidism. The study points out the clear indications of thyroid excision in patients undergoing total laryngectomy. We can suggest that total thyroidectomy should be done with total laryngectomy in cases which have gross clinical, radiological or intraoperative thyroid gland involvement, subglottic extension and thyroid cartilage invasion. This can save the patients from the brunt of unnecessary morbid hypothyroidism and hypoparathyroidism.

Conference report on the Indo Global Summit on Head and Neck Oncology (IGSHNO 2017-BMCON-IV), 24-26 February 2017, Jaipur, India.

'The multidisciplinary approach: expanding treatment horizons for head and neck cancer' was the major theme of the Indo Global Summit on Head and Neck Oncology (IGSHNO 2017-BMCON-IV). The meeting, held in Jaipur (Rajasthan, India) from 24 to 26 February 2017, assembled 600 participants from India and worldwide. It was organised by the Bhagwan Mahaveer Cancer Hospital and Research Centre (BMCHRC), Jaipur. BMCHRC Jaipur is one of the largest superspeciality oncology research and treatment centres in north India. The vision of BMCHRC has been to foster collaboration between oncologists, encouraging dialogue in an open forum that improves the care and outcomes of patients with cancer using the latest advances in cancer treatment. IGSHNO 2017 was part of this aim and vision. The organising team, including Dr Anil Gupta (Organising Secretary), Dr Lalit Mohan Sharma (Organising Secretary), Dr Pawan Singhal (Chairperson, scientific programme), Dr Tej Prakash Soni (Treasurer, Organising Secretary, Radiotherapy workshop), Dr Umesh Bansal and Dr Dinesh Yadav (Joint Organising Secretary), Dr Anjum Khan (Organising Secretary, Palliative care workshop), Dr Gaurav Pal Singh (Organising Secretary, Dental and prosthodontics workshop) and Dr (Maj Gen) SC Pareek (Medical Director, BMCHRC, Jaipur, India) worked hard for the previous 6 months to make this conference a successful academic event. IGSHNO 2017, held over three days, is a chance for oncologists from different parts of India to come together and discuss ongoing research, recent announcements and introduce new developments in head and neck cancer. It consisted of 51 lectures, seven debates, 10 panel discussions, oral paper presentations, e-poster sessions, a quiz for postgraduate students, a live surgery workshop, a prosthodentics workshop for dentists, a radiotherapy contouring workshop for radiation oncologists, a pain and palliative care workshop and a meet the expert session-all focusing on the multidisciplinary treatment of head and neck cancer. Special highlights from IGSHNO 2017 included the radiotherapy contouring workshop, the live surgery workshop by internationally renowned head and neck oncosurgeons, the dental and prosthodontics workshop and the pain and palliative care workshop.

A prospective study on the role of octreotide in management of chyle fistula neck.

OBJECTIVE: To study the effectiveness of octreotide in managing chyle fistula neck and its effect on duration of hospitalization. STUDY DESIGN: Prospective study. METHODS: A total of 19 patients with chyle fistula following neck dissection over a period of 10 years were included in the study. All the patients first underwent conservative management of the chyle leak, including suction drainage, pressure dressings, bed rest, and nutritional modifications. In all of the cases, chyle leak persisted despite conservative management. Octreotide was started in a dose of 100 µg subcutaneously every 8 hours for 5 days in cases with low-output leaks and for 7 days in cases with high-output leaks. In all of the cases, the duration of chyle leak after starting treatment with octreotide and the duration of hospitalization was recorded. RESULTS: Chyle leak stopped in all the cases using octreotide. The mean duration of hospitalization was 13.8 days. CONCLUSION: Chyle leak stopped within 5 days of starting octreotide in the low-output cases and within 7 days in the high-output cases. This permitted early resumption of a regular oral diet and reduced morbidity associated with chyle fistula. The rapid response and minimal side effect profile make octreotide a promising addition to the medical management of a chyle fistula.

Association of naso-Oro-pharyngeal structures with the sleep architecture in suspected obstructive sleep apnea.

The study was conducted to find out the association of various naso-oro-pharyngeal structures with sleep macro-architecture in suspected obstructive sleep apnea subjects. Study included 51 subjects with suspected obstructive sleep apnea. Subjects with possible central apnea and those consuming any substance that can affect sleep architecture were excluded. Level I polysomnography was performed after thorough physical examination. Overnight study was scored in 30 s epochs to find out the polysomnographic variables. Surgical treatment was offered wherever indicated. Subjects with moderate to severe obstructive sleep apnea were manually titrated on CPAP with the polysomnogram. SPSS v 17.0 was used for statistical analysis. We did not find any difference in the sleep architecture between genders. Sleep Efficiency was better in subjects with dental overjet, dental attrition, high tongue base, macroglossia, lesser oral cavity volume, edematous uvula, increased submental fat, hypertrophied facial muscles and Mallampatti grade III-IV. Shorter Sleep Latency was seen in subjects with tender TMJ and Mallampatti Gr III-IV. REM latency was shorter in subjects with high tongue base, macroglossia and hypertrophied muscles of mastication. Increased REM was observed in subjects with high tongue base, edematous uvula and tender TMJ. Enlarged tonsils had reversed effect with poor sleep efficiency, increased REM latency and decreased REM. CPAP therapy (N = 20) lessened awake time, decreased N2 and increased REM. Oro-pharyngeal structures affect the sleep architecture in suspected OSA subjects. Nasal structures do not affect the sleep architecture in these subjects and enlarged tonsils have opposite effect. Sleep architecture changes on the titration night with CPAP.

Impact of anatomical and radiological findings for consideration of functional endoscopic sinus surgery.

Endoscopic sinus surgery is being done more accurately and with better diagnosis and planning with the help of high resolution CT scan. It has played an invaluable role in the delineation of the sinonasal pathology and anatomic variations preoperatively. To correlate the CT scan findings with endoscopic findings with respect to anatomical variants and pathology and evaluation of its impact on surgical planning. A prospective study conducted on 300 patients who presented to the ENT out patient department with sinonasal diseases and underwent Functional endoscopic sinus surgery. There is a need to evaluate and correlate the findings to deduce the extent of relations CT findings have to that of findings observed during endoscopy as they really affect the surgical planning and outcomes.