The optimal ratio of endoscope-sheath diameter with negative-pressure ureteral access sheath: an in vitro research.

PURPOSE: To maintain safe intrarenal pelvic pressure (IPP), the combination of flexible ureteroscope (fURS) and traditional ureteral access sheath (T-UAS) should maintain a basic rule that is the ratio of endoscope-sheath diameter (RESD) ≤ 0.75. However, the negative-pressure ureteral access sheath (NP-UAS) may break the rule of negative pressure suction. This study aimed to examine the effect of NP-UAS on IPP and flow rate (FR) with varying RESD. METHODS: In a 3D-printed renal model, flexible ureteroscopy lithotripsy (fURL) was replicated. Six sizes of fURS paired with 12Fr T-UAS and NP-UAS resulted in six distinct RESDs of 0.63, 0.78, 0.87, 0.89, 0.90, and 0.91. While the irrigation pressure (IRP) was set between 100 and 800 cmH2O and the sucking pressure (SP) was set between 0 and 800 cmH2O, the IPP and FR were measured in each RESD. RESULTS: NP-UASs can reduce the IPP and increase the FR at the same RESD compared to T-UASs. The IPP decreased with increasing SP with NP-UAS. When RESD ≤ 0.78, T-UAS and NP-UAS can maintain IPP < 40 cmH2O in most circumstances. When RESD = 0.87, it is challenging for T-UAS to sustain IPP < 40 cmH2O; however, NP-UAS can do so. When RESD ≥ 0.89, it is difficult to maintain an IPP < 40 cmH2O even with NP-UAS. CONCLUSION: NP-UAS can decrease IPP and increase FR compared with T-UAS. To maintain a safe IPP, it is recommended that RESD < 0.85 when utilizing NP-UAS.

Factors affecting the intraoperative calculi excretion during flexible ureteroscopy lithotripsy: an in vitro analysis.

OBJECTIVE: To explore the parameters influencing intraoperative calculi excretion (ICE) during flexible ureteroscopy lithotripsy (fURL) using in vitro simulation experiments. METHODS: 3D-printed human kidney models were used to simulate the elimination of gravel during fURL. The factors influencing the ICE during fURL were analyzed by comparing the effects of different degrees of hydronephrosis (mild, moderate, and severe), surgical positions (supine and lateral position), ratios of endoscope-sheath diameter (RESD) (0.625, 0.725, and 0.825), gravel sizes (0.50-1.00 mm, 0.25-0.50 mm, and 0.10-0.25 mm), and ureteral access sheaths (UASs) (traditional UAS and negative-pressure UAS) on ICE. RESULTS: The impacts of various UAS, RESD, degree of hydronephrosis, surgical positions, and gravel sizes on ICE were all significant (p < 0.05). We found no evidence of multicollinearity for all the independent variables, and the linear regression equation fitted as ICE ( g / min ) = 0.102 + 0.083 ∗ UAS grade - 0.050 ∗ RESD grade - 0.048 ∗ hydronephrosis grade + 0.065 ∗ position grade - 0.027 ∗ gravel size grade (R2 = 0.569). CONCLUSION: Employing negative-pressure UAS, smaller RESD, milder hydronephrosis, lateral position, and smaller gravel size contribute to improved ICE during fURL. Among them, the adoption of negative-pressure UAS had the most substantial effects.

Usefulness and Educational Benefit of a Virtual Scale Endoscope in Measuring Colorectal Polyp Size.

INTRODUCTION: The virtual scale endoscope (VSE) is a newly introduced endoscope that helps endoscopists in measuring colorectal polyp size (CPS) during colonoscopy by displaying a virtual scale. This study aimed to determine the usefulness of the VSE for CPS measurement and the educational benefit of using VSE images to improve CPS estimation accuracy. METHODS: This study included 42 colorectal polyps in 26 patients treated at Hiroshima University Hospital. In study 1, CPS measured using a VSE before endoscopic mucosal resection was compared with CPS measured on resected specimens, and the agreement between the two measurement methods was evaluated via Bland-Altman analysis. In study 2, 14 endoscopists (5 beginners, 5 intermediates, and 4 experts) took a pre-test to determine the size of 42 polyps. After the pre-test, a lecture on CPS measurement using VSE images was given. One month later, the endoscopists took a post-test to compare CPS accuracy before and after the lecture. RESULTS: In study 1, Bland-Altman analysis revealed no fixed or proportional errors. The mean bias ±95% limits of agreement (±1.96 standard deviations) of the measurement error was -0.05 ± 0.21 mm, indicating that the agreement between two measurement methods was sufficient. In study 2, the accuracy of CPS measurement was significantly higher among beginners (59.5% vs. 26.7%, p < 0.01) and intermediates (65.2% vs. 44.3%, p < 0.05) in the post-test than in the pre-test. CONCLUSION: The VSE accurately measures CPS before resection, and its images are useful teaching tools for beginner and intermediate endoscopists.

A generic scope actuation system for flexible endoscopes.

BACKGROUND: A scope actuation system assists a surgeon in steering a scope for navigating an operative field during an interventional or diagnostic procedure. Each system is tailored for a specific surgical procedure. The development of a generic scope actuation system could assist various laparoscopic and endoscopic procedures. This has the potential to reduce the deployment and maintenance costs for a hospital, making it more accessible for clinical usage. METHODS: A modular actuation system (for maneuvering rigid laparoscopes) was adapted to enable incorporation of flexible endoscopes. The design simplifies the installation and disassembly processes. User studies were conducted to assess the ability of the system to focus onto a diagnostic area, and to navigate during a simulated esophagogastroduodenoscopy procedure. During the studies, the endoscope was maneuvered with (robotic mode) and without (manual mode) the actuation system to navigate the endoscope's focus on a predefined track. RESULTS: Results show that the robotic mode performed better than the manual mode on all the measured performance parameters including (a) the total duration to traverse a track, (b) the percentage of time spent outside a track while traversing, and (c) the number of times the scope focus shifts outside the track. Additionally, robotic mode also reduced the perceived workload based on the NASA-TLX scale. CONCLUSIONS: The proposed scope actuation system enhances the maneuverability of flexible endoscopes. It also lays the groundwork for future development of modular and generic scope assistant systems that can be used in both laparoscopic and endoscopic procedures.

Upper gastrointestinal endoscopic submucosal dissection using an ultrathin endoscope: a retrospective, single-center evaluation.

BACKGROUND: Recent studies have reported the therapeutic use of endoscopic submucosal dissection (ESD) using an ultrathin endoscope for targeting pharyngeal and distal side lesions in the stenosis or as a less invasive treatment via the nasal route. However, the effectiveness and safety of these treatments remain undetermined. Therefore, this study aimed to review treatment outcomes and discuss the advantages and precautions of the treatments based on our experience. METHODS: This study included 13 patients with 14 lesions who underwent 14 sessions of upper gastrointestinal ESD using an ultrathin endoscope between December 2021 and August 2023. The outcome measures included lesion background, en bloc resection rate, en bloc complete resection rates, and incidence of adverse events (including post-operative bleeding, intraoperative perforation, and delayed perforation). RESULTS: The lesions in the esophagus, stomach, and duodenum were eight, three, and three, respectively, and the median length (range) of each located lesion was 16.5 (6-26), 17 (9-36), and 10 (4-16) mm, respectively. En bloc resection and en bloc complete resection rates were 100 and 92.9%, respectively. The only adverse event was an intraoperative perforation observed during duodenal ESD, resulting from the assistant's inadvertent expansion of the SOUTEN at the final dissection stage. CONCLUSION: Our results demonstrate that ESD with an ultrathin endoscope effectively reaches lesions in difficult locations and enables treatment within a small working space. Therefore, ESD using an ultrathin endoscope is a treatment option for lesions located distally to gastrointestinal stenosis, highly fibrotic lesions, and duodenal tumors.

Development of a novel multipoint traction device for gastric and colorectal endoscopic submucosal dissection and evaluation of its efficacy and safety.

BACKGROUND: Proper traction allows safer and easier endoscopic submucosal dissection; however, single-point traction may not be sufficient. In this study we assessed the safety, efficacy, and feasibility of our newly developed multipoint traction device. METHODS: During an ex vivo study using a Konjac training model, two experts and two trainees resected 80 mock lesions of 20-mm diameter by performing endoscopic submucosal dissection with and without multipoint traction. The primary outcome was the success rate of the procedure involving traction. The secondary outcomes were the submucosal dissection time, dissection speed, and perforation during endoscopic submucosal dissection. During the in vivo study, to clarify the initial clinical outcomes, we used data from the electronic medical record of patients at our institution who underwent gastric and colorectal endoscopic submucosal dissection, which was performed by experts with our newly developed multipoint traction device, from March to December 2022. RESULTS: The ex vivo study indicated that all traction procedures were successful. Higher resection speeds were observed with endoscopic submucosal dissection with traction than without traction (P < 0.001). Perforations were not observed. During the first in vivo clinical study, traction was feasible during 20 gastric and colorectal endoscopic submucosal dissection procedures. No adverse events occurred. CONCLUSIONS: Our multitraction device can increase the submucosal dissection speed and simplify endoscopic submucosal dissection techniques, thus safely reducing technical challenges. The application of this device for endoscopic submucosal dissection could lead to safer and more efficient procedures. Clinical registration UMIN Clinical Trials Registry, Japan (registration number UMIN000053384).

Comparative Optics of the Surgical Microscope and Rigid Endoscopes in Neurosurgery.

This chapter is intended to provide a brief overview of the optics of surgical microscopes and rigid endoscopes, with the aim of providing the reader with the principles dictating the nature of surgical visualization when either of the visual control systems is used. It is not by any means geared toward elaborating on the detailed optical physics of these systems, which is beyond the scope and objective of this chapter.

Fully Endoscopic Nontubular Retractor Approach for Intraaxial Tumors.

BACKGROUND: Fully endoscopic or endoscope-controlled approaches are essentially keyhole approaches in which rigid endoscopes are the sole visualization tools used during the whole procedure. At the early attempts of endoscope-assisted cranial surgery, it was noted that rigid endoscopes enabled overcoming the problem of suboptimal visualization when small exposures are used. The technical specifications and design of the currently available rigid endoscopes are associated with a group of unique features that define the endoscopic view and lay the basis for its superiority over the microscopic view during brain surgery. Fully endoscopic resection of intraparenchymal brain tumors is a minimally invasive approach that is not routinely practiced by neurosurgeons, with a few major series published so far. Unfamiliarity with the technique, steep learning curve, and concerns about inadequate exposure and decreased visibility may explain this fact. The majority of the purely endoscopic resections for intraparenchymal brain lesions are performed nowadays through tubular retractor systems. In very limited instances, however, the fully endoscopic technique is performed without tubular retractors. In this chapter, we elaborate on the surgical technique and nuances of the fully endoscopic nontubular retractor approach for intraaxial tumors. METHODS: From a prospective database of endoscopic procedures maintained by the senior author, clinical data, imaging studies, and operative charts and videos of cases undergoing fully endoscopic excision for intraaxial brain tumors were retrieved and analyzed. The pertinent literature was also reviewed. RESULTS: The surgical technique of the fully endoscopic nontubular retractor approach for intraaxial tumors was formulated. CONCLUSION: The endoscopic technique has many advantages over the conventional procedures. In our hands, the technique has proven to be feasible, efficient, and minimally invasive with excellent results.

Fully Endoscopic Retrosigmoid Approach for Cerebellopontine Angle Tumors.

BACKGROUND: Fully endoscopic or endoscope-controlled approaches are essentially keyhole approaches in which rigid endoscopes are the sole visualization tools used during the whole procedure. At the early attempts of endoscope-assisted cranial surgery, it was noted that rigid endoscopes enabled overcoming the problem of suboptimal visualization when small exposures are used. The technical specifications and design of the currently available rigid endoscopes are associated with a group of unique features that define the endoscopic view and lay the basis for its superiority over the microscopic view during brain surgery. Fully endoscopic retrosigmoid approach for cerebellopontine angle tumors is a minimally invasive approach that is not routinely practiced by neurosurgeons, with few series published so far. Unfamiliarity with the technique, steep learning curve, and concerns about inadequate exposure, neurovascular injury, and decreased visibility may explain this fact. In this chapter we elaborate on the surgical technique and nuances of the fully endoscopic retrosigmoid approach and present an overview of the published series. METHODS: From a prospective database of endoscopic procedures maintained by the senior author, clinical data, imaging studies, operative charts, and videos of cases undergoing fully endoscopic retrosigmoid approach for cerebellopontine angle tumors were retrieved and analyzed. The pertinent literature was also reviewed. RESULTS: The surgical technique of the fully endoscopic retrosigmoid approach was formulated. CONCLUSION: The endoscopic technique has many advantages over the conventional procedures. In our hands, the technique has proven to be feasible, efficient, and minimally invasive with excellent results.

Fully Endoscopic Resection of Frontal Osteomas.

BACKGROUND: Osteomas are the most common primary bone tumors of the calvaria, with an incidence of less than 0.5%. In skull vault osteomas, the exostotic form that grows from the outer table is more common than the enostotic ones which arise from the inner table and grow intracranially. Osteomas of the forehead are very noticeable and disfiguring; patients usually seek medical advice for cosmetic reasons. Forehead osteomas were traditionally excised via either a direct incision over the lesion using the naturally occurring creases or a conventional bicoronal flap. More recently, endoscopic approaches for excision of forehead osteomas were introduced. The results were very encouraging and the technique was adopted by many groups worldwide yet with many technical variations. In this chapter we elaborate on the surgical technique and nuances of the fully endoscopic resection of frontal osteomas. METHODS: From a prospective database of endoscopic procedures maintained by the senior author, clinical data, imaging studies, operative charts, and videos of cases of forehead osteomas were retrieved and analyzed. The pertinent literature was also reviewed. RESULTS: The surgical technique of the fully endoscopic resection of frontal osteomas was formulated. CONCLUSION: The endoscopic technique has many advantages over the conventional procedures. In our hands, the technique has proven to be less time-consuming, efficient, and minimally invasive with excellent cosmetic results.

Endoscopic Supraorbital Translaminar Approach.

Surgical selection for third ventricle tumors demands meticulous planning, given the complex anatomic milieu. Traditional open microsurgical approaches may be limited in their access to certain tumors, prompting the exploration of alternative techniques. The endoscopic supraorbital translaminar approach (ESOTLA) has emerged as a promising alternative for managing these tumors. By combining a minimally invasive keyhole approach with endoscopic visualization, the ESOTLA provides enhanced illumination and a wider angle of view within the third ventricle. This unique advantage allows for improved access to retrochiasmatic tumors and reduces the need for frontal lobe and optic chiasm retraction required of microscopic techniques, decreasing the risk of neurocognitive and visual deficits. Complications related to the ESOTLA are rare and primarily pertain to cosmetic issues and potential compromise of the hypothalamus or optic apparatus, which can be minimized through careful subarachnoid dissection. This chapter offers a comprehensive description of the technical aspects of the ESOTLA, providing insights into its application, advantages, and potential limitations. Additionally, a case description highlights the successful surgical extirpation of an intraventricular papillary craniopharyngioma via the ESOTLA followed by targeted therapy. To better illustrate the stepwise dissection through this novel approach, a series of cadaveric and intraoperative photographs are included.

Fully Endoscopic Supraorbital Approach for Anterior Cranial Base Meningiomas.

BACKGROUND: Anterior cranial base meningiomas include those meningiomas originating from the tuberculum sellae, the planum sphenoidale, or the olfactory groove, with surgical excision being the main treatment modality for these tumors. Conventional microscopic and endoscope-assisted versions of the supraorbital keyhole approach via an eyebrow incision emerged into minimally invasive options that are frequently utilized nowadays for treating these tumors. At the early attempts of endoscope-assisted cranial surgery, it was noted that rigid endoscopes enabled overcoming the problem of suboptimal visualization when small exposures are used. The technical specifications and design of the currently available rigid endoscopes are associated with a group of unique features that define the endoscopic view and lay the basis for its superiority over the microscopic view during brain surgery. Notwithstanding, the fully endoscopic or endoscope-controlled version of the supraorbital keyhole approach is not routinely practiced by neurosurgeons, with few series published so far. In this chapter we elaborate on the surgical technique and nuances of the fully endoscopic supraorbital approach for anterior cranial base meningiomas. METHODS: From a prospective database of endoscopic procedures maintained by the senior author, clinical data, imaging studies, operative charts, and videos of cases undergoing fully endoscopic excision of anterior cranial base meningiomas via supraorbital approach were retrieved and analyzed. The pertinent literature was also reviewed. RESULTS: The surgical technique of the fully endoscopic supraorbital approach for anterior cranial base meningiomas was formulated. CONCLUSION: The fully endoscopic supraorbital approach for anterior cranial base meningiomas has many advantages over the conventional procedures. In our hands, the technique has proven to be feasible, efficient, and minimally invasive with excellent results.

Endoport-Guided Endoscopic Excision of Intraaxial Brain Tumors.

OBJECTIVE: Transcortical approaches using a spatula-based retraction system have traditionally been used for the microsurgical resection of deep-seated intraventricular and parenchymal brain tumors. Recently, transparent cylindrical or tubular retractors have been developed to provide a stable corridor to access deeper brain lesions and perform bimanual microsurgical resection. The flexible endoports minimize brain retraction injury during surgery and, along with the superior vision of endoscopes, offer several advantages over standard microsurgery. In this chapter, we describe the surgical technique of the endoport-guided endoscopic excision of deep-seated intraaxial brain tumors. METHODS: The endoscopic endoport technique that we use at our institution for the surgical management of intraventricular and intraparenchymal brain tumors has been described in detail with illustrative cases. RESULTS: Results from the literature review of intraventricular and intraparenchymal port surgery were analyzed, and the feasibility and safety of this technique were discussed. Surgical complication avoidance and management were highlighted. The port technique offers numerous potential advantages, including (1) reducing focal brain injury by distributing retraction forces homogenously, (2) minimizing white matter disruption and the risk of fascicle injury during cannulation, (3) ensuring the stability of the surgical corridor during the procedure, (4) preventing inadvertent expansion of the corticectomy and white fiber tract dissection throughout surgery, and (5) protecting the surrounding tissues against iatrogenic injuries caused by instrument entry and reentry. CONCLUSION: The endoport-assisted endoscopic technique is safe and offers an effective alternative option for the resection of intraventricular and intraparenchymal lesions.

Purely Endoscopic Evacuation of Intracranial Hematomas.

Cerebral hemorrhage is a frequent disease and one of the main causes of disabilities. Even in the case of cerebral hemorrhage, if there were a treatment that would improve the functional prognosis, the benefits would be immeasurable. Although there are limited reports with a high level of evidence in past studies, it has been found that surgery can be effective if a large amount of hematoma can be removed in a minimally invasive manner. Also, it has become clear that the control of bleeding becomes a problem when surgery is performed within 2 days after the onset of stroke and that the therapeutic time window might be longer. In Japan, since the introduction of the transparent sheath by Nishihara et al., endoscopic hematoma removal has been widely performed and has become the standard surgical procedure. The three basic equipment needed for this surgery are a rigid scope, a suction coagulator, and a transparent sheath. The key point of the surgery is to search for hematomas and bleeding points through a transparent sheath and coagulate the bleeding vessels. In this chapter, we will introduce surgical techniques using these devices, but it is important to carefully decide on surgical options by considering your own technique, the condition of each patient, and the devices available in the area.

360 Degrees Endoscopic Access to and Through the Orbit.

The treatment of pathologies located within and surrounding the orbit poses considerable surgical challenges, due to the intricate presence of critical neurovascular structures in such deep, confined spaces. Historically, transcranial and craniofacial approaches have been widely employed to deal with orbital pathologies. However, recent decades have witnessed the emergence of minimally invasive techniques aimed at reducing morbidity. Among these techniques are the endoscopic endonasal approach and the subsequently developed endoscopic transorbital approach (ETOA), encompassing both endonasal and transpalpebral approaches. These innovative methods not only facilitate the management of intraorbital lesions but also offer access to deep-seated lesions within the anterior, middle, and posterior cranial fossa via specific transorbital and endonasal corridors. Contemporary research indicates that ETOAs have demonstrated exceptional outcomes in terms of morbidity rates, cosmetic results, and complication rates. This study aims to provide a comprehensive description of endoscopic-assisted techniques that enable a 360° access to the orbit and its surrounding regions. The investigation will delve into indications, advantages, and limitations associated with different approaches, while also drawing comparisons between endoscopic approaches and traditional microsurgical transcranial approaches.

Ultrasonic assessment of gastric solid contents in patients undergoing upper endoscope with sedation.

BACKGROUND: Perioperative reflux aspiration presents a grave concern during sedation or general anesthesia, particularly when solid gastric contents prompt acute upper respiratory obstruction, potentially resulting in fatal consequences for patients. Currently, there are limited means for promptly assessing solid gastric contents in clinical settings. Therefore, this study examined the efficacy of ultrasound assessment for solid gastric contents, offering a rapid and non-invasive approach for early detection and decision-making regarding interventions. METHODS: The study included 400 patients scheduled for upper endoscopy procedures, which encompassed both gastroscope and gastroscope combined colonoscopy examinations with sedation. Ultrasound scanning of the antrum was performed while patients were positioned semi-sitting or in the right lateral decubitus (RLD) posture. The evaluation of solid gastric contents relied on direct visual observation during endoscopy. Gastric volume measurement occurred subsequent to endoscopic suction of gastric contents. Receiver operating characteristic curves were utilized to assess the effectiveness of ultrasonography in discerning solid contents. RESULT: Seven patients undergoing gastroscope with sedation were found to have solid gastric contents. The sensitivity, specificity, positive predictive value, and negative predictive value of the ultrasound qualitative evaluation of solid contents were 85.7%, 99%, 60%, and 99.7%, respectively. CONCLUSION: Solid stomach contents can be evaluated qualitatively with reasonable accuracy using ultrasonography. Additionally, in patients undergoing upper endoscopy and assessed to have solid gastric contents with ultrasound, administration of mild sedation is recommended. TRIAL REGISTRATION: www.chictr.org.cn (ChiCTR2100048994); registered 19/07/2021.

Fully endoscopic microvascular decompression for hemifacial spasm: a clinical study and analysis.

Fully endoscopic microvascular decompression (MVD) of the facial nerve is the main surgical treatment for hemifacial spasm. However, the technique presents distinct surgical challenges. We retrospectively analyzed prior cases to consolidate surgical insights and assess clinical outcomes. Clinical data from 16 patients with facial nerve spasms treated at the Department of Neurosurgery in the First Affiliated Hospital of Bengbu Medical College, between August 2020 and July 2023, were retrospectively examined. Preoperatively, all patients underwent magnetic resonance angiography to detect any offending blood vessels; ascertain the relationship between offending vessels, facial nerves, and the brainstem; and detect any cerebellopontine angle lesions. Surgery involved endoscopic MVD of the facial nerve using a mini Sigmoid sinus posterior approach. Various operative nuances were summarized and analyzed, and clinical efficacy, including postoperative complications and the extent of relief from facial paralysis, was evaluated. Fully endoscopic MVD was completed in all patients, with the offending vessels identified and adequately padded during surgery. The offending vessels were anterior inferior cerebellar artery in 12 cases (75%), vertebral artery in 3 cases (18.75%), and posterior inferior cerebellar artery in 1 case (6.25%). Intraoperative electrophysiological monitoring revealed that the lateral spread response of the facial nerve vanished in 15 cases and remained unchanged in 1 case. Postoperative facial spasms were promptly alleviated in 15 cases (93.75%) and delayed in 1 case (6.25%). Two cases of postoperative complications were recorded-one intracranial infection and one case of tinnitus-both were resolved or mitigated with treatment. All patients were subject to follow-up, with no instances of recurrence or mortality. Fully endoscopic MVD of the facial nerve is safe and effective. Proficiency in endoscopy and surgical skills are vital for performing this procedure.

Endoscopic retrosigmoid trans-petrosal fissure approach for vestibular schwannomas: case series.

The management of vestibular schwannoma (VS) remains one of the most formidable challenges in neurosurgery owing to the eloquent nature of surrounding anatomy. Although endoscopy-assisted microsurgery has recently gained momentum in cerebellopontine angle region surgery, the feasibility of pure endoscopic technique has been rarely reported. Here we present the operative technique and preliminary outcomes of fully endoscopic retrosigmoid trans-petrosal fissure approach (ER-TPFA) for VS surgery. Clinical data of 36 consecutive cases of VS treated with the ER-TPFA from March 2021 to March 2023 were analyzed. The patients were placed in a modified lateral park-bench position, with the Dandy incision and suboccipital craniotomy performed. With the endoscopic holder, endoscopic procedures were performed using standard two-hand microsurgical techniques by one surgeon. Arachnoidal dissection of the petrosal fissure was performed for identifying the brainstem end of facial nerve and separating the tumor from the cerebellum, without brain retraction seen in traditional microsurgical technique. The tumors had an averaged size of 3.0 cm in diameter. According to the Hannover classification, nearly all the tumors were grade III-IV (97.3%). Using ER-TPFA, 33 patients (91.7%) achieved gross total resection. Anatomic preservation of the facial nerve was achieved in 35 cases, with 33 patients (91.7%) retaining a House-Brackmann score of 1-2 postoperatively. Four out of ten patients still had serviceable hearing 6 months after operation. Postoperatively, there was no post-craniotomy hematoma, cerebellar edema, and new-onset cerebellar ataxia. With a better visualization of the cerebellopontine angle region, ER-TPFA may help preserve facial nerve function and maintain high gross total resection rate while minimizing complications. We believe this retractorless technique can be a safe and effective alternative for the management of VS with satisfactory clinical results.

Peroral endoscopic myotomy compared to laparoscopic Heller myotomy and pneumatic dilation in the treatment of achalasia: a systematic review.

Peroral endoscopic myotomy (POEM) is an intervention for the treatment of achalasia which has gained popularity over the last decade. It's efficacy and invasiveness are comparable to laparoscopic Heller myotomy (LHM). The purpose of this systematic review is to compare POEM to existing therapies. The systematic review was performed following the preferred reporting items for systematic reviews and meta-analyses (PRISMA) guidelines. MEDLINE, EMBASE, Web of Science and Cochrane Libraries were searched using keywords: esophageal achalasia, POEM, LHM, pneumatic dilation (PD), and related terms. The studied outcomes were Eckardt score, clinical success, hospital stay, cost-utility analysis, complications, and post-treatment gastro-esophageal reflux disease. Articles were reviewed by one researcher and uncertainty was resolved by a second researcher. The search strategy retrieved 1948 citations. After removing duplicates and applying the exclusion criteria, 91 studies were selected for full-text review of which a total of 31 studies were considered eligible for further analysis, including two studies which were found through manual searching. POEM has improved efficacy compared to PD with similar cost-effectiveness. POEM results showed comparable patient outcomes when compared with laparoscopic myotomy. Overall, POEM is a feasible first-line treatment for achalasia.

Short-term lumbar disc and lumbar stability changes of one-hole split endoscope technique treatment of spinal stenosis.

OBJECTIVE: Investigating the early biomechanical effects of the one-hole split endoscope (OSE) technique on lumbar spine after decompression surgery. METHODS: A retrospective analysis was conducted on 66 patients with lumbar spinal stenosis (LSS) who underwent OSE technique surgery at the affiliated hospital of Binzhou Medical University from September 2021 to September 2022. The patients had complete postoperative follow-up records. The mean age was (51.73 ± 12.42) years, including 33 males and 33 females. The preoperative and postoperative imaging data were analyzed, including disc height (DH), foraminal height (FH), lumbar lordosis angle (LLA), changes in disc angle, anterior-posterior translation distance, and lumbar intervertebral disc Pfirrmann grading. The visual analogue scale (VAS) was applied to evaluate the severity of preoperative, postoperative day 1, postoperative 3 months, and final follow-up for back and leg pain. The Oswestry Disability Index (ODI) was applied to assess the functionality at all the listed time points. The modified MacNab criteria were applied to evaluate the clinical efficacy at the final follow-up. RESULTS: In 66 patients, there were statistically significant differences (p < 0.05) in DH and FH at the affected segments compared to preoperative values, whereas no significant differences (p > 0.05) were found in DH and FH at the adjacent upper segments compared to preoperative values. There was no statistically significant difference in the LLA compared to preoperative values (p > 0.05). Both the affected segments and adjacent upper segments showed statistically significant differences in Pfirrmann grading compared to preoperative values (p < 0.05). There were no statistically significant differences in the changes in disc angle or anterior-posterior translation distance in the affected or adjacent segments compared to preoperative values (p > 0.05). The VAS scores for back and leg pain, as well as the ODI, significantly improved at all postoperative time points compared to preoperative values. Among the comparisons at different time points, the differences were statistically significant (p < 0.05). The clinical efficacy was evaluated at the final follow-up using the modified MacNab criteria, with 51 cases rated as excellent, 8 cases as good, and 7 cases as fair, resulting in an excellent-good rate of 89.39%. CONCLUSIONS: The OSE technique, as a surgical option for decompression in the treatment of LSS, has no significant impact on lumbar spine stability in the early postoperative period. However, it does have some effects on the lumbar intervertebral discs, which may lead to a certain degree of degeneration.