Endoscopy

Ablative Therapy for Barrett Esophagus: Caveat Emptor.

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Cancer can still occur after successful eradication of dysplasia with radiofrequency ablation.

Radiofrequency ablation (RFA) for patients with Barrett esophagus with high-grade dysplasia (HGD) has been clearly established as an acceptable and preferred treatment option for the majority of these patients. In the initial multicenter trial, RFA completely eradicated dysplasia in 91% of patients with HGD (JW Gastroenterol May 27 2009) and in 95% who were followed up for 2 years. Repeat RFA was performed in 55% of patients after the 1-year primary end point — mostly based on the discretion of the endoscopist rather than biopsy indication (JW Gastroenterol Nov 4 2011). No cancers were reported. The inference by some clinicians is that patients who have had successful ablative therapy can be considered cured and can be discontinued from surveillance. However, a new case report provides contrary evidence.

Three patients underwent successful RFA treatment of Barrett esophagus with HGD at tertiary academic centers; procedures were performed by nationally recognized experts in RFA. Two patients underwent endoscopic mucosal resection before RFA. The first patient had five post-RFA surveillance endoscopies during 2 years before subsquamous HGD was detected. The second patient had normal neosquamous epithelium at 3 months but subsquamous esophageal adenocarcinoma detected at 6 months. The third patient underwent two endoscopies at 3-month intervals, and at 9 months, a nodular area was noted and a subsquamous esophageal adenocarcinoma was detected.

Comment: This report emphasizes the ongoing risk for cancer following successful RFA treatment in patients with Barrett esophagus and HGD. These cases clearly demonstrate the need for meticulous surveillance. However, until the optimal surveillance schedule after ablative therapy is defined in national guidelines, experts currently recommend surveillance intervals of 3 months in year 1, 6 months in year 2, and 1 year thereafter. Quadrant biopsies should be taken every 1 cm in addition to separate biopsies of any visible lesions. Although RFA poses less risk than surgery, it is far from a cure.

Source: Journal Watch Gastroenterology

 

Frontal bur hole through an eyebrow incision for image-guided endoscopic evacuation of spontaneous intracerebral hemorrhage.

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Surgical evacuation of spontaneous intracerebral hemorrhage (sICH) remains a subject of controversy. Minimally invasive techniques for hematoma evacuation have shown a trend toward improved outcomes. The aim of the present study is to describe a minimally invasive alternative for the evacuation of sICH and evaluate its feasibility.

Methods

The authors reviewed records of all patients who underwent endoscopic evacuation of an sICH at the UCLA Medical Center between March 2002 and March 2011. All patients in whom the described technique was used for evacuation of an sICH were included in this series. In this approach an incision is made at the superior margin of the eyebrow, and a bur hole is made in the supraorbital bone lateral to the frontal sinus. Using stereotactic guidance, the surgeon advanced the endoscopic sheath along the long axis of the hematoma and fixed it in place at two specific depths where suction was then applied until 75%–85% of the preoperatively determined hematoma volume was removed. An endoscope’s camera, then introduced through the sheath, was used to assist in hemostasis. Preoperative and postoperative hematoma volumes and reduction in midline shift were calculated and recorded. Admission Glasgow Coma Scale and modified Rankin Scale (mRS) scores were compared with postoperative scores.

Results

Six patients underwent evacuation of an sICH using the eyebrow/bur hole technique. The mean preoperative hematoma volume was 68.9 ml (range 30.2–153.9 ml), whereas the mean postoperative residual hematoma volume was 11.9 ml (range 5.1–24.1 ml) (p = 0.02). The mean percentage of hematoma evacuated was 79.2% (range 49%–92.7%). The mean reduction in midline shift was 57.8% (p < 0.01). The Glasgow Coma Scale score improved in each patient between admission and discharge examination. In 5 of the 6 patients the mRS score improved from admission exam to last follow-up. None of the patients experienced rebleeding.

Conclusions

This minimally invasive technique is a feasible alternative to other means of evacuating sICHs. It is intended for anterior basal ganglia hematomas, which usually have an elongated, ovoid shape. The approach allows for an optimal trajectory to the long axis of the hematoma, making it possible to evacuate the vast majority of the clot with only one pass of the endoscopic sheath, theoretically minimizing the amount of damage to normal brain.

Source: Journal of Neurosurgery.

 

 

 

Endoscopic approaches to the trigeminal nerve and clinical consideration for trigeminal schwannomas: a cadaveric study.

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The course of the trigeminal nerve straddles multiple fossae and is known to be very complex. Comprehensive anatomical knowledge and skull base techniques are required for surgical management of trigeminal schwannomas. The aims of this study were to become familiar with the endoscopic anatomy of the trigeminal nerve and to develop a minimally invasive surgical strategy for the treatment of trigeminal schwannomas.

Methods

Ten fresh cadavers were studied using 5 endoscopic approaches with the aid of 4-mm 0° and 30° endoscopes to identify surgical landmarks associated with the trigeminal nerve. The endoscopic approaches included 3 transcranial keyhole approaches (the extradural supraorbital, extradural subtemporal, and retrosigmoid approaches), and 2 endonasal approaches (the transpterygoid and the transmaxillary transpterygoid approaches).

Results

The trajectories of the extradural supraorbital, transpterygoid, and extradural subtemporal approaches corresponded with the course of the first, second, and third divisions of the trigeminal nerve, respectively. The 3 approaches demonstrated each division in intra- and extracranial spaces, as well as the Meckel cave in the middle cranial fossa. The interdural space at the lateral wall of the cavernous sinus was exposed by the extradural supraorbital and subtemporal approaches. The extradural subtemporal approach with anterior petrosectomy and the retrosigmoid approach visualized the trigeminal sensory root and its neighboring neurovascular structures in the posterior cranial fossa. The transmaxillary transpterygoid approach revealed the course of the third division in the infratemporal fossa.

Conclusions

The 5 endoscopic approaches effectively followed the course of the trigeminal nerve with minimal invasiveness. These approaches could provide alternative options for the management of trigeminal schwannoma.

Source: Journal of Neurosurgery.

 

 

 

Endoscopic Clip-Assisted Feeding Tube Placement Reduces Repeat Endoscopy Rate: Results from a Randomized Controlled Trial.

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To determine whether endoscopic clip-assisted nasoenteral feeding tube placement is more effective than standard feeding tube placement with transnasal endoscopy.

METHODS:

 

Between August 2009 and February 2011, 143 patients referred for endoscopic nasoenteral feeding tube placement were randomized between clip-assisted and standard nasoenteral tube placement. Endoscopies were performed in the endoscopy unit and intensive care unit in a tertiary referral center in the Netherlands. For the clip-assisted procedure, the feeding tube was introduced with a suture fixed to the tip, picked up in the stomach with an endoclip and attached (as distal as possible) to the duodenal wall. In the standard group, a guide wire was placed in the duodenum using a transnasal endoscope, followed by blind insertion of a feeding tube over the guide wire. Primary end point was a repeat endoscopy for incorrect tube placement or spontaneous retrograde tube migration. Secondary end points were incorrect tube placement, spontaneous migration of feeding tube, directs medical costs, and procedure-related (serious) adverse event (SAE).

RESULTS:

 

Of the 143 patients included, 71 were randomly assigned to clip-assisted tube placement, and 72 to standard tube placement. Four (5.6%) repeat endoscopies were performed in the clip-assisted group vs. 19 (26.4%) in the standard group (relative risk reduction (RRR) 0.79; 95% confidence interval (CI) 0.40–0.92). The number needed to clip to avoid one repeat endoscopy was 4.8 (95% CI 3.1–11.3). Repeat endoscopies were mostly performed for incorrectly placed tubes, 3 (4.2%) in the clip-assisted group vs. 16 (22.2%, RRR 0.81; 95% CI 0.38–0.94) in the standard group. Spontaneous retrograde tube migration occurred in one (1.4%) clip-assisted placement and three (4.2%) standard tubes. Median costs were higher for clip-assisted tube placement (519 vs. 423, P<0.01). Four (5.6%) SAEs occurred after clip-assisted feeding tube placement vs. one (1.4%) after standard feeding tube placement (P=0.21).

CONCLUSIONS:

 

Clip-assisted endoscopic nasoenteral feeding tube placement results in fewer repeat endoscopies than standard endoscopic nasoenteral tube placement, due to a higher success rate of initial placement. When tubes are adequately placed, retrograde tube migration rarely occurs.

Source: American Journal of Gastroenterology.