Anesthesia Medication's Impacts on Inflammatory and Neuroendocrine Immune Response in Patients Undergoing Digestive Endoscopy.

The aim of this study was to explore the impact of anesthetic drugs currently used to perform lower digestive endoscopy on serum concentrations of inflammation markers and catecholamines. We selected 120 patients and divided them into three lots of 40 patients each: L1, in which no anesthetics were used; L2, in which propofol was used; and L3, in which propofol combined with fentanyl was used. All patients had serum concentrations of adrenaline/epinephrine (EPI), noradrenaline/norepinephrine (NE), tumor necrosis factor alpha (TNF-α), interleukin-4 (IL-4), IL-6, IL-8, and IL-10, taken at three time points: at the beginning of the endoscopic procedure (T0), 15 min after (T1), and 2 h after the end of the endoscopic procedure (T2). The results of the research showed changes in the levels of catecholamines and interleukins (ILs) at T0, with an increased response in L1 above the mean recorded in L2 and L3 (p < 0.001). At T1, increased values were recorded in all lots; values were significantly higher in L1. At T2, the values recorded in L3 were significantly lower than the values in L2 (student T, p < 0.001) and L1, in which the level of these markers continued to increase, reaching double values compared to T0 (student T, p < 0.001). In L2 at T1, the dose of propofol correlated much better with NE, EPI, and well-known cytokines. Our results show that propofol combined with fentanyl can significantly inhibit the activation of systemic immune and neuroendocrine response during painless lower digestive endoscopy.

Endoscopic Ultrasound-Guided Gastroenterostomy for Malignant Gastric Outlet Obstruction: A Minimally Invasive Alternative to Palliative Surgical Bypass.

Gastric outlet obstruction is a mechanical obstruction to the flow of gastric contents to the intestines. The most common causes of malignant gastric outlet obstruction (MGOO) are pancreatic and gastric cancers. MGOO is associated with reduced quality of life and poor prognosis due to malnourishment from the inability to tolerate oral intake. Surgical gastrojejunostomy and endoscopic placement of enteral stents are palliative options with different advantages and disadvantages. We present a case of MGOO treated with endoscopic ultrasound-guided gastroenterostomy, a minimally invasive alternative to palliative surgical bypass.

Post-Endoscopy Parotid Swelling: A Rare Complication.

Parotid gland swelling, or parotitis, typically associated with infectious causes, can uncommonly result from non-infectious factors such as mechanical trauma following endoscopic procedures. We present a case of a 46-year-old female with liver cirrhosis who developed right parotid swelling shortly after undergoing endoscopy for evaluation of gastrointestinal symptoms. The patient's clinical course, imaging findings, and successful resolution with conservative measures are detailed. The etiology of post-endoscopy parotid swelling is multifactorial, involving potential mechanisms such as mechanical trauma, salivary gland dysfunction, infection, ductal obstruction, or allergic reactions to medications. Diagnosing this rare complication requires a comprehensive clinical evaluation, including a detailed history, symptom assessment, and imaging studies such as ultrasound. Management involves a combination of symptomatic relief, identification, and treatment of the underlying cause, emphasizing the importance of early recognition to prevent complications. In our case, warm compression provided pain relief, and the swelling subsided without the need for medical or surgical intervention. Regular follow-up evaluations and imaging studies are crucial to assess treatment response and ensure the resolution of the swelling. This case contributes to the limited literature on post-endoscopy parotid swelling, emphasizing the significance of recognizing and managing this rare complication promptly. Healthcare professionals should be vigilant, and further research is encouraged to better understand its pathophysiology and optimize management strategies in order to improve patient outcomes.

Can my surgeon scope? Trends in endoscopy training volume and experience among general surgery residents in the United States: a nationwide analysis.

INTRODUCTION: Endoscopy is a major part of surgical training. Accreditation Council for Graduate Medical Education (ACGME) has set standards regarding the minimum volume of endoscopy cases required for graduation. However, there is paucity of high-quality data on the number of cases that most surgical graduates perform. METHODS: We conducted a retrospective analysis of operative case logs of all general surgery residents graduating from ACGME-accredited programs from 2010 to 2023. Data on mean number of endoscopy cases, including mean in each subcategory, were retrieved. Mann-Kendall trend test was used to investigate trends in endoscopy experience. RESULTS: Between 2010 and 2023, the mean overall endoscopy procedures per resident remained stable, with 129.5 in 2010 and 132.1 in 2023 (t = 0.429; p-value = 0.037). The majority of these cases were performed as surgeon junior (76.6% in 2010; 80.9% in 2023), while the remaining cases were logged as surgeon chief. The most substantial contribution to the overall volume was from flexible colonoscopy (mean: 64.1 in 2010 and 67.2 in 2023). The volume for colonoscopy remained fairly stable (t = 0.429; p-value = 0.036). This was followed by esophagogastroduodenoscopy (mean: 35.3 in 2010 and 35.5 in 2023), which saw a significant increase in volume (t = 0.890; p-value ≤ 0.001). There was a significant increase in the number of overall upper endoscopic procedures (t = 0.791; p-value ≤ 0.001), while lower endoscopic procedures did not change significantly (t = 0.319; p-value = 0.125). The procedural volume for endoscopic retrograde cholangiography, sigmoidoscopy, cystoscopy/ureteroscopy, laryngoscopy, and bronchoscopy decreased significantly (p-value < 0.05 for all). CONCLUSION: The overall endoscopy volume for general surgery residents has largely remained stable, with a minor increase in esophagogastroduodenoscopy and no change in colonoscopy. Future research should investigate whether simulation-based exercises can bridge the gap between procedural volume and learning curve requirements for endoscopy.

The Risk of Endoscopy-Related Bleeding in Patients with Liver Cirrhosis: A Retrospective Study.

Background and Objectives: The risk of bleeding after endoscopic procedures in patients with liver cirrhosis remains unclear because of secondary blood coagulation disorders. In this study, we used various indices to evaluate the risk of bleeding in patients with cirrhosis. Materials and Methods: Patients with liver cirrhosis aged ≥18 years who underwent endoscopic interventions at Kyung Hee University Hospital at Gangdong between February 2007 and September 2021 were included. Clinical information, including demographic data, laboratory results, the presence of cirrhosis complications, and the degree of fibrosis, was checked and evaluated based on medical records. Results: A total of 101 patients with cirrhosis were analyzed. A total of 16 of the 101 patients (15.8%) experienced bleeding after the endoscopic procedure. One patient (0.99%) presented with spurting, while the others presented with mild oozing. All patients underwent hemostatic procedures using hemoclips. The presence of a varix significantly increased post-endoscopic bleeding (p = 0.03). Patients with FIB > 3.25 showed a statistically significant bleeding tendency (p = 0.00). Conclusions: There was no significant difference in bleeding risk according to the platelet count, prothrombin time, Child−Pugh score, and model for end-stage liver disease (MELD). Considering the degree of liver fibrosis and the invasiveness of the planned procedure, most endoscopic procedures can be performed safely but should be further evaluated in a cohort with a larger sample size.

New Year's silent killer in Japan: Undigested mochi.

Swallowed rice cake (mochi) without chewing retained in the stomach intactly. We successfully treated the hardened mochi without surgery. Eye-catching images showed as many as 10 intact mochi in the stomach and endoscopic crushing procedure.

Validity and Usefulness of YouTube Videos Related to Endoscopic Transsphenoidal Surgery for Patient Information.

Objectives This article evaluates the completeness and accuracy of YouTube videos related to endoscopic transsphenoidal surgery (ETS) as a source for patient information. Design YouTube was searched using relevant terms pertaining to ETS. Videos were evaluated independently by two physician reviewers experienced in ETS. Video demographics including uploader source along with validity scores based on predetermined checklists were captured. Setting Internet. Participants Not applicable. Main Outcome Measures A novel ETS scoring checklist, the modified DISCERN criteria, and Journal of the American Medical Association (JAMA) benchmark score were used to measure completeness and accuracy of videos. video power index (VPI) was calculated to reflect popularity. Intraclass correlation coefficient was calculated for rater agreement. Results Seventy-nine videos were included in final scoring and analysis. The ETS score, DISCERN, JAMA, and mean VPI across all included videos were 5.0 ± 2.7, 2.4 ± 0.83, 2.19 ± 0.62, and 8.92 ± 18.1, respectively. Based on the ETS score checklist, 31 (39%) of the videos were rated as poor, 30 (38%) were moderately useful, 17 (22%) were useful, and 1 (1%) was exceptional. There was a significant positive correlation between the ETS, DISCERN, and JAMA scores ( p < 0.001), but no correlation with VPI and the validity scores. There were no significant differences comparing validity scores based on the uploader source. Conclusion YouTube videos related to ETS have limited usefulness and poor overall validity for patient information. Clinicians should direct patients to other validated sources of information and aim to improve the comprehensiveness of ETS-related videos.

Impact of intravenous and topical lidocaine on clinical outcomes in patients receiving propofol for gastrointestinal endoscopic procedures: a meta-analysis of randomised controlled trials.

BACKGROUND: The efficacy of i.v. or topical lidocaine as an anaesthesia adjunct in improving clinical outcomes in patients receiving gastrointestinal endoscopic procedures under propofol sedation remains unclear. METHODS: Electronic databases (MEDLINE, EMBASE, and Cochrane Library) were searched for RCTs comparing the clinical outcomes with or without lidocaine application (i.v. or topical) in patients receiving propofol for gastrointestinal endoscopic procedures from inception to 29 March 2021. The primary outcome was propofol dosage, while secondary outcomes included procedure time, recovery time, adverse events (e.g. oxygen desaturation), post-procedural pain, and levels of endoscopist and patient satisfaction. RESULTS: Twelve trials (1707 patients) published between 2011 and 2020 demonstrated that addition of i.v. (n=7) or topical (n=5) lidocaine to propofol sedation decreased the level of post-procedural pain (standardised mean difference [SMD]=-0.47, 95% confidence interval [CI]: -0.8 to -0.14), risks of gag events (risk ratio [RR]=0.51, 95% CI: 0.35-0.75), and involuntary movement (RR=0.4, 95% CI: 0.16-0.96). Subgroup analysis demonstrated that only i.v. lidocaine reduced propofol dosage required for gastrointestinal endoscopic procedures (SMD=-0.83, 95% CI: -1.19 to -0.47), increased endoscopist satisfaction (SMD=0.75, 95% CI: 0.21-1.29), and shortened the recovery time (SMD=-0.83, 95% CI: -1.45 to -0.21). Intravenous or topical lidocaine did not affect the incidence of oxygen desaturation (RR=0.72, 95% CI: 0.41-1.24) or arterial hypotension (RR=0.6, 95% CI: 0.22-1.65) and procedure time (SMD=0.21, 95% CI: -0.09 to 0.51). CONCLUSION: This meta-analysis demonstrated that i.v. or topical lidocaine appears safe to use and may be of benefit for improving propofol sedation in patients undergoing gastrointestinal endoscopic procedures. Further large-scale trials are warranted to support our findings.

Accidental ingestion of a long dental crown.

It is recommended that a sharp-pointed object, such as a dental crown, in the proximal duodenum be retrieved endoscopically if this can be accomplished safely.

Endoscopic Procedures in the Treatment of Ureteroenteric Anastomotic Strictures: A Systematic Review and Meta-Analysis.

Objective: To evaluate the safety and efficacy of endoscopic procedures for ureteroenteric anastomotic strictures (UESs) after radical cystectomy and urinary diversion. Methods: We performed a meta-analysis of relevant articles through March 2020 using PubMed, Embase, and Cochrane Central Register to assess the efficacy of endoscopic procedures in UES according to the PRISMA and PICOS criteria. The main endpoints were success rate and complications, and we also compared the efficacy of different methods and stricture length and side in UES. Cochrane Collaboration's Revman version 5.3 and Stata version 15.1 software were used for statistical analysis. Results: A total of 18 retrospective studies with 697 patients were included. The median follow-up ranges from 12 to 62.5 months. Patients treated with endoscopic procedures had an overall success rate of 46%. The pooled rate of Clavien-Dindo ≥ 3 complications was 3.8% among included studies. Laser vaporization and stent insertion (48 and 47%) had a relatively high success rate than balloon dilatation (35%). In subgroup analysis, the success rate of endoscopic procedures for ≤ 1-cm strictures was significantly higher than that for >1-cm ones [odds ratio (OR), 8.65; 95% confidence interval (CI), 3.53-21.21; P < 0.00001]. In addition, the success rate in cases with strictures of the right side was relatively higher than that in cases with strictures of the left side (OR, 1.72; 95% CI, 1.05-2.81; P = 0.03). Conclusion: Our pooled studies showed that endoscopic operation is feasible and associated with a moderate success rate along with a relatively low incidence of perioperative complications in the treatment of UES, especially with length ≤ 1 cm and right side. Although there is still no consensus on endoscopic technique for UES regarding balloon dilatation, stent insertion, and laser vaporization, we believe that endoscopic management is a safety and available approach for UES with close follow-up.

Open Versus Endoscopic Osteotomy of Posterosuperior Calcaneal Tuberosity for Haglund Syndrome: A Retrospective Cohort Study.

BACKGROUND: Although endoscopic calcaneoplasty and retrocalcaneal debridement have been extensively applied to treat Haglund syndrome, evidence of the value of the endoscopic procedure remains to be fully established. PURPOSE/HYPOTHESIS: The purpose of this study was to compare the postoperative outcomes and the amount of osteotomy between open and endoscopic surgery for the treatment of Haglund syndrome. It was hypothesized that endoscopic calcaneoplasty would lead to higher patient satisfaction and lower complication rates compared with open surgical techniques. STUDY DESIGN: Cohort study; Level of evidence, 3. METHODS: The following postoperative outcomes were compared between the open surgery group (n = 20) and the endoscopic surgery group (n = 27): visual analog scale for pain, American Orthopaedic Foot & Ankle Society ankle-hindfoot scale, Foot Function Index, Tegner score, Ankle Activity Score, and 36-Item Short Form Health Survey; postoperative complications; and duration of surgery. To determine the extent of resection, the authors compared the calcaneal height ratio, calcaneal resection ratio, calcaneal resection angle, pitch line, and Haglund deformity height between groups. The learning curve for endoscopic calcaneoplasty was also calculated. RESULTS: There were no significant differences between the open and endoscopic groups on any outcome score. Two patients in the open group reported temporary paresthesia around the incisional site, indicating sural nerve injuries; no complication was reported in the endoscopy group. None of the parameters for extent of resection were statistically significant between the groups. The duration of surgery was 44.90 ± 10.52 and 65.39 ± 11.12 minutes in the open and endoscopy groups, respectively (P = .001). Regarding the learning curve for endoscopic calcaneoplasty (6 surgeons; 27 follow-up patients; 9 patients lost to follow-up), the duration of surgery reached a steady point of 55.68 ± 4.19 minutes after the fourth operation. CONCLUSION: The results of this study indicated that the endoscopy procedure was as effective as the open procedure. The endoscopic procedure required significantly more time than the open procedure, and the duration of the endoscopic procedure was shortened only after the fourth operation, suggesting that it requires high technical skills and familiarity with the anatomic relationships.

Diaphragmatic Hernia after Radiofrequency Ablation.

Diaphragmatic hernia (DH) is a defect, which can be congenital or can develop later in life. Moreover, chromosomal and genetic abnormalities, environmental exposures, and nutritional deficiencies may be related to the development of congenital DH. In contrast, the risk factors of acquired DH include traumas, such as blunt injuries due to traffic accidents and surgical procedures. We report the case of a 71-year-old man admitted to our gastroenterology department for the treatment of esophageal varices. Four days after the endoscopic treatment, the patient vomited severely and reported severe right upper abdominal pain. He was diagnosed with DH, and surgical fixation was performed. The diaphragmatic injury lesion was located on the estimated needle track of percutaneous radiofrequency ablation, which was performed through the thoracic diaphragm with artificial pleural effusion for hepatocellular carcinoma.

Endoscopic treatment for acute appendicitis with coexistent acute pancreatitis: Two case reports.

BACKGROUND: Appendectomy is the procedure of choice for the treatment of acute appendicitis. However, surgery may not be appropriate for patients with coexisting severe illness or comorbidities such as acute pancreatitis (AP). Endoscopic retrograde appendicitis treatment (ERAT) may be a novel alternative to surgery for treating such patients where existing medical therapies have failed. CASE SUMMARY: We report 2 cases of moderately severe AP who developed acute uncomplicated appendicitis during their hospital stay and did not respond to traditional medical therapy. One patient had moderately severe AP due to hyperlipidemia, while the other patient had a gallstone induced by moderately severe AP. Neither patient was fit to undergo an appendectomy procedure because of the concurrent AP. Therefore, the alternative and minimally invasive ERAT was considered. After written informed consent was collected from the patients, the ERAT procedure was performed. Both patients exhibited fast postoperative recovery after ERAT with minimal surgical trauma. CONCLUSION: ERAT is a safe and effective minimally invasive endoscopic procedure for acute appendicitis in patients with coexistent AP.

Diagnostic Yield of Endoscopic Procedures in Children: Experience of a Portuguese Center.

BACKGROUND: Over the last decades, the use of gastrointestinal (GI) endoscopic procedures has been increased in children worldwide, allowing the early diagnosis and therapeutic intervention in multiple GI diseases. AIMS AND METHODS: In order to evaluate the appropriateness and the diagnostic yield of initial GI endoscopic techniques in children in a Portuguese tertiary hospital, we performed a retrospective cohort study during a 12-month period. RESULTS: A total of 308 procedures were performed in 276 patients; the median age was 11 years and 50.4% were males. Esophago-gastro-duodenoscopy (EGD) corresponded to 81.8% of the procedures and ileo-colonoscopy (IC) to the remaining; 11.6% of the patients underwent both EGD and IC. Overall, 51.3% of the exams showed abnormal macroscopic findings, and 69.6% showed histopathological signs of disease, with IC showing significantly more positive results than EGD (p < 0.05). Considering the different indications independently, abnormal serology for celiac disease, suspected ingestion of foreign bodies, suspected inflammatory bowel disease, and food impaction were frequent in our population; and in the majority of the cases, the suspected diagnosis was confirmed: celiac disease, ingestion of foreign bodies, inflammatory bowel disease, and eosinophilic esophagitis, respectively. On the other hand, despite the high frequency of epigastric pain in this population, only nearly one-third of the patients showed abnormal histological findings. The final diagnosis was established in 63% of the patients, and 39.1% initiated the new treatment. DISCUSSION: Our results emphasize the importance of endoscopic procedures, especially IC, in the diagnosis of GI diseases in pediatric patients, as well as the careful choice of the endoscopic techniques in those with less specific symptoms, as chronic abdominal pain. In this particular situation, given the proportion of cases that may be due to functional disease, good characterization of the clinical context is needed, and endoscopy should be reserved for a second-line approach. CONCLUSION: It is important to monitor and examine the endoscopic techniques as an index of quality criteria for clinical practice.

INTRODUÇÃO: Ao longo das últimas décadas, a utilização dos procedimentos endoscópicos gastrointestinais (GI) nas crianças tem aumentado globalmente, permitindo o diagnóstico precoce e a intervenção terapêutica em múltiplas doenças GI. OBJETIVOS E MÉTODOS: Por forma a avaliar a adequabilidade e a rentabilidade diagnóstica na utilização de técnicas endoscópicas GI iniciais em crianças, realizamos um estudo retrospetivo de coorte durante um período de 12 meses num hospital terciário Português. RESULTADOS: Foram realizados 308 procedimentos em 276 doentes, a idade mediana foi 11 anos e 50.4% eram do sexo masculino. As esófago-gastro-duodenoscopias (EGD) corresponderam a 81.8% dos procedimentos e as ileocolonoscopias (IC) aos restantes; 11.6% dos doentes foram submetidos aos dois exames. No total, 51.3% dos exames mostraram alterações macroscópicas e 69.6% mostraram sinais histopatológicos de doença, com as IC a mostrar significativamente mais resultados positivos que as EGD (p < 0.05). Considerando as diferentes indicações independentemente, a presença de serologias positivas para doença celíaca, a suspeita de ingestão de corpos estranhos, a suspeita de doença inflamatória intestinal e a impactação alimentar foram frequentes na nossa população, e na maioria dos casos a suspeita diagnóstica foi confirmada: doença celíaca, ingestão de corpo estranho, doença inflamatória intestinal e esofagite eosinofílica, respetivamente. Por outro lado, apesar da elevada frequência de doentes com dor epigástrica a motivar o estudo endoscópico, apenas em perto de um terço dos mesmos encontrou-se alterações histológicas. O diagnóstico final foi estabelecido em 63, e 39.1% dos doentes iniciaram novo tratamento. DISCUSSÃO: Os resultados obtidos enfatizam a importância da utilização de técnicas endoscópicas, particularmente a IC, no diagnóstico de doenças GI nos doentes pediátricos, e da escolha criteriosa das mesmas nos doentes com sintomas menos específicos como dor abdominal crónica. Nesta situação particular, dada a proporção de casos que podem dever-se a doença funcional, uma boa caracterização do contexto clínico é essencial, e a endoscopia deve ser reservada para uma segunda linha de abordagem diagnóstica. CONCLUSÃO: A monitorização e a auditoria dos exames endoscópicos são importantes, como um índice de qualidade para a prática clínica.

Delayed acute subdural hematoma treated with endoscopic procedure: A case report.

Background: Delayed acute subdural hematoma (DASDH) is defined as late onset ASDH with the absence of any abnormal radiological and clinical findings at initial examination. Moreover, this entity is very rare in traumatic brain injury and its mechanism is still unclear. Recently, endoscopic surgery for ASDH has also been performed. In this case, we describe some considerations of the mechanism of DASDH and review previous literature and usefulness of endoscopic surgical procedure for ASDH. Case Description: A 73-year-old man fell at night, and visited a former medical institution by himself. No abnormal neurological finding was detected. Head computed tomography (CT) detected no abnormal finding. He was diagnosed minor head injury and was hospitalized at midnight and discharged after brain magnetic resonance image (MRI) next day. Brain MRI also detected no abnormal findings. Three days later, he visited our hospital himself, because of the severe headache. Neurologically, he had a mild consciousness disturbance and head CT revealed left ASDH. We performed endoscopic evacuation of hematoma under local anesthesia. Then, the clot was evacuated under the endoscopic procedure through dilated burr hole and pulsatile bleeding from the cortical artery was observed, which was considered to be the source of the ASDH. The patient's consciousness disturbance was improved immediately after surgery and he discharged without neurological deficit. Conclusion: We revealed the source of bleeding of DASDH under endoscopic procedure and described hypothesis and speculation of its cause in our case. DASDH is rare entity, so we need further experiences and more considerations.

Novel detachable stents for the treatment of benign esophageal strictures.

The radial force of esophageal stents may not completely change during extraction and therefore, the procedure of stent removal may cause tissue damage. The present study reports the manufacture of 2 novel detachable stents, which were designed to reduce tissue damage through their capacity to be taken or fall apart prior to removal and evaluated the supporting properties of these stents and the extent of local mucosal injury during their removal. The stents were manufactured by braiding, heat-setting, coating and connecting. The properties of the stents were evaluated by determining the following parameters: Expansion point, softening point, stent flexibility, radial compression ratio and radial force. A total of 18 rabbits with induced esophageal stricture were randomly assigned to 3 groups as follows: Detachable stent (DS) group, biodegradable stent (BS) group and control group. The stricture rate, complications, survival, degradation and stent removal were observed over 8 weeks. The stents of the DS and BS groups provided a similar supporting effect. The stricture rate, incidence of complications and survival were also similar between the 2 groups, while significant differences were noted between the DS and control groups and between the BS and control groups. In the BS group, the stents were degraded and moved to the stomach within 7 weeks (2 in 6 weeks and 3 in 7 weeks). The debris was extracted using biopsy forceps. In the DS group, all stents were easy to remove and 2 cases exhibited minor hemorrhage. In conclusion, the 2 types of novel detachable stent provided an equally efficient supporting effect in vitro and in vivo and may reduce the incidence of secondary injury during stent removal.

Feasibility and Safety of Endoscopic Procedure in Burr-Hole Surgery for Chronic Subdural Hematoma in Patients of Very Advanced Age.

OBJECTIVE: The usefulness of endoscopic procedures for chronic subdural hematoma (CSDH) has been described, but the indications in patients of very advanced age have not been analyzed. The aim of this study was to evaluate the feasibility, safety, and usefulness of introduction of an endoscopic procedure for such patients. METHODS: We retrospectively analyzed the data of 540 CSDHs treated by burr-hole surgery with endoscopic examination. The safety of the endoscopic procedure was assessed according to postoperative complications, morbidity, and mortality. The outcome was evaluated by statistical comparison among 4 different age-groups, and the recurrence rate and risk factors for recurrence was investigated in patients of very advanced age. RESULTS: Postoperative complications occurred in 7 cases (1.5%). The 6-month morbidity and mortality were 13.5% and 4.5%. No complications, morbidity, or mortality associated with the additional endoscopic procedure occurred even in patients of very advanced age. The endoscopic features of trabecular structures and residual septa separating the cavity were also risk factors for recurrence in patients of very advanced age. Releasing of the septa showed the possibility of decreasing the risk of recurrence to 6.6% in patients aged ≥85 years as well as in younger patients. There were some inevitable problems such as prolongation of the surgical time and inadequate endoscopic surgical skill. CONCLUSIONS: An endoscopic procedure for CSDH can be safely indicated and useful even in patients aged ≥85 years. However, clinicians should carefully select the patients based on clinical information associated with risk factors for recurrence.

Unilateral Occipital Transtentorial Approach with Multimodal Assistance for Resection of Large Supracerebellar Hemangioblastomas: Preliminary Experience of 2 Cases.

BACKGROUND: The surgical resection of large supracerebellar hemangioblastomas (SHBs) is exceptionally challenging due to their vascularity and deep anatomic location and is associated with a high risk of postoperative complications and mortality. Access to the posterior incisural space can be achieved by either an infratentorial supracerebellar approach or occipital transtentorial approach (OTA). However, the optimal surgical strategy has not yet been established. Here, we report 2 cases of large SHBs that were successfully and safely resected via a unilateral OTA with multimodal assistance. CASE DESCRIPTION: Two patients presented to our hospital with ataxia due to large, solid SHBs. After preoperative embolization, gross total resection of the SHBs was achieved via an OTA. Furthermore, endoscopic assistance was used to resect the remnant portion of the tumor in the second patient. Both patients experienced transient ataxia but were discharged from the hospital without serious complications. CONCLUSIONS: The combination of an OTA with preoperative embolization and endoscopic assistance may reduce the intraoperative risk and contribute to improved outcome in patients with such clinically challenging tumors.

Subcapsular Hepatic Hematoma Post-ERCP: Case Report and Review of the Literature.

INTRODUCTION: Hepatic hematoma is a rare but possible complication of ERCP. We describe the case of a 75-year old man with a large, 8 × 12 cm, sub-capsular and intra-parenchymal hematoma post ERCP, affecting the right liver segments and treated conservatively. AREAS COVERED: A review of literature has been performed, highlighting two possible mechanisms: hematoma may occur as the result of accidental laceration of a small intrahepatic vessel by the guidewire, whereas the other hypothesis posits that the hepatic damage is secondary to traction on the biliary system exerted by the balloon. We speculate that in case of anomalies of the biliary tree, the incidence of this complication is higher than expected. EXPERT COMMENTARY: In case of hepatic hematoma post ERCP, a conservative approach should always be considered before proceeding to interventional radiologic procedures or to surgical therapy.

An artificial neural network model for prediction of hypoxemia during sedation for gastrointestinal endoscopy.

OBJECTIVE: This study was designed to assess clinical predictors of hypoxemia and develop an artificial neural network (ANN) model for prediction of hypoxemia during sedation for gastrointestinal endoscopy examination. METHODS: A total of 220 patients were enrolled in this prospective observational study. Data on demographics, chronic concomitant disease information, neck circumference, thyromental distance and anaesthetic dose were collected and statistically analysed. RESULTS: Univariate analysis indicated that body mass index (BMI), habitual snoring and neck circumference were associated with hypoxemia. An ANN model was developed with three variables (BMI, habitual snoring and neck circumference). The area under the receiver operating characteristic curve for the ANN model was 0.80. CONCLUSIONS: The ANN model developed here, comprising BMI, habitual snoring and neck circumference, was useful for prediction of hypoxemia during sedation for gastrointestinal endoscopy.