A case of intra-abdominal gossypiboma diagnosed preoperatively by endoscopic ultrasound fine-needle-aspiration.

Gossypiboma is an extremely rare adverse event occurring post-surgery, where surgical gauze is left within the body. If aseptically retained, it can lead to the formation of granulation tissue through chronic inflammation and adhesion with surrounding tissues, potentially persisting asymptomatically for many years. While diagnosis of this condition has been reported through various imaging modalities such as abdominal ultrasound and computed tomography, cases not presenting with typical findings are difficult for preoperative diagnosis, and instances where it is discovered postoperatively exist. Particularly when in contact with the gastrointestinal tract within the abdominal cavity, differentiation from submucosal tumors of the digestive tract becomes problematic. This report describes the imaging characteristics of endoscopic ultrasound and the usefulness of endoscopic ultrasound-fine-needle-aspiration for tissue diagnosis in the preoperative diagnosis of intra-abdominal gossypiboma.

EUS-guided hydrogel injection to separate pancreatic head carcinoma from duodenum for enhanced radiotherapy: Multi-site feasibility study.

Background and study aims The proximity of a pancreas head tumor to the duodenum often limits delivery of an ablative dose of radiation therapy. This study evaluated the feasibility and safety of using an injectable polyethylene glycol (PEG) hydrogel between the head of the pancreas and duodenum. Patients and methods In a multi-site feasibility cohort study of patients with localized pancreatic cancer, PEG hydrogel was injected under endoscopic ultrasound guidance to temporarily position the duodenum away from the pancreas. Procedure characteristics were recorded, including hydrogel volume and space created. Patients were monitored for adverse events (AEs) and radiotherapy toxicity. Results In all six intent-to-treat patients (four with borderline resectable, two with locally advanced disease), the ability to place and visualize PEG hydrogel and create space between the duodenum and the head of the pancreas was successful. There were no procedure-related AEs resulting in radiotherapy delay. There were no device-related AEs and no reports of pancreatitis. Conclusions PEG hydrogel was successfully placed, created space between the duodenum and the head of the pancreas, and was not associated with major toxicity. Enhancing radiotherapy for pancreatic cancer by using PEG hydrogel to create peri-duodenal space could have beneficial implications for treatment and warrants more exploration.

Diagnostic value of ultrasound-guided fine-needle aspiration cytology in the pathological natures of thyroid nodules: A retrospective study.

Objective: Thyroid nodules, a clinical disease with high incidence, include benign and malignant types. This study aims to evaluate the diagnostic value of ultrasound-guided fine-needle aspiration cytology (US-FNAC) in determining the pathological nature of thyroid nodules and to conduct an in-depth analysis of its diagnostic efficacy across nodules of varying sizes. Material and Methods: This retrospective study identified 116 patients undergoing thyroidectomy in Zibo Central hospital from January 2022 to March 2023, with 98 meeting the study's inclusion criteria. All patients received ultrasound and US-FNAC examinations before surgery to analyze the ultrasonic features of thyroid nodules. The diagnosis results of pathological natures obtained by US-FNAC were analyzed with the result of post-operative pathological examination as the gold standard. The patients were divided into four groups according to the median and quartile of nodular diameters to explore the diagnostic efficacy of US-FNAC for the pathological natures of thyroid nodules with various diameters and comprehensively evaluate its application value. The evaluation tool of diagnostic efficacy was the receiver operator characteristic (ROC) curve. Results: A total of 98 puncture nodules were evaluated, with a diameter of 0.8-5.2 cm. Post-operative pathological examination showed 10 (10.20%) benign and 88 (89.80%) malignant lesions. The ultrasound examination showed 14 (14.29%) benign and 84 (85.71%) suspected malignant lesions. The US-FNAC results showed 2 cases (2.04%) of type I, 9 cases (9.18%) of type II, 3 cases (3.06%) of type III, 29 cases (29.59%) of type IV, 39 cases (39.80%) of type V, and 16 cases (16.33%) of type VI, including 9 (9.18%) benign and 84 (85.72%) malignant lesions and 5 (5.10%) uncertain pathological natures. According to the median and quartile of nodular diameters, specifically, 1.90 (1.60, 2.30) cm, 93 nodules with decided pathological natures were divided into groups Q1 (n = 24, ≤1.6 cm), Q2 (n = 26, 1.7-1.9 cm), Q3 (n = 24, 2.0-2.3 cm), and Q4 (n = 19, >2.3 cm). The results of ROC analysis showed that the area under the curve (AUC), sensitivity, and specificity of US-FNAC diagnosis were 0.894, 98.80%, and 80.00%, respectively. The AUCs of US-FNAC in groups Q1, Q2, Q3, and Q4 were 0.978, 1.000, 0.977, and 0.971. The AUCs of Q1 group, Q2 group, Q3 group and Q4 group were all > 0.9, and US-FNAC had high diagnostic efficiency for the pathological properties of thyroid nodules with different diameters. Conclusion: US-FNAC has a high diagnostic efficiency for the pathological properties of thyroid nodules. Whether the nodule diameter has an effect on the accuracy of this method requires more clinical evidence.

Safety Practices in Al-Baha: A Cross-Sectional Study on Parental Awareness of Child Choking Events.

BACKGROUND: Instances of choking continue to pose a concern for the health and safety of children. This study aims to assess parents' understanding, awareness, and perspectives on child choking. METHODS: A cross-sectional study was conducted in the Al-Baha region of Saudi Arabia from September 13, 2023, to October 3, 2023. Data collection was done via an electronically validated questionnaire among parents aged 18 years and above, covering knowledge, attitudes, and practices. Statistical analysis was performed using the Mann-Whitney U test, the Kruskal-Wallis test, the Shapiro-Wilk test, and the Kolmogorov-Smirnov test. Any result below 0.05 (p < 0.05) was considered significant. RESULTS: Out of 819 participants, 705 individuals were included in the analysis. The results indicated that there was a good level of knowledge (55%) regarding handling child choking situations. Interestingly, females demonstrated higher levels of awareness compared to males (79.4% versus 20.6%). Attitudes toward managing child choking incidents were rated as overall moderate, with 66.5% showing poor practices, such as being hesitant to seek medical assistance if symptoms improved. A majority of choking cases occurred at home (85%), underscoring the importance of enhancing intervention strategies through increased knowledge dissemination. Notably, the internet and social media platforms (71.8%) emerged as primary sources of information on dealing with child choking incidents. There was significant interest in cardiopulmonary resuscitation (CPR) classes (69.2%), although many people found it hard to make time for them (45%). CONCLUSIONS: Parents in the Al-Baha area seem to have a good understanding but some concerning attitudes when it comes to child choking situations. It is important to spread awareness, correct misconceptions, and encourage CPR training.

Malignant tracheoesophageal fistula treated with septal occluder device.

Septal occluder devices can be used with palliative intent to close tracheoesophageal fistulas and improve the quality of life of patients.

Percutaneous pulmonary thrombectomy with aspiration catheters in patients with high-risk pulmonary embolism and absolute contraindication to systemic thrombolysis.

BACKGROUND: High-risk Pulmonary Embolism (PE) mortality remains very high. Systemic thrombolysis is effective but carries significant complications and contraindications related to the hemorrhagic risk. Percutaneous thrombectomy using aspiration catheters may be an alternative in patients with a high bleeding risk. OBJECTIVE: This study aimed to evaluate the results of catheter-directed thrombectomy using aspiration dedicated catheters in patients with high-risk PE and absolute contraindication to systemic thrombolysis, with specific focus on procedural success, safety, and in-hospital outcomes. METHODS: A prospective study enrolled all consecutive patients diagnosed with high-risk pulmonary embolism and absolute contraindication to systemic thrombolysis, who underwent percutaneous pulmonary thrombectomy using dedicated aspiration catheters. The study documented the effectiveness and complications of the procedure, as well as patient outcomes at discharge and during the follow-up period. RESULTS: Thirteen patients underwent percutaneous pulmonary thrombectomy using aspiration dedicated catheters. The procedure was successful for all patients, resulting in hemodynamic and respiratory improvement within the first 24 h. No deaths attributable to cardiovascular or respiratory causes occurred during admission or follow-up. Furthermore, no serious adverse events or complications were reported during the procedure or hospitalization. CONCLUSIONS: Percutaneous pulmonary thrombectomy with dedicated aspiration catheters in patients with high-risk pulmonary embolism and contraindications to systemic thrombolysis was associated with excellent clinical results and low rate of complications.

Fiberoptic Endoscopy Evaluation of Swallowing (FEES) Findings Associated with High Pneumonia Risk in a Cohort of Patients at Risk of Dysphagia.

Aspiration detected in the fiberoptic endoscopy evaluation of swallowing (FEES) has been inconsistently associated with pneumonia, with no evidence of the risk of pneumonia from other alterations in swallowing safety detected in FEES. We conducted a dynamic, ambidirectional cohort study involving 148 subjects at risk of dysphagia in a tertiary university hospital. Our aim was to determine the risk of pneumonia attributed to alterations in swallowing safety detected during FEES. We used multivariate negative binomial regression models to adjust for potential confounders. The incidence density rate (IR) of pneumonia in patients with tracheal aspiration of any consistency was 26.6/100 people-years (RR 7.25; 95% CI: 3.50-14.98; P < 0.001). The IR was 19.7/100 people-years (RR 7.85; 95% CI: 3.34-18.47; P < 0.001) in those with laryngeal penetration of any consistency and 18.1/100 people-years (RR 6.24; 95% CI: 2.58-15.09; P < 0.001) in those with pharyngeal residue of any consistency. When adjusted for aspiration, the association of residue and penetration with pneumonia disappeared, suggesting that their risk of pneumonia is dependent on the presence of aspiration and that only aspiration is independently associated with pneumonia. This increased risk of pneumonia was significant in uni- and multivariate negative binomial regression models. We found an independently increased risk of pneumonia among patients with dysphagia and aspiration detected during FEES. Alterations in the oral and pharyngeal phases of swallowing, without aspiration, did not increase the risk of pneumonia.

A real-world study of foreign body aspiration in children with 4227 cases in Western China.

The early diagnosis and treatment of foreign body aspiration (FBA) can significantly improve the overall prognosis of children. There are significant differences in the epidemiology and clinical characteristics of FBA in different regions. Therefore, we conducted a real-world study in the western region of China with over 4000 patients. The aim of this study was to improve the understanding of FBA in terms of its types, the specific months of its occurrence, and the distribution of primary caregiver characteristics in western China. We collected the clinical and epidemiological data of children who were diagnosed with FBA in our hospital over the past 20 years through a big data centre. We matched the data of healthy children who underwent routine physical examinations at the paediatric health clinic during the same period to analyse the differences in the data of actual guardians. A total of 4227 patients from five provinces were included in this study. Foreign bodies were removed by rigid bronchoscopy in 99.4% (4202/4227) of patients, with a median age of 19 months and a median surgical duration 16 min. January was the most common month of onset for 1725 patients, followed by February, with 1027 patients. The most common types of foreign objects were melon peanuts, seeds and walnuts, accounting for 47.2%, 15.3%, and 10.2%, respectively. In the FBA group, the proportion of grandparents who were primary caregivers was 70.33% (2973/4227), which was significantly greater than the 63.05% in the healthy group (2665/4227) (P < 0.01). FBA most commonly occurs in January and February. More than 60% of FBAs occur between the ages of 1 and 2 years, and the incidence of FBA may be greater in children who are cared for by grandparents. A rigid bronchoscope can be used to remove most aspirated foreign bodies in a median of 16 min.

Evaluation and application of American College of Radiology Thyroid Imaging Reporting and Data System for improved malignancy detection in paediatric thyroid nodules.

OBJECTIVE: The American College of Radiology Thyroid Imaging Reporting and Data System (TI-RADS) is a widely used method for the management of adult thyroid nodules. However, its use in paediatric patients is controversial because adult fine needle aspiration biopsy (FNAB) recommendations may lead to delayed diagnoses of cancer in children. The objectives of this study were to evaluate the performance of TI-RADS in paediatric thyroid nodules and to tailor FNAB recommendations for children. METHODS: Consecutive surgically resected paediatric thyroid nodules from two tertiary care centres between 2003 and 2021 were reviewed. Ultrasounds were blindly scored by radiologists according to TI-RADS. Management recommendations based on TI-RADS were evaluated. Various modelling methodologies were used to determine the optimal cutoff for FNAB in children. RESULTS: Of the 96 patients, 79 (82%) were female and the median age at surgery was 16.1 years. Fifty (52%) nodules were malignant on surgical pathology. The area under the receiver operating characteristic curve of TI-RADS for predicting malignancy was 0.78. Adult TI-RADS recommendations would have resulted in 4% of cancerous nodules being lost to follow-up. Modifications to TI-RADS (FNAB of all TR3 nodules ≥1.5 cm, FNAB of TR4 and TR5 nodules ≥0.5 cm, surveillance of nodules ≥1 cm, consider surgery for nodules >4 cm) reduced this missed malignancy rate to 0%. CONCLUSIONS: TI-RADS can risk-stratify paediatric thyroid nodules. However, the system requires modifications to reduce the missed malignancy rate in paediatric thyroid nodules. Our data suggest that lower size thresholds for FNAB are warranted in children.

Safety and Efficacy of Endoscopic Ultrasound-Guided Fine-Needle Aspiration Biopsy of Littoral Cell Angioma.

Littoral cell angioma (LCA) is a rare vascular tumor of the spleen that often requires histopathological analysis for diagnosis due to non-specific imaging features. The current approach is either splenectomy or image-guided percutaneous biopsy which carries notable procedure-associated morbidity and limited accuracy. We present a novel case of LCA successfully diagnosed with endoscopic ultrasound fine-needle aspiration biopsy (EUS-FNAB), demonstrating its potential to reduce the morbidity associated with traditional percutaneous biopsy methods. This case highlights EUS-FNAB's advantage in minimizing complications and its effectiveness in diagnosing vascular tumors of the spleen, supporting its inclusion in the diagnostic algorithm for splenic lesions. Further cases are encouraged to explore EUS-FNAB's role in diagnosing rare vascular tumors such as LCA to establish its efficacy and safety profile.

Impact of glucagon-like peptide receptor agonists on endoscopy and its preoperative management: Guidelines, challenges, and future directions.

Glucagon-like peptide receptor agonists (GLP-1RA) are used to treat type 2 diabetes mellitus and, more recently, have garnered attention for their effectiveness in promoting weight loss. They have been associated with several gastrointestinal adverse effects, including nausea and vomiting. These side effects are presumed to be due to increased residual gastric contents. Given the potential risk of aspiration and based on limited data, the American Society of Anesthesiologists updated the guidelines concerning the preoperative management of patients on GLP-1RA in 2023. They included the duration of mandated cessation of GLP-1RA before sedation and usage of "full stomach" precautions if these medications were not appropriately held before the procedure. This has led to additional challenges, such as extended waiting time, higher costs, and increased risk for patients. In this editorial, we review the current societal guidelines, clinical practice, and future directions regarding the usage of GLP-1RA in patients undergoing an endoscopic procedure.

Bedside diagnosis of silent aspiration using mobile dynamic digital radiography: a preliminary study.

PURPOSE: This study aimed to assess reliable options for bedside diagnosis of silent aspiration in the intensive care unit by examining the use of default grayscale images (DGI) obtained using a mobile, general-purpose, radiography system capable of dynamic digital radiography (M-DDR) and inverted grayscale images (IGI) of DGI. METHODS: This cohort study (exploratory and preliminary) involved 18 adult patients (mean age, 89.0 years) for whom a swallowing assessment request was received from their primary physicians. Fifty-six IGI videoclips were evaluated by three specialists using the penetration-aspiration scale (PAS), with the gold standard being the consensus reading of all three specialists. Another three speech-language pathologists (SLPs) assessed 56 DGI and IGI videoclips using the PAS. PAS scores 1 and 2 were classified as normal range, PAS scores 3-5 as pathological laryngeal penetration, and PAS scores 6-8 as aspiration. The correct rates with IGI and DGI were then determined, and the level of agreement of IGI and DGI evaluations was evaluated. RESULTS: The correct rate of all evaluators was 100% for normal range, 80-100% for pathological laryngeal penetration, and 83-100% for aspiration with IGI and 100% for normal range, 90% for pathological laryngeal penetration, and 83% for aspiration with DGI. The kappa coefficient for IGI and DGI showed almost complete agreement for abnormal conditions. CONCLUSION: Dynamic imaging of swallowing 2-5 ml of liquid using M-DDR performed for elderly patients at the bedside showed that aspiration assessments by SLPs obtained from DGI videos immediately after imaging are acceptable.

Endoscopic ultrasound-guided needle-based confocal laser endomicroscopy for pancreatic cystic lesions: current status and future prospects.

Pancreatic cystic lesions (PCLs) have increased in prevalence due to the increased usage and advancements in cross-sectional abdominal imaging. Current diagnostic techniques cannot distinguish between PCLs requiring surgery, close surveillance, or expectant management. This has increased the morbidity and healthcare costs from inappropriately aggressive and conservative management strategies. Endoscopic ultrasound (EUS) needle-based confocal laser endomicroscopy (nCLE) allows for microscopic examination and delineation of the surface epithelium of PCLs. Landmark studies have identified characteristics distinguishing various types of PCLs, confirmed the high diagnostic yield of EUS-nCLE (especially for PCLs with an equivocal diagnosis), and shown that EUS-nCLE helps to change management and reduce healthcare costs. Refining procedure technique and reducing procedure length have improved the safety of EUS-nCLE. The utilization of artificial intelligence and its combination with other EUS-based advanced diagnostic techniques would further improve the results of EUS-based PCL diagnosis. A structured training program and device improvements to allow more complete mapping of the pancreas cyst epithelium will be crucial for the widespread adoption of this promising technology.

Utilizing a Guiding Catheter to Improve Endovascular Therapy Outcomes for Acute Vertebrobasilar Artery Occlusion in Patients with Tortuous Vessels.

Objective Stable and swift placement of a guiding catheter in endovascular therapies for acute vertebrobasilar artery occlusion is often difficult because of the tortuous bends of the vertebral or subclavian artery especially in older people. The use of a delivery assist guiding catheter (DAGC) shortens the time with stable support to deliver a therapeutic treatment catheter to the target lesions. Herein, we reported the clinical and radiographic outcomes in endovascular therapies utilizing the DAGC for acute vertebrobasilar artery occlusions in actual clinical settings. Materials and Methods Between January 2018 and December 2021, 33 consecutive patients (males, 20[60.6%]; median age, 78 years) using a DAGC for acute vertebrobasilar artery occlusion were analyzed retrospectively. Reperfusion was graded using postinterventional angiograms based on the "thrombolysis in cerebral infarction" (TICI) classification. Furthermore, the time from puncture to recanalization and the rate of effective recanalization achievement were investigated. Results Effective recanalization with TICI 2b or 3 was achieved in 28 (84.8%) patients, and the median time from puncture to recanalization was only 44 minutes, despite the high rate of older patients in our cohort. In contrast, asymptomatic intracranial hemorrhage as a complication was observed in only 3 (9.1%) patients. Conclusion The DAGC contributes to the shortening of recanalization time and improves the outcomes of endovascular therapies for acute vertebrobasilar artery occlusion.

Role of Virtual Bronchoscopy in Evaluation of Suspected Foreign Body in Children's Tracheobronchial Tree.

Introduction The presence of foreign bodies in the airways remain a diagnostic challenge to healthcare professionals. They can become life threatening emergencies that require immediate intervention or go unnoticed for weeks and even months. Prevention is best but early recognition remains a critical factor in treatment of foreign body inhalation in children. Objective To study the diagnostic advantages of virtual over rigid bronchoscopy in the evaluation of children with suspected foreign body in the tracheobronchial tree and plan for early management. Methods A crossectional study conducted at a tertiary care hospital & medical college in India. A total 24 patients (0-12-years-old) who presented with complaints of sudden onset of coughing, choking, and breathing difficulty were included during the 2-year duration, from January 2018 to December 2019. All patients underwent virtual and rigid bronchoscopy. Results In 8 patients, foreign bodies detected by virtual bronchoscopy were confirmed by rigid bronchoscopy. There was one case in which virtual bronchoscopy showed no foreign body, but rigid bronchoscopy detected it. In 15 cases virtual and rigid bronchoscopy did not show foreign bodies. The sensitivity, specificity, positive and negative predictive value of virtual bronchoscopy were 88.88, 100, 100, and 93.75%, respectively. Conclusions Virtual bronchoscopy is less invasive and does not require general anesthesia but cost and availability are limitations. It can be used as method of investigation in children with suspected foreign body aspiration.

Sealing the Breach: A Surgical Solution for Tracheoesophageal Fistula With a Simple Two-Layer Closure.

Tracheoesophageal puncture (TEP) followed by voice prosthesis placement stands as the primary method for voice rehabilitation after laryngectomy, heralded for its effectiveness. While generally well-tolerated, the procedure does pose potential long-term complications. These include prosthesis valve leakage, scarring, and prosthesis displacement, all of which can impede phonation capabilities. Of these, prosthesis leakage emerges as the most critical concern, precipitated by the progressive widening of the fistula. This complication can precipitate aspiration pneumonitis, stemming from the loss of physical separation between the esophagus and trachea. This case series details three instances where persistent tracheoesophageal fistula arose following TEP, necessitating surgical intervention. Herein, we present the clinical manifestations, surgical approach employing a simple two-layer closure, and ensuing outcomes.

Single Center Experience with the JETi Hydrodynamic Thrombectomy System for Acute Limb Ischemia.

OBJECTIVE: Acute limb ischemia (ALI) remains a vascular emergency with high morbidity and mortality. While the JETi Hydrodynamic Thrombectomy System (Abbott, Abbott Park, IL) offers a percutaneous approach to fragment and aspirate thrombus in patients with arterial occlusions, data on its efficacy and safety is limited. This study reports our early experience using the JETi device to treat ALI at our institution. METHODS: This is a single-center retrospective review of ALI patients treated with the JETi device between September 2020 and December 2022. Patients were included if the JETi device was used either as primary intervention or as an adjunct procedure. The primary endpoint was technical success defined as <50% residual thrombus post-intervention. Secondary endpoints included achieving complete resolution of the thrombus on angiogram, acute kidney injury (AKI), major bleeding, 30-day major amputation, and 30-day mortality. RESULTS: A total of 59 JETi procedures for ALI (mean age 62 years [IQR 56,71]) were performed on 39 males and 20 females. Median time from onset of symptoms to hospitalization was 24 hours (IQR 4-168). Rutherford classifications were I (10), IIa (27), IIb (14) and undocumented (8). Etiology of ALI was native vessel thrombosis (27), embolism (16), graft/stent thrombosis (14), and iatrogenic (2). A total of 124 vessels were treated, with an average of 2.1 vessels per procedure. The primary outcome was achieved in 86% (107/124) of the arteries, with 82% (102/124) successfully opened using the JETi device alone without the need for any adjunctive therapy. Complete resolution of the thrombus using JETi was achieved in 81% (101/124) arteries, with or without the use of adjunctive therapy. 6.7% (4/59) of patients required a major limb amputation within 30 days despite successful recanalization, and one 30-day mortality was recorded. Complications included distal embolization (5), access site hematoma (2), and acute kidney injury (4). No major bleeding, hemolysis-induced AKI, or vessel dissection or perforation were observed. CONCLUSION: The JETi device appears to be a safe and effective percutaneous treatment option in the management of ALI. It provides definitive treatment with a high technical success rate of 86% and a good safety profile.

Automatic Clinical Assessment of Swallowing Behavior and Diagnosis of Silent Aspiration Using Wireless Multimodal Wearable Electronics.

Dysphagia is more common in conditions such as stroke, Parkinson's disease, and head and neck cancer. This can lead to pneumonia, choking, malnutrition, and dehydration. Currently, the diagnostic gold standard uses radiologic imaging, the videofluoroscopic swallow study (VFSS); however, it is expensive and necessitates specialized facilities and trained personnel. Although several devices attempt to address the limitations, none offer the clinical-grade quality and accuracy of the VFSS. Here, this study reports a wireless multimodal wearable system with machine learning for automatic, accurate clinical assessment of swallowing behavior and diagnosis of silent aspirations from dysphagia patients. The device includes a kirigami-structured electrode that suppresses changes in skin contact impedance caused by movements and a microphone with a gel layer that effectively blocks external noise for measuring high-quality electromyograms and swallowing sounds. The deep learning algorithm offers the classification of swallowing patterns while diagnosing silent aspirations, with an accuracy of 89.47%. The demonstration with post-stroke patients captures the system's significance in measuring multiple physiological signals in real-time for detecting swallowing disorders, validated by comparing them with the VFSS. The multimodal electronics can ensure a promising future for dysphagia healthcare and rehabilitation therapy, providing an accurate, non-invasive alternative for monitoring swallowing and aspiration events.