Bougienage versus endoscopy for esophageal coin removal in children

BACKGROUND: Foreign body ingestion is a common pediatric problem. Coins are by far the most common ingested foreign bodies. When ingested coins become lodged in the esophagus, they may cause serious complications if they are not removed in a timely manner. Endoscopic removal is the preferred treatment in many pediatric centers as its safety and effectiveness are well established. OBJECTIVES: We performed this study to evaluate safety and effectiveness of an alternative method of managing esophageal coins, using bougienage technique. METHODS: Previously healthy children presenting to the local emergency room with uncomplicated, witnessed coin ingestion of less than 24 hours duration were prospectively recruited with an intent-to-treat analysis. A single oral passage of a Hurst bougie dilator was performed by a gastroenterologist to dislodge the esophageal coin into the stomach. If bougienage was successful (x-ray showing coin in the stomach), patients were discharged and instructions were given for monitoring stools until passage of the coin through anus was confirmed. If bougienage was unsuccessful, the child developed symptoms at any time or if a coin remained intragastric for 4 weeks, endoscopic removal was planned. Children whose parents declined to participate in the bougienage treatment received the standard endoscopic removal and their hospital records were used as controls. RESULTS: A total of 10 children were enrolled in this study, with a mean age of 3.2 years (11 mo to 10 y), 6 boys and 4 girls. All received little or no sedation. Nine children (90%) were successfully treated using bougienage, all of whom spontaneously passed the ingested coins, with a mean duration of 2.6 days (1 to 7 d) without subsequent intervention. A single case failed bougienage and underwent endoscopic removal. Three children declined bougienage treatment and underwent endoscopic removal. There were no reported minor or major adverse events with any of our cases. The mean health care cost for the hospital visit for bougienage treatment was $1210, compared with $3100 for the endoscopic removal (P<0.001). Furthermore, the mean time spent in the hospital from diagnosis to discharge was 2 hours for bougienage-treated patients compared with 8 hours for endoscopic treatment (P<0.001). CONCLUSIONS: Bougienage of impacted esophageal coins is an effective, safe, and more economic treatment modality for selected pediatric patients with uncomplicated coin ingestion. This simple technique may provide a valuable tool to emergency room physicians or primary care doctors especially when endoscopy is not readily available.     

Efficacy of Esophageal Bougienage by Emergency Physicians in Pediatric Coin Ingestion

Study objective: To determine the efficacy and safety of bougienage performed by properly trained pediatric emergency medicine physicians to advance a recently ingested coin lodged in the esophagus into the stomach. Methods: We carried out a prospective study of consecutive cases at two university-affiliated pediatric hospitals. Our subjects were 31 children, each with an ingested coin lodged in the esophagus, who met criteria for bougienage: a single coin ingested in the preceding 24 hours, radiographically localized in the esophagus; no history of esophageal disease, esophageal surgery, or foreign body removal; and no sign of respiratory compromise. The bougienage procedure involved a single pass of a Hurst bougie dilator from the mouth to the stomach with the unsedated patient sitting upright. Results: In all cases, the coin was successfully advanced into the stomach with a single pass of the bougie dilator. No patient experienced an acute complication or delayed surgical complication related to the procedure. In one case the coin was vomited after the procedure and recovered without complications. Mild abdominal pain developed in two patients, who were reevaluated 2 weeks after the procedure. In each case the coin was present in the stomach and was removed endoscopically without subsequent complications. Conclusion: When used by trained emergency physicians, esophageal bougienage is a safe, effective, cost-containing treatment for dislodging and advancing ingested coins from the esophagus into the stomach that requires no sedation or general anesthesia. [Emslander HC, Bonadio W, Klatzo M: Efficacy of esophageal bougienage by emergency physicians in pediatric coin ingestion. Ann Emerg Med June 1996;27:726-729.]     

Coin ingestion: Does every child need a radiograph?

We studied 80 children who presented to the emergency department (ED) with a complaint of coin ingestion to determine whether radiographs are necessary in all situations and to determine which symptoms or signs are predictive of esophageal coins. Radiographs were considered positive if the coin was in the esophagus. Radiographs were positive in 25 (31%) of patients, of whom 11 (14%) had no symptoms or signs in the ED. Fifty-five (69%) of the 80 patients had subdiaphragmatic foreign bodies (44 [55%]), or no foreign bodies (11 [14%]) seen on films. Fourteen (18%) of the children required removal of the coin. Variables correlating with positive radiograph, in order of significance, included localization, choking at ingestion, drooling in the ED, vomiting, and chest pain (P less than .05). Symptom type was predictive of radiographic findings, and it may be predictive of need for removal. All 14 patients with symptoms or signs in the ED had positive films, as compared to 11 of 66 (16.6%) with no symptoms (chi square = 33.555; P less than .001). Although this relationship is significant, the finding of esophageal foreign body in 17% of patients with no symptoms leads us to recommend that all patients have a chest radiograph if coin ingestion is suspected.     

Epidemiology and management of oesophageal coin impaction in children

ObjectiveThe epidemiology of oesophageal coin impaction in children is poorly understood. We aimed to assess characteristics of patients with coin impaction and identify predictors of type of coin impacted and management strategies.MethodsCases of coin impaction from 2002 to 2009 were identified by querying a tertiary care centre's billing, clinical, and endoscopy databases for the International Classification of Diseases, 9th Revision code “935.1 – foreign body in the oesophagus.” Charts were reviewed to confirm case status and to extract pertinent data.ResultsOf 113 patients with oesophageal coin impaction (55% male; 45% Caucasian; mean age 2.9 years), 65 (58%) swallowed a penny, 85 (80%) had the impaction in the proximal oesophagus, and 103 (91%) required a procedure. Thirty-five (34%) patients had an upper endoscopy performed by a gastroenterologist and 68 (66%) had a laryngoscopy or oesophagoscopy performed by an otolaryngologist. Only 2 minor complications were noted. There was no significant relationship between the coin type and location of impaction, but 99% of cases performed by otolaryngologists were for proximally impacted coins, compared to 49% for gastroenterologists (p < 0.001).ConclusionsOesophageal coin impaction disproportionately affected young children and extraction was frequently required. Whilst pennies were the most commonly impacted coin, there were no clear predictors on impaction based on coin type.     

Asymptomatic esophageal perforation by a coin in a child

Ingestion of coins by children is a common event that rarely causes serious complications. We present a case of asymptomatic esophageal perforation by a penny in a child who presented with wheezing six months after the ingestion. When esophagography and triple endoscopy failed to show the perforation, thoracotomy resulted in successful removal of the foreign body, which was encased in granulation tissue between the trachea and esophagus. Complications of foreign body ingestion are discussed.     

婴幼儿上消化道异物内镜取出术的诊治体会

目的 总结内镜下婴幼儿上消化道异物取出的方法及技巧.方法 采用成人胃镜,静脉麻醉下对14例婴幼儿上消化道异物进行治疗.结果 内镜检查3例未见异物,11例异物成功取出.7例硬币中有5例使用鼠齿钳取出,2例使用鼠齿钳＋乳胶套的方法取出;1例磁铁片,使用网篮取出;1例大头针,使用橡胶头异物钳＋磁性异物钳取出;1例铁钉,使用圈套器取出;1例金属条,使用鼠齿钳＋外套管取出.14例患儿均无并发症.结论 内镜下婴幼儿上消化道异物取出术是安全的,创伤小、并发症少.针对不同的异物需采用不同的操作工具,可取得事半功倍的效果.     

Factors Associated with Development of Complications After Endoscopic Foreign Body Removal

Background/Aims:

We analyzed the clinical characteristics of patients who underwent endoscopic foreign body removal and the risk factors of complications.

Patients and Methods:

The medical records of 415 patients treated from January 2000 to August 2011 for suspected foreign bodies were retrospectively reviewed. Patient characteristics, endoscopic findings, clinical outcomes, and risk factors of complications were analyzed.

Results:

Foreign bodies were detected endoscopically in 315 patients. Fish bone fragment (36.9%) and coins (15.3%) were the most common type of foreign bodies in adults and children, respectively. Complications associated with endoscopic procedure occurred in 26 patients (8.3%); 20 of the patients were treated conservatively and the other six patients underwent surgical treatment. Perforation (14%) was the most common complication. By univariate and multivariate analysis, the risk factors associated with complication after endoscopic foreign body removal were long duration from ingestion to endoscopy (P = 0.009) and existence of initial mucosal injury (P = 0.018).

Conclusions:

Most foreign bodies were successfully removed by endoscopy without complication, but long duration from ingestion to endoscopy and mucosal injury were risk factors of complications of endoscopic foreign body removal. Patients with these risk factors could require more careful treatment.     

'Where the money is': a case report of the successful removal of a large number of coins by esophagogastroduodenoscopy utilizing a Roth net

OBJECTIVE: To demonstrate the use of a Roth net and to determine the maximum number of coins that can be removed per net. METHODS: During esophagogastroduodenoscopy, a Roth net was passed multiple times in order to retrieve 49 ingested coins without the use of an over tube. RESULTS: Removal of 49 coins of various sizes was accomplished. The largest of the coins was 2.4 cm. Because of damage to the nets during the withdrawal past the gastroesophageal junction, several nets were required. But, there was minimal trauma to the esophageal mucosa and no complications. CONCLUSIONS: Removal of ingested foreign objects requires individually tailored treatment. From an extensive literature search, there does not appear to be consensus for standard of care based on the variability of presentation and multiple modalities available for removal.     

Ebstein畸形合并右侧旁道的射频消融及靶点图特征探讨

报道６例Ｅｂｓｔｅｉｎ畸形合并右侧房室旁道患者（１例为外科手术切断未成功），其中顺向型房室折返性心动过速（ＡＶＲＴ）５例、逆向型１例。６例中有心房颤动和电击复律史者３例。经导管射频消融均成功地阻断了旁道。与心内结构正常的１５例右后侧壁显性旁道消融结果比较，平均消融时程（１３９±７４ｍｉｎｖｓ１１３±４６ｍｉｎ）、Ｘ线曝光时间（２８±１７ｍｉｎｖｓ２３±１２ｍｉｎ）均无显著性差异（Ｐ＞０．０５）。平均随访８±５月，１例术后６个月复发，经再次消融成功。其余病例未服用任何抗心律失常药物无心动过速复发。无并发症发生。提出掌握Ｅｂｓｔｅｉｎ畸形旁道消融的有效靶点图特征及其消融的特殊性，此种病人的消融疗效可与心内结构正常的旁道者相当     

Endoscopic submucosal dissection of gastric neoplasms using a snare tip

Background: Endoscopic submucosal dissection (ESD) enables the complete removal of gastric lesions regardless of tumor size. ESD is typically performed using one of several available electrocautery knives and endoscopic mucosal resection (EMR) is performed using a diathermic snare. We aimed to investigate the clinical outcomes and complications in patients in whom a snare tip was used for ESD.

Materials and methods: We retrospectively evaluated the medical records of 30 patients who underwent removal of a gastric lesion using a snare tip by ESD or hybrid ESD (ESD with snaring). For hybrid ESD, snaring was performed after an adequate submucosal dissection. The clinical outcomes according to the endoscopic procedure performed were evaluated.

Results: ESD was performed in 12 patients and hybrid ESD was performed in 26 patients. Overall en-bloc and complete resection rates were both 97.4%. There was one case where piece-meal resection was performed in the hybrid ESD group. There were no procedure related complications such as perforation or bleeding. The mean specimen size was 2.8?±?0.6?cm in the ESD group and 2.3?±?0.5?cm in the hybrid ESD group (p?=?.031). The mean procedure time did not differ between the two methods (12.8?min in ESD and 9.7?min in hybrid ESD, p?=?.060).

Conclusions: The snare tip can be used as an electrocautery knife to incise the mucosa and dissect the submucosa during removal of a gastric lesion.     

Extraction des corps étrangers du tractus digestif haut par voie endoscopique : expérience d’un service de gastro-entérologie. À propos de 92 cas

Background

Foreign body ingestion is frequent in children and in specific high risk groups of adults such as those with underlying esophageal disease, prisoners, the mentally retarded and those with psychiatric illness.

Aims

To report the management and outcomes of patients with suspected ingestion of foreign bodies treated by endoscopic extraction.

Methods

Between 1985 and 2007 a total of 72 patients with 102 suspected foreign bodies underwent endoscopic procedures.

Results

A total of 92 foreign bodies were found in 62 patients. In the pediatric population, coins were the most frequent foreign body ingested (57 %) and in prisoners, metal objects were the most frequent (82 %). Bolus food impaction was located in the esophagus, coins and metallic foreign bodies in the stomach. Endoscopic extraction was possible in 92 % of cases without any complications.

Conclusion

Endoscopic removal of foreign bodies located in the upper gastro-intestinal tract is safe and successful.     

Endoscopic management of foreign bodies in the upper-GI tract: experience with 1088 cases in China

BACKGROUND: Reports on endoscopic management of ingested foreign bodies of the upper-GI tract in China are scarce. OBJECTIVE: To report our experience and outcome in the management of ingestion of foreign bodies in Chinese patients. SETTING AND PATIENTS: Between January 1980 and January 2005, a total of 1088 patients (685 men and 403 women; age range, 1 day to 96 years old) with suspected foreign bodies were admitted to our endoscopy center. INTERVENTIONS: All patients underwent endoscopic procedure after admission. MAIN OUTCOME MEASUREMENTS: Demographic and endoscopic data, including age, sex, and referral sources of patients, types, number and location of foreign bodies, associated upper-GI diseases, endoscopic methods, and accessory devices for removal of foreign bodies were collected and analyzed. RESULTS: A total of 1090 foreign bodies were found in 988 (90.8%) patients. The types of foreign bodies varied greatly: mainly food boluses, coins, fish bones, dental prostheses, or chicken bones. The foreign bodies were located in the pharynx (n = 12), the esophagus (n = 577), the stomach (n = 441), the duodenum (n = 50), and the surgical anastomosis (n = 10). The associated GI diseases (n = 88) included esophageal carcinoma (33.0%), stricture (23.9%), diverticulum (15.9%), postgastrectomy (11.4%), hiatal hernia (10.2%), and achalasia (5.7%). A rat-tooth forceps and a snare were the most frequently used accessory devices. The success rate for foreign-body removal was 94.1% (930/988). CONCLUSIONS: Ingestion of foreign bodies is a common clinic problem in China. Endoscopy procedures are frequently performed, and a high proportion of patients with foreign bodies require endoscopic intervention.     

Endoscopic removal of foreign bodies in children

The ingestion of foreign bodies such as coins, fish bones, plastic toy parts, batteries, and needles is common in children. Although the majority of ingested foreign bodies pass through the gastrointestinal tract unaided, some children require either nonsurgical or surgical intervention. The medical records of children who presented to the pediatric emergency department of a single tertiary referral center between December 2001 and May 2006 were reviewed. A total of 87 patients underwent an endoscopic procedure because of suspected foreign body ingestion and foreign bodies were identified by endoscopy in 74 patients (85.1%). The mean age of these 74 patients was 3.4 years (range, 6 months to 13 years). The most common site of foreign body lodgement was the esophagus (n = 38, 51.4%); other sites included the stomach (n = 33, 44.6%) and duodenum (n = 3, 4.0%). The types of foreign bodies included coins (n = 42, 56.8%), button batteries (n = 16, 21.6%), sharp objects (n = 9, 12.2%), chicken bones (n = 2, 2.7%) and others (n = 5, 6.7%). Only two foreign bodies (button batteries) in the duodenum could not be removed successfully by endoscopy. Instead, they were moved into the intestine and then eliminated spontaneously the following day. There were no major complications caused by foreign body ingestion or endoscopic procedures. The outcome of all patients was uneventful without morbidity or mortality. In our experience, endoscopic removal of foreign bodies under general anesthesia is an effective and safe method in children; the method also prevents erosion and perforation of the gastrointestinal tract.     

Catheter ablation of accessory pathways in infants and children weighing less than 10 kg]

INTRODUCTION: Low weight is considered an independent risk factor for the appearance of complications in radiofrequency catheter ablation of accessory pathways in children. OBJECTIVES: The purpose of this study was to evaluate the results and long term follow-up of radiofrequency catheter ablation in eight infants and small children of accessory pathways of less than 10 kg in weight. METHODS AND RESULTS: There were 3 boys and 5 girls with a mean age of 6.3 +/- 5 months (range, 2.5 to 17) and an average weight of 6.2 +/- 1.9 kg (range, 3.5 to 9). The eight patients underwent a single successful ablation procedure. Five left free wall pathways were ablated by transseptal approach, two right posteroseptal pathways were ablated from the inferior vena cava and a left posteroseptal was approached from the inferior vena cava into the coronary sinus. A deflectable 5F bipolar electrode catheter with a 3 mm tip was used in the first five patients and a deflectable 5F tetrapolar catheter with a 4 mm tip and temperature monitoring using closed loop control in the 3 remaining patients. An abrupt increment in impedance due to the development of a coagulum was observed in 2 procedures. One patient developed an acute ischemic complication during ablation of a left lateral accessory pathway by transseptal approach. This patient had mild pericardial effusion after the procedure. Moderate pericardial effusion was also noted in another patient after radiofrequency ablation that resolved itself spontaneously. In the remainder of the procedures there were not complications. After a mean follow-up of 32.3 +/- 22.1 months (median 42) all patients are asymptomatic without antiarrhythmic treatment. CONCLUSIONS: a) radiofrequency catheter ablation can be performed successfully in infants and small children weighing less than 10 kg, and b) echocardiography must be performed inmediately after the procedure in infants to investigate pericardial effusion.     

Transcatheter closure of atrial septal defect with Amplatzer® device in children aged less than 10 years old: Immediate and late follow‐up

Aims: To analyze the efficacy and follow‐up results of percutaneous closure of Atrial septal defect (ASD) with the Amplatzer® septal occluder in children aged <10 years old. Methods: Between November 1998 and September 2005, 27 patients diagnosed with ASD were treated percutaneously with an Amplatzer septal occluder. The procedure was carried out in the cathlab, under general anesthesia and with both fluoroscopy and transesophageal echocardiography guidance. Basal physical examinations and echocardiograms were performed prior to the procedure and at 30 days, 6, and 12 months of follow‐up. Survival free of symptom was estimated by Kaplan–Meier. Results: The mean age, weight, height, body mass index, and corporal surface was: 5.35 ± 2.11 years, 23.07 ± 9.43 kg, 110.55 ± 17.6 cm, 16.77 ± 2.42 kg/m², and 1.24 ± 2.44 m². The prevalence of septal aneurysm was 3.7% and all patients presented single secundum ASD. The mean stretched diameter by fluoroscopy and transesophageal echocardiography were 17.18 ± 6.75 mm and 16.77 ± 5.99 mm, and the prostheses sizes were 18.83 ± 6.98 mm, ranging from 10 to 30 mm. The systolic and diastolic pulmonary pressures were 25.26 ± 5.97 mm Hg and 13.38 ± 3.40 mm Hg, respectively. The procedure time was 82.92 ± 29.14 min and the hospital stay was 2.20 ± 0.26 days. Clinical and echocardiography follow‐ups were performed within 11.59 ± 4.42 months and all devices were in the correct position with no residual shunt. Right ventricular diameter decreased from 19.38 ± 5.23mm to 11.38 ± 11.92 (P 0.001). No major complications or deaths occurred; two patients had a hematoma at the vascular access. Conclusion: Secundum atrial septal defect closure can be safely and successfully performed with the Amplatzer septal occluder in children younger than 10 years old. © 2008 Wiley‐Liss, Inc.     

Mahaim纤维的电生理特征和导管射频消融

探讨Mahaim纤维的电生理特征和导管射频消融的可行性。 1996年 5月至 1999年 4月对 4例拟诊为Mahaim纤维引起的逆向型房室折返性心动过速的病人进行了电生理检查和射频导管消融。男 3例、女 1例 ,年龄 31± 19岁 ,心动过速发作史 15± 14年 ,频率 2 0 1± 17(180～ 2 2 0 )次 /分 ,发作时均有明显的心悸症状。 4例窦性心律时心电图除 1例轻微预激外均正常。心房程序电刺激可以诱发心动过速。心室起搏时从房室结逆传 ,静脉注射ATP 2 0mg室房分离。 4例Mahaim心动过速均只有前传并呈递减传导特性。 1例同时合并房室结折返性心动过速。 2例导管操作发生心房颤动并经过Mahaim纤维前传 ,1例持续发作、1例短暂发作。 4例分别在心房起搏、心动过速和心房颤动时三尖瓣心房侧标测和消融。心室预激较体表V1导联QRS波起始处提前 40± 6 (34～ 46 )ms处消融均获成功 ,1例靶点位于右前侧壁、3例位于右后侧壁。能量 35± 5W ,消融 5± 3次 ,X线透视时间 38± 2 1min。无手术相关的并发症。合并房室结折返性心动过速 1例同时作了慢径改良。分别随访 3个月～ 3年无 1例心动过速复发。临床研究证实 ,导管射频消融是治疗Mahaim介导的心动过速的有效、可行和安全的方法     

Endoscopic management of foreign bodies in the upper gastrointestinal tract:A review

Foreign body ingestion is a common condition, es-pecially among children who represent 80% of these emergencies. The most frequently ingested foreign bodies in children are coins, toys, magnets and batter-ies. Most foreign body ingestions in adults occur while eating, leading to either bone or meat bolus impaction. Flexible endoscopy is the therapeutic method of choice for relieving food impaction and removing true foreign bodies with a success rate of over 95% and with mini-mal complications. This review describes a comprehen-sive approach towards patients presenting with foreign body ingestion. Recommendations are based on a review of the literature and extensive personal experi-ence.     

Use of a double-channel duodenoscope for diagnostic and therapeutic ERCP

BACKGROUND: A double-channel duodenoscope has the potential to shorten ERCP procedure time or improve procedure success rates because tasks can be done in parallel through variably situated accessory channels. METHODS: We prospectively evaluated a prototype double-channel duodenoscope in 102 patients, recording findings, procedural success, and potential advantages or problems associated with the instrument. RESULTS: Both channels were used in 79 cases (77%) and a single-channel in the remainder. Ninety-nine percent (101 of 102) of diagnostic and 95% (87 of 92) of therapeutic ERCPs were successful. Instrument advantages included decreased procedure time (23%), cannulation/procedural ease (16%), and miscellaneous (6%). Disadvantages were noted in 15% of the patients and were related to instrument diameter and diameter of the accessory channels. CONCLUSIONS: Additional study of second generation dual-channel duodenoscopes appears warranted.     

射频消融治疗儿童快速性心律失常100例

探讨射频导管消融（ＲＦＣＡ）在治疗儿童快速性心律失常中的临床价值，采用ＲＦＣＡ治疗儿童室上性心动过速（ＳＶＴ）９３例、特发性室性心动过速（ＩＶＴ）７例。结果：ＳＶＴ消融成功率为９１．４％，右侧旁道消融成功率低于左侧旁道及房室结慢径路消融的成功率（８１．８％ｖｓ９６．８％及９６．６％；Ｐ均＜０．０５）。随访３７．３±２０．７个月，８例复发，其中２例发作次数较术前减少，口服普罗帕酮可预防发作，另６例再次消融成功。ＩＶＴ首次消融均成功，随访１９．５±１０．３个月，２例复发，均再次消融成功。全组无并发症发生。结果提示ＲＦＣＡ治疗儿童快速性心律失常是有效的、安全的。     

Direct endoscopic biopsy for subepithelial tumor larger than 20 mm after removal of overlying mucosa

Objective: An accurate diagnosis of a subepithelial tumor (SET) using endoscopic ultrasound (EUS) without tissue acquisition is difficult. Treatment plan for a SET may be influenced by endoscopic tissue diagnosis. We aimed to clarify the clinical outcomes of direct endoscopic biopsy for SET after removal of the overlying mucosa.

Methods: We evaluated the medical records of 15 patients. All patients underwent direct endoscopic biopsy for a SET larger than 20?mm (involving proper muscle layer) after removal of the overlying mucosa. The rate of achieving an accurate diagnosis and the treatment decision after the procedure were evaluated.

Results: The patients’ mean age was 55.1?±?14.7 years. The patient population predominantly comprised men (9/15, 60%). The mean tumor size was 24.3?±?7.8?mm. The mean biopsy number was 3.5?±?1.7. No major complications occurred with the procedure. The mean procedure time was 15?±?7.4?min. An accurate diagnosis was achieved in 93.3% of patients (14/15). The main pathological diagnoses after direct endoscopic SET biopsy were leiomyoma (33.3%, 5/15) and ectopic pancreas (33.3%, 5/15) followed by gastrointestinal stromal tumor (GIST) (13.3%, 2/15) and schwannoma (13.3%, 2/15). The treatment plan was influenced by the result of biopsy in 80% of patients (9/15), and unnecessary surgical resection was avoided.

Conclusions: Direct endoscopic SET biopsy after removal of the overlying mucosa using an endoscopic conventional snare was a useful diagnostic tool with high diagnostic accuracy and low risk of complications.