Microscope and endoscopic pituitary surgery

Having just celebrated the centenary of the first transsphenoidal pituitary operation by (Schloffer in Austria in Beitr Klin Chir 50:767–817, 1906), and this year the quarter centenary of the first published report of a therapeutic use of the neuroendoscope (for colloid cysts of the third ventricle) (Powell et al. in Neurosurgery 13:234–237, 1983), it is time to consider the relative merits of microscopic and endoscopic approaches for pituitary surgery. Although transsphenoidal endoscopic surgery has only been utilised by pioneers such as Jho since the mid-1990s (Jho et al., 1996), there is no doubt that it has already gained an important place in the neurosurgical armamentarium, but there is both confusion and propaganda about which method of surgery has most to offer, and indeed whether or not there is any real difference at all.     

鼻内镜手术治疗非侵袭性真菌性鼻-鼻窦炎35例分析

目的探讨非侵袭性真菌性鼻-鼻窦炎的病因、临床特点和鼻内镜手术方法及疗效。方法对35例非侵袭性真菌性鼻-鼻窦炎患者采用鼻内镜手术治疗,回顾性分析患者的临床资料。结果术后随访6个月,患者症状消失,无复发病例。结论非侵袭性真菌性鼻-鼻窦炎具有独特的鼻内镜及CT表现,鼻内镜手术清除病灶是治疗非侵袭性真菌性鼻-鼻窦炎的有效手段,术中应尽量扩大鼻窦的自然开口,术后定期冲洗窦腔以及定期复查可降低复发。     

A research agenda for gastrointestinal and endoscopic surgery

Background

Development of a research agenda may help to inform researchers and research-granting agencies about the key research gaps in an area of research and clinical care. The authors sought to develop a list of research questions for which further research was likely to have a major impact on clinical care in the area of gastrointestinal and endoscopic surgery.

Methods

A formal group process was used to conduct an iterative, anonymous Web-based survey of an expert panel including the general membership of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES). In round 1, research questions were solicited, which were categorized, collapsed, and rewritten in a common format. In round 2, the expert panel rated all the questions using a priority scale ranging from 1 (lowest) to 5 (highest). In round 3, the panel re-rated the 40 questions with the highest mean priority score in round 2.

Results

A total of 241 respondents to round 1 submitted 382 questions, which were reduced by a review panel to 106 unique questions encompassing 33 topics in gastrointestinal and endoscopic surgery. In the two successive rounds, respectively, 397 and 385 respondents ranked the questions by priority, then re-ranked the 40 questions with the highest mean priority score. High-priority questions related to antireflux surgery, the oncologic and immune effects of minimally invasive surgery, and morbid obesity. The question with the highest mean priority ranking was: “What is the best treatment (antireflux surgery, endoluminal therapy, or medication) for GERD?” The second highest-ranked question was: “Does minimally invasive surgery improve oncologic outcomes as compared with open surgery?” Other questions covered a broad range of research areas including clinical research, basic science research, education and evaluation, outcomes measurement, and health technology assessment.

Conclusions

An iterative, anonymous group survey process was used to develop a research agenda for gastrointestinal and endoscopic surgery consisting of the 40 most important research questions in the field. This research agenda can be used by researchers and research-granting agencies to focus research activity in the areas most likely to have an impact on clinical care, and to appraise the relevance of scientific contributions.     

The use of a retractor system (SynFrame) for open, minimal invasive reconstruction of the anterior column of the thoracic and lumbar spine

In 65 consecutive cases of trauma (n=55), pseudo-arthrosis (n=4) and metastasis (n=6), anterior reconstruction of the thoracic and lumbar spine was performed using a new minimal invasive but open access procedure. No operation had to be changed into an open procedure. The thoracolumbar junction was approached by a left-sided mini-thoracotomy (n=50), the thoracic spine by a right-sided mini-thoracotomy (n=8) and the lumbar spine by a left sided mini-retroperitoneal approach (n=7), using a new table-mounted retractor system called SynFrame (Stratec Medical, Switzerland). The anterior column was reconstructed using a variety of materials: autologous tricortical crest (n=11), autologous spongiosa (n=12), allografts (n=4) and cages (n=38). The mean overall operating time was 170 min (range 90-295 min); the time of surgery varied, depending on the spine pathology and the magnitude of the intervention in the anterior part of the spine. Mean overall blood loss was 912 ml, and only 7 out of the 65 patients needed blood transfusions. There were neither intra- nor postoperative complications related to the minimal access in particular, nor visceral/vascular complications. No intercostal neuralgia, no post-thoracotomy pain syndromes, no superficial or deep wound infections and no deep venous thromboses occurred. Four cases of pseudo-obstruction were treated conservatively. In this study, we describe the new minimal access technology to the anterior part of the thoracal and lumbar spine on the basis of 65 cases completed within 1 year. This open, but minimal invasive, access technology offers, in our view, additional advantages to the "pure" endoscopic procedures of spinal surgery.     

Practice of endoscopic surgery in Europe

Summary The outcome of a questionnaire designed to determine the current state of endoscopic surgery conducted amongst members of the European Association for Endoscopic Surgery (EAES) in April to June 1992 is presented. The data received from 266 surgical departments in 26 countries of Europe involved 2,592 staff surgeons of whom 866 practice endoscopic surgery are evaluated. The questionnaire is focused on basic aspects of minimal-access surgery — the motives, the procedures performed, attitudes to training, and different aspects of equipment used. The outcome confirms the presence of a solid beginning for the future development and spread of minimal-access surgery.     

Tachocomb used in endoscopic surgery

Background: Diffuse bleeding from parenchymatous organs or bleeding of the lung both in conventional and endoscopic surgery has to this day been treated with the usual methods — coagulation, tamponade, or oversewing. Methods: With the development by the pharmaceutical industry of a collagen fleece coated with fibrin glue (Tachocomb), an additional method of hemostasis became available. Results: The positive results obtained with the fibrin-coated collagen fleece in conventional surgery encouraged us to employ it when performing endoscopic operations. Especially with laparoscopic cholecystectomies, but also in other endoscopic operations, the application of Tachocomb has proved very successful. Nevertheless, the method of applying Tachocomb was not adequate, and limited its use, which made it necessary for us to develop an application system for endoscopic use. Conclusions: The application system, which consists of a fan as the Tachocomb carrier and a mounting support, worked well during the first tests. In order to confirm this, clinical studies will now be carried out.     

A new multipurpose retractor and dissector

Summary Dissection of large subcutaneous pockets has been fabricated using a new retractor dissector. Pockets for tissue expanders and various prostheses can be created through small incisions. Retraction during insertion of silastic prostheses is simplified.     

一种可调控的甲状腺弧形拉钩的制作和使用

【摘要】 目的 研制一种甲状腺自动拉钩,并规范此自动拉钩的使用方法及注意事项。方法 将自研的甲状腺自动拉钩应用于临床,并总结、分析甲状腺自动拉钩的使用效果、使用技巧。结果〓所有使用自研的甲状腺拉钩协助手术的病例均顺利完成手术。共63例,平均出血量为12.79克、平均的手术时间为87.83分。结论〓本自研的甲状腺拉钩安装、操作方便,可提供稳定的、充分的术野,从而减少手术时间及手术出血量。同时能减轻手术医生的劳动强度,提高工作效率,有临床推广应用价值。     

不同脊柱内镜手术治疗腰椎间盘突出症的疗效及并发症比较

目的:比较经皮内镜椎间孔入路腰椎间盘髓核摘除术(percutaneous endoscopic transforaminal discectomy,PETD)、经皮内镜椎板间入路腰椎间盘髓核摘除术(percutaneous endoscopic interlaminar discectomy,PEID)和单侧双通道内镜(unilateral biportal endoscopic,UBE)技术在单节段腰椎间盘突出症(lumbar disc herniation,LDH)中的临床疗效及并发症发生率。方法:回顾性分析2019年10月至2021年8月采用脊柱内镜治疗的121例单节段LDH患者,根据治疗方法不同分为3组。PETD组48例,男19例,女29例;年龄18~72(44.0±13.9)岁;L_3,4节段3例,L_4,5节段27例,L₅S₁节段18例;PEID组43例,男23例,女20例;年龄20~69(40.1±12.1)岁;L_3,4节段1例,L_4,5节段15例,L₅S₁节段27例;UBE组30例,男12例,女,18例;年龄29~72(41.2±15.0)岁;L_3,4节段1例,L_4,5节段18例,L₅S₁节段11例。观察并比较3组手术时间、出血量、透视次数、并发症等情况。分别于术前、术后3个月及末次随访时采用疼痛视觉模拟评分(visual analogue scale,VAS) 进行腰痛及下肢痛评估,采用Oswestry功能障碍指数(Oswestry disfunction index,ODI) 进行腰椎功能评价,并于末次随访时采用改良MacNab标准评价临床疗效。结果:所有患者完成脊柱内镜手术治疗,并经门诊及(或)电话进行至少12个月的随访。PETD、PEID组术中各发生1例硬膜囊破裂,硬膜囊破口小,术后均无明显不适。UBE组术中发生2例硬膜囊破裂;1例术后出现脑脊液漏,平卧位休息、补液等治疗后好转;1例术后无明显不适。(1)PETD组与PEID组手术时间、出血量及住院日比较,差异无统计学意义(P>0.05),UBE组手术时间、出血量及住院日多于PETD及PEID组(P<0.05)。PEID组与UBE技术组透视次数比较,差异无统计学意义(P>0.05),PETD组透视次数多于PEID组和UBE组(P<0.05)。(2)术后3个月UBE组腰痛VAS高于PETD和PEID组(P<0.05);而PETD组与PEID组比较,差异无统计学意义(P>0.05)。末次随访3组腰痛VAS组间比较,差异无统计学意义(P>0.05)。(3)3组术后各时间点下肢痛VAS及ODI较术前明显改善(P<0.05),组间比较差异无统计学意义(P>0.05),不同时间点-手术分组交互作用差异均无统计学意义(P>0.05)。(4)末次随访时按照改良MacNab标准,PETD组优27例,良16例,中4例,差1例;PEID组优27例,良12例,中3例,差1例;UBE组优16例,良10例,中2例,差2例;3组比较,差异无统计学意义(χ²=0.308,P>0.05)。3组各发生1例LDH复发,2例经对症治疗后症状改善,1例于外院就诊治疗。结论:PETD、PEID及UBE技术治疗LDH均可取得良好的早期临床疗效,并发症率相似。PETD及PEID均为单通道微创手术,术中组织损伤轻,术后恢复快;但PETD术中透视次数相对较多,PEID更合适L₅S₁节段;UBE为双通道手术,术中软组织损伤较重,但显露宽泛,更合适复杂病例。     

Intracerebral tension pneumocephalus complicating endoscopic sinus surgery: case report

Background  Various forms of intracranial air have been described in the literature. Aim  This report aims to present clinical, radiological and intraoperative findings of a rare intracranial air entrapment case after endoscopic sinus surgery.     

An endoscopic dural retractor for spinal stenosis surgery.

Adequate neural decompression is the goal of lumbar stenosis surgery. Often because of limited visualization of the nerve root, significant portions of the facet joints are removed for decompression enhancing the potential for the development of instability. Clearly, the goal to better visualize the anatomy of the lateral recess while decompressing the nerve root may result in better root decompression and a smaller potential for instability secondary to bone loss. In order to accomplish this goal we have designed an endoscopic dural retractor that while retracting the dura permits simultaneous visualization of the anatomy of the lateral recess and the activity of instruments used to decompress it. The endoscopic dural retractor contains a 10000 pixel endoscope that allows a direct lateral view into the lateral recess while the dura is being retracted. This is a view that cannot be achieved with the operating microscope. One can easily appreciate the anatomy of the lateral recess including the facet joint, ligamentum flavum, lateral dura and nerve root. Ten geriatric cadaver lateral recesses were decompressed endoscopically using the endoscopic retractor. Compression of the nerve root by the facet and ligamentum could easily be identified. One could visually monitor the use of instruments on removal of ligamentum flava and bone compressing the nerve root. In all cases the ligament was easily removed and the facet joint was undercut only enough to decompress the nerve. This instrument has the potential for less invasive decompression of spinal stenosis and further study of its utility is planned.     

Modified devascularization surgery for isolated gastric varices assessed by endoscopic ultrasonography

Background This study aimed to assess the role of endoscopic ultrasonography (EUS) in the surgical management of isolated gastric varices (IGV), and to report the authors experience in the treatment of IGV with modified devascularization surgery.Methods In this study, 26 cirrhotic patients with IGV were treated with devascularization surgery for variceal hemorrhage. Preoperatively, percutaneous transhepatic portography (PTP) and EUS were used to determine the mode of therapy for IGV. Fundectomy was performed for 14 patients with fundic IGV, whereas 12 patients with cardiac IGV underwent proximal gastrectomy.Results A significantly higher proportion of patients with cardiac varices showed grade 3 IGV on preoperative EUS than those who had fundic varices (p < 0.05). No major complications were observed during or after the operation, and only one patient died of prolonged shock and massive transfusion. Postoperatively, gastric varices had been eradicated completely in 25 of 26 patients, as determined by EUS study. During a mean follow-up period of 50 months, two patients had recurrent varices without bleeding, as demonstrated by EUS. The overall 5-year survival rate for the fundic IGV group was 67.9%, whereas that for the cardiac IGV group was 64.3% (p > 0.05).Conclusions This study showed that devascularization surgery is highly effective for the prevention of recurrent bleeding from IGV and provides an alternative treatment method. Preoperatively, EUS is very helpful in detailed devascularization of patients with specific IGV, and may be used also for postoperative follow-up evaluation.     

阿司匹林对鼻内镜手术围术期出血影响的临床观察

目的探讨阿司匹林对鼻内镜手术围术期出血的影响。方法回顾性分析2018-10—2021-03于郑州大学第一附属医院鼻科行鼻内镜手术并长期口服阿司匹林的67例患者的临床资料。根据围术期阿司匹林用药情况分为持续用药组(31例)和停药组(36例)。选取同期行鼻内镜手术未口服阿司匹林的中老年患者为对照组(30例)。记录术中出血量、血栓弹力图、术后出血情况及并发症,并对影响长期口服阿司匹林患者行鼻内镜手术的危险因素行Logistic回归分析。结果(1)3组患者中两两间的最大振幅(MA)、凝血综合指数(CI)差异均有统计学意义(P<0.05)。3组术后均有1例发生出血,行数据方差分析,3组间差异无统计学意义(P>0.05)。(2)鼻窦炎伴鼻息肉患者中,以及单纯鼻窦炎患者中,3组患者两两间的术中出血量差异均无统计学意义(P>0.05)。当显著性水平为0.05时,影响鼻内镜手术的独立危险因素为停用阿司匹林和BMI值。结论阿司匹林对鼻内镜手术围术期出血无明显影响,长期口服阿司匹林患者鼻内镜手术前可不停用阿司匹林。     

A new triaxial fiberoptic soft tissue retractor

The triaxial configuration of this fiberoptic instrument allows for operation through a small incision site and expansion within the wound. It also has a self-retaining aspect.     

从传统到腹腔镜：开展甲状腺微创腔镜手术初期感悟

目的 探讨甲状腺微创腔镜手术的安全性、可行性及其优势.方法 回顾性分析福建医科大学附属协和医院甲状腺外科笔者所在治疗组自 2011 年 11 月至 2013 年 8月完成甲状腺手术 1048 例患者的临床资料,其中开放手术（ open thyroidectomy,OT ）组 721 例,腔镜辅助（ video-assisted thyroidectomy,VAT ）组 252 例,胸乳入路全腔镜甲状腺手术（ total endoscopic thyroidectomy,TET ）组 75 例.对比分析三种术式在喉返神经麻痹、甲状旁腺机能减退、乳糜漏、术后出血、Horner 综合症、手术时间、甲状旁腺辨识个数、喉上神经外支辨识率、第一天引流量、引流天数、引流总量、淋巴结个数、术后住院天数及病理甲状旁腺检出率等方面的差异.结果 所有手术均顺利完成,未出现术中大出血和术式转换.喉返神经麻痹、永久性甲状旁腺机能减退、乳糜漏、术后出血等并发症三组之间的差异无统计学意义（ P ＞ 0.05 ）;一过性甲状旁腺机能减退及 Horner 综合征等并发症三组之间差异有统计学意义（ P ＜ 0.05 ）.VAT、TET 及 OT 组在手术时间、第一天引流量、引流天数、引流总量、喉上神经外支辨识率等方面差异有统计学意义（ P ＜ 0.05 ）,甲状旁腺辨识个数、淋巴结个数、术后住院天数及病理甲状旁腺检出率等方面差异无统计学意义（ P ＞ 0.05 ）.VAT 组与 OT 组比较,手术时间、第一天引流量、引流时间、术后引流总量,喉上神经外支辨识率等方面差异有统计学意义（ P ＜ 0.05 ）;甲状旁腺辨识个数、淋巴结个数、术后住院天数及病理甲状旁腺检出率等方面差异无统计学意义（ P ＞ 0.05 ）.TET 组与 OT 组比较,手术时间、第一天引流量、引流总量、引流时间、喉上神经外支辨识率等方面差异有统计学意义（ P ＜ 0.05 ）,甲状旁腺辨识个数、淋巴结个数、术后住院天数及病理甲状旁腺检出率差异无统计学意义（ P ＞ 0.05 ）.结论 甲状腺微创腔镜手术具有等同于 OT 手术的治疗效果及安全性;VAT 手术具有明显的微创优势;TET手术具有明显的美容优势.     

Transforaminal endoscopic surgery for symptomatic lumbar disc herniations: a systematic review of the literature

The study design includes a systematic literature review. The objective of the study was to evaluate the effectiveness of transforaminal endoscopic surgery and to compare this with open microdiscectomy in patients with symptomatic lumbar disc herniations. Transforaminal endoscopic techniques for patients with symptomatic lumbar disc herniations have become increasingly popular. The literature has not yet been systematically reviewed. A comprehensive systematic literature search of the MEDLINE and EMBASE databases was performed up to May 2008. Two reviewers independently checked all retrieved titles and abstracts and relevant full text articles for inclusion criteria. Included articles were assessed for quality and outcomes were extracted by the two reviewers independently. One randomized controlled trial, 7 non-randomized controlled trials and 31 observational studies were identified. Studies were heterogeneous regarding patient selection, indications, operation techniques, follow-up period and outcome measures and the methodological quality of these studies was poor. The eight trials did not find any statistically significant differences in leg pain reduction between the transforaminal endoscopic surgery group (89%) and the open microdiscectomy group (87%); overall improvement (84 vs. 78%), re-operation rate (6.8 vs. 4.7%) and complication rate (1.5 vs. 1%), respectively. In conclusion, current evidence on the effectiveness of transforaminal endoscopic surgery is poor and does not provide valid information to either support or refute using this type of surgery in patients with symptomatic lumbar disc herniations. High-quality randomized controlled trials with sufficiently large sample sizes are direly needed to evaluate if transforaminal endoscopic surgery is more effective than open microdiscectomy.     

Treatment of embryonal rhabdomyosarcoma of the sinus and orbit with chemotherapy, radiation, and endoscopic surgery

Parameningeal rhabdomyosarcoma in children has a lower survival than rhabdomyosarcoma at other more favorable sites. This report describes the case of a 14-year-old girl who was successfully treated with multimodal therapy including chemotherapy, radiation, and endoscopic surgery.     

非创伤性修复技术应用于治疗儿童乳牙龋齿的价值

探究对乳牙龋齿患儿应用非创伤性修复技术（ART）的效果。方法 选取2022年6月-2023年 6月我院收治的乳牙龋齿患儿84例作为研究对象,应用随机数字表法分为对照组和观察组,各42例。对照 组行传统修复技术治疗,观察组行ART治疗,比较两组临床效果、炎症因子水平、修复治疗时间、治疗 后即刻VAS评分、填充物脱落状况、患儿家属满意情况。结果 观察组总有效率为92.86%,高于对照组 的73.81%（P ＜0.05）;观察组治疗3 d后TNF-α、hs-CRP、IL-6水平低于对照组（P ＜0.05）;观察组 修复治疗时间短于对照组,治疗后即刻VAS评分低于对照组（P ＜0.05）;观察组治疗后6个月完整保留 率高于对照组,部分脱落、完全脱落率低于对照组（P ＜0.05）;观察组患儿家属治疗满意度高于对照 组（P ＜0.05）。结论 在儿童乳牙龋齿治疗中,ART可提升临床疗效,有助于减轻患儿痛感,抑制炎 症反应,防止填充物脱落,且患儿家属满意度较高。