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The increasing complexity of advanced endoscopic techniques places a high demand on the endoscopist’s expertise. Thus, live porcine models have been more frequently used for training. We briefly describe a hands-on postgraduate endoscopic course regarding a novel method of treatment of anastomotic strictures in a porcine model. The porcine model of Crohn’s disease anastomotic stricture with two artificial side-to-side ileo-colonic anastomoses was used. Participants performed endoscopic stricturotomy under supervision at one of two equipped endoscopic stations. Available animals were endoscopically re-examined 3 months after the course. Twelve anastomoses were prepared for the course. Eleven circumferential stricturotomies together with horizontal cut and clip placement were conducted. All anastomoses were passable for the scope after the procedure, and no case of perforation or bleeding occurred. All anastomoses available for re-examination remained passable for the endoscope after 3 months. We successfully organised the first endoscopic hands-on course for the training of endoscopic stricturotomy on a large animal model.

Iatrogenic perforation (IP) is a rare but severe complication of endoscopy, and occurrences grow with the expansion of interventional endoscopy. Apart from symptoms and physical signs, CT scans provide an immediate and comprehensive diagnosis of IP and its severity. The general treatment is broad-spectrum antibiotics, intravenous nutrition, and close monitoring. Endoscopic treatments are considered as the first-line therapy. Endoclips are usually utilized for small perforations, while endoclips with endoloops and over the scope clip system are preferred for large ones. Covered self-expandable metal stents are effective for esophageal perforations. Fibrin glue and band ligation can be attempted, when the location of perforation is difficult for the clip placement. Close observation is required after the procedure. If endoscopic closure fails or deterioration occurs, surgical treatments should be requested. Keywords: Gastrointestinal perforation, Endoscopic treatment, Clip, Stent

BACKGROUND The role of prophylactic clipping for the prevention of delayed polypectomy bleeding (DPB) remains unclear and conclusions from prior meta-analyses are limited due to the inclusion of variety of resection techniques and polyp sizes. AIM To conduct a meta-analysis on the effect of clipping on DPB following endoscopic mucosal resection (EMR) of colorectal lesions ≥ 20 mm. METHODS We performed a search of PubMed and the Cochrane library for studies comparing the effect of clipping vs no clipping on DPB following endoscopic resection. The Cochran Q test and I2 were used to test for heterogeneity. Pooling was conducted using a random-effects model. RESULTS Thirteen studies with a total of 7794 polyps were identified, of which data was available on 1701 cases of EMR of lesions ≥ 20 mm. Prophylactic clipping was associated with a lower rate of DPB (1.4%) when compared to no clipping (5.2%) (pooled OR: 0.24, 95%CI: 0.12-0.50, P < 0.001) following EMR of lesions ≥ 20 mm. There was no significant heterogeneity among the studies (I2 = 0%, P = 0.67). CONLUSION Prophylactic clipping may reduce DPB following EMR of large colorectal lesions. Future trials are needed to further identify risk factors and stratify high risk cases in order to implement a cost-effective preventive strategy.

Endoscopically placed clips have gained a prominent role in the management of bleeding or perforation during endoscopic mucosal resection of large colonic polyps. Clips may be used to treat intraprocedural complications, but may also be placed prophylactically when patients are at an increased risk for post-procedural bleeding or delayed perforation. Polyp size, location, resection technique, and appearance of the resection defect can all influence the decision on whether to place prophylactic clips. Not all post-polypectomy defects require clip placement. The downsides of clip placement include increased cost and the possibility of “clip artifact” mimicking residual polyp on surveillance examinations. When clipping, attention to proper technique can ensure secure closure of the defect and efficient placement of additional clips. Over-the-scope clips and endoscopic suturing are other strategies which can be used for treatment of bleeding or perforation, though each requires attachment to the scope and training for use.

Background The purpose of this study was to assess mitochondrial dysfunction in a murine model of supraspinatus tendinopathy. Methods Eighty-four mice (168 limbs) were included in the study. Supraspinatus tendinopathy was induced by inserting a microsurgical clip in the subacromial space of 63 mice bilaterally (126 limbs). Forty-two of these limbs were harvested at 4 weeks postoperatively, 42 underwent clip removal at 4 weeks after the initial procedure and were harvested at 2 weeks, and 42 underwent clip removal at 4 weeks and were harvested at 4 weeks. Forty-two limbs in the remaining 21 mice did not undergo surgical intervention and were utilized as the control group. Outcomes included biomechanical, histological, gene expression, superoxide dismutase (SOD) activity, and transmission electron microscopy (TEM) analyses. Results Radiographs confirmed stable clip position in the subacromial space at 4 weeks. Biomechanical testing demonstrated a 60% decrease in failure force of the supraspinatus tendons at 4 weeks compared with the control group. The failure force gradually increased at 2 and 4 weeks after clip removal. Histological analysis demonstrated inflammation surrounding the tendon with higher modified Bonar scores at 4 weeks after clip placement followed by gradual improvement following clip removal. The expression of mitochondrial-related genes was decreased at 4 weeks after clip placement and then significantly increased after clip removal. SOD activity decreased significantly at 4 weeks after clip placement but increased following clip removal. TEM images demonstrated alterations in morphology and the number of mitochondria and cristae at 4 weeks after clip placement with improvement after clip removal. Conclusions Mitochondrial dysfunction appears to be associated with the development of tendinopathy. Clinical relevance Mitochondrial protection may offer a potential strategy for delaying the development of tendinopathy and promoting tendon healing.

Over-the-scope-clip (OTSC) System is a relatively new endoluminal intervention for gastrointestinal (GI) leaks, fistulas, and bleeding. Here, we present a single center experience with the device over the course of 4 years.Retrospective chart review was conducted for patients who received endoscopic OTSC treatment. Primary outcome is the resolution of the original indication for clip placement. Secondary outcomes are complications and time to resolution.Forty-one patients underwent treatment with the OTSC system from 2011 to 2015 with average follow-up of 152 days. The average age is 53.7. The most common site of clip placement was in the stomach (44%). Clips were placed after surgical complication for 28 patients (68%), endoscopic complications for 8 patients (19%), and spontaneous presentation in 5 patients (12%). Technical success was achieved in all patients. Overall, 34 patients (83%) were successfully treated. Nine patients required multiple clips and three patients required additional treatment modalities after OTSC. Four patients used the OTSC as a bridging therapy to surgery. Using OTSC for palliation versus nonpalliative indications was associated with lower rates of treatment success (50% versus 86%, P = .028). Using OTSC for symptoms6 months had higher rates of treatment success than those experiencing longer symptoms (88% versus 65%, P = .045). There were no major morbidities or mortalities directly associated with the OTSC system. Complications from clip use were pain in two patients (5%) and hematemesis in one patient (3%).The OTSC System can be a very successful treatment for iatrogenic or spontaneous GI leaks and bleeds. Treatment success is more likely in patients treated within 6 months of diagnosis and less likely to when used for palliation. It was also successfully used as bridging therapy in several patients.

Background and study aims The efficacy of endoclips for colonic diverticular hemorrhage remains unclear. The aim of the current study was to evaluate the safety and efficacy of endoclips versus endoscopic band ligation (EBL) for the treatment of colonic diverticular hemorrhage. Patients and methods At Nara City Hospital, 93 patients with colonic diverticular hemorrhage with stigmata of recent hemorrhage (SRH) were treated using endoclips or EBL between January 2013 and December 2018. We classified the patients treated by endoclips into the direct clipping group and indirect clipping group. Endoclips were placed directly onto the vessel if technically feasible (direct clipping). When direct placement of endoclips onto the vessel was not possible, the diverticulum was closed in a zipper fashion (indirect clipping). Patient demographics, rate of early rebleeding within 30 days after initial treatment, and complications were retrospectively evaluated. Results Of the 93 patients, 34, 28, and 31 were in the direct clipping group, indirect clipping group, and EBL group, respectively. Rates of early rebleeding in the direct clipping, indirect clipping, and EBL groups were 5.9 % (2/34), 35.7 % (10/28), and 6.5 % (2/31), respectively (P = 0.006: direct clipping vs indirect clipping, P = 1: direct clipping vs EBL). No complications occurred in any groups. All patients who had early rebleeding in the direct clipping group underwent EBL, and no further bleeding occurred after repeat therapy. Conclusions Direct clip placement is acceptable as the first treatment choice for colonic diverticular hemorrhage. When direct placement of endoclips is not possible, EBL should be performed instead of indirect clipping.

Transcatheter edge-to-edge repair has been shown to be an alternative treatment option in selected inoperable patients with severe tricuspid regurgitation (TR) [(1)][1]. However, the optimal clip placement strategy remains to be established. Reduction of TR can be achieved by a triple-orifice

Gastrointestinal bleeding (GIB) is a common cause of hospitalization that requires appropriate diagnosis and treatment. The first step in management of any bleeding patient is early initiation of appropriate resuscitation measures. How and when to endoscopically approach a patient with GIB depends on the anticipated bleeding source and the hemodynamics of the patient. Modern endoscopists possess a variety of nonthermal treatment modalities that can help achieve hemostasis at a site of gastrointestinal bleeding, including submucosal injection, hemostatic clip placement, rubber band ligation, and hemostatic sprays. The indications and techniques for use of these methods will be discussed in this chapter. Less common and specialized bleeding treatment modalities include over-the-scope clip placement, intravascular coil/glue injection, and endoscopic suturing. An appropriate understanding and judicious use of these hemostatic devices improves outcomes for patients presenting with gastrointestinal bleeding.

Background: When treating intracranial aneurysms with open microsurgery, rare cases arise in which an ipsilateral approach leads to poor visualization, lack of proximal control, or potential damage to nearby vital structures due to the anatomy of the aneurysm. Case Description: We describe a patient with a small, unruptured aneurysm arising from the medial aspect of the distal supraclinoid internal carotid artery (ICA), just below the ICA bifurcation. A contralateral surgical approach was chosen because our view of the aneurysm from an ipsilateral approach would have been obstructed by the ICA. The contralateral approach provided excellent exposure of the aneurysm and allowed for precise clip placement without complications. Conclusions: Contralateral approaches may be a good option for some small medially pointing aneurysm of large proximal cerebral arteries.

Background Intracranial aneurysms (IAs) located in the midline region represent formidable challenge owing to their deep location. The objective of this study was to assess feasibility and identify the limitations of endoscopic endonasal clipping of IAs. We further aimed to describe the locations and characteristics of aneurysms that may be amenable for endoscopic endonasal clipping; thus outlining the indications of these approaches. Methods Fifteen latex-injected cadaveric heads were used for endoscopic endonasal exposure of anterior and posterior cerebral circulations. An aneurysm simulator model with 2 different sizes was used at the common sites for IAs to emulate a real surgery. Key measured parameters included “exposure of vessels and their respective perforators,” “ability to gain proximal/distal control,” and “possibility of clip placement” according to the size, direction, and location of the aneurysm model. Maneuverability of instruments and the need for pituitary gland transposition were assessed and recorded as well. Results Exposure of the anterior communicating artery complex and the common sites of posterior circulation aneurysms were feasible. The size, location, and direction of the aneurysm model had an impact on obtaining proximal and/or distal control, and the ability of clip placement. Conclusions Clipping of midline aneurysms of the posterior circulation is feasible via endoscopic endonasal approach. Small-sized ventrally and medially directed aneurysm models carried a better probability of getting proximal and/or distal control, as well as better overall ability to place a clip. The endonasal route seems to provide a limited condition for proper management of anterior circulation aneurysms.

Treatment failure of anal fistula results in high re-occurrence rate.Efficacy and safety of a nitinol closure clip system (bear-claw clip) were evaluated for anal fistulae treatment in a 36-month long-term follow-up study.Twenty-two patients were included. No patient had been treated with a bear-claw clip system before. All patients were fully continent before treatment. Follow-up time was 36 months (range 19-48 months). We observed a re-occurrence rate of 41% (nine patients) with presence of an active fistula. Time to recurrence was on average 6.9 months (range 3-11 months). Thirteen patients (59%) showed a complete healing of the fistula. Placed clip was removed in all patients on average after almost 5.8 months (3-12 months), in three cases the clip was left in situ. We did not observe any incontinence; one patient reported recurrent burning after defecation once the clip system was removed.Clip placement is a minimally invasive sphincter-preserving procedure with minimal complications and with an acceptable recurrence rate in the long term. However, bear-claw clip placement should probably be offered patients as a treatment option before more invasive procedures with higher perioperative morbidity are taken into consideration.

BACKGROUND: The objective of the study was to compare direct measurement with a conventional method for evaluation of clip placement in stereotactic vacuum-assisted breast biopsy (ST-VAB) and to evaluate the accuracy of clip placement using the direct method. METHODS: Accuracy of clip placement was assessed by measuring the distance from a residual calcification of a targeted calcification clustered to a clip on a mammogram after ST-VAB. Distances in the craniocaudal (CC) and mediolateral oblique (MLO) views were measured in 28 subjects with mammograms recorded twice or more after ST-VAB. The difference in the distance between the first and second measurements was defined as the reproducibility and was compared with that from a conventional method using a mask system with overlap of transparent film on the mammogram. The 3D clip-to-calcification distance was measured using the direct method in 71 subjects. RESULTS: The reproducibility of the direct method was higher than that of the conventional method in CC and MLO views (P = 0.002, P < 0.001). The median 3D clip-to-calcification distance was 2.8 mm, with an interquartile range of 2.0-4.8 mm and a range of 1.1-36.3 mm. CONCLUSION: The direct method used in this study was more accurate than the conventional method, and gave a median 3D distance of 2.8 mm between the calcification and clip.

Background: The use of surgical ligation clips is considered as the gold standard for the closure of vessels, particularly in laparoscopic surgery. The safety of clips is mainly achieved by the deep indentation of the metal bar with a high retention force. A novel double-shanked (DS) titanium clip was compared to two single-shanked clips with respect to axial and radial pull-off forces.Methods: In a porcine model (8 animals, 51±1 kg), arteries were prepared immediately after euthanisation, assigned to either a medium (2–4 mm; n=120) or a medium-large (3.5–7 mm; n=120) clip size group, and clipped with the appropriate clip size. After dissection, axial and radial pull-off forces were measured.Results: The axial pull-off force of the DS-Clip was higher than one single-shanked clip and comparable to the other single-shanked clip, and overall was linearly correlated to the cross-sectional area of the clip. The radial pull-off force of the DS-Clip was significantly higher than both single-shanked clips and, for the single-shanked clips, was correlated to the total clip thickness. The variation of radial pull-off force was lower for the DS-Clip due to a defined catch in the clip applier.Conclusions: The radial pull-off force was lower than the axial pull-off force in total and therefore appears to be the critical point of dislocation. Due to the higher total holding mass, the DS-Clip provided a clear advantage in this regard and might therefore decrease the dislocation rate. The catch in the applier increases the reproducibility in clip placement.

Introduction Tumor localization is a key step in laparoscopic colorectal surgery. Endoscopic tattooing is widely practiced with a satisfactory accuracy, whereas few studies have investigated its shortcomings. The aim of our study is to assess the accuracy and efficiency of a tumor localization protocol without endoscopic tattooing. Methods The tumor localization protocol was performed for 788 colorectal cancer/polyp patients undergoing laparoscopic colorectal resection. The localization accuracy was evaluated by the intraoperative exploration and the anatomopathologic results. Results The localization accuracy was 100% in our study. The drawbacks of endoscopic tattooing were overcome. Only 16.6% of the patients underwent preoperative endoscopic clip placement. Intraoperative colonoscopy was performed as a planned and purposive procedure instead of a remedial measurement. The misplacement of the camera port for laparoscopy was avoided in 18 cases (2.3%) guided by this protocol. Conclusions Colorectal tumor localization could be improved by this tumor localization protocol without endoscopic tattooing.

When esophageal leakage is suspected, diagnostic work-up usually starts with endoscopy followed by CT of the thorax. Clinicians should consider esophageal leakage a clinical emergency as early diagnosis and treatment are associated with improved outcome. Upon diagnosis, acute therapeutic management in a specialized center with appropriate multidisciplinary infrastructure and expertise is indicated as innovative endoscopic treatment options have become reasonable alternatives to invasive surgical interventions. Promising endoscopic treatment options include esophageal stent placement, endoscopic vacuum therapy, and over-the-scope clip placement. In effort to evaluate the current literature, a systematic literature search was performed on studies reporting clinical outcome of patients treated with these endoscopic treatment options for benign esophageal perforations and anastomotic leakage. The systematic search yielded 15 studies (932 patients) discussing stent placement, 14 studies (295 patients) discussing endoscopic vacuum therapy, and 8 studies (41 patients) discussing over-the-scope clip placement. Clinical success was achieved in the majority of all patients. However, the studies predominantly consisted of small single-center retrospective case series. Careful selection of patients is therefore recommended when considering endoscopic therapy for esophageal leakage. Furthermore, clinical tools may aid in predicting patients’ prognosis and selection of patients that could benefit from endoscopic therapy. In the future, randomized studies comparing available endoscopic treatment options are needed to guide treatment choice for patients with esophageal leakage in daily clinical practice.

The purpose of this study was to determine if seroma cavity visualization could be further improved with placement of gold fiducial markers in each anatomic wall of the seroma cavity compared with placement of surgical titanium clips at the surgeon's discretion.We identified patients with breast cancer who received breast-conservation surgery. Patients were grouped into 3 categories: patients without clips, patients with titanium clips placed at the discretion of the treating surgeon, and patients with gold fiducial markers directly sutured to each wall of the seroma cavity. Cavity visualization was determined using the cavity visualization score criteria.A total of 262 patients met the criteria for the study; 119 patients did not have surgical clips placed during breast-conservation surgery, 109 patients received surgical titanium clip placement at the surgeon's discretion, and 34 patients received directed placement of gold fiducial markers in each anatomic wall of the seroma cavity. There was improvement in the visualization of the seroma cavity in patients who received directed gold fiducial marker placement in each wall of the seroma cavity compared with titanium clip placement at the surgeon's discretion (P.05). An association was not identified between the quantity of titanium clips used, the amount of seroma walls with titanium clips present, or the time interval between surgery and radiation therapy planning with cavity visualization when surgical titanium clips were placed at the surgeon's discretion.The placement of a gold fiducial marker in each of the seroma cavity walls improved visualization of the seroma cavity compared with the placement of titanium clips at the surgeon's discretion. This technique may be utilized in order to assist in planning a seroma boost following whole breast irradiation or in accelerated partial breast irradiation.

Object The management of unruptured intracranial aneurysms remains controversial. The goal of this study was to evaluate the clinical community agreement in decision making regarding unruptured intracranial aneurysms. Methods A portfolio of 41 cases of unruptured intracranial aneurysms with angiographic images, along with a short description of the patient presentation, was sent to 28 clinicians (16 radiologists and 12 surgeons) with varying years of experience in the management of unruptured intracranial aneurysms. Five senior clinicians responded twice at least 3 months apart. Nineteen cases (46%) were selected from patients recruited in the Canadian UnRuptured Endovascular versus Surgery trial, an ongoing randomized comparison of coil embolization and clip placement. For each case, the responder was to first choose between 3 treatment options (observation, surgical clip placement, or endovascular coil embolization) and then indicate their level of certainty on a quantitative 0–10 scale. Agreement in decision making was studied using κ statistics. Results Decisions to coil were more frequent (n = 612, 53%) than decisions to clip (n = 289, 25%) or to observe (n = 259, 22%). Interjudge agreement was only fair (κ = 0.31 ± 0.02) for all cases and all judges, despite substantial intrajudge agreement (range 0.44–0.83 ± 0.10), with high mean individual certainty levels for each case (range 6.5–9.4 ± 2.0 on a scale of 0–10). Agreement was no better within specialties (surgeons or radiologists), within capability groups (those able to perform endovascular coiling alone, surgical clipping alone, or both), or with more experience. There was no correlation between certainty levels and years of experience. Agreement was lower when the cases were taken from the randomized trial (κ = 0.19 ± 0.2) compared with nontrial cases (κ = 0.35 ± 0.2). Conclusions Individuals do not agree regarding the management of unruptured intracranial aneurysms, even when they share a background in the same specialty, similar capabilities in aneurysm management, or years of practice. If community equipoise is a necessary precondition for trial participation, this study has found sufficient uncertainty and disagreement among clinicians to justify randomized trials.

A 74-year-old female patient presented to our outpatient clinic for a 1-month follow-up visit after combined transcatheter mitral and tricuspid valve repair for valvular regurgitation. Echocardiography confirmed proper clip placement with significantly reduced mitral and tricuspid regurgitation.

Aim To investigate current practice regarding clip placement after breast biopsy. Materials and methods In June 2011, an online survey instrument was designed using an Internet-based survey site ( www.surveymonkey.com ) to assess practices and opinions of breast radiologists regarding clip placement after breast biopsy. Radiologists were asked to give personal practice data, describe their current practice regarding clip deployment under stereotactic, ultrasonographic, and magnetic resonance imaging (MRI) guidance, and describe what steps are taken to ensure quality control with regards to clip deployment. Results The response rate was 29.9% in France (131 respondents) and 46.7% in Quebec (50 respondents). The great majority of respondents used breast markers in their practice (92.1% in France and 96% in Quebec). In both countries, most reported deploying a clip after percutaneous biopsy under stereotactic or MRI guidance. Regarding clip deployment under ultrasonography, 38% of Quebec radiologists systematically placed a marker after each biopsy, whereas 30% of French radiologists never placed a marker in this situation, mainly due to its cost. Finally, 56.4% of radiologists in France and 54% in Quebec considered that their practice regarding clip deployment after breast percutaneous biopsy had changed in the last 5 years. Conclusion There continues to be variations in the use of biopsy clips after imaging-guided biopsies, particularly with regards to sonographic techniques. These variations are likely to decrease over time, with the standardization of relatively new investigation protocols.

In some cases of cerebral aneurysm clipping, direct clip application to the aneurysm neck may be difficult or the aneurysm may rupture unexpectedly. In these cases, a clip may be temporarily applied to the parent artery to reduce aneurysmal wall tension, facilitate permanent clip placement, or control bleeding if the aneurysm ruptures. In certain circumstances, even applying a temporary clip may be challenging. We present a case in which the aneurysm ruptured and IV administration of adenosine was required to facilitate clipping. This case suggests that administering multiple consecutive precalculated doses of adenosine may be a safe method to manage aneurysmal rupture.

Purpose: With the extent of breast tissue manipulation using oncoplastic surgical techniques, there lies a challenge in marking the tumor bed for adjuvant radiation therapy planning. Two competing techniques in doing so exist and involve the traditional placement of surgical clips in the surgical tumor bed or the newer technique of placing a Biozorb marker in the tumor bed. Our goal was to perform a cost-utility assessment to see which tumor bed marking approach is more cost-effective. Based on device list prices and clinical outcomes from a comprehensive literature review, we assessed if an approach either dominated or had an incremental cost-utility ratio of less than $50,000/QALY since either would signify cost-effectiveness. Results: From a cost comparison, the Biozorb marker ($1250) was far costlier than the clip applier device ($50). Our PRISMA search (Figure 1) reviewed 133 articles for clip placement and 42 articles for Biozorb placement in oncoplastic surgery with 2 clip placement articles and 3 Biozorb articles meeting criteria. The available data for either marking technique suggests reasonable tumor bed identification for adjuvant radiation treatment without clear clinical advantages supporting one technique over the other. Overall clinical equivalence in the setting of a clear cost advantage suggests dominant cost-effectiveness in favor of clips. Conclusion: Using surgical clips to identify the tumor bed in oncoplastic surgery is dominant and more cost-effective over the Biozorb technique as clips are relatively inexpensive while both techniques reasonably identify the tumor bed.

We demonstrate two techniques in this video clip that can be used when performing robotic-assisted laparoscopic partial nephrectomy. First, we use the fourth arm of the robot with a long-tip grasper to occlude the renal artery during the resection of the mass. Second, we show a novel method for securing the mattress sutures when performing the repair of the kidney. Both maneuvers help to increase the safety of the procedure and decrease the warm ischemia time to the kidney.

We present the results of a retrospective study employing intraoperative micro-Doppler ultrasonography (MDU) in verifying proper clip placement during cerebral aneurysmal surgery. One hundred and thirty-four patients surgically treated for 147 intracranial aneurysms were studied. Thirteen patients harboring 17 aneurysms were surgically treated on an elective basis, while 121 patients with 130 aneurysms, presented with subarachnoid hemorrhage (SAH). Blood flow velocities of the parent and adjacent vessels as well as the aneurysmal sac were measured using a Conforma Micro-Doppler (Cook Vascular Inc., Leechburg, PA, USA). Pre- and post-operative cerebral angiography was obtained in all our patients. In 23 aneurysms (15.6%) there was decreased or absent flow in the parent vessel or in one of the adjacent vessels after clipping. In another 19 aneurysms (12.9%), MDU demonstrated flow through the aneurysmal dome even though the aneurysmal neck appeared to be totally obliterated. Presence of SAH, anatomic location and size of the aneurysm were associated with improper clip placement in a statistically significant fashion. The false positive rate for MDU was 2% while there were no false negative findings in our study. MDU appears to be a non-invasive, reliable alternative methodology to intra-operative angiography. This inexpensive method may lend itself to routine usage in aneurysm surgery.

Deep enteroscopy has increased our ability to diagnose, treat, and palliate small intestinal causes of gastrointestinal (GI) bleeding. The therapeutic interventions for small bowel bleeding depend on the etiology, size, and location of the lesions and include primarily injection therapies, thermal coagulation, clip placement, or any combination thereof. Important differences in endoscopic approach exist when treating small bowel bleeding relative to other parts of the GI tract. First, the small bowel is long and tortuous, often making it challenging to obtain a satisfactory endoscopic position to target the lesion of interest. Advanced endoscopic skills are mandatory to maneuver the enteroscope through the small bowel. Second, the wall of the small intestine is thin. Therefore, particular attention is required during injection and/or application of noncontact or contact thermal therapies, such as argon plasma or bipolar coagulation. Third, passage and utilization of available hemostatic tools during deep enteroscopy can be difficult. The proceduralist treating small bowel bleeding disorders should be versed in advanced endoscopic techniques, be familiar with devices available for therapeutic enteroscopy, and be able to improvise and troubleshoot during challenging enteroscopic procedures.

Objective The purpose of this study was to explore the endoscopic endonasal approach to the anterior communicating artery complex. Design Anatomic, morphometric analysis of human cadaver heads. Subjects Fifteen latex-injected adult cadaver heads. Main Outcome Measures The anatomic boundaries of the operative field and the dimensions of exposure of the anterior communicating artery (ACoA) complex were measured and clip placement feasibility was assessed. Results Exposure of the ACoA and bilateral A1 and A2 segments was accomplished in all 15 cadaver heads. Average length of the exposed ACoA was 3 ± 1 mm, the left A1 was 5 ± 3 mm and right A1 was 5 ± 1 mm, while the A2 segment was 5 ± 2 mm bilaterally. The average distance from the alar floor to the ACoA was 95 mm, while proximal lateral limit measured between the alar floor margins was 36 mm. The distal lateral limit as defined by the distance between the lateral most exposed margins of the chiasm was 19 mm. Clip placement was accomplished for the ACoA and the A1 and A2 segments bilaterally in all specimens. Conclusion The endoscopic, endonasal transtuberculum, transplanum approach is an anatomically feasible alternative to treating select aneurysms of the ACoA complex.

A 39-year-old woman underwent 11-gauge vacuum-assisted stereotactic biopsy of a cluster of calcifications at the 5 o’clock location in the left breast. Initial clip placement was confirmed by mammograms to be at the biopsy site. The patient experienced episodic minimal bleeding at the skin entry site when she went home. The patient presented 6 weeks later with a history of progressive discomfort and lump at the stereotactic breast biopsy scar site. Ultrasound confirmed clip migration to the skin incision site. The clip was removed percutaneously by the radiologist, relieving the patient of her symptoms.

The goal of this study was to compare the accuracy of clip placement of a collagen-plug biopsy marking device with that of the more conventional, previously evaluated metallic tissue-marking clips. SUBJECTS AND METHODS. The placement accuracy of 31 collagen-plug marking devices was compared with the placement accuracy of 43 metallic marker clips deployed at biopsies performed between August 1, 2002, and November 20, 2002. The precision of marker placement was assessed by determining the position of the clip relative to the targeted mammographic lesion. Statistical analysis comparing the distance from the clip to the targeted lesion was performed.Using a two-group Wilcoxon's rank sum test, we found the clip-to-target distances for the collagen-plug central titanium marker were significantly different from the clip-to-target distances of the conventional metallic marker clips (p = 0.04). There were significantly fewer cases in which the clip-to-target distance was 1 cm or greater on at least one mammographic projection with the collagen-plug marker (5/31) than with the conventional metallic marker clip (19/43) (chi-square test, p = 0.02).The collagen-plug marking device is an effective alternative to existing marker clips, and use of this device may result in fewer cases in which the marker clip is substantially displaced (or = 1 cm) away from the actual biopsy site.

The objective of this study was to compare the accuracy of current methods of determining clip location (immediate stereotactic images versus postprocedure two-view mammograms) after stereotactic-guided, vacuum-assisted breast biopsy (VABB). Retrospective review was made of 101 lesions for which a localizing clip was placed during stereotactic VABB. Clip-to-lesion distances were measured by 1) stereotactic images (x, y, and z coordinates), and 2) postbiopsy two-view mammograms compared to prebiopsy two-view mammograms. The mean clip-to-lesion distance was 5.7 mm from stereotactic images, while the mean clip-to-lesion distances were 3.6 and 9.4 mm from same-view and orthogonal-view mammogram measurements, respectively. Stereotactic coordinate measurements compared to orthogonal-view mammogram clip-to-lesion measurements showed a significant difference (p < 0.001), as did the same-view mammogram compared to both stereotactic images and orthogonal-view mammogram (p < 0.001). The number of clips found to be less than 20 mm from the lesion (defined as clinically significant) was significantly higher for measurements from orthogonal-view mammograms (n = 19) compared to both stereotactic images (n = 0) and same-view mammograms (n = 5) (p < 0.001). Determination of clip location based on stereotactic images significantly underestimated the clip-to-lesion distance. Stereotactic images obtained at the conclusion of clip placement during VABB are not reliable in determining clip location relative to the targeted lesion. Although stereotactic images can confirm deployment of the clip, a two-view postbiopsy mammogram is necessary to determine clip location relative to the targeted lesion.

Background: Needle localization breast biopsy (NLBB) is the standard for removal of breast lesions after vacuum assisted core biopsy (VACB). Disadvantages include a miss rate of 0% to 22%, a positive margin rate of approximately 50%, and vasovagal reactions (approximately 20%). We hypothesized that clip migration after VACB is clinically significant and may contribute to the positive margin rates seen after NLBB. Methods: We performed a retrospective review of postbiopsy films in patients who had undergone VACB with stereotactic clip placement for abnormal mammograms. We measured the distance between the clip and the biopsy site in standard two view mammograms. The location of the biopsy air pocket was confirmed using the prebiopsy calcification site. The Pythagorean Theorem was used to calculate the distance the clip moved within the breast. Pathology reports on NLBB or intraoperative hematoma-directed ultrasound-guided breast biopsy (HUG, which localizes by US the VACB site) were reviewed to assess margin status. Results: In all, 165 postbiopsy mammograms on patients who had VACB with clip placement were reviewed. In 93 evaluable cases, the mean distance the clip moved was 13.5 mm ± 1.6 mm, SEM (95% CI = 10.3 mm to 16.7 mm). Range of migration was 0 to 78.3 mm. The median was 9.5 mm. In 21.5% of patients the clip was more than 20 mm from the targeted site. Migration of the clip did not change with the age of the patient, the size of the breast or location within the breast. In the subgroup of patients with cancer, margin positivity (including those with close margins) after NLBB was 60% versus 0% in the HUG group. Conclusions: Significant clip migration after VACB may contribute to the high positive margin status of standard NLBBs. Surgeons cannot rely on needle localization of the clip alone and must be cognizant of potential clip migration. HUG as an alternative biopsy technique after VACB eliminates operator dependency on clip location and may have superior results in margin status.

Purpose We investigated the feasibility of using surgical clips as markers for tumor localization and their effect on the imaging evaluation of treatment responses after neoadjuvant chemotherapy (NAC). Methods A total of 16 breast cancers confirmed by needle biopsy in 15 patients were included in this study from October 2012 to June 2014. Under ultrasonography (US)-guidance, the surgical clips were placed prior to NAC. Additional mammography, breast US, and breast magnetic resonance examinations were performed within 10 days before surgery. The time period from marker insertion to operation date was documented. Images acquired via the three modalities were evalu-ated for the following parameters: location of clip, clip migration (>1 cm), the presence of complications from clip placement, and the effect of clips on the assessment of treatment. Results The mean time period was 128.6±34.4 days (median, 132.0 days) from the date of clip insertion to the date of surgery. The mean number of inserted clips was 2.3±0.7 (median, 2.0). Clip migration was not visualized by imaging in any patient, and there were no complications reported. Surgical clips did not negatively affect the assessment of treatment responses to NAC. Conclusion Surgical clips may replace commercial tissue markers for tumor localization in breast cancer patients undergoing NAC without migration. Surgical clips are well tolerated and safe for the patient, easily visualized on imaging, do not interfere with treatment response, and are cost-effective.

It is essential to collapse giant carotid-ophthalmic (OA) segment aneurysms for successful microsurgical clipping. We present a trapping-evacuation technique utilising hybrid operating theater capabilities to soften OA aneurysms. The patients were prepared for both microsurgical and endovascular procedures. After the majority of the aneurysm was exposed, a balloon was placed at the orifice of the aneurysm to fully block the blood flow. When the balloon was inflated, blood was evacuated from the aneurysm sac to eliminate the space occupying effect. Subsequently, the aneurysm neck was clearly exposed which greatly facilitated clip placement. A control angiogram was obtained prior to closing the wound to ensure complete aneurysm obliteration. After the establishment of a hybrid operating theater in our hospital, two aneurysms were successfully clipped using this technique. Although postoperative complications occurred in both patients, none of the events were related to the endovascular procedure or the trapping-evacuation technique. As a well-organized procedure designed for use in a hybrid operating theater, the current trapping-evacuation technique is an option for the surgical clipping of giant OA aneurysms.

We describe a novel technique for marking non-palpable breast lesions with the aim of selecting the best approach prior to performing a biopsy. The technique employs a new coil, specifically designed for breast localization, guided by stereotaxy. This technique is reserved for selected cases in which the lesion is seen peripherally in only one mammographic view with negative or non-conclusive ultrasonographic results, and deeply seated after a stereotactic study. Once the coil is released beside the lesion, the shortest approach from the skin may be employed to perform the biopsy. To our knowledge, this is the first report of this technique.