Search

Background: Esophageal diverticula were traditionally treated with open surgery, which is associated with significant morbidity and mortality rates. Management has shifted to minimally invasive approaches with several advantages. We examine outcomes in patients with esophageal diverticula treated with minimally invasive techniques by a multidisciplinary surgical team at a single center. Materials and Methods: A retrospective review of a prospectively maintained database was performed for patients who underwent minimally invasive surgery for esophageal diverticula at our institution from June 2010 to December 2022. Primary outcomes were 30-day morbidity and mortality rates. Secondary outcomes were symptom resolution, length of stay (LOS), readmission, and need for reintervention. Results: A total of 28 patients were identified. Twelve patients had pharyngeal diverticula, 7 patients had midesophageal diverticula, and 9 patients had epiphrenic diverticula. Thirty-day morbidity and readmission rates were 10.7% (3 patients), 1 pharyngeal (sepsis), 1 midesophageal (refractory nausea), and 1 epiphrenic (poor oral intake). There were no esophageal leaks. Average LOS was 2.3 days, with the pharyngeal group experiencing a significantly shorter LOS (1.3 days versus 3.4 days for midesophageal, P < .01 versus 2.8 days for epiphrenic, P < .05). Symptom resolution after initial operation was 78.6%. Reintervention rate was 17.9%, and symptom resolution after reintervention was 100%. There were no mortalities. Conclusion: This study demonstrates that esophageal diverticula can be repaired safely and efficiently when performed by a multidisciplinary team utilizing advanced minimally invasive endoscopic and robotic surgical techniques. We advocate for the management of this rare condition at a high-volume center with extensive experience in foregut surgery. [ABSTRACT FROM AUTHOR]

The objective of this study was to demonstrate the oncologic efficacy of awake endoscopic laryngeal surgery in the treatment of T1-T2 glottic carcinoma. This is a retrospective study. Seventy-one patients with early glottic carcinoma (T1a- 26, T1b- 18, T2- 27) who underwent awake flexible endoscopic laryngeal surgery under local anesthesia and mild intravenous sedation were included in the study. In 64 cases (90.1%) only endoscopic tumor ablation by Nd:YAG laser (in 32.4% of cases being preceded by diathermy snare excision) was performed, and in 7 T2 cases postoperative radiotherapy was also offered. There were no complications during or after the endoscopic surgery. Ultimate control of disease, including salvage treatment, was obtained in 67 patients (94.4%). Cure without recurrence was achieved in 60 cases (84.5%). Local control without salvage radiotherapy or/and open surgery was achieved in 64 (90.1%) patients. Larynx preservation was obtained in 66 (93.0%) cases. At 5 years from the beginning of endoscopic treatment, 74.6% of the patients were alive and free of disease. The best results were obtained in the T1a group of treated patients, all the patients being free of disease with the preserved larynx. Awake endoscopic laryngeal surgery is a safe and oncologically efficient method of treatment of early glottic carcinoma that can be considered as an alternative to the traditional approach, primarily, for patients with risks/contraindications for radiotherapy, general anesthesia, and transoral microsurgery, and also for the patients who prefer to avoid general anesthesia with its related risks and would rather choose office-based laryngeal surgery. [ABSTRACT FROM AUTHOR]

Abstract Objectives Flexible endoscopy does not have a system that can automatically evacuate surgical smoke generated in the gastrointestinal lumen. We aimed to investigate the feasibility and potential usefulness of automatic smoke evacuation systems in flexible endoscopy. Methods [Bench] After surgical smoke generated in the stomach was evacuated by the evacuator, the degree of residual smoke and gastric luminal collapse were evaluated to optimize the evacuator settings. [Animal] Insufflation, suction, and total operation time to complete the protocol of 10 cauterizations of the gastric mucosa were measured in three groups: “manual suction only,” “manual suction with automatic evacuation (50% force),” and “manual suction with automatic evacuation (70% force).” The stability of endoscopic visualization and operability was evaluated by 10 endoscopists blinded to those suction settings, and the number of manual suctions, insufflations, and total operation time were measured. Results [Bench] The degree of residual smoke and gastric luminal collapse were inversely correlated. [Animal] When the automatic evacuator was partially used, there was no difference in the insufflation time, but the suction time (vs 50%; p = 0.011, vs. 70%; p = 0.011) and total operation time (vs. 50%; p = 0.012, vs. 70%; p = 0.036) were significantly reduced compared to manual operation only. Furthermore, manual suction with automatic evacuation (50% force) significantly improved the stability of endoscopic visualization and operability compared to manual operation only (p = 0.041, p = 0.0085). Conclusions The automatic smoke evacuation in flexible gastrointestinal endoscopy was potentially feasible and useful by improving the device setting.

Simple Summary: This report describes three successful cases of gastrointestinal foreign body removal from psittacine birds via endoscopy. Our findings suggest that a potentially effective endoscopic removal approach may involve ventral recumbency with anesthesia via a mask or endotracheal intubation when dealing with a limited number of blunt foreign bodies within a short operation time. This case report offers valuable insights and practical guidance for the efficient and safe removal of foreign bodies in avian patients. Although the use of incision-free endoscopy for foreign body (FB) removal in dogs and cats has been extensively documented, its application in birds remains limited. Thus, we present the endoscopic removal of gastrointestinal (GI) FBs from psittacine birds, employing different patient positioning and anesthesia methods. Two blue-and-yellow macaws (Ara ararauna) and a Triton cockatoo (Cacatua galerita triton) were examined. X-ray imaging revealed FBs situated in the proventriculus in each case. The FBs, all identified as feeding tubes, were safely removed using grasping forceps during the endoscopic procedure, and no severe complications occurred. Based on the outcomes of each operation, the most suitable patient position may be ventral recumbency rather than dorsal recumbency, with the use of a mask or endotracheal intubation, depending on the anticipated operation time. However, a larger number of cases would be necessary to confirm the optimal patient positioning and anesthesia method. [ABSTRACT FROM AUTHOR]

The expanding role of flexible endoscopy (FE) has helped to establish better diagnostic strategies and fewer invasive therapies within the lumen of the gastrointestinal (GI) tract. Endoscopic skills represent critical tools for surgeons since they markedly impact perioperative outcomes. Although it is widely recognized that endoscopy plays a key role in digestive surgery, endoscopic curricula and syllabi may vary depending on geographical regions, which have their own standardized guidelines such as the United States and countries with numerous disparities such as Western Europe. Such heterogeneous practices represent a call for action, particularly as surgical societies aim to expand cutting-edge endoscopy within surgery. This article outlines the crucial role of intraoperative endoscopy in commonly performed digestive surgeries and stresses the need to develop standardized endoscopic training curricula in surgery, particularly in Europe. [ABSTRACT FROM AUTHOR]

Background: Fundamentals of endoscopic surgery (FES) completion is mandatory for certification by the American Board of Surgery (ABS). As early simulation and competency assessment can bolster development of trainee proficiency, we sought to determine the optimal timing for FES examination by evaluating pass rates based on training level and previous endoscopic experience. Methods: PGY2-5 residents at a university-based medical center who were novice to FES were assigned to complete FES training and testing. Training year, prior endoscopic experience, and FES exam scores were recorded with pre- and post-test surveys. Results: Most residents in the program (88%) were able to complete FES training and testing within a single academic year. Most required only a single faculty-led session (88%) to feel confident to take the exam, augmented by varying numbers of independent practice sessions (50% 1–2, 19% 3–5, 27% > 5). After training, most (84%) felt confident that they would pass the exam, and 93% did so on their first attempt. While higher written exam scores were noted in the PGY5 group, there were no other statistically significant differences in overall pass rates or technical exam scores based on PGY level (p = 0.24). A number of previously completed endoscopic cases did not correlate with exam scores (p = 0.24 written, p = 0.91 technical). Conclusion: Fundamentals of endoscopic surgery (FES) certification can be successfully completed by junior level general surgery residents regardless of previous endoscopic experience. Moving this exam to earlier training years can benefit resident development and preparedness in the clinical setting without negatively impacting pass rates. [ABSTRACT FROM AUTHOR]

Zenker per-oral endoscopic myotomy (ZPOEM) has become a promising technique for Zenker's diverticulum (ZD). The aim of this study was to add to the limited body of literature evaluating the safety and efficacy of ZPOEM. A prospectively maintained database was retrospectively reviewed to identify patients who underwent ZPOEM at two separate institutions between January 2020 and January 2022. Demographics, preoperative and postoperative clinical data, intraoperative data, adverse events, and length of stay were analyzed. A total of 40 patients (mean age 72.5 years, 62.5% male) were included. Average operative time was 54.7 minutes and average length of stay was 1.1 days. There were three adverse events, and only one was related to the technical aspects of the procedure. Patients showed improvement in the Functional Oral Intake Scale (FOIS) scores at 1 month (5 vs 7, p  < 0.0001). The median FOIS scores remained 7 at both 6 and 12 months, although this improvement was not statistically significant at these time intervals (p  = 0.46 and 0.37, respectively). Median dysphagia scores were decreased at 1 (2.5 vs 0, p  < 0.0001), 6 (2.5 vs 0, p  < 0.0001), and 12 months (2.5 vs 0, p  = 0.016). The number of patients reporting ≥1 symptom was also decreased at 1 (40 vs 9, p  < 0.0001) and 6 months (40 vs 1, p  = 0.041). Although the number of patients reporting ≥1 symptom remained consistent at 12 months, this was not statistically significant (40 vs 1, p  = 0.13). ZPOEM is a safe and highly effective treatment for the management of ZD. [ABSTRACT FROM AUTHOR]

Introduction: The conventional rigid-90° and rigid-70° laryngostroboscopy has been so far considered the gold standard in assessing the vibratory behavior of the vocal folds and the glottal closure configuration during phonation. Meanwhile, this rigid laryngostroboscopy is more and more replaced by flexible chip-on-tip systems. The aim of this study was to evaluate the influence of these different endoscopic techniques on glottal closure configuration and on visibility of the complete focal fold length including anterior commissure during phonation. Methods: Twenty-one euphonic subjects were enrolled (mean age 34.6 ± 9.5; m = 10, f = 11). They were examined with the three laryngoscopic techniques (conventional rigid-90°, rigid-70°, and flexible chip-on-tip laryngoscopy during low and high voice pitch with soft and loud voice intensity). For evaluating the degree of glottal closure, a modified classification of Södersten et al. was applied and the visibility of the anterior commissure was evaluated. The correlation of the three endoscopic techniques was assessed with Cohen and Fleiss' kappa. Results: In even low loud phonation, the rigid-90° and rigid-70° endoscopies revealed a complete closure of the glottis in only 47.6% of subjects but with flexible endoscopy in 81%. The complete vocal fold length with anterior commissure was best visible with flexible endoscopy in 90.5% in low-soft and high-soft phonation. The rigid-90° endoscopy showed a slight agreement in comparison with the flexible endoscopy in regard to the types of vocal fold closure with a Cohen's kappa coefficient k = 0.199. The rigid-90° endoscopy showed an almost perfect agreement with k = 0.84 when compared to the rigid-70° endoscopy. The flexible endoscopy compared to the rigid-70° endoscopy showed a fair agreement with k = 0.346. Conclusion: We found mainly corresponding results in both rigid-90° and rigid-70° endoscopic techniques which can be explained by the same transoral approach with the tongue pulled out, whereas the flexible transnasal endoscopy mainly gives a better view on the anterior commissure. The influence of transorally or transnasally guided endoscopic techniques needs to be considered in interpretation of laryngostroboscopic parameters like vocal fold closure and supraglottal hyperactivity. [ABSTRACT FROM AUTHOR]

The expanding role of flexible endoscopy (FE) has helped to establish better diagnostic strategies and fewer invasive therapies within the lumen of the gastrointestinal (GI) tract. Endoscopic skills represent critical tools for surgeons since they markedly impact perioperative outcomes. Although it is widely recognized that endoscopy plays a key role in digestive surgery, endoscopic curricula and syllabi may vary depending on geographical regions, which have their own standardized guidelines such as the United States and countries with numerous disparities such as Western Europe. Such heterogeneous practices represent a call for action, particularly as surgical societies aim to expand cutting-edge endoscopy within surgery. This article outlines the crucial role of intraoperative endoscopy in commonly performed digestive surgeries and stresses the need to develop standardized endoscopic training curricula in surgery, particularly in Europe.

Background and study aim: Zenker's diverticulum is a rare disease that affects quality of life due to dysphagia and regurgitation. This condition can be treated by various surgical or endoscopic methods. Patients and method: Patients treated for Zenker's diverticulum in three centers in the south of France between 2014 and 2019 were included. The primary objective was clinical efficacy. Secondary objectives were technical success, morbidities, recurrences, and need for a new procedure. Results: One hundred forty-four patients with a total of one hundred sixty-five procedures performed were included. A significant difference was found between the different groups in terms of clinical success (97% for open surgery versus 79% for rigid endoscopy versus 90% for flexible endoscopy, p = 0.009). Technical failure occurred more frequently in the rigid endoscopy group than in the flexible endoscopy and surgical groups (p = 0.014). Median procedure duration, median time to resumption of feeding, and hospital discharge were statistically shorter for endoscopies than for open surgery. On the other hand, more recurrences occurred in patients treated by endoscopy than those treated by surgery, and more reinterventions were required. Conclusion: Flexible endoscopy appears to be as effective and safe as open surgery in the treatment of Zenker's diverticulum. Endoscopy allows a shorter hospital stay at the expense of a higher risk of recurrence of symptoms. It could be used as an alternative to open surgery for the treatment of Zenker's diverticulum, especially in frail patients. [ABSTRACT FROM AUTHOR]

Context: Competence in flexible endoscopy is essential for all surgeons during this era of minimal access surgery. However, fewer surgeons have expertise in endoscopy due to a lack of training and interest. The Indian Association of Gastrointestinal Endo Surgeons devised a short-structured training course in the art and science of endoscopy. Aims: This study aimed to find the impact of the endoscopy training course (Endoscopic Fellowship of Indian Association of Gastrointestinal Endo Surgeons [EFIAGES]) in improving the endoscopic skill of surgeons. Settings and Design: Twenty-two-part electronic survey forms were sent to all 375 candidates who took the course between 2016 and 2019 for this retrospective observational study. Subjects and Methods: The following outcome measures were noted, namely technical competence in endoscopy before the course, delegate feedback about the course modules, volume of endoscopies before and after the course and quality indicators such as reaching up to duodenum (D2) and caecum before and after the course. Statistical Analysis Used: Statistical analysis of the impact of the course was done using Chi-square test. Results: Responses from 262 out of a total of 375 candidates were received. Seventy-seven per cent of trainees were pleased with content and mode of conduct of the course. The quality indicator of gastroscopy with the ability to reach D2 in 90% of the caseload was achieved by only 28% of trainees before the EFIAGES. This increased to 72% of candidates after the course and similar results were seen with colonoscopy also. Most of the candidates noted a distinct improvement in their endoscopic navigation skills subsequent to the course. Conclusions: Endoscopy skill transfer was possible with a short-structured endoscopy course. The surgical fraternity should realise the importance of endoscopy skills in the current era of surgical practice.

There is an ever increasing volume of colorectal surgery being performed endoscopically by anal access, as well as greater employment of robotics for these procedures. Intraluminal visualization for perianal operations is today dependent on insufflation of the bowel. When full-thickness resections above the peritoneal reflection become necessary, the peritoneal cavity becomes inflated, facilitating infection and necessitating general anesthesia and patient intubation. Our patented tool was originally envisioned to enable abdominal cavity access via a single 2cm port incision, suitable for insufflation-free laparoscopic surgery, under local anesthesia (e.g., cholecystectomy). On further consideration, this instrument was modified to be used for perianal colorectal surgery. [ABSTRACT FROM AUTHOR]

Aims: The traditional approach for the management of benign laryngeal lesions is transoral microsurgery. In cases of anatomic particularities, such as insufficient cervical extension, short mandible, temporomandibular joint ankylosis etc., and contraindications for general anesthesia, transoral microsurgery is not possible. In such cases transnasal flexible endoscopic surgery under local anesthesia can be a relevant alternative. The purpose of the study was to assess the possibilities of flexible endoscopic management of benign nonepithelial lesions of the larynx. Materials and methods: Flexible endoscopic surgical interventions were performed on 315 patients with different benign nonepithelial lesions of the larynx. The larynx pathology was represented by following lesions: myxoid polyp, polypoid degeneration of vocal folds, fibrous polyp, angiofibrous polyp, angiomatous polyp, nonspecific granuloma, cyst, lipoma, neurofibroma and amyloidosis. In 97,8% of the cases interventions were performed under local anesthesia with spontaneous respiration. In 88,6% of the cases interventions were performed as outpatient procedures. Results: In all the cases the expected result was obtained – complete ablation of the visible lesion. In 7 cases repeated interventions were performed for recurrent lesions. Conclusion: Flexible endoscopic surgery is an efficient method for the treatment of benign nonepithelial lesions of the larynx, that offers a relevant therapeutic alternative, especially for the patients who have contraindications for general anesthesia or transoral microsurgery. The advantages of the method, worthy of mentionning, are positive economic effect and time economy, the intervention being possible in an outpatient setting for the majority of patients. [ABSTRACT FROM AUTHOR]

Background: The aim of this study was to investigate the feasibility of flexible endoscopy‐guided tracer injection for sentinel lymph node (SLN) identification in patients with laryngeal and pharyngeal carcinoma. Methods: Sixteen cT1‐4N0‐2M0 patients with laryngeal or pharyngeal carcinoma underwent intra‐ and peritumoral [99mTc]Tc‐nanocolloid injections after topical anesthesia under endoscopic guidance. SPECT–CT scans were performed at two time points. Results: Tracer injection and visualization of SLNs was successful in 15/16 (94%) patients. Median number of tracer injections was 1 intratumoral and 3 peritumoral. The median duration of the endoscopic procedure including tracer injection after biopsy taking was 7 min (range 4–16 min). A total of 28 SLNs were identified which were all visualized on the early and late SPECT–CT. Most SLNs were visualized in neck levels II and III. Conclusions: Flexible endoscopy‐guided tracer injection for SLN identification is a feasible and fast procedure in laryngeal and pharyngeal carcinoma patients. [ABSTRACT FROM AUTHOR]

The robot‐assisted flexible access surgery represented by the emerging robot‐assisted flexible endoscopy (FE) and natural orifice transluminal endoscopic surgery demands flexible and continuum manipulators instead of the rigid and straight instruments in the traditional minimally invasive surgery (MIS). These flexible manipulators are required to advance through the tortuous and narrow anatomic paths via natural orifices for dexterous diagnostic examination and therapeutic operations. Therefore, developing flexible endoscopic manipulators with the capacity of snake‐like movements for flexible access and variable stiffness regulation for operations to address these flexible access surgical difficulties is demanding but remains challenging. To address such challenges, herein, it is proposed that a novel distal continuum joint based on the hybrid pneumatic and cable‐driven approach achieves variable stiffness capacity, excellent bending characteristics in both flexible and rigid states, satisfactory motion consistency and shape‐locking ability during the rigid‐flexible transition, and relatively high loading capacity for flexible gastrointestinal endoscopic robots. Characterization experiments validate these performances, and phantom and ex vivo experiments have been performed to demonstrate the feasibility and effectiveness for FE. The presented method demonstrates an effective and practical approach to enabling continuum robots with both flexible access and tunable stiffness capacity and supports a convenient extension for MIS applications. [ABSTRACT FROM AUTHOR]

Purpose: During endoscopic sinus surgery (ESS), difficult-to-reach pathologies need an extended endoscopic approach or an external approach. We started to use a flexible interventional endoscope (FIE) to evaluate the necessity of those approaches. The study's objective is to describe our experience and define patients who could benefit from this technique. Methods: We reviewed every patient who benefited from FIE associated with ESS at our tertiary University Hospital between January 2021 and February 2022. Results: During this period, we did 107 ESS, and 14 patients benefited from the FIE, representing 13% of our ESS. The median duration of the flexible endoscopy time was 14 min (4–38 min). We identified three groups of patients who can benefit from the FIE. The first one is for patients with a fungal infection, to control and to clean lateral recesses in a noninvasive manner. The second one is for patients with a pathology of the lateral frontal sinus, to remove the frontoethmoidal cells or mucocele with the biopsy forceps through the working channel. The third group is for patients with inverted papillomas, to precisely identify the insertion and to decide on the most appropriate surgical approach. Conclusions: In selected cases, using flexible endoscopy during ESS helps decide the optimal surgical approach and sometimes treat the pathology through a limited approach. Prospective studies for each group of patients are needed to confirm the benefit of this new combined procedure. [ABSTRACT FROM AUTHOR]

Objective: To determine if simulation training is required to pass the FES skills test and assess the relationship between simulation training, clinical training, and FES skills test performance. Summary of Background Data: The ABS began requiring completion of the Flexible Endoscopy Curriculum for all applicants beginning in 2018. The role of simulation-based training in FES skills test performance after this requirement has not been evaluated. Methods: De-identified data from the initial FES skills tests after the Flexible Endoscopy Curriculum requirement was reviewed, and 731 unique participants with reported simulation experience demographics were identified. Self-reported data included sex, upper (UE) and lower (LE) endoscopy experience, and simulator training hours (SE). Final FES skills exam scores and pass/fail designations for each participant were reported by the FES program staff. Results: There was a statistically discernible difference in mean FES total scores between those reporting no SE and more experienced groups (P = 0.002), and between less and more experienced UE and LE groups (P < 0.001). There was no statistically discernible difference in FES skills exam pass rates between SE groups (P = 0.2), but there was a strong relationship between clinical experience (UE & LE) and pass rate (P < 0.001). Finally, on logistic regression analysis, LE was a discernible predictor of passing [odds ratio (OR) = 1.4, 95% confidence interval (CI) 1.1–1.8, P = 0.02], while UE [odds ratio (OR) = 1, 95% CI 0.8-1.3, P = 0.9] and SE (OR = 1,95% CI 0.9– 1.3, P = 0.7) were not. Conclusions: There is no threat to the validity of the FES skills test from a need for simulation training to pass the FES skills test. Similarly, the amount of simulation practice is not predictive of passing, but can improve performance on certain FES tasks. [ABSTRACT FROM AUTHOR]

Background: The treatment of Zenker's diverticulum has been shifted from open cricopharyngeal myotomy and rigid endoscopy to the use of flexible endoscopy. Few studies evaluate general surgeon's performance of flexible endoscopic management of Zenker's diverticulum as the majority are performed by gastroenterologists. The objective of our case series is to show that general surgeons trained in surgical endoscopy can perform this procedure with favorable outcomes. Methods: A retrospective review of peroral cricopharyngeal myotomies performed at Spectrum Health hospital in Grand Rapids, Michigan by a single surgical endoscopist between the 2018 and 2021 was conducted. The primary outcome was the improvement of dysphagia. Intra-procedural complications, post-procedural complications, hospital length of stay, time to oral intake, and recurrence were also evaluated. Age, sex, body mass index, diverticulum size, and procedure time were abstracted. Median (ranges) and frequencies (percentages) are used to describe the patient population and outcomes. Results: Forty patients were included in the study. Median age was 74 years old (60–95) with a male predominance (n = 27, 67.5%). Median BMI was 28 kg/m2 (18–43), average procedure length of 64 min (41–119), diverticulum size of 28 mm (19–90), and average length of stay of 0.9 days (0–8). There were no intra-procedural complications. All patients had a post-procedural esophagram prior to initiation of diet. Esophageal leak was the only complication that occurred, which was found on post-procedural esophagram (n = 5). Only two patients had clinical sequelae. All leaks closed without additional surgical intervention. The majority of patients had their diet resumed and discharged the same day of the procedure. Frequency of recurrence was 17.5% (n = 7). Conclusion: Our study demonstrates that general surgeons trained in endoscopy can perform endoscopic myotomies for Zenker's diverticula on a wide range of sizes, with favorable patient outcomes, and few complications. [ABSTRACT FROM AUTHOR]

Zenker's Diverticulum, named after Dr Friedrich Albert von Zenker (1825-1898) who in 1877 reported a series of 23 cases and first hypothesized its pathophysiology, is an uncommon pathology, occurring in elderly patients, predominantly males. It is suspected by the association of dysphagia and regurgitation, and diagnosed by a barium swallow radiography with video fluoroscopy. For a long time, its treatment was reserved for open surgery, then rigid endoscopy performed by ENT surgeons, despite a high morbidity rate for the former and technical limitations for the latter. Finally, the first septotomy with a flexible endoscope was reported very recently in 1995 by two different teams. Since then, endoscopic techniques have been adapted over the last two decades with increasing success and safety profile replacing conventional surgery as first line treatment according to ESGE recommendations (European Society of Gastrointestinal Endoscopy). This mini-review aims to provide a synthesis of therapeutic methods with emphasis on the availability of flexible endoscopy and its future progress with the advent of Z-POEM. [ABSTRACT FROM AUTHOR]

The robot‐assisted flexible access surgery represented by the emerging robot‐assisted flexible endoscopy (FE) and natural orifice transluminal endoscopic surgery demands flexible and continuum manipulators instead of the rigid and straight instruments in the traditional minimally invasive surgery (MIS). These flexible manipulators are required to advance through the tortuous and narrow anatomic paths via natural orifices for dexterous diagnostic examination and therapeutic operations. Therefore, developing flexible endoscopic manipulators with the capacity of snake‐like movements for flexible access and variable stiffness regulation for operations to address these flexible access surgical difficulties is demanding but remains challenging. To address such challenges, herein, it is proposed that a novel distal continuum joint based on the hybrid pneumatic and cable‐driven approach achieves variable stiffness capacity, excellent bending characteristics in both flexible and rigid states, satisfactory motion consistency and shape‐locking ability during the rigid‐flexible transition, and relatively high loading capacity for flexible gastrointestinal endoscopic robots. Characterization experiments validate these performances, and phantom and ex vivo experiments have been performed to demonstrate the feasibility and effectiveness for FE. The presented method demonstrates an effective and practical approach to enabling continuum robots with both flexible access and tunable stiffness capacity and supports a convenient extension for MIS applications.

Although the use of incision-free endoscopy for foreign body (FB) removal in dogs and cats has been extensively documented, its application in birds remains limited. Thus, we present the endoscopic removal of gastrointestinal (GI) FBs from psittacine birds, employing different patient positioning and anesthesia methods. Two blue-and-yellow macaws (Ara ararauna) and a Triton cockatoo (Cacatua galerita triton) were examined. X-ray imaging revealed FBs situated in the proventriculus in each case. The FBs, all identified as feeding tubes, were safely removed using grasping forceps during the endoscopic procedure, and no severe complications occurred. Based on the outcomes of each operation, the most suitable patient position may be ventral recumbency rather than dorsal recumbency, with the use of a mask or endotracheal intubation, depending on the anticipated operation time. However, a larger number of cases would be necessary to confirm the optimal patient positioning and anesthesia method.

Abstract Background Several modalities are available for the diagnosis of rectal cancer, including conventional gold standard rigid endoscopy and recent flexible endoscopy and magnetic resonance imaging (MRI). Each modality affects the management of these patients. Aim To compare the accuracy of flexible endoscopy and MRI in the measurement of tumor height in patients with rectal cancer. Methods and Results This study included 174 patients with rectal cancer who underwent flexible endoscopy and MRI for the measurement of tumor height. Data on patient demographics, comorbidities, treatment, and histopathology were identified and collected. We evaluate intraclass correlation coefficient (ICC) and Bland–Altman plot to test the agreement between the measurements. ICC were excellent with an ICC of 89% (95%CI 48%–99%). The mean ± standard deviation of the distance from the anal verge to the distal part of the tumor was 7.73 ± .47 for flexible endoscopy and 6.21 ± 0.39 for MRI, with mean difference of 1.52 (p ˂ .001). The accordance between the two modalities was not affected by sex, age, body mass index, histopathology, or metastasis. Conclusion Excellent agreement between flexible endoscopy and MRI was noted, and no factor was found to affect such concordance.

Background: Reported incidence of anastomotic leakage (AL) of rectal anastomoses is up to 29% with an overall mortality up to 12%. Nevertheless, there is no uniform evidence-based diagnostic procedure for early detection of AL. The objective of this prospective clinical trial was to demonstrate the diagnostic value of early postoperative flexible endoscopy for rectal anastomosis evaluation. Methods: Flexible endoscopy between 5 and 8th postoperative day was performed consecutively in 90 asymptomatic patients. Sample size calculation was made using the two-stage Simon design. Diagnostic value was measured by management change after endoscopic evaluation. Anastomoses were categorized according to a new classification. Study is registered in German Clinical Trials Register (DRKS00019217). Results: Of the 90 anastomoses, 59 (65.6%) were unsuspicious. 20 (22.2%) were suspicious with partial fibrin plaques (n = 15), intramural hematoma and/or local blood coagulum (n = 4) and ischemic area in one. 17 of these anastomoses were treated conservatively under monitoring. In three a further endoscopic re-evaluation was performed and as consequence one patient underwent endoscopic vacuum therapy. 11 (12.2%) AL were detected. Here, two could be treated conservatively under monitoring, four with endoscopic vacuum therapy and five needed revision surgery. No intervention-related adverse events occurred. A change in postoperative management was made in 31 (34.4%) patients what caused a significant improvement of diagnosis of AL (p < 0.001). Conclusions: Early postoperative endoscopic evaluation of rectal anastomoses is a safe procedure thus allows early detection of AL. Early treatment for suspicious anastomoses or AL could be adapted to avoid severe morbidity and mortality. [ABSTRACT FROM AUTHOR]

Mastering a surgical skill requires experience and repetition, yet opportunities for surgical trainees to gain real experience are variable and limited by case load. Surgical simulators have emerged in an attempt to overcome these limitations. However, the few currently available skills simulators for flexible endoscopy are costly, have limited accessibility and versatility, lack portability, and require dedicated time for practice. The use of a portable skills simulator to teach flexible endoscopy may provide a feasible alternative. This study introduces a novel, low-cost, portable, endoscopic simulation system for training basic endoscopic skills. Using custom software, the simulator presents a virtual environment featuring 3D models of anatomy, endoscopes, and endoscopic tools. The virtual endoscope and its tools are directly controlled in the simulation by motion input from a custom-manufactured portable endoscopic controller that communicates data via a Bluetooth interface. This two-part study presents proof of concept and initial pilot data examining the face/content validity and preliminary construct validity of the portable endoscopic simulator. In part 1, experts (n = 2) and novices (n = 6) provided ratings of fidelity and utility as a training tool. In part 2, experts (n = 4) and novices (n = 4) completed 10 simulated sequential basic endoscopic tasks, and time to completion was assessed. Findings indicate that the simulator has good utility as a training tool, but some features require modification to be more realistic. Furthermore, both novices and experts improved on the task with repeated measurements (p < 0.001), but there were no significant differences between experts and novices in time to completion. Although more robust validation is required, this simulator appears promising as a feasible and cost-effective tool for providing simulation training on basic endoscopic skills. [ABSTRACT FROM AUTHOR]

Background: During postoperative follow-up, the visible range of maxillary sinus (MS) is limited, even combining 0° and 70° rigid endoscopes together. Flexible endoscope has been used in larynx examinations for a long time, but rarely in nasal cavity and sinus. We aimed to evaluate the application values of rigid and flexible endoscopes for visualization of MS.Methods: We followed up 70 patients with lesions in MS via both rigid and flexible endoscopes. In addition, we used thin-slice CT image of the sinus to create a MS model and divided it into two parts for 3D printing. The inner surface of the 3D-printed sinus was marked with grid papers of the same size (5 mm × 5 mm), then the visual range under rigid endoscopes with different angle and flexible endoscopes was calculated and analyzed.Results: In clinical follow-up, we found that flexible endoscopy can reach where rigid endoscopy cannot, which is more sensitive than medical imaging. Endoscopes showed the largest observation range of the posterolateral wall, more than half of which can be visualized by 0° endoscope. Almost all of the posterolateral wall can be revealed under 45° endoscope, 70° endoscope and flexible endoscope. The visual range of each wall under flexible endoscope is generally greater than that under rigid endoscopes, especially of the anterior wall, medial wall and inferior wall.Conclusion: There was obviously overall advantage of using flexible endoscope in postoperative follow-up of MS lesions. Flexible endoscopy can expand the range of observation, and improve the early detection of the recurrent lesion. We recommend flexible endoscope as a routine application. [ABSTRACT FROM AUTHOR]

Flexible endoscopic evaluation of swallowing with sensory testing (FEESST) is a promising clinical tool to assess airway integrity via the laryngeal adductor reflex (LAR). The current clinical protocol relies on sensory threshold detection, as relatively little is known about the motor response of this sensorimotor airway protective reflex. Here, we focused on characterizing normative LAR motion dynamics in 20 healthy young participants using our prototype high-pressure syringe-based air pulse device and analytic software (VFtrack™) that tracks vocal fold (VF) motion in endoscopic videos. Following device bench testing for air pulse stimulus characterization, we evoked and objectively quantified LAR motion dynamics in response to two suprathreshold air pulse stimuli (40 versus 60 mm Hg), delivered to the arytenoid mucosa through a bronchoscope working channel. The higher air pressures generated by our device permitted an approximate 1 cm endoscope working distance for continual visualization of the bilateral VFs throughout the LAR. Post hoc video analysis identified two main findings: (1) there are variant and invariant subcomponents of the LAR motor response, and (2) only a fraction of suprathreshold stimuli evoked complete glottic closure during the LAR. While the clinical relevance of these findings remains to be determined, we have nonetheless demonstrated untapped potential in the current FEESST protocol. Our ongoing efforts may reveal LAR biomarkers to quantify the severity of laryngeal pathology and change over time with natural disease progression, spontaneous recovery, or in response to intervention. The ultimate goal is to facilitate predictive modeling of patients at high risk for dysphagia-related aspiration pneumonia. [ABSTRACT FROM AUTHOR]

Bowen Hu,1 Huanfei Ding2 1Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People’s Republic of China; 2Department of Ultrasound, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, 450052, Henan, People’s Republic of ChinaCorrespondence: Bowen Hu, Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital of Zhengzhou University, No. 1 Eastern Jianshe Road, Zhengzhou, 450052, Henan, People’s Republic of China, Tel +86-15286819833, Email fcchubw@zzu.edu.cnAbstract: Endoscopic thyroidectomy has evolved from a hybrid approach utilizing a laparoscopic assistant and robotic-assistance to pure flexible endoscopic thyroidectomy without laparoscopic assistance. However, all the hybrid approaches are complicated and results in scar somewhere on the body surface. Current experimental and clinical studies focus on the implementation of new minimally invasive approaches such as flexible endoscopic thyroidectomy which leaves no scar on the body surface and easier to perform. Flexible endoscopic thyroidectomy is seeming to be a relatively safe and feasible technique with good outcomes. However, more research, particularly using newly developed tools to further improve this technique, and large scaled practice is needed to make it more available to patients worldwide. This article summarizes established endoscopic thyroidectomy techniques and highlight the pros and cons of different available endoscopic approaches to thyroid resection, and discussed how flexible endoscopic thyroidectomy compares to the well establish techniques and future perspective.Keywords: NOTES, endoscopic thyroidectomy, flexible endoscopy, laparoscopy, robotic endoscopic surgery

The management of children with concomitant ureteropelvic junction (UPJ) obstruction and calyceal stones remains challenging. The various treatment options available for pediatric nephrolithiasis may require multiple sessions, and the techniques by themselves are not designed for simultaneous correction of UPJ obstruction. Recently, success in combining robot-assisted laparoscopic pyeloplasty (RALP) and flexible endoscopy has been reported by multi-institutional studies to treat children with concomitant UPJ obstruction and renal stones. Given the paucity of technical details of this novel approach in the existing literature, we herein report our techniques to treat two girls aged 6 and 10 years who had concomitant UPJ obstruction and multiple stones in mid- and lower poles calyces. Three robotic ports were used without any assistant ports. A flexible endoscope, either a cystoscope or a single-use ureteroscope, was introduced via the undocked epigastric port to perform nephroscopy and stones removal after the renal pelvis was opened. The rest of the RALP was completed in the usual manner. Technical modifications were employed to facilitate the flexible endoscope to examine the entire calyceal system. Both patients underwent successful surgical procedures by the combined approach without any intra- or post-operative complications. Three and 14 stones were removed from each of the patients respectively. Postoperative investigations demonstrated successful correction of UPJ obstruction and complete stone clearance in both patients. A combined approach of RALP and flexible endoscopy is a safe and effective technique to treat concurrent UPJ obstruction and calyceal stones in children.

Background: Flexible endoscopy is a valuable tool for the gastrointestinal (GI) surgeon, creating a need for effective and efficient training curricula in therapeutic endoscopic techniques for trainees and practicing providers. Here, we present a simulation-based modular curriculum using an "into the fire" approach with hands-on pre- and post-testing to teach endoscopic stenting to practicing surgeons.Methods: Three advanced flexible endoscopy courses were taught by expert surgical endoscopists from 2018 to 2019. The stenting module involved using self-expandable metal stents to manage simulated esophageal and gastroduodenal strictures on a non-tissue GI model. Based on the educational theories of inquiry-based learning, the simulation curriculum was designed with a series of pre-tests, didactics, mentored hands-on instructions, and post-tests. Assessments included a confidence survey, knowledge-based written test, and evaluation form specific to the hands-on performance of endoscopic stenting.Results: Twenty-eight practicing surgeons with varying endoscopic experiences participated in the course. Most of the participants (67.9%) had completed over 100 upper endoscopic procedures and 57.1% were certified in Fundamentals of Endoscopic Surgery. After completing the modular curriculum, participant confidence survey scores improved from 11.4 ± 4.2 to 20.7 ± 4.0 (p < 0.001). Knowledge-based written test scores also improved from 7.1 ± 1.2 to 8.4 ± 0.9 (p < 0.001). In terms of technical performance, overall hands-on performance scores improved from 21.3 ± 2.7 to 28.9 ± 1.2 (p < 0.001) with significant improvement in each individual component of the assessment (all p values < 0.01) and the greatest improvement seen in equipment handling (88%) and flow of procedure (54%).Conclusion: Our modular simulation curriculum using an "into the fire" approach to teach endoscopic stenting is effective in improving learner knowledge, confidence, and hands-on performance of endoscopic stenting. This approach to simulation is effective, efficient, and adaptable to teaching practicing surgeons with varying levels of experience. [ABSTRACT FROM AUTHOR]

Background: Zenker's diverticulum (ZD) was historically treated with an open transcervical myotomy with diverticulectomy, but endoscopic approaches have gained popularity, though with little recent data. This study aimed to report flexible endoscopic cricopharyngomyotomy (FEC) outcomes, particularly in smaller diverticula., Methods: Patients with ZD treated with FEC at a tertiary center were reviewed. Patients were grouped by diverticulum size: small (sZD)≤1.5 ​cm; medium (mZD) ​> ​1.5 ​cm., Results: Of 30 patients, median age, BMI, sex, and comorbidities were similar between sZD (n ​= ​18) and mZD (n ​= ​12). Overall, 80.0 ​% had the procedure performed with a needle knife. Median number of clips for mucosotomy closure (5.0[5.0,6.0]vs.7.0[5.0,7.0]clips;p ​= ​0.051), operative time (59.5[51.0,75.0]vs.74.5[51.0,93.5]minutes;p ​= ​0.498), length-of-stay (1.0[1.0,1.0]vs.1.0[1.0,1.0]days;p ​= ​0.397), and follow-up (20.8[1.1,33.4]vs.15.6[5.4,50.4]months;p ​= ​0.641) were comparable. There were no postoperative leaks; incomplete myotomy occurred in one sZD, yielding a clinical success rate of 96.7 ​%., Conclusions: FEC has a high success rate for ZD and an advantage in small diverticula, difficult to treat with stapling or open technique., Competing Interests: Declaration of competing interest P. Colavita, MD is a research grant recipient from Medtronic; however, this grant is unrelated to the study and has not affected the objectivity of the data. A. Holland, MD, W. Lorenz, MD, A. Ricker, MD, B. Mead, MD, and G. Scarola, MS have no conflicts of interest or financial ties to disclose. There is nothing related to intellectual property that needs to be disclosed. Authors do not participate in any activities or organizations that may compete with or impact this study. This study was not funded by any outside entity other than ourselves, including specific funding agencies in the public, commercial, or not-for-profit sectors. Finally, we have not utilized artificial intelligence writing assistance in the creation of this manuscript., (Copyright © 2024 Elsevier Inc. All rights reserved.)

Abstract Background To avoid the inconvenience of triangulation among various rigid operating instruments in mediastinoscopy-assisted esophagectomy, we invented a new technique: used a flexible endoscope to mobilize thoracic esophagus and dissected mediastinal lymph nodes through the left cervical incision. This technology has not been reported so far. In this study, we introduce our long-term experience and demonstrate this new technique. Methods Twenty-nine patients with early esophageal cancer underwent mediastinoscopy-assisted esophagectomy in our hospital from June 2018 to September 2020. Among them, 12 patients used flexible mediastinoscopy, and 17 patients used conventional rigid mediastinoscopy and instruments to observe their therapeutic effect. Results There were no significant differences between the two groups in gender, average age, body mass index, incidence of adverse reactions, bleeding volume, and postoperative hospital stay. The operation time of flexible mediastinoscopy group was significantly shorter than that of rigid mediastinoscopy group (192.9 ± 13.0 vs 246.8 ± 6.9 min, p

Diagnostic and therapeutic potentials of flexible endoscopy have been increasing. Several surgical procedures are now performed in flexible endoscopic platform. However, it is disturbing to find that only few surgeons are keen to acquire this expertise. Endoscopic skills are not optional but essential for every general surgeon. Sooner the surgical fraternity realise this, it is better for the prospects of future surgeons. Surgical societies should implement measures to highlight the importance of endoscopy training and strive to provide adequate training opportunities.

Purpose: This study aims to evaluate management pathways, outcomes and safety of rigid endoscopy (RE) and flexible endoscopy (FE) for the treatment of impacted foreign bodies of the upper gastrointestinal tract (UGIT) in adults. Methods: Retrospective study, included all patients undergoing RE or FE for impacted UGIT foreign body over an 11-year-period. Results: A total of 144 patients were included (95 FE and 49 RE). FE were performed under local anaesthetic or sedation, and RE under GA. Success rate of FE and RE were 95.8% and 95.9% respectively. During FE an intra-procedural biopsy was performed in 45/95 (47.3%); with 26/95(27.4%) identifying mucosal pathology. Complications was significantly higher in patients having RE (40.8% versus 6.3%, p =.001). Conclusion: FE and RE are effective for the therapeutic management of impacted UGIT foreign bodies. However, FE can be performed under LA and was associated with fewer complications, favouring FE where possible as a first line option. [ABSTRACT FROM AUTHOR]

Objective: To compare the accuracy of lateral skull film, flexible endoscopy, and intraoperative rigid endoscopy in assessment of adenoid size.Methods: A cross-sectional study was conducted in 43 pediatric patients undergoing ENT surgery from July 2017 to December 2018. All patients underwent preoperative lateral skull film, flexible endoscopy, and intraoperative rigid endoscopy.Results: The average adenoidal-nasopharyngeal (A/N) ratio obtained from lateral skull film, flexible endoscopy, and intraoperative rigid endoscopy was 72.9, 79.5, and 81.6, respectively. There was a moderate correlation between A/N ratio from lateral skull film and intraoperative rigid endoscopy (Pearson's correlation: 0.567, p˂0.001). Whereas, the A/N ratio from flexible endoscopy compared to intraoperative rigid endoscopy showed a stronger correlation (Pearson's correlation: 0.791, p˂0.001). From linear regression analysis, the intraoperative adenoid measurement was estimated from the results of flexible endoscopy (intraoperative rigid endoscopy: 0.72 [flexible endoscopy] +24.47) and lateral skull film (intraoperative rigid endoscopy = 0.65 [lateral skull film] + 34) CONCLUSION: Flexible endoscopy yields the most accuracy in the assessment of adenoid size and nasopharynx visualization, without radiation exposure or anesthesia. Despite less accuracy, lateral skull film is more availability in every hospital. The correlation of adenoid size measurement in this study can also be applied for the actual size of adenoid. [ABSTRACT FROM AUTHOR]

Abstract Background Self‐assembling peptides (TDMs) comprise synthetic amphipathic peptides that immediately react to changes in pH and/or inorganic salts to transform into a gelatinous state. The first generation of these peptides (TDM‐621) is currently used as a hemostatic agent in Europe. However, TDM‐621 exhibits slow gel‐formation and low retention capabilities on tissue surfaces. The second generation (TDM‐623) was therefore developed to encourage faster gel‐formation and better tissue‐sealing capabilities. Aim The aim of this study was to verify the efficacy of TDM‐623 in terms of its hemostatic effect in endoscopic surgery. Materials and methods Evaluation of the hemostatic effect in endoscopic surgery (animal study) was performed using eight porcine in spine position. Following systemic heparinization, we established a “bleeding model” by endoscopic grasping forceps on the anterior walls of the stomach and duodenum. In the hemostasis method, an endoscope with a distal hood was brought into contact with the bleeding point, and 1 ml TDM‐623 was applied to the wound. After TDM‐623 gelation, the endoscope was removed, and the acute hemostatic effect (after 2 min) was confirmed. Result In the endoscopic bleeding model, 17 of the 23 cases (74%) showed complete hemostatic effects on the anterior wall of the stomach, and 18 of the 20 cases (80%) on the anterior wall of the duodenum, respectively. None of the applied gels were displaced from the anterior walls of the stomach and duodenum. Conclusion The new self‐assembling peptide (TDM‐623) showed high hemostatic effects. TDM‐623 had potential usefulness for upper gastrointestinal endoscopic surgery.

Background: In‐office biopsies (IOB) using local anaesthetic for laryngopharyngeal tumours has become an increasingly popular approach since the advent of distal chip endoscopes. Although a wide range of studies advocate use in clinical practice, the widespread application of the procedure is hampered by concerns regarding diagnostic accuracy. Objective: To assess the diagnostic accuracy of IOB performed via flexible endoscopy. In addition, to analyse modifiable factors that may affect diagnostic accuracy of IOB. Design: A systematic review following the PRISMA guidelines was conducted. PubMed, EMBASE, the Cochrane Library, Web of Science and CINAHL were used in the literature database search. Quality assessment of included studies was perfomed using the Newcastle‐Ottawa Scale. Results: A total of 875 studies were identified, 16 of which were included into the systematic review; 1572 successful biopsies were performed using flexible endoscopy; 1283 cases were accurately diagnosed in the outpatient setting (81.6%) and 289 samples did not provide an accurate diagnosis (18.4%). The median sensitivity of IOB was 73%, and the specificity was 96.7%. Analysis of variable factors did not show any significant differences in method of approach, size of equipment (forceps) and additional lighting system or learning curve. Conclusion: IOB are a viable tool for diagnostic workup of laryngopharyngeal tumours. Clinicians should be wary of reported limitations of IOB when benign or pre‐malignant diagnoses are made. In cases suspicious of malignancy, confirmatory investigation should be conducted. [ABSTRACT FROM AUTHOR]

Endoscopy for revealing the orifice of congenital H‐type tracheoesophageal fistula (cTEF) is important for diagnostics and therapeutics. To facilitate the identification and catheterization of cTEF, we developed a new modified flexible endoscopy technique using a laryngeal mask with intermittent airflow. A retrospective case series study was conducted from April 2016 to July 2019 at a national regional children's medical center. Twelve infants with cTEF underwent this flexible endoscopy technique. The intermittent positive pressure airflow through laryngeal mask was able to reveal the orifice of cTEF easily in tracheal lumen. Under the visual flexible endoscope, cannulation with a 3‐Fr ureteral catheter in fistula was successfully used in all cases. There were no immediate or delayed complications. This case series shows that the flexible endoscopy technique is a safe, easy, and technically efficient approach for diagnosis and cannulation of cTEF. [ABSTRACT FROM AUTHOR]

Abstract The endoscope was traditionally used as a diagnostic instrument. In past decades, it has increasingly been adapted for therapeutic intents. Subsequently, the master–slave robotic concept was introduced into the field of endoscopy to potentially reduce the difficulty and complication rates of endoscopic therapeutic procedures. As interest in robotic endoscopy intensified, progressively more robotic endoscopic platforms were developed, tested, and introduced. Nevertheless, the future of robotic endoscopy hinges on the ability to meet specific clinical needs of procedurists. Three aspects are vital in ensuring continued success and clinical adoption of the robotic endoscope—demonstration of clinical safety and cost‐efficacy of the device, widespread availability of directed training opportunities to enhance technical skills and clinical decision‐making capabilities of the procedurist, and continued identification of new clinical applications beyond the current uses of the device. This review provides a brief discussion of the historical development of robotic endoscopy, current robotic endoscopic platforms, use of robotic endoscopy in conventional therapeutic endoscopic procedures, and the future of robotic endoscopy.

Diagnostic and therapeutic potentials of flexible endoscopy have been increasing. Several surgical procedures are now performed in flexible endoscopic platform. However, it is disturbing to find that only few surgeons are keen to acquire this expertise. Endoscopic skills are not optional but essential for every general surgeon. Sooner the surgical fraternity realise this, it is better for the prospects of future surgeons. Surgical societies should implement measures to highlight the importance of endoscopy training and strive to provide adequate training opportunities. [ABSTRACT FROM AUTHOR]

This is a difficult task, due to the thick keratin layer on the tumour surface and hard tumour consistency, and requires a special effort from the clinician, which usually is not necessary in case of biopsy of papilloma or typical SCC. Diagnosis is difficult because the tumour appears macroscopically "malignant" and microscopically "benign".5 The presence of the thick layer of keratin on the tumour surface creates major obstacles for obtaining an adequate biopsy material, which frequently results in inadequate traditional biopsy and inconclusive histologic response. In order to obtain an adequate biopsy specimen for histologic confirmation of the nature of tumour, flexible endoscopic snare diathermy excision under local anaesthesia with lidocaine 2% was used. [Extracted from the article]

Background: Appropriate tissue tension and clear visibility of the dissection area using traction are essential for effective and safe endoscopic submucosal dissection (ESD). We developed a robotic assistive traction device for flexible endoscopy and compared its safety and efficiency in ESD between experienced and novice endoscopists. Methods: Robotic ESD was performed by experienced and novice endoscopist groups (n = 2, each). The outcomes included time to complete each ESD step, total procedure time, size of the dissected mucosa, rate of en bloc resection, and major adverse events. Furthermore, incision and dissection speeds were compared between groups. Results: Sixteen gastric lesions were resected from nine live pigs. The submucosal incision speed was significantly faster in the expert group than in the novice group (P = 0.002). There was no significant difference in the submucosal dissection speed between the groups (P = 0.365). No complications were reported in either group. Conclusions: When the robot was assisting in the ESD procedure, the dissection speed improved significantly, especially in the novice surgeons. Our robotic device can provide simple, effective, and safe multidirectional traction during ESD. [ABSTRACT FROM AUTHOR]