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The main causes for cerebrospinal fluid (CSF) leaks are known to be traumatic, iatrogenic, neoplastic, a meningoencephalocele, congenital bone defects, and spontaneous. Off-label intrathecal administration of fluorescein is widely used to localize a CSF leak. Complications are rare and low dose administration is described to be safe. In this case report, we present a case of a patient, who showed a CSF leak due to an encephalocele. Low dose fluorescein was applied intrathecally via lumbar catheter, the CSF leaks could be identified, and multilayered closure was performed. Postoperatively, the patient presented with motor and sensory deficits in the lower limbs which regressed only partially within 2 months. A possible explanation may be an increased local concentration of fluorescein, possibly on the basis of a preexisting lumbar spinal canal stenosis. To our knowledge, this is the first case in which a dose as low as 20 mg of fluorescein (2% saline mixture) led to persisting paraplegia. Therefore, the potential benefits and risks of the intrathecal fluorescein use in the detection of a CSF leak have to be discussed comprehensively prior to surgery. [ABSTRACT FROM AUTHOR]

Background: Transnasal endoscopy (TNE) does not require general anesthesia, an attractive characteristic for monitoring eosinophilic esophagitis (EoE). We evaluated the adequacy of TNE-obtained esophageal biopsies using the EoE Histology Scoring System (EoEHSS). Methods: The Cincinnati Center for Eosinophilic Disorders database was searched for esophageal biopsies obtained by the same endoscopist, using either TNE or conventional endoscopy (CE). Whole-slide biopsy images were evaluated. The Mann-Whitney test was used for median (interquartile range) values and Fisher exact test for categorical variables. P ≤.05 was considered significant. Results: Median age (P =.82) or height (P =.83) did not differ between TNE (n = 17) and CE (n = 17) groups. Although median largest piece size (mm2) differed between the groups (TNE: 0.59 (0.45, 0.86), CE: 2.24 (1.09, 2.82), P <.001), all 8 EoEHSS features were evaluated in each group; only 1 feature (lamina propria fibrosis) was missing in both groups (TNE: 19/34, CE: 11/34, P =.09). The median peak eosinophil count/high-power field differed (TNE: 3 (0, 29), CE: 16 (1, 66), P =.03), but overall grade (TNE: 0.17 (0.10, 0.29), CE: 0.22 (0.14, 0.46), P =.12), stage (TNE: 0.14 (0.10, 0.24), CE: 0.20 (0.10, 0.43), P =.15), and non-eosinophil-related individual EoEHSS scores did not differ. Conclusions: TNE- and CE-obtained esophageal biopsies are similarly sufficient for evaluation of key pathological features in EoE. [ABSTRACT FROM AUTHOR]

Airway management is a vital part of anesthesia practices, intensive care units, and emergency departments, and a proper pre-operative assessment can guide clinicians' plans for securing an airway. Complex airway assessment has recently been at the forefront of anesthesia research, with a substantial increase in annual publications during the last 20 years. In this paper, we provide an extensive overview of the literature connected with pre-operative airway evaluation procedures, ranging from essential bedside physical examinations to advanced imaging techniques such as ultrasound (US), radiography, computed tomography (CT), and magnetic resonance imaging (MRI). We discuss transnasal endoscopy, virtual endoscopy, 3D reconstruction-based technologies, and artificial intelligence (AI) as emerging airway evaluation techniques. The management of distorted upper airways associated with head and neck pathology can be challenging due to the intricate anatomy. We present and discuss the role of recent technological advancements in recognizing difficult airways and assisting clinical decision making while highlighting current limitations and pinpointing future research directions. [ABSTRACT FROM AUTHOR]

Resumen: Introducción y objetivo: La endoscopia transnasal (ETN) ha probado su utilidad diagnóstica; sin embargo, no se ha aceptado de manera generalizada debido a que se realiza sin sedación y no se han llevado a cabo estudios que reporten el uso de métodos que mejoren su tolerabilidad. El objetivo fue evaluar la tolerabilidad de la ETN cuando se realiza de manera simultánea con un dispositivo audiovisual como distractor. Métodos: Se evaluaron 50 pacientes y 10 de ellos rechazaron participar. El procedimiento se explicó utilizando un dispositivo audiovisual. Antes de la aleatorización se aplicaron escalas de ansiedad y depresión. Los pacientes se dividieron en 2 grupos: grupo i (utilizando un dispositivo audiovisual durante el procedimiento) y grupo ii (sin dispositivo). Se utilizaron escalas numéricas de ansiedad y dolor. Se monitorizaron signos vitales antes, durante y después de la endoscopia. Se aplicó una escala de satisfacción al final del estudio y 24 horas después. Resultados: El promedio de edad fue 41.6 años y 35 (87.5%) pacientes fueron de sexo femenino. La indicación más frecuente para ETN fue enfermedad por reflujo gastroesofágico refractario. No se encontraron comorbilidades significativas y ningún participante contaba con puntuación de ansiedad o depresión significativa. Un paciente del grupo ii no toleró la ETN debido a dolor nasal. No se encontró diferencia significativa en niveles de ansiedad y dolor, signos vitales y escala de satisfacción entre grupos. Conclusiones: Nuestro estudio mostró que la ETN es bien tolerada y tiene un porcentaje alto de aceptación en nuestros pacientes. El uso de dispositivos audiovisuales distractores no incrementó la tolerancia al procedimiento endoscópico. Abstract: Introduction and objective: Transnasal endoscopy (TNE) has proven its diagnostic utility, but it has not been widely accepted given that it is performed without sedation. There are no previous studies on the use of methods to improve its tolerability. Our aim was to evaluate the tolerability of TNE, when simultaneously performed with an audiovisual device as a distractor. Methods: We evaluated 50 patients, 10 of whom did not agree to participate. The performance of the procedure was explained, using an audiovisual device. Before randomization, we applied anxiety and depression scores. Patients were divided into 2 groups: Group I (using an audiovisual device during the procedure) and Group II (without a device). Anxiety and numeric pain rating scales were used, and vital signs were monitored and recorded before, during, and after the endoscopy. An overall procedure satisfaction score was applied at the end of the study and 24 h later. Results: Mean age was 41.6 years and 35 of the patients were women (87.5%). The most frequent indication for TNE was refractory gastroesophageal reflux disease. There were no severe comorbidities, and none of the patients had a significant anxiety or depression score. One patient in Group II did not tolerate TNE due to nasal pain. There was no statistically significant difference between groups, regarding anxiety, pain, vital signs, and satisfaction scale. Conclusion: Our study showed that TNE was well tolerated and had a high acceptance rate in our patients. The use of distracting audiovisual devices did not increase tolerance to the endoscopic procedure.

BackgroundUnsedated transnasal endoscopy is becoming an increasingly popular option for the evaluation of upper gastrointestinal tract disorders in adults and children worldwide. This innovative technology has transformative potential as it provides for a more efficient, safe, and cost-effective method for endoscopy and reduces the risks associated with anesthesia, which is particularly relevant in pediatrics as endoscopy is commonly done under general anesthesia or conscious sedation. The aim is to address knowledge gaps amongst pediatric gastroenterologists who may be considering the development of a TNE program, detailing how to implement sedation-free TNE into practice for pediatric patients and current and forthcoming technologies.MethodsWe conducted a comprehensive review of current literature and collection of data from experts and clinicians in the field on how sedation-free programs were started and being conducted. We aimed to collate the data to provide a guide to address knowledge gaps with a focus on setting up and starting a sedation-free endoscopy program.ResultsHere in, we provide a detailed guide for implementing a sedation-free endoscopy program in pediatrics including design and layout of a TNE unit, special staffing needs, equipment, current and forthcoming technologies, financial considerations and training considerations. We highlight special considerations that are relevant in pediatrics incorporating distraction or dissociation techniques such as Virtual Reality Systems, developmentally appropriate preparation for children, and topical analgesia.ConclusionSedation-free endoscopy is a rapidly growing option for pediatric patients. Development of an unsedated pediatric endoscopy program will improve patient care, decrease the need for anesthesia, provide a lower cost and safe alternative to traditional sedated endoscopy, and is a viable component to a pediatric gastroenterology practice.

Purpose: the aim of this multicenter study is to preliminarily assess the role of the Endoscopic Endonasal Approach (EEA) in ultra-early (i.e., within 12 h) management of selected neurosurgical emergencies in terms of clinical and radiological outcomes. Methods: 26 patients affected by sellar/parasellar pathologies with rapid progression of symptoms were managed with EEA within 12 h from diagnosis in three Italian tertiary referral Centers from January 2016 to December 2019. Both clinical and radiological data have been collected preoperatively as well as post-operatively in order to perform retrospective analysis. Results: The average time from admission to the operating room was 5.5 h (±2.3). The extent of resection was gross-total in 20 (76.9%), subtotal in 6 (23.1%) patients. One patient experienced re-bleeding after a subtotal removal of a hemorrhagic lesion. Patients with a longer time from admission (>4 h) to the operatory room (OR) experienced stable impairment of the visual acuity (p = 0.033) and visual field (p = 0.029) in the post-operative setting. Conclusions: The Endoscopic Endonasal Approach represents a safe, effective technique that can be efficiently used with good results in the management of selected neurosurgical emergencies in centers with adequate experience. [ABSTRACT FROM AUTHOR]

Photoimmunotherapy for head and neck cancer (HNC-PIT) is a newly developed locoregional treatment targeting the epidermal growth factor. This treatment consists in administering cetuximab sarotalocan sodium that conjugates cetuximab with the dye IRdye700DX, which is activated by near-infrared ray illumination at 690 nm. HNC-PIT has been conditionally approved in Japan in September 2020 for the treatment of unresectable locally advanced or unresectable locoregionally recurrent HNC. However, its outcomes on the local recurrence of the nasopharyngeal squamous cell carcinoma (NPSCC) remain undetermined. In this report, we assessed the effects of HNC-PIT assisted by transnasal endoscopy on the local recurrence of NPSCC. A 77-year-old male presented with a local recurrence of NPSCC. The initial diagnosis revealed a squamous cell carcinoma, T2N2M0 stage III, positive for Epstein-Barr virus-encoded small RNA by in situ hybridization, which was treated with concurrent chemoradiotherapy (CRT). However, local recurrence was detected 14 months after CRT. We performed HNC-PIT under transnasal endoscopy. Seven months have passed since the HNC-PIT treatment, and the patient is alive without delayed adverse events and evidence of recurrence. Local recurrence of NPSCC, which is difficult to treat with minimally invasive surgery, is considered a potential candidate for HNC-PIT. [ABSTRACT FROM AUTHOR]

Background A new image-enhanced endoscopy method called texture and colour enhancement imaging (TXI) enhances brightness, surface irregularities, and subtle colour changes in endoscopic images. However, it is unclear whether TXI and narrow-band imaging (NBI) with third-generation high-vision transnasal ultrathin endoscopy are advantageous over white-light imaging (WLI) for detecting atrophy, intestinal metaplasia, map-like redness and gastric cancer. We investigated to compare the endoscopic efficacy for evaluation of gastritis between TXI and NBI with high-vision transnasal endoscopy and clarified the endoscopic efficacy of TXI and NBI compared to WLI.Methods We enrolled 60 patients who underwent high-vision transnasal endoscopy as part of a health check-up from March to November 2021 and randomized patients into two groups (the WLI-NBI group and the WLI-TXI group) using the minimization method based on Helicobacter pylori infection status, age and sex. Colour differences determined using the International Commission on Illumination 1976 (L∗, a∗, b∗) colour space was compared between WLI and TXI or NBI.Results No significant differences were observed in colour differences surrounding atrophy, intestinal metaplasia and map-like redness between NBI and TXI (p = .553, .057 and .703, respectively). Endoscopic scores based on the Kyoto classification of gastritis for atrophy, intestinal metaplasia, and map-like redness were similar between WLI and TXI. In contrast, NBI identified intestinal metaplasia at a significantly greater rate than WLI (p = .018). Further, colour differences surrounding atrophy and intestinal metaplasia on TXI and NBI were significantly greater than those on WLI (atrophy: TXI vs WLI p = .003, NBI vs WLI p

One of the most severe side effects of photoimmunotherapy (PIT) for head and neck cancer is pain. As there are presently no detailed reports on pain and pain management in PIT, we conducted a retrospective case series study. We conducted a retrospective study of five patients who had received PIT at the National Cancer Center Hospital East between January 2021 and June 2022 using medical chart data. All patients experienced pain, evidenced by an increased numerical rating scale (NRS) after PIT, regardless of the illumination method. The daily change in mean NRS rating shows that the pain was highest on the day of PIT, with ratings of 6.8 and 7.8 for the frontal and cylindrical diffuser methods, respectively; it dropped the following day quickly. Four of the five patients received fentanyl injections for postoperative pain management beginning on postoperative day (POD) 0. All patients who underwent therapy using a cylindrical diffuser required postoperative pain management with opioid drugs. Pain after PIT tended to be most intense immediately after or one hour after illumination and declined the following day, suggesting the need to have a pain relief plan in place in advance. [ABSTRACT FROM AUTHOR]

Conventional esophagogastroduodenoscopy (cEGD) is currently the gold standard endoscopic procedure for diagnosis and surveillance of Barrett's esophagus (BE). This procedure is however less suitable for widespread screening because of its invasiveness and costs. An alternative endoscopic procedure is unsedated transnasal endoscopy (uTNE). We performed a systematic review and meta-analysis to evaluate the diagnostic accuracy, patient tolerability, technical success rate, and safety of uTNE compared with cEGD for detecting BE and related neoplasia. PubMed, EMBASE, and Cochrane Library were searched for studies that reported the diagnostic accuracy of uTNE compared with cEGD for detecting BE and related neoplasia. Eight prospective studies were included, in which 623 patients underwent both uTNE and cEGD. Pooled sensitivity and specificity of uTNE for detecting columnar epithelium were 98% (95% CI 83–100%) and 99% (95% CI 82–100%), respectively. Pooled sensitivity and specificity of uTNE for detecting intestinal metaplasia in biopsies were 89% (95% CI 78–95%) and 93% (95% CI 71–98%), respectively. In three of the six studies that reported patient tolerability, a higher patient tolerability of uTNE compared with cEGD was reported. The technical success rate of uTNE ranged from 89% to 100% and no (serious) adverse events were reported. This systematic review and meta-analysis provides evidence that uTNE is an accurate, safe, and well-tolerated procedure for the detection of columnar epithelium and can be considered as screening modality for BE. [ABSTRACT FROM AUTHOR]

BackgroundThe objective of the study is to investigate the surgical methods and clinical effects of high-flow revascularization in microsurgery combined with endoscopic endonasal surgery for skull base tumors with intracranial and extracranial involvement.MethodsThe relationships between skull base tumors and internal carotid artery (ICA), tumor location and size, and the extent of tumor invasion were assessed. Preoperative CT perfusion (CTP), magnetic resonance (MR) perfusion-weighted imaging (PWI) (MR-PWI), and digital subtraction angiography (DSA) were performed to evaluate collateral circulation and brain tissue perfusion. Then craniotomy through the fronto-orbitozygomatic approach was performed, based on which four cases received extended middle skull base approach+Dolenc approach + Fukushima bypass type I, and six cases received extended middle skull base approach+Fukushima bypass type III. After surgery, DSA, CT angiogram (CTA), and CTP/PWI were performed to evaluate the patency of the reconstructed vessels and cerebral perfusion, and contrast-enhanced MRI to evaluate the degree of tumor resection. All patients were followed up for 6–12 months.ResultsAmong the 10 cases investigated, gross total resection was achieved in 8 cases, subtotal resection in 1 case, and partial resection in 1 case, as confirmed by CT and enhanced MRI. The patency of revascularization vessels was observed using fluorescein angiography during the operation in all patients and via DSA and CTA postoperatively in nine patients. One patient underwent ventilator-assisted ventilation because of respiratory failure and failed to undergo DSA and CTA. Regarding postoperative complications, one patient developed watershed cerebral infarction on the operated side but no sequelae after drug treatment, three patients developed facial numbness, which improved after 3 months, and two patients experienced worsened diplopia. After 6 to 12 months of follow-up on the nine evaluable patients, the Glasgow Outcome Scale (GOS) was 4–5 after surgery. In addition, 6-month follow-up results showed that one patient with clival chondrosarcoma developed recurrence on contrast-enhanced MRI, while no relapse was observed in the other patients.ConclusionFor skull base tumors with intracranial and extracranial invasion and involving the ICA, revascularization might improve the total resection rate and reduce the recurrence rate and risk of intraoperative bleeding and postoperative ischemia.

A new image-enhanced endoscopy method called texture and colour enhancement imaging (TXI) enhances brightness, surface irregularities, and subtle colour changes in endoscopic images. However, it is unclear whether TXI and narrow-band imaging (NBI) with third-generation high-vision transnasal ultrathin endoscopy are advantageous over white-light imaging (WLI) for detecting atrophy, intestinal metaplasia, map-like redness and gastric cancer. We investigated to compare the endoscopic efficacy for evaluation of gastritis between TXI and NBI with high-vision transnasal endoscopy and clarified the endoscopic efficacy of TXI and NBI compared to WLI. We enrolled 60 patients who underwent high-vision transnasal endoscopy as part of a health check-up from March to November 2021 and randomized patients into two groups (the WLI-NBI group and the WLI-TXI group) using the minimization method based on Helicobacter pylori infection status, age and sex. Colour differences determined using the International Commission on Illumination 1976 (L∗, a∗, b∗) colour space was compared between WLI and TXI or NBI. No significant differences were observed in colour differences surrounding atrophy, intestinal metaplasia and map-like redness between NBI and TXI (p =.553,.057 and.703, respectively). Endoscopic scores based on the Kyoto classification of gastritis for atrophy, intestinal metaplasia, and map-like redness were similar between WLI and TXI. In contrast, NBI identified intestinal metaplasia at a significantly greater rate than WLI (p =.018). Further, colour differences surrounding atrophy and intestinal metaplasia on TXI and NBI were significantly greater than those on WLI (atrophy: TXI vs WLI p =.003, NBI vs WLI p <.001; intestinal metaplasia: TXI vs WLI p =.016, NBI vs WLI p <.001). However, TXI and NBI were not advantageous over WLI for detecting map-like redness. Third-generation high-vision transnasal ultrathin endoscopy using TXI and/or NBI is useful for detecting atrophic borders and intestinal metaplasia. High-vision transnasal endoscopy using TXI or NBI is useful for diagnosing and detecting atrophy and intestinal metaplasia. TXI and NBI increase colour differences surrounding atrophy and intestinal metaplasia, thereby increasing diagnostic efficiency to improve risk stratification for gastric cancer. The image quality and detection rate have improved markedly with the latest ultrathin high-vision transnasal endoscopes. [ABSTRACT FROM AUTHOR]

The diagnosis and monitoring of eosinophilic esophagitis (EoE) relies on clinical symptoms and histological examination of the esophageal mucosa. Currently, esophagogastroduodenoscopy with biopsy is the standard of care in the diagnosis and monitoring of EoE. Unsedated transnasal endoscopy (TNE) is a less invasive and less costly procedure that can be performed without general anesthesia. Here, we describe the first case of a 15-year-old adolescent girl who underwent TNE exclusively to identify all food triggers for EoE. She underwent 12 TNEs over a period of 4 years to identify food triggers for EoE to ultimately achieve the remission of her disease., (© 2024 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.)

Background and Aim: Transnasal endoscopy (TNE) has been proven to reduce the need for intravenous anesthesia and the cost of the exams compared to conventional esophagogastroduodenoscopy (EGD) in adults. The objective of this study is to evaluate the benefits and the adverse effects of TNE in adolescents compared to conventional EGD., Methods: We reviewed the pediatric patients from 2012 to 2022, who had undergone TNE at National Taiwan University Hospital due to epigastralgia. Age and gender-matched controls, who had undergone conventional EGD for epigastralgia at the same time, were also recruited., Results: Totally 15 patients, aged between 12 and 20 years old, who had undergone TNE for epigastralgia at National Taiwan University Hospital were recruited as the study group. Another 60 age and gender-matched adolescents were also recruited in the control group. The needs of conscious sedation (9.3% vs 58.3%), hospitalization rate (13.3% vs 43.3%), the mean exam time (7.34 vs 9.96 min), and the cost of endoscopy (57.6 vs 93.2 USD) were significantly lower in the group of TNE as compared with the conventional EGD group. There was no difference in the percentage of complications, including dizziness, epistaxis, nausea, and vomiting, after procedures (P > 0.05.) CONCLUSIONS: TNE is a cost-effective exam and it also reduces the exposure to conscious sedation, the need for hospitalization and the exam time, making it a good choice for adolescents who are scheduled to undergo EGD for epigastralgia., (Copyright © 2024 Formosan Medical Association. Published by Elsevier B.V. All rights reserved.)

Background: Image-enhanced endoscopy methods such as narrow-band imaging (NBI) are advantageous over white-light imaging (WLI) for detecting gastric atrophy, intestinal metaplasia, and cancer. Although new third-generation high-vision ultrathin endoscopes improve image quality and resolution over second-generation endoscopes, it is unclear whether the former also enhances color differences surrounding atrophy and intestinal metaplasia for endoscopic detection. We compared the efficacy of a new third-generation ultrathin endoscope and an older second-generation endoscope. Methods: We enrolled 50 Helicobacter pylori-eradicated patients who underwent transnasal endoscopy with a second-generation and third-generation endoscope (GIF-290N and GIF-1200N, respectively) in our retrospective study. Color differences based on the International Commission on Illumination 1976 (L*, a*, b*) color space were compared between second-generation and third-generation high-vision endoscopes. Results: Color differences surrounding atrophy produced by NBI on the GIF-1200N endoscope were significantly greater than those on GIF-290N (19.2 ± 8.5 vs. 14.4 ± 6.2, p = 0.001). In contrast, color differences surrounding intestinal metaplasia using both WLI and NBI were similar on GIF-1200N and GIF-290N endoscopes. NBI was advantageous over WLI for detecting intestinal metaplasia on both endoscopes. Conclusions: NBI using a third-generation ultrathin endoscope produced significantly greater color differences surrounding atrophy and intestinal metaplasia in H. pylori-eradicated patients compared with WLI. [ABSTRACT FROM AUTHOR]

The diagnosis of eosinophilic esophagitis (EoE) is based on clinical symptoms of esophageal dysfunction and eosinophil predominant esophageal inflammation. Clinical symptoms in children with EoE vary based on age and may be nonspecific. EoE has a male predominance with the majority having comorbid atopic disorders. At present, treatment options include medications (proton pump inhibition, swallowed topical steroids), dietary therapy or biologic therapy (dupilumab, approved for those ≥12 years of age). Outside of EoE in the context of oral immunotherapy, EoE is typically chronic requiring lifelong therapy. Long-term complications including feeding difficulties, malnutrition, and fibrostenotic disease., Competing Interests: Disclosure M. Bauer, has served as a consult for Sanofi. N. Nguyen, has served as a consultant for Regeneron/Sanofi and is on the advisory board for EvoEndo. C.A. Liacouras, has served a speaker and consultant for Abbott; a speaker for Regeneron and a speaker for Sanofi., (Copyright © 2023 Elsevier Inc. All rights reserved.)

Background: Unsedated transnasal endoscopy is becoming an increasingly popular option for the evaluation of upper gastrointestinal tract disorders in adults and children worldwide. This innovative technology has transformative potential as it provides for a more efficient, safe, and cost-effective method for endoscopy and reduces the risks associated with anesthesia, which is particularly relevant in pediatrics as endoscopy is commonly done under general anesthesia or conscious sedation. The aim is to address knowledge gaps amongst pediatric gastroenterologists who may be considering the development of a TNE program, detailing how to implement sedation-free TNE into practice for pediatric patients and current and forthcoming technologies., Methods: We conducted a comprehensive review of current literature and collection of data from experts and clinicians in the field on how sedation-free programs were started and being conducted. We aimed to collate the data to provide a guide to address knowledge gaps with a focus on setting up and starting a sedation-free endoscopy program., Results: Here in, we provide a detailed guide for implementing a sedation-free endoscopy program in pediatrics including design and layout of a TNE unit, special staffing needs, equipment, current and forthcoming technologies, financial considerations and training considerations. We highlight special considerations that are relevant in pediatrics incorporating distraction or dissociation techniques such as Virtual Reality Systems, developmentally appropriate preparation for children, and topical analgesia., Conclusion: Sedation-free endoscopy is a rapidly growing option for pediatric patients. Development of an unsedated pediatric endoscopy program will improve patient care, decrease the need for anesthesia, provide a lower cost and safe alternative to traditional sedated endoscopy, and is a viable component to a pediatric gastroenterology practice., Competing Interests: JF is Co-Founder, Chief Medical Office, and Board Member of EvoEndo, Inc. He also listed as an inventor on patents related to endoscopic and virtual reality technologies. Nathalie Nguyen is a consultant to EvoEndo, Inc. The remaining authors declare that the research was conducted in absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2024 Friedlander, Leinwand, Bhardwaj and Nguyen.)

Introduction: Unsedated transnasal endoscopy (TNE) as transnasal esophagoscopy (TN-Eso) has emerged as a promising alternative to esophagogastroduodenoscopy (EGD) under sedation to assess eosinophilic esophagitis (EoE). We report our center's experience using single-use gastroscopes to perform sedation-free transnasal EGD (TN-EGD) with biopsies in an office-based setting., Methods: A retrospective review was performed on patients with eosinophilic esophagitis who underwent office-based sedation-free TNE with topical analgesia and virtual reality (VR) procedural dissociation and distraction. A sterile, single-use, ultra-slim 3.5 mm outer diameter, 110 cm long gastroscope with 2 mm working channel (EvoEndo) was used to perform TNE with biopsies/brushings. Data including demographics, procedure success rate, total visit time, biopsy adequacy, procedure time, procedural preference, and complications were collected., Results: Office-based TNE was completed in 8 patients (six males, age range 11-20 years). The endoscope was advanced by an experienced transoral endoscopist successfully through the nares into stomach (transnasal esophagogastroscopy [TN-EG]) in all subjects (100%) and into the duodenum (TN-EGD) in seven subjects (87.5%). Biopsies were obtained from esophagus in all cases and from the stomach/duodenum in five cases. Histological assessment, esophageal brushing, disaccharidase enzyme analysis, or duodenal aspirate analysis were performed as indicated. EoE reevaluation was the primary indication to perform endoscopy in all patients. Visual and histologic findings were all adequate for assessment. There were no significant adverse events., Conclusion: Office-based TN-EGD with VR procedural distraction and dissociation using single-use gastroscopes was effective to monitor EoE, gastritis, and duodenitis in a pediatric practice., Competing Interests: Joel A. Friedlander is Chief Medical Officer and Board Member of EvoEndo®, Inc. He is listed on numerous patents and pending patents related to endoscopic and virtual reality technologies. The remaining authors declare no conflict of interest., (© 2023 The Authors. JPGN Reports published by Wiley Periodicals LLC on behalf of The European Society for Pediatric Gastroenterology, Hepatology, and Nutrition and the North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition.)

Introduction and Aim: Transnasal endoscopy (TNE) has proven its diagnostic utility, but it has not been widely accepted given that it is performed without sedation. There are no previous studies on the use of methods to improve its tolerability. Our aim was to evaluate the tolerability of TNE, when simultaneously performed with an audiovisual device as a distractor., Methods: We evaluated 50 patients, 10 of whom did not agree to participate. The performance of the procedure was explained, using an audiovisual device. Before randomization, we applied anxiety and depression scores. Patients were divided into 2 groups: Group I (using an audiovisual device during the procedure) and Group II (without a device). Anxiety and numeric pain rating scales were used, and vital signs were monitored and recorded before, during, and after the endoscopy. An overall procedure satisfaction score was applied at the end of the study and 24 h later., Results: Mean age was 41.6 years and 35 of the patients were women (87.5%). The most frequent indication for TNE was refractory gastroesophageal reflux disease. There were no severe comorbidities, and none of the patients had a significant anxiety or depression score. One patient in Group II did not tolerate TNE due to nasal pain. There was no statistically significant difference between groups, regarding anxiety, pain, vital signs, and satisfaction scale., Conclusion: Our study showed that TNE was well tolerated and had a high acceptance rate in our patients. The use of distracting audiovisual devices did not increase tolerance to the endoscopic procedure., (Copyright © 2022 Asociación Mexicana de Gastroenterología. Published by Masson Doyma México S.A. All rights reserved.)

Background: The objective of the study is to investigate the surgical methods and clinical effects of high-flow revascularization in microsurgery combined with endoscopic endonasal surgery for skull base tumors with intracranial and extracranial involvement., Methods: The relationships between skull base tumors and internal carotid artery (ICA), tumor location and size, and the extent of tumor invasion were assessed. Preoperative CT perfusion (CTP), magnetic resonance (MR) perfusion-weighted imaging (PWI) (MR-PWI), and digital subtraction angiography (DSA) were performed to evaluate collateral circulation and brain tissue perfusion. Then craniotomy through the fronto-orbitozygomatic approach was performed, based on which four cases received extended middle skull base approach+Dolenc approach + Fukushima bypass type I, and six cases received extended middle skull base approach+Fukushima bypass type III. After surgery, DSA, CT angiogram (CTA), and CTP/PWI were performed to evaluate the patency of the reconstructed vessels and cerebral perfusion, and contrast-enhanced MRI to evaluate the degree of tumor resection. All patients were followed up for 6-12 months., Results: Among the 10 cases investigated, gross total resection was achieved in 8 cases, subtotal resection in 1 case, and partial resection in 1 case, as confirmed by CT and enhanced MRI. The patency of revascularization vessels was observed using fluorescein angiography during the operation in all patients and via DSA and CTA postoperatively in nine patients. One patient underwent ventilator-assisted ventilation because of respiratory failure and failed to undergo DSA and CTA. Regarding postoperative complications, one patient developed watershed cerebral infarction on the operated side but no sequelae after drug treatment, three patients developed facial numbness, which improved after 3 months, and two patients experienced worsened diplopia. After 6 to 12 months of follow-up on the nine evaluable patients, the Glasgow Outcome Scale (GOS) was 4-5 after surgery. In addition, 6-month follow-up results showed that one patient with clival chondrosarcoma developed recurrence on contrast-enhanced MRI, while no relapse was observed in the other patients., Conclusion: For skull base tumors with intracranial and extracranial invasion and involving the ICA, revascularization might improve the total resection rate and reduce the recurrence rate and risk of intraoperative bleeding and postoperative ischemia., Competing Interests: The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© 2023 Wang and Tong.)

Transnasal endoscopic skull base surgery has been increasing in volume in recent years and its indications are constantly expanding. The potential occurrence of intraoperative and postoperative neurovascular complications deserves special attention from neurosurgeons. Multimodal intraoperative neurophysiological monitoring technology allows neurosurgeons to monitor cerebral perfusion and the functional status of the associated cranial nerves in real time, thereby enabling surgeons to make prompt adjustments in surgical procedures and strategies and reduce the risks of postoperative neurological complications in patients. Based on available literature, we reviewed how appropriate monitoring strategies were optimized for different key components of transnasal endoscopic skull base procedures, intending to provide reference for clinicians., (Copyright© by Editorial Board of Journal of Sichuan University (Medical Sciences).)

CO2 insufflation has proven effective in reducing patients' pain after colonoscopies but has not been examined in esophagogastroduodenoscopies. Therefore, we examined the effect of CO2 insufflation in examinees who underwent transnasal endoscopies without sedation. This study is a single-center, prospective, double-blind, case-control trial conducted between March 2017 and August 2018. Subjects were assigned weekly to receive insufflation with either CO2 or air. The primary outcome was improvement of abdominal pain and distension at 2 h and 1-day postprocedure. In total, 336 and 338 examinees were assigned to the CO2 and air groups, respectively. Visual analog scale (VAS) scores for abdominal distension (15.4 vs. 25.5; p < 0.001) and distress from flatus (16.0 vs. 28.8; p < 0.001) at 2 h postprocedure were significantly reduced in the CO2 group. VAS scores for pain during the procedure (33.5 vs. 37.1; p = 0.059) and abdominal pain after the procedure (3.9 vs. 5.7; p = 0.052) also tended to be lower at 2 h postprocedure, but all parameters showed no significant difference at 1-day postprocedure. All procedures were safely completed through the planned program, and no apparent adverse events requiring treatment or follow-up occurred. In conclusion, CO2 insufflation may reduce postprocedural abdominal discomfort from transnasal esophagogastroduodenoscopies. (UMIN000028543). [ABSTRACT FROM AUTHOR]

In oral endoscopy, linked color imaging (LCI) detects atrophic border and gastric mucosal diseases better than white light imaging (WLI), but its usefulness in transnasal endoscopy has not been fully investigated. Here, we retrospectively compared WLI and LCI using the L*a*b* color space in images from 57 patients aged ≥20 years who had undergone transnasal endoscopy as part of a health check-up from May 2016 to January 2017. We measured color differences at the atrophic/non-atrophic and fundic/pyloric mucosal borders. Gastritis severity scored using the Kyoto classification of gastritis was similar between the two techniques. However, in patients with current and with past Helicobacter pylori infection, color difference at the atrophic border was greater with LCI (21.58 ± 6.97 and 27.34 ± 10.32, respectively) than with WLI [14.42 ± 5.95 ( p  = 0.004) and 17.9 ± 8.48 ( p <0.001)]; in those never infected with Helicobacter pylori , color difference at the fundic/pyloric mucosal border was greater with LCI than with WLI ( p <0.001). Because of its enhancement of atrophic border detection, we recommend linked color imaging as the method of choice for transnasal endoscopy in health check-ups, particularly for identifying people at high risk of gastric cancer., Competing Interests: No potential conflicts of interest were disclosed., (Copyright © 2022 JCBN.)

Background: Transnasal endoscopy has recently become common in Japan. Although transnasal endoscopy has many advantages, nasal pain and epistaxis are common complaints. To reduce nasal pain and epistaxis, we developed a new tube sheath system for transnasal endoscopy. This new tube sheath system (outer sheath and inner tube), called the Nasal Slider, is produced by TOP Corporation, Japan., Methods: A tube sheath longer than the nasal concha is inserted to reduce pain along the nasal turbinate. Because the sheath is left in place, tubes can be passed through the nose multiple times without causing additional pain. A total of 34 consecutive patients (mean age 68.1 years; 22 men and 12 females) who had undergone transnasal endoscopy in the past were selected for transnasal endoscopy with the Nasal Slider. After the transnasal endoscopy was completed, patients who gave consent for use of the Nasal Slider were interviewed by using 3 questionnaires on nasal discomfort, nasal pain, and epistaxis., Results: Because the transnasal endoscope passes inside the sheath, epistaxis can be prevented. Thirty of 34 selected patients underwent transnasal endoscopy using the Nasal Slider. Twenty-seven and 28 patients reported feeling less nasal discomfort and pain, respectively, with the Nasal Slider than during examinations without the Nasal Slider. No epistaxis developed in any patient examined with the Nasal Slider., Conclusions: The Nasal Slider appears to reduce nasal pain and epistaxis during transnasal endoscopy and is currently used in many hospitals in Japan.

Endoscopy has been a crucial part of the diagnostic and therapeutic modality in pediatric gastrointestinal disorders. This article outlines recent advances in pediatric gastrointestinal endoscopy, including transnasal endoscopy, functional luminal imaging probe, peroral endoscopic myotomy, mucosal impedance, endoscopic vacuum-assisted closure system, chromoendoscopy, artificial intelligence, and machine learning., Competing Interests: Disclosure A. Krasaelap has nothing to disclose. D. Lerner is the founder of Lerner Media Inc., (Copyright © 2021 Elsevier Inc. All rights reserved.)