Gastric outlet obstruction with ascites: EUS-guided gastro-enterostomy is feasible

Background and study aims Endoscopic ultrasound-guided gastro-enterostomy(EUS-GE) is a recently described novel minimally invasive endoscopic procedure for patients having malignant gastric outlet obstruction (GOO). The safety of EUS-GE in the presence of ascites with GOO is not known. The objective of the study was to evaluate the feasibility and safety of EUS-GE in patients with GOO and ascites. Patients and methods Consecutive patients with GOO who underwent EUS-GE between January 2019 and March 2021 constituted the study population. EUS-GE was performed using either EPASS or free-hand technique. The technical success, clinical success, adverse events, and survival times were evaluated. The outcomes were compared between patients with and without ascites. Results A total of 31 patients with GOO underwent EUS-GE of whom 29 (93.5 %) had malignant and two (6.4 %) had benign etiologies. Ascites was observed in 12 out of 31 (38.7%) patients and all had underlying malignancy. Majority (27, 87 %) of the EUS-GE procedures were performed using EPASS technique, and 4 (13 %) underwent free-hand technique. Eleven of 12 patients with ascites and GOO underwent EUS GE using EPASS technique. The technical success (91.6 % vs. 89.4 %; P = 0.841), clinical success (83.3 % vs. 89.4 %; P = 0.619), mean procedure time (32 vs. 31.6 min; P = 0.968) and adverse events (0 % vs. 10.5 %; P = 0.245) were not significantly different between patients with or without ascites. However, the median survival time was significantly low in patients with ascites when compared to without ascites (36 vs. 290 days; P < 001). Conclusions Ascites is a common occurrence in patients with malignant GOO. EUS GE is feasible in presence of ascites with EPASS technique.

The aiming device for cervical distractor pin insertion: a proof-of-concept, feasibility study

Background Restoration of cervical lordosis after anterior discectomy and fusion is a desirable goal. Proper insertion of the vertebral distraction or Caspar pin can assist lordotic restoration by either putting the tips divergently or parallel to the index vertebral endplates. With inexperienced surgeons, the traditional free-hand technique for Caspar pin insertion may require multiple insertion attempts that may compromise the vertebral body and increase radiation exposure during pin localization. Our purpose is to perform a proof-of-concept, feasibility study to evaluate the effectiveness of a pin insertion aiming device for vertebral distraction pin insertion. Methods A Smith-Robinson approach and anterior cervical discectomy were performed from C3 to C7 in 10 human cadaveric specimens. Caspar pins were inserted using a novel pin insertion aiming device at C3-4, C4-5, C5-6, and C6-7. The angles between the cervical endplate slope and Caspar pin alignment were measured with lateral cervical imaging. Results The average Superior Endplate-to-Caspar Pin angle (SE-CP) and the average Inferior Endplate-to-Caspar Pin angle (IE-CP) were 6.2 ± 2.0° and 6.3 ± 2.2° respectively. For the proximal pins, the SE-CP and the IE-CP were 4.0 ± 1.1°and 5.2 ± 2.4° respectively. For the distal pins, the SE-CP and the IE-CP were 7.7 ± 1.4° and 6.2 ± 2.0° respectively. No cervical endplate violations occurred. Conclusion The novel Caspar pin insertion aiming device can control the pin entry points and pin direction with the average SE-CP and average IE-CP of 6.2 ± 2.0° and 6.3 ± 2.2°, respectively. The study shows that the average different angles between the Caspar pin and cervical endplate are less than 7°.

Transpedicular fixation of the spine with two-level navigation templates for narrow pedicles

Objective. To assess the correctness of transpedicular screw insertion in thoracic and lumbar vertebrae using two-level navigation templates for narrow pedicles.Material and Methods. Two-level navigation templates were used in surgical treatment of four patients aged 14–17 years with scoliotic deformity and multiple pedicles of small width (less than 4.35 mm). In each patient, the least favorable zones were selected for implantation using navigation templates. The rest of planned pedicle screws were inserted using free-hand technique. All patients underwent CT scanning postoperatively. Screws inserted to pedicles less than 4.35 mm in width were classified as correctly placed if they did not extend beyond the medial cortical layer by more than 2 mm.Results. Out of 68 pedicles planned for screw placement, 42 were narrower than 4.35 mm. In the pedicles difficult for implantation, 29 screws were inserted using navigation templates and 13 by free-hand technique. Screws classified as correctly placed were 28 from those inserted with navigation templates and 9 from those implanted by free-hand technique. Difference in results of screw placement in narrow pedicles with navigation templates and by free-hand technique was statistically significant (exact Fisher test, p < 0.05).Conclusion. Transpedicular screw placement with two-level navigation templates in narrow pedicles is more correct than insertion by free hand technique.

A useful intraoperative technique for transiliac-transsacral screws: a point-to-point coaxial guide apparatus

Background The transiliac-transsacral screw placement is a clinical challenge for surgeons. This study explored a point-to-point coaxial guide apparatus assisting the transiliac-transsacral screw insertion and aimed to investigate the feasibility and accuracy of the guide apparatus in the treatment of posterior ring unstable pelvic fracture compared with a free-hand technique. Methods A retrospective study was performed to evaluate patients treated with transiliac-transsacral screws assisted by the point-to-point coaxial guide apparatus or free-hand technique. The intraoperative data of operative time and radiation exposure times were recorded. Postoperative radiographs and CT scans were performed to scrutinize the accuracy of screws position. The quality of the postoperative fracture reduction was assessed according to Matta radiology criteria. The pelvic function was assessed according to the Majeed scoring criteria at 6 months postoperatively. Results From July 2017 to December 2019, a total of 38 patients were included in this study, 20 from the point-to-point guide apparatus group and 18 from the free-hand group. There were no significant differences between the two groups in gender, age, injury causes, pelvic fracture type, screws level, and follow-up time (P > 0.05). The average operative time of the guide apparatus group for each screw was significantly less than that in the free-hand group (25.8 ± 4.7 min vs 40.5 ± 5.1, P < 0.001). The radiation exposure times were significantly lower in the guide apparatus group than that in the free-hand group (24.4 ± 6.0 vs 51.6 ± 8.4, P < 0.001). The intraosseous and juxtacortical rate of screw placement (100%) higher than in the free-hand group (94.4%). Conclusion The point-to-point coaxial guide apparatus is feasible for assisting the transiliac-transsacral screw in the treatment of posterior unstable pelvic fractures. It has the advantages of simple operation, reasonable design and no need for expensive equipment, and provides an additional surgical strategy for the insertion of the transiliac-transsacral screw.

Breach Rate Analysis of Pedicle Screw Instrumentation using Free-Hand Technique in the Surgical Correction of Adolescent Idiopathic Scoliosis

Introduction: Free-hand technique is one of the techniques used by spine surgeon during pedicle screw instrumentation of surgical correction of spinal deformities, including scoliosis. The previous studies showed that this technique is safe. However, some inherent factors may influence its outcomes, including screw breaching which is potentially violates spinal cord and other intimate structures. To con?rm the safety and accuracy of this technique, additional study measuring the breach rate of pedicle screw placement in scoliosis is mandatory. Materials and Methods: We performed a retrospective study of patients with adolescent idiopathic scoliosis (AIS) from Fatmawati General Hospital, Jakarta, treated for surgical correction during a period of 2017–2018 using free-hand technique for pedicle screw instrumentation. Post-operative computed tomography scan (CT scan) was analyzed to measure the medial and lateral breaches. P < 0.05 was deemed to be statistically significant. Results: A total of 94 pedicle screws from six female patients with AIS were included in our study. Overall breach occurred in 33% instrumented screws, the majority of it was a low-grade breach. Of the breached screws, medial and lateral breach occurred in 20% and 12% of screws, respectively. There were no differences in the overall, medial, and lateral breaches between thoracic and lumbar vertebrae (P > 0.05). Medial breach was significantly higher in middle thoracic segment compared to other thoracic segments (P = 0.048). Risk of medial breach was 3 times higher in the convex side of deformity (P = 0.012), whereas risk of lateral breach was 4.6 times higher in the concave side of the deformity (P = 0.021). Conclusion: The majority of breached screws were low-grade violation within the safe zone, with no neurological sequelae. Our study found that free-hand technique is safe and effective method of pedicle screw instrumentation for correction of AIS. Some inherent factors may influence the risk of

The Aiming Device for Cervical Distractor Pin Insertion: A Developmental and Experimental Study

Background: Restoration of cervical lordosis after anterior discectomy and fusion is a desirable goal. Proper insertion of the vertebral distraction or Caspar pin can assist lordotic restoration by either putting the tips divergently or parallel to the index vertebral endplates. With inexperienced surgeons, the traditional free-hand technique for Caspar pin insertion may require multiple insertion attempts that may compromise the vertebral body and increase radiation exposure during pin localization. Our purpose is to evaluate the effectiveness of pin insertion aiming device for vertebral distraction pin insertion.Methods: A Smith-Robinson approach and anterior cervical discectomy were performed from C3 to C7 in 10 human cadaveric specimens. Caspar pins were inserted using a novel pin insertion aiming device at C3-4, C4-5, C5-6, and C6-7. The angles between the cervical endplate slope and Caspar pin alignment were measured with lateral cervical imaging.Results: The average Superior Endplate-to-Caspar Pin angle (SE-CP) and the average Inferior Endplate-to-Caspar Pin angle (IE-CP) were 6.2 ± 2.0° and 6.3 ± 2.2° respectively. For the proximal pins, the SE-CP and the IE-CP were 4.0 ± 1.1°and 5.2 ± 2.4° respectively. For the distal pins, the SE-CP and the IE-CP were 7.7 ± 1.4° and 6.2 ± 2.0° respectively. No cervical endplate violations occurred.Conclusion: The novel Caspar pin insertion aiming device can control the pin entry points and pin direction with the average SE-CP and average IE-CP of 6.2 ± 2.0° and 6.3 ± 2.2°, respectively. The study shows that the average different angles between the Caspar pin and cervical endplate are less than 7°.

Comparison of the 3D-printed operation guide template technique and the free-hand technique for S2-alar-iliac screw placement

Background To compare the safety and accuracy of the 3D-printed operation guide template technique and the free-hand technique in the placement of the S2-alar-iliac (S2AI) screw. Methods We conducted a retrospective analysis of 47 patients undergoing S2AI screw placement in our hospital, divided into the 3D-printed operation guide template group and the free-hand screw placement group. The duration of single S2AI screw placement was documented in all patients. A postoperative CT scan was performed to assess screw placement effectiveness according to the distance from the screw tip to the breach of the cortical bone wall. Results In total, 42 screws were placed in the guide template group, with an average screw placement duration of 151.6 ± 44.8 s. Screw placement grading was as follows: 40 screws in grade 0, two in grade 1, and none in grades 2 and 3. This grading resulted in excellent and good rates of 95.2% and 100%, respectively. In total, 52 screws were placed in the free-hand group, with an average screw placement duration of 138.3 ± 45.9 s. Screw placement grading was as follows: 42 screws in grade 0, seven in grade 1, three in grade 2, and none in grade 3. This grading resulted in excellent, good and acceptable rates 80.8%, 94.2% and 100%, respectively. Screw placement duration did not significantly differ between the groups (p > 0.05). The excellent rate of screw placement was greater in the guide template group than in the free-hand group (p < 0.05), but the good and acceptable rates did not significantly differ between the two groups (p > 0.05). Conclusion Both techniques can be applied to S2AI screw placement. The 3D-printed guide technique is superior to the free-hand technique in terms of safety and accuracy.