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UCSF Salivary Endoscopy Course 2014

Basic Set Up and Instruments

Rohan R. Walvekar, MD

Department of Otolaryngology & Head Neck Surgery

Louisiana State University Health Sciences Center

New Orleans, LA

DisclosureI have the following relationship(s) with commercial interests.

Hood Laboratories *Walvekar Salivary Stent

Cook Industries

Medtronic Xome

A commercial interest is any entity producing, marketing, re-selling, or distributing health care goods or services consumed by, or used on, patients.

� Instruments for Exposure of the Oral Cavity� Anesthesia – Nasal Intubation is preferred

� Epistaxis• Pre-op nasal endoscopy to document spurs,

deviated septum or other abnormality• Afrin and lubricated nasal trumpet while

patient is in preoperative holding area � Disposable Plastic cheek retractor� Dental splints � Jennings's mouth gag � Minnesota and Sweetheart

retractors

Basic Sialendoscopy Set

� Dilator System � Marchal Dilator System

� Probes No.0000 to No.8� Schaitkin’s Fluted Dilators \

� No.0 – 5� Conical Dilator � Helps to transition between dilators� Useful usually once papilla is dilated up to Marchal

No.1 or 2 dilator� Bougies (increasing diameter)

� Compatible with 0.4 mm guide wire� COOK Dilator System with Operating Sheath

� Guide Wire � Cook Dilators 1-8

Basic Sialendoscopy Set

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Schaitkin Salivary Dilator Set

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Sialendoscopy

Kolenda Introducer Set (COOK)

Sialendoscopy

Sialendoscopy

Sialendoscopes

Geisthoff UW. Basic sialendoscopy techniques. Otolaryngol Clin N Am 42 (2009) 1029-1052

� 1.3 mm Marchal*

� 1.1 mm Erlangen*

� 1.6 mm Erlangen*

*Karl Storz, Tuttlingen, Germany

Fiberoptic channel Irrigation Port

Interventional Port

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� Fifth generation endoscopes

� Original was flexible

� 1.3 mm semi rigid scope with 6000 pixels, 0.25mm rinsing channel and 0.65mm working channel

Marchal Sialendoscope� Sialendoscopes� 0.8 mm

� Pediatric diagnostic sialendoscopy� No interventional channel

� 1.1 mm “all in one” Erlangen Sialendoscope� Can be autoclaved� Interventional Tools that can be used with the scope

� 0.4 mm guide wire basket� 0.4 mm stone basket � Laser fiber (Holmium laser)� Hand held microburr

� Does not have a protective sheath� Dilate up to No.3 or 4 prior to endoscopy

Basic Sialendoscopy Set

� Sialendoscopes� 1.3 mm Marchal “all in one” scope

� Autoclavable. � Interventional Tools that similar to 1.1 Erlangen

scope� Does have a protective sheath� Optics are excellent� Dilate up to No.4 / 5 prior to endoscopy� Gentle bend at the tip of the scope

Basic Sialendoscopy Set

� 1.6 mm “all in one” Erlangen Sialendoscope� Can be autoclaved� Interventional Tools that can be used with the scope

� 0.4/6 mm guide wire basket� 0.4/6 mm stone basket � Cup forceps**

� Does not have a protective sheath� Dilate up to No.5 or 6 prior to endoscopy

� Balloon Dilator (Storz) – compatible with all in one scopes

Basic Sialendoscopy Set

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Sialendoscopy

� IV Extension Tubing� 20 cc syringe � Vessel loops� Angled Forces with and without teeth� Standard Endoscopy Tower and Monitor with recording

capabilities**Accessories� Disposables

� Stone baskets� Guide wires� Cleaning brushes� Stents (Hood Laboratories)*� Balloon Dilator

� Not Disposable� Hand-held micro burr� Stone forceps

Basic Sialendoscopy Set

Three way stopcock/valve

STORZ WIRE BASKETS COOK WIRE BASKETS - - N Gage

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LSU Sialendoscopy Course

Diagnostic Sialendoscopy

Rohan R. Walvekar, MD

Department of Otolaryngology & Head Neck Surgery

Louisiana State University Health Sciences Center

New Orleans, LA

� 100% Successful endoscopy

� Ductal or papillary stenosis in 7/15 (47%)

� Essentially normal endoscopy in 8/15 (53%)

� Symptoms improved in 13/15 (87%) cases

Diagnostic Sialendoscopy Data

Bowen M et al. Diagnostic and Interventional Sialendoscopy: A preliminary experience. 2010 Laryngoscope (accepted for publication)

� Progressive dilation� Marchal Dilator System

(No.0000 to No.6)

� Conical dilator

� Seldinger technique� Guide wire and bougies

� Papillotomy� 25% (7/28)

� Successful endoscopy� 96% (27/28)

Sialendoscope CannulationSERIAL DILATION USING THE DILATOR SYSTEM

SELDINGER TECHNIQUE USING GUIDE WIRE AND BOUGIES (adopted from Chossegros et al2)

Success of Diagnostic Endoscopy ~ 95-98%

Rate Limiting Step : Dilation of Papilla

� Approaches to the papilla

� Dilation technique

� Seldinger technique

� With bougies

� With sialendoscope

� Papillotomy

� Proximal papillotomy and sialodochoplasty

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Papillotomy for diagnostic endoscopy…consequences..

Distal Papillotomy and Dilation Followed by Sialodochoplasty and Stent Placement

Acknowledgements� Dan W Nuss MD, Faculty and Residents Department of Otolaryngology

Head Neck Surgery, LSU HSC, New Orleans, LA

� Barry Schaitkin, MD (University of Pittsburgh)

� OR Staff

(Our Lady of the Lake Regional Medical Center)

� Head Neck Center,

(Our Lady of the Lake Medical Center)

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Avoid Complications

�Local Anesthesia:�-Lidocaine 4.5mg/kg (<300mg)�-Lidocaine/epineprine 7mg/kg (<500 mg)

�MAC (sedation):�-Over�-Under

�Local Anesthesia:�-Beware of ETT position�-NO atropine or like medication

Technical Problems

�Maceration of the papilla:�measured traction

�Avoid creating pseudo-orifices:�injection�forceps�dilators

Technical Problems

�Overinjection of NSS:�-60cc syringe with IV extender�-control your assistant enthusiasm�-maintain one port open�-in the submandibular area it can lead � to AIRWAY COMPROMISE

Technical Problems

�False Passage (papilla):�-do not force the dilator�-do not cut the papilla

�Ductal Perforation:�-do not advance blindly�-do not force the instrument in�-abort if identified

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Equipment Failure

�Be cognizant of the turns:�-scope is semi-rigid (it is fragile) �-straighten the duct using manual traction

and pressure

�Be cognizant of the teeth

�Have back up gear

The Learning Curve