An 86-year-old male patient with a history of arterial hypertension was admitted to the emergency room with acute diarrhea, cough, dyspnea, and fever that started 5 days before admission. Blood analysis revealed a hemoglobin level of 14.3

Background & Aims: Hepatocellular carcinoma (HCC) is the second leading cause of

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Video Video 1 Cost-effective modified endoscopic vacuum therapy for GI transmural defects. Step-by-step process of manufacturing and potential advantages. Cut half gauze to the ideal size to cover only the fenestrated portion of the nasogastric tube (NGT). Wrap the gauze around the fenestrated portion of the NGT. The assistance of another person is important in this process. Cut the antimicrobial incise drape to match the size of the fenestrated portion of the NGT. Note that the incise drape is a very strong adhesive; therefore, 3 people are usually required to assemble it properly. Next, the suture is used to fix the gauze and drape to the NGT. Perform fixation of the modified sponge in 3 places. The first knot is in the proximal portion, just below the last fenestra of the NGT, as a marker of where the vacuum system starts. The second knot is at the distal end, to avoid migration of the modified sponge. The third knot is in the middle of the modified sponge, which is essential to serve as a guide during endoscopic placement. For example, in cases of defects without collection in which the sponge will be placed in an intraluminal position, it is ideal to place the vacuum system in the middle of the defect; in cases of intracavitary placement, it will work as a guide to how much of the modified sponge will be inside the collection. Finally, use a needle to make innumerable punctures in the modified sponge system to obtain adequate aspiration. An 18G needle is recommended because, in addition to having an adequate diameter, it is very sharp, which facilitates perforation of the modified sponge system. After creation of the modified endoscopic vacuum therapy, the functionality test is performed. Turn on the wall suction system, connect the distal end of the NGT to the tube of the canister connected on the wall, and place the NGT inside a bowl with a liquid solution. The aspiration of a large amount of liquid indicates proper functioning of the modified endoscopic vacuum therapy system. The device is then ready to be positioned endoscopically in the patient. After proper positioning, connect the NGT to the suction tube to avoid migration of the device upon removal of the scope. In addition to the cost-effective device as described, in our practice we also use wall suction to reduce costs associated with the use of the vacuum machine. Use the antimicrobial incise drape to seal the connection between the NGT and the suction tube to avoid leakage within the connection. Last, owing to instability of the negative wall pressure, a 20F intravenous catheter is connected to the tube to maintain a negative pressure between –75 and –150 mmHg, as confirmed by laboratory studies performed by our group.

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The use of endoscopic techniques has gained significant popularity over the past decade. The potential advantages of angled lenses to visualize around tight corridors without retracting have proven to be an attractive feature. The limitation of endoscopy has been the inability to obtain a true three-dimensional perspective for which microscopy is ideal. Therefore we postulated that for complex intradural lesions the merger of the two technologies would prove to be ideal. In this paper we report our experience with simultaneous microscopy and endoscopy, using picture-in-picture technology, for intracranial vascular and oncological surgery. We have found it useful to offer enough visualization to allow for performing surgery and not just for inspection.

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