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Dimitri COUMAROS

Hôpitaux Universitaires de Strasbourg
Strasbourg, France
MD
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Heller myotomy and intraluminal fundoplication: a NOTES technique
Background and study aims: It is generally accepted that the most effective method of treating achalasia is a surgical myotomy. Nevertheless, if a myotomy alone is performed, reflux may occur in up to 50% of patients. This video demonstrates a transoral incisionless stepwise approach to both esophageal Heller myotomy and partial fundoplication.
Materials and methods: The first step in this experiment consisted in creating the esophageal myotomy. Under general anesthesia, with the pig supine, endoscopy was performed to assess the location of the EGJ. The mucosa on the right postero-lateral esophageal wall was cut with the needle-knife 15cm above the LES. The initial incision was dilated with blunt dissection and the scope eased into the submucosal space. A submucosal tunnel was created with the assistance of CO2 and blunt dissection and extended distally toward the LES. Once the GEJ was clearly identified, the muscular layer was incised in a distal-to-proximal fashion using the IT knife. The scope was then withdrawn back into the lumen and the mucosal flap sealed by the application of endoscopic clips. The adequacy of endoscopic myotomy was evaluated assessing manometric lower esophageal sphincter (LES) profile and postoperative LES pressure fall and evaluated by comparing the EGJ diameter and volume profile before, after and during the division of the esophageal muscular fibers using the Functional Lumen Imaging Probe "endoflip”. The second step of the treatment consisted in building a transoral incisionless fundoplication. Four weeks later, a gastroesophageal valve was created endoscopically using the EsophyX device (EsophyX™, EndoGastric Solutions).
Results: Both Heller myotomy and subsequent endoscopic fundoplication were successfully accomplished with an operative time of 45 min and 20 min respectively. No injury to the esophagus or breach of the esophageal mucosa occurred.
Conclusions: A stepwise transoral incisionless approach to esophageal Heller myotomy and partial fundoplication is feasible in the porcine model.
Surgical intervention
9 years ago
473 views
7 likes
0 comments
04:53
Heller myotomy and intraluminal fundoplication: a NOTES technique
Background and study aims: It is generally accepted that the most effective method of treating achalasia is a surgical myotomy. Nevertheless, if a myotomy alone is performed, reflux may occur in up to 50% of patients. This video demonstrates a transoral incisionless stepwise approach to both esophageal Heller myotomy and partial fundoplication.
Materials and methods: The first step in this experiment consisted in creating the esophageal myotomy. Under general anesthesia, with the pig supine, endoscopy was performed to assess the location of the EGJ. The mucosa on the right postero-lateral esophageal wall was cut with the needle-knife 15cm above the LES. The initial incision was dilated with blunt dissection and the scope eased into the submucosal space. A submucosal tunnel was created with the assistance of CO2 and blunt dissection and extended distally toward the LES. Once the GEJ was clearly identified, the muscular layer was incised in a distal-to-proximal fashion using the IT knife. The scope was then withdrawn back into the lumen and the mucosal flap sealed by the application of endoscopic clips. The adequacy of endoscopic myotomy was evaluated assessing manometric lower esophageal sphincter (LES) profile and postoperative LES pressure fall and evaluated by comparing the EGJ diameter and volume profile before, after and during the division of the esophageal muscular fibers using the Functional Lumen Imaging Probe "endoflip”. The second step of the treatment consisted in building a transoral incisionless fundoplication. Four weeks later, a gastroesophageal valve was created endoscopically using the EsophyX device (EsophyX™, EndoGastric Solutions).
Results: Both Heller myotomy and subsequent endoscopic fundoplication were successfully accomplished with an operative time of 45 min and 20 min respectively. No injury to the esophagus or breach of the esophageal mucosa occurred.
Conclusions: A stepwise transoral incisionless approach to esophageal Heller myotomy and partial fundoplication is feasible in the porcine model.
Endoscopic palliative therapy of an obstructing rectal cancer
Fifteen per cent of rectal cancers are unresectable because of local extension or metastasis.
Endoscopic palliative treatments have been described to avoid surgical palliative procedures (ileostomy, colostomy), which inevitably affect the patient's quality of life.
Endoscopic electrocoagulation, laser therapy and cryotherapy have been used for this purpose, but they need multiple therapeutic sessions: these have a high cost and cause patient discomfort.
Permanent stenting with Self Expanding Metal Stents (SEMS) has been increasingly used for the palliative treatment of obstructing gastrointestinal tumors.
This is the case of a 74-year-old man with an adenocarcinoma of the rectum, T4 N+ M+, that was admitted to our surgical department with sub-occlusion and rectal bleeding.
Under endoscopic-fluoroscopic control, a SEMS was delivered with no complications and the patient was discharged the day after. He was scheduled for a palliative chemotherapy.
Endoscopic stent introduction is a safe palliative procedure performed to improve the quality of life of patients with inoperable tumors of the rectum.
Surgical intervention
10 years ago
2407 views
12 likes
0 comments
02:30
Endoscopic palliative therapy of an obstructing rectal cancer
Fifteen per cent of rectal cancers are unresectable because of local extension or metastasis.
Endoscopic palliative treatments have been described to avoid surgical palliative procedures (ileostomy, colostomy), which inevitably affect the patient's quality of life.
Endoscopic electrocoagulation, laser therapy and cryotherapy have been used for this purpose, but they need multiple therapeutic sessions: these have a high cost and cause patient discomfort.
Permanent stenting with Self Expanding Metal Stents (SEMS) has been increasingly used for the palliative treatment of obstructing gastrointestinal tumors.
This is the case of a 74-year-old man with an adenocarcinoma of the rectum, T4 N+ M+, that was admitted to our surgical department with sub-occlusion and rectal bleeding.
Under endoscopic-fluoroscopic control, a SEMS was delivered with no complications and the patient was discharged the day after. He was scheduled for a palliative chemotherapy.
Endoscopic stent introduction is a safe palliative procedure performed to improve the quality of life of patients with inoperable tumors of the rectum.
Endoscopic metal stenting of common bile duct for unresectable pancreatic cancer
Obstructive jaundice occurs in many patients with unresectable pancreatic cancer.
Endoscopic therapy is the best palliative option for inoperable pancreatic cancers, either for the treatment of a potential duodenal stenosis or, in the majority of cases, for the treatment of the associated jaundice.
Metal stents are preferable to plastic stents in patients who have a life expectancy of more than 3 months. The obstruction of the common bile duct is due to cancer of the head of the pancreas that compresses the biliary tree. However, in a few cases, the mucosa of the ampulla is also involved with malignancy from the adjacent pancreas.
We present the case of two patients with unresectable pancreatic cancer, obstructive jaundice and pruritus, in which the drainage of the common bile duct was achieved with an Endoscopic Retrograde Cholangio-Pancreatography (ERCP) with insertion of an uncovered metal stent (Wallflex® type) with subsequent relief of the jaundice.
Endoscopic drainage of the common bile duct for obstructive jaundice for unresectable pancreatic cancer is the preferred palliative approach in this type of patient.
Surgical intervention
10 years ago
2373 views
7 likes
0 comments
04:28
Endoscopic metal stenting of common bile duct for unresectable pancreatic cancer
Obstructive jaundice occurs in many patients with unresectable pancreatic cancer.
Endoscopic therapy is the best palliative option for inoperable pancreatic cancers, either for the treatment of a potential duodenal stenosis or, in the majority of cases, for the treatment of the associated jaundice.
Metal stents are preferable to plastic stents in patients who have a life expectancy of more than 3 months. The obstruction of the common bile duct is due to cancer of the head of the pancreas that compresses the biliary tree. However, in a few cases, the mucosa of the ampulla is also involved with malignancy from the adjacent pancreas.
We present the case of two patients with unresectable pancreatic cancer, obstructive jaundice and pruritus, in which the drainage of the common bile duct was achieved with an Endoscopic Retrograde Cholangio-Pancreatography (ERCP) with insertion of an uncovered metal stent (Wallflex® type) with subsequent relief of the jaundice.
Endoscopic drainage of the common bile duct for obstructive jaundice for unresectable pancreatic cancer is the preferred palliative approach in this type of patient.
Endoscopic treatment of esophagojejunostomy dehiscence after total gastrectomy with a fully covered self-expandable metallic stent
The most frequent complications after upper GI surgery are leaks and stenosis. These complications are associated with significant morbidity and mortality rates.
Conservative treatments such as Self-Expanding Metal Stents (SEMS) and balloon dilatation have been described for the treatment of these complications, but stay controversial yet.
We report a case of a 66-year-old woman who underwent a total gastrectomy for a neuro-endocrine tumor that developed an anastomotic dehiscence six days after surgery, successfully treated with a covered SEMS. The stent was well-tolerated and left in place for two weeks. Its ablation confirmed through endoscopic and enhanced X-ray upper series the development of a granulation tissue, along with epithelial proliferation, enough to produce a perfectly closed and healing anastomotic defect. No further surgery was required; oral feeding was started and has been well-tolerated and the patient was soon discharged.
In this case where the use of surgery seemed inevitable and not risk-free, the placement of a removable SEMS was demonstrated to be a safe and efficient technique.
Surgical intervention
10 years ago
1550 views
29 likes
0 comments
04:57
Endoscopic treatment of esophagojejunostomy dehiscence after total gastrectomy with a fully covered self-expandable metallic stent
The most frequent complications after upper GI surgery are leaks and stenosis. These complications are associated with significant morbidity and mortality rates.
Conservative treatments such as Self-Expanding Metal Stents (SEMS) and balloon dilatation have been described for the treatment of these complications, but stay controversial yet.
We report a case of a 66-year-old woman who underwent a total gastrectomy for a neuro-endocrine tumor that developed an anastomotic dehiscence six days after surgery, successfully treated with a covered SEMS. The stent was well-tolerated and left in place for two weeks. Its ablation confirmed through endoscopic and enhanced X-ray upper series the development of a granulation tissue, along with epithelial proliferation, enough to produce a perfectly closed and healing anastomotic defect. No further surgery was required; oral feeding was started and has been well-tolerated and the patient was soon discharged.
In this case where the use of surgery seemed inevitable and not risk-free, the placement of a removable SEMS was demonstrated to be a safe and efficient technique.
Transvaginal hybrid sleeve gastrectomy in a patient with a BMI of 40: live surgery during a NOTES course
Laparoscopic sleeve gastrectomy is a relatively new procedure, which is gaining popularity for the treatment of morbid obesity. In this live video demonstration from the March 2009 NOTES Advanced Course at IRCAD in Strasbourg, Dr. Michel Vix performs a hybrid natural orifice transluminal endoscopic sleeve gastrectomy using the vagina as the natural orifice and only two operative 5mm ports. It is a very interesting video demonstration showing that sleeve gastrectomy for the treatment of morbid obesity is feasible and safe in selected patients using the hybrid transvaginal mini-laparoscopic-assisted natural orifice surgery.
Surgical intervention
10 years ago
429 views
9 likes
0 comments
15:54
Transvaginal hybrid sleeve gastrectomy in a patient with a BMI of 40: live surgery during a NOTES course
Laparoscopic sleeve gastrectomy is a relatively new procedure, which is gaining popularity for the treatment of morbid obesity. In this live video demonstration from the March 2009 NOTES Advanced Course at IRCAD in Strasbourg, Dr. Michel Vix performs a hybrid natural orifice transluminal endoscopic sleeve gastrectomy using the vagina as the natural orifice and only two operative 5mm ports. It is a very interesting video demonstration showing that sleeve gastrectomy for the treatment of morbid obesity is feasible and safe in selected patients using the hybrid transvaginal mini-laparoscopic-assisted natural orifice surgery.
First NOTES cholecystectomy
This video shows the first totally NOTES cholecystectomy via a transvaginal approach in a 30-year-old woman with symptomatic cholelithiasis. The operation was performed by a multidisciplinary team, which included a gynecologist who performed and closed the colpotomy. The peritoneal cavity was entered through an incision in the posterior vaginal cul-de-sac. The transvaginal access to the peritoneal cavity and the introduction of the double channel gastroscope (KARL STORZ-Endoskope®, Germany) were performed under laparoscopic control by a 2 mm needle-scope.
The placement of this 2 mm needle-port was mandatory to insufflate CO2 and to monitor the pneumoperitoneum and it turned out helpful for further retraction of the gallbladder. Complete identification of the structures of Calot’s triangle was achieved. The dissection began in close proximity of the gallbladder at the junction between the infundibulum and the cystic duct. The peritoneum covering the cystic duct was incised anteriorly and posteriorly and gently brushed away with blunt dissection. Once sufficiently skeletonized, the cystic duct and artery were clipped twice on patient side and once on gallbladder side and divided with endoscopic scissors. Using an endoscopic grasper and a Storz unipolar round-tip electrode, the gallbladder was dissected away from the intrahepatic fossa and placed in a specimen retrieval bag prior to removal through the vagina. The operative site was checked to ensure hemostasis and rule out any inadvertent injury to the adjacent organs. The colpotomy was closed with interrupted 2/0 Vicryl stitches.
All the procedure was carried out using a standard double channel video flexible gastroscope and standard endoscopic instruments. All the principles of laparoscopic cholecystectomy were strictly respected. At no stage of the procedure there was a need of laparoscopic assistance. No complications occurred during the procedure. The advantages of laparoscopy, namely minimal postoperative pain and abdominal scarring appeared to be enhanced by this approach. The patient had no postoperative pain, “no scars” and was discharged on the second postoperative day.
Surgical intervention
12 years ago
793 views
17 likes
0 comments
04:09
First NOTES cholecystectomy
This video shows the first totally NOTES cholecystectomy via a transvaginal approach in a 30-year-old woman with symptomatic cholelithiasis. The operation was performed by a multidisciplinary team, which included a gynecologist who performed and closed the colpotomy. The peritoneal cavity was entered through an incision in the posterior vaginal cul-de-sac. The transvaginal access to the peritoneal cavity and the introduction of the double channel gastroscope (KARL STORZ-Endoskope®, Germany) were performed under laparoscopic control by a 2 mm needle-scope.
The placement of this 2 mm needle-port was mandatory to insufflate CO2 and to monitor the pneumoperitoneum and it turned out helpful for further retraction of the gallbladder. Complete identification of the structures of Calot’s triangle was achieved. The dissection began in close proximity of the gallbladder at the junction between the infundibulum and the cystic duct. The peritoneum covering the cystic duct was incised anteriorly and posteriorly and gently brushed away with blunt dissection. Once sufficiently skeletonized, the cystic duct and artery were clipped twice on patient side and once on gallbladder side and divided with endoscopic scissors. Using an endoscopic grasper and a Storz unipolar round-tip electrode, the gallbladder was dissected away from the intrahepatic fossa and placed in a specimen retrieval bag prior to removal through the vagina. The operative site was checked to ensure hemostasis and rule out any inadvertent injury to the adjacent organs. The colpotomy was closed with interrupted 2/0 Vicryl stitches.
All the procedure was carried out using a standard double channel video flexible gastroscope and standard endoscopic instruments. All the principles of laparoscopic cholecystectomy were strictly respected. At no stage of the procedure there was a need of laparoscopic assistance. No complications occurred during the procedure. The advantages of laparoscopy, namely minimal postoperative pain and abdominal scarring appeared to be enhanced by this approach. The patient had no postoperative pain, “no scars” and was discharged on the second postoperative day.