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Bernard DALLEMAGNE

Hôpitaux Universitaires de Strasbourg
Strasbourg, France
MD
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Fourth antireflux procedure in a patient with a BMI of 35: esophagogastric disconnection and Roux-en-Y gastrojejunostomy
We present an esophagogastric disconnection and Roux-en-Y gastrojejunostomy as the fourth antireflux procedure in an obese patient with recurrent severe GERD despite high-dose PPI therapy. After previous Nissen fundoplications and a redo procedure with a partial posterior fundoplication, the patient now presented with an intrathoracic migration of the posterior fundoplication. In these complex redo scenarios in conjunction with a high BMI, the strategy of esophagogastric disconnection and Roux-en-Y reconstruction similarly to obesity surgery is increasingly being used.
B Dallemagne, S Perretta, B Seeliger, D Mutter, J Marescaux
Surgical intervention
8 months ago
890 views
351 likes
0 comments
21:18
Fourth antireflux procedure in a patient with a BMI of 35: esophagogastric disconnection and Roux-en-Y gastrojejunostomy
We present an esophagogastric disconnection and Roux-en-Y gastrojejunostomy as the fourth antireflux procedure in an obese patient with recurrent severe GERD despite high-dose PPI therapy. After previous Nissen fundoplications and a redo procedure with a partial posterior fundoplication, the patient now presented with an intrathoracic migration of the posterior fundoplication. In these complex redo scenarios in conjunction with a high BMI, the strategy of esophagogastric disconnection and Roux-en-Y reconstruction similarly to obesity surgery is increasingly being used.
Laparoscopic pancreatectomy with preservation of splenic vessels: a live broadcast from IRCAD America Latina, Barretos, Brazil
In this instructional video, Dr. Bernard Dallemagne demonstrated the main principles and key steps of laparoscopic pancreatectomy with the preservation of splenic vessels (Kimura technique) in a 58-year-old woman with a complex cyst of the body and tail of the pancreas. He briefly described the technical aspects and maneuvers for a better exposure and dissection of the inferior and superior border of the pancreas. He highlighted the tips and tricks for opening the gastrocolic ligament, the identification and dissection of vessels, the mobilization of the pancreas, dissection line reinforcement, and specimen removal.
B Dallemagne, S Perretta, R Araujo
Surgical intervention
11 months ago
4664 views
593 likes
1 comment
38:09
Laparoscopic pancreatectomy with preservation of splenic vessels: a live broadcast from IRCAD America Latina, Barretos, Brazil
In this instructional video, Dr. Bernard Dallemagne demonstrated the main principles and key steps of laparoscopic pancreatectomy with the preservation of splenic vessels (Kimura technique) in a 58-year-old woman with a complex cyst of the body and tail of the pancreas. He briefly described the technical aspects and maneuvers for a better exposure and dissection of the inferior and superior border of the pancreas. He highlighted the tips and tricks for opening the gastrocolic ligament, the identification and dissection of vessels, the mobilization of the pancreas, dissection line reinforcement, and specimen removal.
LIVE INTERACTIVE SURGERY: paraesophageal hernia repair: critical value of extrasaccular approach
Paraesophageal hernia (PEH) repair is a challenging procedure. Repositioning of the herniated stomach and the reduction of the sac from the mediastinum is mandatory in order to decrease the risk of recurrence. The dissection and reduction of the sac must be performed following stepwise and precise dissection rules: it must be carried out outside of the sac, in an anatomical cleavage plane. Recurrence is also related to the type of crural repair performed, some authors advocating the systematic use of prosthetic or biological reinforcement. In this video, we present a PEH repair and cruroplasty protected with an absorbable mesh and contemporary Nissen fundoplication.
B Dallemagne, S Perretta, M Diana, F Longo, D Mutter, J Marescaux
Surgical intervention
1 year ago
4800 views
435 likes
0 comments
54:47
LIVE INTERACTIVE SURGERY: paraesophageal hernia repair: critical value of extrasaccular approach
Paraesophageal hernia (PEH) repair is a challenging procedure. Repositioning of the herniated stomach and the reduction of the sac from the mediastinum is mandatory in order to decrease the risk of recurrence. The dissection and reduction of the sac must be performed following stepwise and precise dissection rules: it must be carried out outside of the sac, in an anatomical cleavage plane. Recurrence is also related to the type of crural repair performed, some authors advocating the systematic use of prosthetic or biological reinforcement. In this video, we present a PEH repair and cruroplasty protected with an absorbable mesh and contemporary Nissen fundoplication.
LIVE INTERACTIVE SURGERY: thoracoscopic esophageal diverticulectomy and myotomy
A 65-year-old woman was referred to our hospital with complaints of dysphagia. She had a surgical history of cesarean section and cholecystectomy. Esophageal motility examination showed a normal lower esophageal sphincter (LES), and the absence of hiatal hernia and spasm in the distal part of the esophagus. The barium X-ray showed a bulky diverticulum in the middle thoracic esophagus and barium collecting inside the diverticulum without obstruction. The 3D-CT image also showed a giant diverticulum in the middle esophagus. The diverticulum was located below the azygos vein and carina of the bronchus and was sticking out from the middle esophagus in the contralateral side of the thoracic aorta. The diverticulum does not invade other organs. The patient was then proposed for an elective surgery, a thoracoscopic esophageal diverticulectomy and myotomy in a prone position.
B Dallemagne, S Perretta, D Mutter, J Marescaux
Surgical intervention
1 year ago
1135 views
111 likes
0 comments
41:44
LIVE INTERACTIVE SURGERY: thoracoscopic esophageal diverticulectomy and myotomy
A 65-year-old woman was referred to our hospital with complaints of dysphagia. She had a surgical history of cesarean section and cholecystectomy. Esophageal motility examination showed a normal lower esophageal sphincter (LES), and the absence of hiatal hernia and spasm in the distal part of the esophagus. The barium X-ray showed a bulky diverticulum in the middle thoracic esophagus and barium collecting inside the diverticulum without obstruction. The 3D-CT image also showed a giant diverticulum in the middle esophagus. The diverticulum was located below the azygos vein and carina of the bronchus and was sticking out from the middle esophagus in the contralateral side of the thoracic aorta. The diverticulum does not invade other organs. The patient was then proposed for an elective surgery, a thoracoscopic esophageal diverticulectomy and myotomy in a prone position.
Laparoscopic cholecystectomy: basic rules
In this key lecture, Dr. Dallemagne provides a brief overview of basic rules for a safe laparoscopic cholecystectomy. He demonstrates the incidence, different causes, and impact of biliary injuries in open, laparoscopic, and single port surgery. He describes the main criteria of dissection with the principle of critical view of safety and highlights the Tokyo and SAGES guidelines in relation to the optimal surgical timing. He mentions the recommended surgical techniques, main maneuvers of the technique with modified cholecystectomy, and when the decision to convert is made depending on complications. He also presents alternative methods for the intraoperative imaging of bile ducts, including the role of cholangiography, near-infrared and fluorescence-guided cholecystectomy.
B Dallemagne
Lecture
1 year ago
5706 views
858 likes
1 comment
39:17
Laparoscopic cholecystectomy: basic rules
In this key lecture, Dr. Dallemagne provides a brief overview of basic rules for a safe laparoscopic cholecystectomy. He demonstrates the incidence, different causes, and impact of biliary injuries in open, laparoscopic, and single port surgery. He describes the main criteria of dissection with the principle of critical view of safety and highlights the Tokyo and SAGES guidelines in relation to the optimal surgical timing. He mentions the recommended surgical techniques, main maneuvers of the technique with modified cholecystectomy, and when the decision to convert is made depending on complications. He also presents alternative methods for the intraoperative imaging of bile ducts, including the role of cholangiography, near-infrared and fluorescence-guided cholecystectomy.
The VERSA LIFTER BAND™: a new option for liver retraction in laparoscopic Roux-en-Y gastric bypass for morbid obesity
During laparoscopic bariatric procedures in morbidly obese patients, the surgeon's operative view is often obscured by the hypertrophic adipose left lobe of the liver.
To provide adequate operative views and working space, an appropriate retraction of the left liver lobe is required.
The use of a conventional liver retractor mandates an additional subxiphoid wound, resulting in patient discomfort for pain and scar formation, with the additional risk of iatrogenic liver injury during retraction maneuvers.
To overcome these limitations, we present the use of a simple, rapid, and safe technique for liver retraction using the VERSA LIFTER™ Band disposable liver suspension system or retractor.
A D'Urso, M Vix, B Dallemagne, HA Mercoli, D Mutter, J Marescaux
Surgical intervention
2 years ago
1645 views
37 likes
0 comments
03:48
The VERSA LIFTER BAND™: a new option for liver retraction in laparoscopic Roux-en-Y gastric bypass for morbid obesity
During laparoscopic bariatric procedures in morbidly obese patients, the surgeon's operative view is often obscured by the hypertrophic adipose left lobe of the liver.
To provide adequate operative views and working space, an appropriate retraction of the left liver lobe is required.
The use of a conventional liver retractor mandates an additional subxiphoid wound, resulting in patient discomfort for pain and scar formation, with the additional risk of iatrogenic liver injury during retraction maneuvers.
To overcome these limitations, we present the use of a simple, rapid, and safe technique for liver retraction using the VERSA LIFTER™ Band disposable liver suspension system or retractor.
Upper GI obstruction due to incarcerated recurrent hiatal hernia with mesh repair
This is the case of a 46-year-old woman with a BMI of 43 who presented to our clinic complaining of aphasia. Her past medical history is significant for a hiatal hernia repair and a diaphragmatic mesh reinforcement performed in July 2013. After surgery, she complained of dysphagia even after the three postoperative months, and the upper GI series showed a recurrence of her hiatal hernia. The dysphagia got worse, and in January 2015, a CT-scan showed a complete blockage of the gastroesophageal junction due to the herniation of the stomach. A 5-trocar technique was used, very similar to what we would use for a Nissen fundoplication.
S Perretta, B Dallemagne, D Mutter, J Marescaux
Surgical intervention
3 years ago
831 views
31 likes
0 comments
12:26
Upper GI obstruction due to incarcerated recurrent hiatal hernia with mesh repair
This is the case of a 46-year-old woman with a BMI of 43 who presented to our clinic complaining of aphasia. Her past medical history is significant for a hiatal hernia repair and a diaphragmatic mesh reinforcement performed in July 2013. After surgery, she complained of dysphagia even after the three postoperative months, and the upper GI series showed a recurrence of her hiatal hernia. The dysphagia got worse, and in January 2015, a CT-scan showed a complete blockage of the gastroesophageal junction due to the herniation of the stomach. A 5-trocar technique was used, very similar to what we would use for a Nissen fundoplication.
When and how to manage esophageal diverticula: surgical and endoscopic procedures
Esophageal diverticula are rare. They may occur in the pharyngoesophageal area (Zenker's), mid-esophagus, or distally (epiphrenic). Most patients with diverticula are asymptomatic. Fewer than one-third of the diverticula produce symptoms severe enough to seek medical attention or to warrant surgery.
Surgical treatment has changed significantly with the development of minimally invasive methods which have increasingly replaced open surgery. If certain indications persist for open surgery, Zenker’s diverticulum is mainly treated with transoral endoscopic flexible or rigid techniques. This approach, which consists of a marsupialization of the diverticulum, also treats the concomitant motor disorder. These esophageal motor disorders are also present in the vast majority of patients with mid-esophageal or epiphrenic diverticula. These diseases are also treated mainly using a minimally invasive approach which consists of a diverticulectomy associated with an esophageal myotomy, which is widely recommended.
B Dallemagne
Lecture
3 years ago
759 views
28 likes
0 comments
24:26
When and how to manage esophageal diverticula: surgical and endoscopic procedures
Esophageal diverticula are rare. They may occur in the pharyngoesophageal area (Zenker's), mid-esophagus, or distally (epiphrenic). Most patients with diverticula are asymptomatic. Fewer than one-third of the diverticula produce symptoms severe enough to seek medical attention or to warrant surgery.
Surgical treatment has changed significantly with the development of minimally invasive methods which have increasingly replaced open surgery. If certain indications persist for open surgery, Zenker’s diverticulum is mainly treated with transoral endoscopic flexible or rigid techniques. This approach, which consists of a marsupialization of the diverticulum, also treats the concomitant motor disorder. These esophageal motor disorders are also present in the vast majority of patients with mid-esophageal or epiphrenic diverticula. These diseases are also treated mainly using a minimally invasive approach which consists of a diverticulectomy associated with an esophageal myotomy, which is widely recommended.
Type III hiatal hernia: stepwise laparoscopic treatment
The surgical treatment of type III hiatal hernia has been thoroughly standardized in the following order: extrasaccular approach, reduction of the entire sac, and esophageal mobilization in order to restore the esophagogastric anatomy. Although it is recommended to combine this with a fundoplication as most authors do, there is still controversy concerning the closure technique of the diaphragmatic defect. Some experts recommend the reinforcement of this closure by means of a synthetic mesh. It is, however, a method which does not prevent recurrence and which can also bring about complications, which can at times be disastrous. As a result, we privilege reinforcement using an absorbable mesh.
B Dallemagne, S Perretta, S Tzedakis, D Mutter, J Marescaux
Surgical intervention
3 years ago
7563 views
274 likes
1 comment
16:21
Type III hiatal hernia: stepwise laparoscopic treatment
The surgical treatment of type III hiatal hernia has been thoroughly standardized in the following order: extrasaccular approach, reduction of the entire sac, and esophageal mobilization in order to restore the esophagogastric anatomy. Although it is recommended to combine this with a fundoplication as most authors do, there is still controversy concerning the closure technique of the diaphragmatic defect. Some experts recommend the reinforcement of this closure by means of a synthetic mesh. It is, however, a method which does not prevent recurrence and which can also bring about complications, which can at times be disastrous. As a result, we privilege reinforcement using an absorbable mesh.
Collis Nissen procedure after lung transplantation and laparoscopic management of mediastinal hematoma
After lung transplantation, GERD causes inflammatory reactions, increasing risks for obliterating bronchiolitis and dysfunctioning graft. Authors first present a laparoscopic Collis Nissen procedure for hiatal hernia and severe esophagitis in a grafted patient. Because of a short esophagus despite extended dissection, a Collis gastroplasty is required. After stapling, cruroplasty is performed, finally followed by a Nissen fundoplication. In case of severe esophagitis, a difficult dissection and inflammatory tissues can lead to more complications such as leak, hemorrhage, slippage, and abscess. Mediastinal hematoma is diagnosed on postoperative day 9, mandating a redo emergency intervention. This rare complication will be managed laparoscopically.
B Dallemagne, S Perretta, HA Mercoli, L Marx, J Marescaux
Surgical intervention
4 years ago
1670 views
58 likes
1 comment
21:07
Collis Nissen procedure after lung transplantation and laparoscopic management of mediastinal hematoma
After lung transplantation, GERD causes inflammatory reactions, increasing risks for obliterating bronchiolitis and dysfunctioning graft. Authors first present a laparoscopic Collis Nissen procedure for hiatal hernia and severe esophagitis in a grafted patient. Because of a short esophagus despite extended dissection, a Collis gastroplasty is required. After stapling, cruroplasty is performed, finally followed by a Nissen fundoplication. In case of severe esophagitis, a difficult dissection and inflammatory tissues can lead to more complications such as leak, hemorrhage, slippage, and abscess. Mediastinal hematoma is diagnosed on postoperative day 9, mandating a redo emergency intervention. This rare complication will be managed laparoscopically.
Laparoscopic left pancreatectomy with spleen preservation for multiple neuroendocrine tumors
Insulinoma is the most common functional neuroendocrine tumor of the pancreas. Most insulinomas are benign and solitary. Surgical resection is preferred for insulinomas and cure is achieved in more than 90% of the patients. Successful surgery requires accurate localization based on contrast enhanced CT-scan, PET-scan, and intraoperative ultrasound. This video shows a laparoscopic left pancreatectomy in a young patient presenting with typical symptoms evocative of Whipple's triad. Preoperative imaging studies identified two pancreatic tumors. Laparoscopic exploration and ultrasound identified four distinct tumors, all of them expressing somatostatin and insulin. This clinical case highlights the necessity and value of ultrasound exploration during surgery for neuroendocrine tumors.
B Dallemagne, D Mutter, L Soler, J Marescaux
Surgical intervention
5 years ago
2552 views
76 likes
0 comments
35:52
Laparoscopic left pancreatectomy with spleen preservation for multiple neuroendocrine tumors
Insulinoma is the most common functional neuroendocrine tumor of the pancreas. Most insulinomas are benign and solitary. Surgical resection is preferred for insulinomas and cure is achieved in more than 90% of the patients. Successful surgery requires accurate localization based on contrast enhanced CT-scan, PET-scan, and intraoperative ultrasound. This video shows a laparoscopic left pancreatectomy in a young patient presenting with typical symptoms evocative of Whipple's triad. Preoperative imaging studies identified two pancreatic tumors. Laparoscopic exploration and ultrasound identified four distinct tumors, all of them expressing somatostatin and insulin. This clinical case highlights the necessity and value of ultrasound exploration during surgery for neuroendocrine tumors.
Laparoscopic partial fundoplication in a patient with scleroderma and severe GERD
Scleroderma is associated with severe esophageal dysmotility and gastroesophageal reflux disease (GERD). Results after antireflux surgery have been suboptimal due to the profound esophageal dysmotility observed in this disease.

Here, we show the case of a 54-year-old patient with scleroderma and severe GERD. The patient presented with both typical GERD symptoms, persistent cough unresponsive to high dose of PPIs, and dysphagia to solids. Preoperative work-up included high-resolution (HR) manometry, which showed a hypotensive lower esophageal sphincter and severely impaired peristalsis as well as impedance pH monitoring, which confirmed the presence of pathological reflux, mainly acid, occurring mostly at night in a recumbent position.
S Perretta, B Dallemagne, J Marescaux
Surgical intervention
5 years ago
3366 views
35 likes
0 comments
09:11
Laparoscopic partial fundoplication in a patient with scleroderma and severe GERD
Scleroderma is associated with severe esophageal dysmotility and gastroesophageal reflux disease (GERD). Results after antireflux surgery have been suboptimal due to the profound esophageal dysmotility observed in this disease.

Here, we show the case of a 54-year-old patient with scleroderma and severe GERD. The patient presented with both typical GERD symptoms, persistent cough unresponsive to high dose of PPIs, and dysphagia to solids. Preoperative work-up included high-resolution (HR) manometry, which showed a hypotensive lower esophageal sphincter and severely impaired peristalsis as well as impedance pH monitoring, which confirmed the presence of pathological reflux, mainly acid, occurring mostly at night in a recumbent position.
Laparoscopic redo Nissen for failed anterior fundoplication
Nissen fundoplication is the most commonly performed antireflux operation. An alternative is the partial fundoplication, either anterior or posterior to the esophagus, which provides adequate control of reflux. The anterior valve is effective, provided that it is properly constructed. It is not a simple fundic plication but it implies precise dissection parameters to create an effective antireflux mechanism. This video shows a redo fundoplication in a patient with an anterior fundoplication that never controlled GERD, because it was built as a simple fundic plication. This cause of failure is typical in inexperienced surgeons, who are afraid of doing a posterior dissection of the gastroesophageal junction. The video also demonstrates the management of a peri-splenic hemorrhage.
B Dallemagne, S Perretta, J Marescaux
Surgical intervention
5 years ago
1985 views
37 likes
0 comments
31:15
Laparoscopic redo Nissen for failed anterior fundoplication
Nissen fundoplication is the most commonly performed antireflux operation. An alternative is the partial fundoplication, either anterior or posterior to the esophagus, which provides adequate control of reflux. The anterior valve is effective, provided that it is properly constructed. It is not a simple fundic plication but it implies precise dissection parameters to create an effective antireflux mechanism. This video shows a redo fundoplication in a patient with an anterior fundoplication that never controlled GERD, because it was built as a simple fundic plication. This cause of failure is typical in inexperienced surgeons, who are afraid of doing a posterior dissection of the gastroesophageal junction. The video also demonstrates the management of a peri-splenic hemorrhage.
POEM endoscopic treatment of achalasia using the EndoFLIP® (Endolumenal Functional Lumen Imaging Probe) imaging system
This is the case of a 75-year-old lady who presented with recurrent symptoms of dysphagia and regurgitation associated with a significant weight loss due to recurrent achalasia. She developed progressive recurrence after a first surgical treatment by an open Heller myotomy and Dor fundoplication back in 1974. This first operation was complicated by an esophageal perforation which required a thoracotomy to be controlled. Several dilatations were attempted with no significant symptoms improvement. One of the most important aspects of POEM is to ensure that the submucosal tunnel adequately extends into the gastric cardia in order to perform a complete and adequate myotomy. To this aim, proper orientation is key but may be difficult even to the experienced eye of the interventional endoscopist familiar with ESD techniques and dissection planes. Six endoscopic cues that assist with this determination have been identified so far. The most useful cue was deemed to be the characteristic appearance of the submucosal space of the cardia of a slightly different color with a somewhat yellowish hue, more capacious than the esophageal submucosal space with more and larger vessels. Identification of the thick, cord-like circular muscle fibers of the lower esophageal sphincter was deemed as the second most useful cue, and noting a bluish coloration of the cardial mucosa from the colored submucosal injection via a retroflexed luminal view was the third most useful cue. Endoscope insertion length within the submucosal tunnel and the palisading mucosal vessels marking the gastroesophageal junction and visible also from inside the submucosal tunnel were deemed helpful but to a lesser degree. Nevertheless, identification of these endoscopic landmarks is not easy nor always reproducible. Creation of the submucosal tunnel is very sensitive to case difficulty and accounts for the large fluctuations in procedure time. Another area of technique variability involves the orientation of the myotomy. In order to improve the recognition of the essential landmarks, we developed a myotomy technique guided by the EndoFLIP® catheter. EndoFLIP® is a unique physiology test that uses both volumetric assessment and pressure readings to calculate compliance and high pressure zones as well as distensibility changes at the gastroesophageal junction. It allows intraoperative assessment of myotomy completion. The use of this device provides a direct immediate feedback with regards to the efficacy of the myotomy. The EndoFLIP® catheter used in this case (EF-325L) has been specifically modified for the POEM procedure. It differs from the standard EndoFLIP® catheter in that it contains an integrated illuminating LED adjacent to the centre measurement electrode. When the catheter is positioned intraluminally at the gastroesophageal junction and secured to this position taping the distal end to the endothracheal tube, it allows to direct dissection towards the cardia.
S Perretta, LL Swanström, B Dallemagne, J Marescaux
Surgical intervention
5 years ago
2733 views
39 likes
0 comments
07:08
POEM endoscopic treatment of achalasia using the EndoFLIP® (Endolumenal Functional Lumen Imaging Probe) imaging system
This is the case of a 75-year-old lady who presented with recurrent symptoms of dysphagia and regurgitation associated with a significant weight loss due to recurrent achalasia. She developed progressive recurrence after a first surgical treatment by an open Heller myotomy and Dor fundoplication back in 1974. This first operation was complicated by an esophageal perforation which required a thoracotomy to be controlled. Several dilatations were attempted with no significant symptoms improvement. One of the most important aspects of POEM is to ensure that the submucosal tunnel adequately extends into the gastric cardia in order to perform a complete and adequate myotomy. To this aim, proper orientation is key but may be difficult even to the experienced eye of the interventional endoscopist familiar with ESD techniques and dissection planes. Six endoscopic cues that assist with this determination have been identified so far. The most useful cue was deemed to be the characteristic appearance of the submucosal space of the cardia of a slightly different color with a somewhat yellowish hue, more capacious than the esophageal submucosal space with more and larger vessels. Identification of the thick, cord-like circular muscle fibers of the lower esophageal sphincter was deemed as the second most useful cue, and noting a bluish coloration of the cardial mucosa from the colored submucosal injection via a retroflexed luminal view was the third most useful cue. Endoscope insertion length within the submucosal tunnel and the palisading mucosal vessels marking the gastroesophageal junction and visible also from inside the submucosal tunnel were deemed helpful but to a lesser degree. Nevertheless, identification of these endoscopic landmarks is not easy nor always reproducible. Creation of the submucosal tunnel is very sensitive to case difficulty and accounts for the large fluctuations in procedure time. Another area of technique variability involves the orientation of the myotomy. In order to improve the recognition of the essential landmarks, we developed a myotomy technique guided by the EndoFLIP® catheter. EndoFLIP® is a unique physiology test that uses both volumetric assessment and pressure readings to calculate compliance and high pressure zones as well as distensibility changes at the gastroesophageal junction. It allows intraoperative assessment of myotomy completion. The use of this device provides a direct immediate feedback with regards to the efficacy of the myotomy. The EndoFLIP® catheter used in this case (EF-325L) has been specifically modified for the POEM procedure. It differs from the standard EndoFLIP® catheter in that it contains an integrated illuminating LED adjacent to the centre measurement electrode. When the catheter is positioned intraluminally at the gastroesophageal junction and secured to this position taping the distal end to the endothracheal tube, it allows to direct dissection towards the cardia.
Laparoscopic stepwise approach of a tumor of the gastroesophageal junction
GISTs are rare neoplasms that account for less than 1% of all gastrointestinal malignancies. GISTs have the capability to become malignant and then metastasize, whereas leiomyomas are almost invariably benign. In clinical practice, preoperative differentiation between GISTs and leiomyomas is usually difficult, even if EUS-guided fine-needle aspiration or trucut biopsy is performed. Leiomyomas are rare in the stomach and duodenum while GIST are more frequent in the stomach.
This patient presented with a 6cm submucosal tumor below the gastroesophageal junction. This video demonstrates the stepwise laparoscopic approach taking into consideration the potentially (pre-)malignant nature of the tumor.
B Dallemagne, S Perretta, S Mandala, J Marescaux
Surgical intervention
5 years ago
1746 views
17 likes
0 comments
26:11
Laparoscopic stepwise approach of a tumor of the gastroesophageal junction
GISTs are rare neoplasms that account for less than 1% of all gastrointestinal malignancies. GISTs have the capability to become malignant and then metastasize, whereas leiomyomas are almost invariably benign. In clinical practice, preoperative differentiation between GISTs and leiomyomas is usually difficult, even if EUS-guided fine-needle aspiration or trucut biopsy is performed. Leiomyomas are rare in the stomach and duodenum while GIST are more frequent in the stomach.
This patient presented with a 6cm submucosal tumor below the gastroesophageal junction. This video demonstrates the stepwise laparoscopic approach taking into consideration the potentially (pre-)malignant nature of the tumor.
Challenges in GERD: Collis fundoplication in a patient with a BMI of 41
Obesity has long been considered a predisposing factor for gastroesophageal reflux. It is also thought to predispose patients to a poorer clinical outcome following antireflux surgery and some authors recommend gastric bypass in obese patient with symptomatic GERD. However, some studies reported that preoperative BMI does not influence the clinical outcome following laparoscopic antireflux surgery and concluded that obesity is not a contraindication for laparoscopic fundoplication (1, 2).
In this video, we present a Collis-Toupet gastroplasty in a woman with a BMI of 41.
References:
1. Winslow ER, Frisella MM, Soper NJ, Klingensmith ME. Obesity does not adversely affect the outcome of laparoscopic antireflux surgery (LARS). Surgical Endoscopy 2003;17:2003-11.
2. Chisholm JA, Jamieson GG, Lally CJ, Devitt PG, Game PA, Watson DI. The effect of obesity on the outcome of laparoscopic antireflux surgery. J Gastrointest Surg 2009;13:1064-70.
B Dallemagne, S Perretta, J Marescaux
Surgical intervention
6 years ago
1528 views
27 likes
0 comments
25:13
Challenges in GERD: Collis fundoplication in a patient with a BMI of 41
Obesity has long been considered a predisposing factor for gastroesophageal reflux. It is also thought to predispose patients to a poorer clinical outcome following antireflux surgery and some authors recommend gastric bypass in obese patient with symptomatic GERD. However, some studies reported that preoperative BMI does not influence the clinical outcome following laparoscopic antireflux surgery and concluded that obesity is not a contraindication for laparoscopic fundoplication (1, 2).
In this video, we present a Collis-Toupet gastroplasty in a woman with a BMI of 41.
References:
1. Winslow ER, Frisella MM, Soper NJ, Klingensmith ME. Obesity does not adversely affect the outcome of laparoscopic antireflux surgery (LARS). Surgical Endoscopy 2003;17:2003-11.
2. Chisholm JA, Jamieson GG, Lally CJ, Devitt PG, Game PA, Watson DI. The effect of obesity on the outcome of laparoscopic antireflux surgery. J Gastrointest Surg 2009;13:1064-70.
Second reoperative antireflux procedure for valve slippage
Redo surgery is technically more demanding than primary fundoplication. In addition, anatomical defects that caused failure may increase technical difficulties. A recent review found that the average success rate after laparoscopic redo operations ranged from 65 to 100 per cent (van Beek D, Auyang E, Soper N. A comprehensive review of laparoscopic redo fundoplication. Surgical Endoscopy: Springer New York; 2010. p 1-7). However, our recent study showed that the failure rate after re-operation is increasing with time, and highlighted the need for accurate preoperative and intraoperative assessment of the causes of failure (Dallemagne B, Arenas Sanchez M, Francart D, Perretta S, Weerts J, Markiewicz S, et al. Long-term results after laparoscopic reoperation for failed antireflux procedures. Br J Surg 2011;98:1581-7). This video shows a third antireflux procedure in a patient presenting with slippage of the fundoplication.
B Dallemagne, S Perretta, J D'Agostino, J Marescaux
Surgical intervention
6 years ago
1391 views
15 likes
0 comments
29:04
Second reoperative antireflux procedure for valve slippage
Redo surgery is technically more demanding than primary fundoplication. In addition, anatomical defects that caused failure may increase technical difficulties. A recent review found that the average success rate after laparoscopic redo operations ranged from 65 to 100 per cent (van Beek D, Auyang E, Soper N. A comprehensive review of laparoscopic redo fundoplication. Surgical Endoscopy: Springer New York; 2010. p 1-7). However, our recent study showed that the failure rate after re-operation is increasing with time, and highlighted the need for accurate preoperative and intraoperative assessment of the causes of failure (Dallemagne B, Arenas Sanchez M, Francart D, Perretta S, Weerts J, Markiewicz S, et al. Long-term results after laparoscopic reoperation for failed antireflux procedures. Br J Surg 2011;98:1581-7). This video shows a third antireflux procedure in a patient presenting with slippage of the fundoplication.
Management of persisting dysphagia after laparoscopic Nissen fundoplication
Dysphagia is a normal observation after fundoplication for GERD. It usually lasts for 4 to 6 weeks and results from esophageal motility disorders related to the esophageal dissection and to the outlet obstruction created by the fundoplication. It is managed by appropriate diet. When dysphagia persists after 3 months, there is some concern and need for objective evaluation. This video shows the management of this type of persisting dysphagia after laparoscopic Nissen fundoplication, during which a big hematoma developed on the wrap. This usually does not lead to any long-term problems but, in this patient, dysphagia persisted over a 3-month period of time and led to re-operation.
B Dallemagne, S Perretta, T Piardi, J Marescaux
Surgical intervention
6 years ago
1798 views
23 likes
0 comments
18:17
Management of persisting dysphagia after laparoscopic Nissen fundoplication
Dysphagia is a normal observation after fundoplication for GERD. It usually lasts for 4 to 6 weeks and results from esophageal motility disorders related to the esophageal dissection and to the outlet obstruction created by the fundoplication. It is managed by appropriate diet. When dysphagia persists after 3 months, there is some concern and need for objective evaluation. This video shows the management of this type of persisting dysphagia after laparoscopic Nissen fundoplication, during which a big hematoma developed on the wrap. This usually does not lead to any long-term problems but, in this patient, dysphagia persisted over a 3-month period of time and led to re-operation.
Laparoscopic transcystic clearance of the common bile duct (CBD) during three-trocar cholecystectomy
Common bile duct stones are found in approximately 16% of patients undergoing laparoscopic cholecystectomy. If the diagnosis is established during intraoperative cholangiography, the surgeon is confronted with a therapeutic dilemma, namely the choice between laparoscopic common bile duct (CBD) exploration, conversion to open surgery, or postoperative endoscopic sphincterotomy. Laparoscopic CBD exploration can be performed through the cystic duct or through a choledochotomy, the choice being mainly guided by the size of the CBD stone and the size of the cystic duct and common bile duct. In this patient with a large cystic duct, small stone and normal CBD size, we have opted for the transcystic extraction, using the Dormia basket under fluoroscopic guidance. The procedure was performed using a three-trocar approach and a new internal retraction device that suspends the gallbladder.
B Dallemagne, T Piardi, J Marescaux
Surgical intervention
6 years ago
3928 views
20 likes
0 comments
12:26
Laparoscopic transcystic clearance of the common bile duct (CBD) during three-trocar cholecystectomy
Common bile duct stones are found in approximately 16% of patients undergoing laparoscopic cholecystectomy. If the diagnosis is established during intraoperative cholangiography, the surgeon is confronted with a therapeutic dilemma, namely the choice between laparoscopic common bile duct (CBD) exploration, conversion to open surgery, or postoperative endoscopic sphincterotomy. Laparoscopic CBD exploration can be performed through the cystic duct or through a choledochotomy, the choice being mainly guided by the size of the CBD stone and the size of the cystic duct and common bile duct. In this patient with a large cystic duct, small stone and normal CBD size, we have opted for the transcystic extraction, using the Dormia basket under fluoroscopic guidance. The procedure was performed using a three-trocar approach and a new internal retraction device that suspends the gallbladder.
Laparoscopic repair of giant type 4 paraesophageal hernia
Type 4 giant hiatal hernias are not common. The stomach is herniated, as well as viscera in the mediastinum, colon, spleen, and even sometimes in the pancreas. Repair is challenging for different reasons. This type of hernia is frequent in older and fragile patients. Reduction of the sac from the mediastinum is mandatory and must be carried out following stepwise and precise dissection rules: it has to be done outside of the sac, in an anatomical cleavage plane. Crural repair is challenging and must be tailored on the quality of the diaphragmatic musculature and size of the orifice. Anti-reflux repair must be performed as well. The laparoscopic approach has radically improved the clinical outcome of this procedure in old patients.
B Dallemagne, E Marzano, S Perretta, J Marescaux
Surgical intervention
6 years ago
4662 views
78 likes
0 comments
21:43
Laparoscopic repair of giant type 4 paraesophageal hernia
Type 4 giant hiatal hernias are not common. The stomach is herniated, as well as viscera in the mediastinum, colon, spleen, and even sometimes in the pancreas. Repair is challenging for different reasons. This type of hernia is frequent in older and fragile patients. Reduction of the sac from the mediastinum is mandatory and must be carried out following stepwise and precise dissection rules: it has to be done outside of the sac, in an anatomical cleavage plane. Crural repair is challenging and must be tailored on the quality of the diaphragmatic musculature and size of the orifice. Anti-reflux repair must be performed as well. The laparoscopic approach has radically improved the clinical outcome of this procedure in old patients.
Esophageal peptic stricture and shortened esophagus managed by a laparoscopic Collis-Nissen procedure
This video presents a laparoscopic Collis-Nissen procedure performed in a 64-year-old man presenting with long-standing reflux disease and esophageal peptic stricture. The patient underwent several (>15) endoscopic dilatations that elicit only temporary improvement of dysphagia. Two esophageal stents were placed without significant improvement after removal. The patient was then referred to surgery. The treatment alternatives were esophagectomy or anti-reflux surgery associated with postoperative dilatations. The first choice was to perform an anti-reflux procedure in order to stop a mixed pathological reflux and reduce the risk of re-stricture. Three months after the procedure, an esophageal stent was placed to dilate the stricture.
B Dallemagne, S Perretta, Gf Donatelli, J Marescaux
Surgical intervention
6 years ago
3260 views
71 likes
0 comments
24:49
Esophageal peptic stricture and shortened esophagus managed by a laparoscopic Collis-Nissen procedure
This video presents a laparoscopic Collis-Nissen procedure performed in a 64-year-old man presenting with long-standing reflux disease and esophageal peptic stricture. The patient underwent several (>15) endoscopic dilatations that elicit only temporary improvement of dysphagia. Two esophageal stents were placed without significant improvement after removal. The patient was then referred to surgery. The treatment alternatives were esophagectomy or anti-reflux surgery associated with postoperative dilatations. The first choice was to perform an anti-reflux procedure in order to stop a mixed pathological reflux and reduce the risk of re-stricture. Three months after the procedure, an esophageal stent was placed to dilate the stricture.
Gastric mucosal laceration managed with endoscopic clipping during ESD in a patient with Child Class A liver cirrhosis
Patients with liver cirrhosis present with portal hypertension (PHT), which causes various pathological changes in the entire gastrointestinal tract (from esophagus to anus). In this video, the Mallory Weiss tear (MWT) occurred accidentally during ESD of a gastric antral adenoma in a cirrhotic patient. It was successfully managed by means of endoscopic clipping. The patient had two episodes of retching during endoscopy, which might have contributed to gastric over-distension. With esophagogastroduodenoscopy (EGD) being so commonly performed in cirrhotic patients and ESD being more and more commonly used for treatment of gastric mucosal lesions, this case report should serve as a precautionary reminder in such case scenarios.
Gf Donatelli, P Dhumane, L Marx, B Dallemagne, J Marescaux
Surgical intervention
6 years ago
760 views
11 likes
0 comments
02:57
Gastric mucosal laceration managed with endoscopic clipping during ESD in a patient with Child Class A liver cirrhosis
Patients with liver cirrhosis present with portal hypertension (PHT), which causes various pathological changes in the entire gastrointestinal tract (from esophagus to anus). In this video, the Mallory Weiss tear (MWT) occurred accidentally during ESD of a gastric antral adenoma in a cirrhotic patient. It was successfully managed by means of endoscopic clipping. The patient had two episodes of retching during endoscopy, which might have contributed to gastric over-distension. With esophagogastroduodenoscopy (EGD) being so commonly performed in cirrhotic patients and ESD being more and more commonly used for treatment of gastric mucosal lesions, this case report should serve as a precautionary reminder in such case scenarios.
Right colon Dieulafoy's lesion: endoscopic treatment
A 78-year-old man presenting with chronic renal failure was admitted to the emergency department of our hospital for bleeding per rectum.
The hemoglobin level was 10.5 g/dL on admission. Given that the patient was hemodynamically stable, decision was made to perform an upper GI endoscopy and a total colonoscopy the following day after standard bowel preparation. Bleeding recurred during the night with a hemoglobin drop to 6.3g/dL, requiring transfusions of 3 Units of blood.
With no further delay, endoscopy was performed. The gastroscopy was normal but at colonoscopy old blood was visualized in the rectum, the sigmoid, and the left and transverse colon. Additional bright red blood was observed at the level of the right colon.
Gf Donatelli, S Perretta, B Dallemagne
Surgical intervention
7 years ago
1577 views
16 likes
1 comment
02:32
Right colon Dieulafoy's lesion: endoscopic treatment
A 78-year-old man presenting with chronic renal failure was admitted to the emergency department of our hospital for bleeding per rectum.
The hemoglobin level was 10.5 g/dL on admission. Given that the patient was hemodynamically stable, decision was made to perform an upper GI endoscopy and a total colonoscopy the following day after standard bowel preparation. Bleeding recurred during the night with a hemoglobin drop to 6.3g/dL, requiring transfusions of 3 Units of blood.
With no further delay, endoscopy was performed. The gastroscopy was normal but at colonoscopy old blood was visualized in the rectum, the sigmoid, and the left and transverse colon. Additional bright red blood was observed at the level of the right colon.
MRI lymphography for esophageal sentinel node mapping: evolution of a NOTES technique
Introduction: Natural Orifice Transluminal Endoscopic Surgery (NOTES) may render conventionally inaccessible anatomic sites accessible in a truly minimally invasive means. Having developed expertise in esophageal mural tunneling for the purposes of endoscopic Heller’s myotomy, we now cautiously explore the feasibility of a transesophageal technique for sentinel node mapping based on MRI lymphography.
Methods: two non-survival porcine models were used to demonstrate how targeted mediastinal lymph node biopsy could be performed transesophageally by a combination of endoscopic submucosal lymphatic mapping, MRI imaging and NOTES.
First, lymphatic mapping of the area of interest is performed by injecting 2mls of methylene blue submucosally using a standard gastroscope inserted into the distal esophagus. This suspension of small molecular size dye particles is rapidly taken up by the submucosal lymphatic efferents and transported to the first echelon draining lymph nodes which are then detectable by their blue discoloration.
After a few minutes, the endoscope is withdrawn proximally to this injection site and a mucosal incision made 15cm from the EGJ to allow creation of a submucosal tunnel using a biliary soft tipped dilatation balloon. This along with the pressure of endoscopic CO2 insufflation allows a space to be formed within the esophageal wall. A second staggered incision then allows exit of the endoscope into the mediastinum proper. Once in this anatomic space, a careful search is performed for blue discolored lymph nodes whereupon standard endoscopic dissection instruments allows selective lymphadenectomy to be performed and the salient nodes withdrawn to the exterior via to esophagotomy. The small diameter of the scope allows for easy retroflection providing good visualization even of the proximal esophagus. The last step is mucosal clip closure to reinforce the mucosal flap seal. The retrieved nodes were MRI scanned to confirm the presence of gadolinium in the dyed nodes.
In the second animal the mapping was performed as described above but instead of retrieving only the sentinel nodes an en bloc esophagogastrectomy was performed to assess the sentinel nodes basin distribution at MRI.
Results: The operative technique proved readily feasible in all its aspects with blue sentinel nodes being found around the distal esophagus. The gadolinium combined with methylene blue was found in the first draining nodes in both animals.
Conclusions: MRI imaging may provide a new tool for sentinel node basin identification, and if proved sufficiently reliable, may represent a step further towards a solely endoscopic diagnosis and resection of the primary tumor.
S Perretta, M Diana, B Dallemagne, R Cahill, J Marescaux
Surgical intervention
7 years ago
126 views
3 likes
0 comments
02:28
MRI lymphography for esophageal sentinel node mapping: evolution of a NOTES technique
Introduction: Natural Orifice Transluminal Endoscopic Surgery (NOTES) may render conventionally inaccessible anatomic sites accessible in a truly minimally invasive means. Having developed expertise in esophageal mural tunneling for the purposes of endoscopic Heller’s myotomy, we now cautiously explore the feasibility of a transesophageal technique for sentinel node mapping based on MRI lymphography.
Methods: two non-survival porcine models were used to demonstrate how targeted mediastinal lymph node biopsy could be performed transesophageally by a combination of endoscopic submucosal lymphatic mapping, MRI imaging and NOTES.
First, lymphatic mapping of the area of interest is performed by injecting 2mls of methylene blue submucosally using a standard gastroscope inserted into the distal esophagus. This suspension of small molecular size dye particles is rapidly taken up by the submucosal lymphatic efferents and transported to the first echelon draining lymph nodes which are then detectable by their blue discoloration.
After a few minutes, the endoscope is withdrawn proximally to this injection site and a mucosal incision made 15cm from the EGJ to allow creation of a submucosal tunnel using a biliary soft tipped dilatation balloon. This along with the pressure of endoscopic CO2 insufflation allows a space to be formed within the esophageal wall. A second staggered incision then allows exit of the endoscope into the mediastinum proper. Once in this anatomic space, a careful search is performed for blue discolored lymph nodes whereupon standard endoscopic dissection instruments allows selective lymphadenectomy to be performed and the salient nodes withdrawn to the exterior via to esophagotomy. The small diameter of the scope allows for easy retroflection providing good visualization even of the proximal esophagus. The last step is mucosal clip closure to reinforce the mucosal flap seal. The retrieved nodes were MRI scanned to confirm the presence of gadolinium in the dyed nodes.
In the second animal the mapping was performed as described above but instead of retrieving only the sentinel nodes an en bloc esophagogastrectomy was performed to assess the sentinel nodes basin distribution at MRI.
Results: The operative technique proved readily feasible in all its aspects with blue sentinel nodes being found around the distal esophagus. The gadolinium combined with methylene blue was found in the first draining nodes in both animals.
Conclusions: MRI imaging may provide a new tool for sentinel node basin identification, and if proved sufficiently reliable, may represent a step further towards a solely endoscopic diagnosis and resection of the primary tumor.