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Laparoscopic management of perforated ulcer of the stomach
A 43-year-old woman with a history of chronic use of NSAIDs was admitted to the emergency care unit for acute abdominal epigastric pain. CT-scan showed both free air and fluid in the peritoneal cavity with marked thickening and irregularity at the level of the gastric antrum and the duodenal bulb. The patient underwent emergency laparoscopy. A large amount of purulent fluid was found in the peritoneal cavity and evacuated. The gastric defect was identified at the level of the anterior wall of the gastric antrum. A 2/0 Vicryl suture is used to oversew the perforation. As an additional protection, an omental patch was brought in place and fixed against the sutured lesion. Abundant peritoneal lavage was performed. The patient was discharged on postoperative day 5. One month later, esophagogastroduodenoscopies (EGDs) with biopsies of the ulcer’s margins were performed.
X Untereiner, M Pizzicannella, B Dallemagne, D Mutter, J Marescaux
Surgical intervention
7 months ago
5491 views
16 likes
2 comments
06:55
Laparoscopic management of perforated ulcer of the stomach
A 43-year-old woman with a history of chronic use of NSAIDs was admitted to the emergency care unit for acute abdominal epigastric pain. CT-scan showed both free air and fluid in the peritoneal cavity with marked thickening and irregularity at the level of the gastric antrum and the duodenal bulb. The patient underwent emergency laparoscopy. A large amount of purulent fluid was found in the peritoneal cavity and evacuated. The gastric defect was identified at the level of the anterior wall of the gastric antrum. A 2/0 Vicryl suture is used to oversew the perforation. As an additional protection, an omental patch was brought in place and fixed against the sutured lesion. Abundant peritoneal lavage was performed. The patient was discharged on postoperative day 5. One month later, esophagogastroduodenoscopies (EGDs) with biopsies of the ulcer’s margins were performed.
Respective indications of EMR and ESD
Endoscopy has increased the detection of early neoplastic lesions of the gastrointestinal tract (GIT) known as gastrointestinal superficial lesions.
Endoscopic resection is adequate in patients with early gastrointestinal cancer with limited or completely nil submucosal involvement. Endoscopic resections are mainly used for high- and low-grade dysplasia. Most lesions can be treated using endoscopic mucosal resection (EMR), however unsuitable for lesions greater than 20mm in size. Endoscopic submucosal dissection (ESD) allows to achieve an ‘en bloc’ resection of the lesions, irrespective of the size of the tumor.
Esophagus:
Endoscopic resection is indicated for esophageal cancers with no risk of lymph node invasion. The size of the lesion is the main criterion for the choice of the procedure.
Barrett’s esophagus: EMR is the gold standard for endoscopic excision in Barrett’s esophagus; the main limitation is piecemeal resection with EMR, which makes histopathological assessment difficult, and the risk of recurrence and residual tumor is high. ESD should be considered for lesions greater than 15mm, poorly lifting tumors, and those at risk for submucosal invasion.
Stomach:
The lesions which should be considered for endoscopic resection because of a very low risk of lymph node metastasis are the following:
- non-invasive neoplasia (dysplasia) independently of size;
- intramucosal differentiated-type adenocarcinoma, without ulceration (size ≤2cm absolute indication, >2cm expanded indication);
- intramucosal differentiated-type adenocarcinoma, with ulcer, size ≤3cm (expanded indication);
- intramucosal undifferentiated-type adenocarcinoma, size ≤2cm (expanded indication);
- differentiated-type adenocarcinoma with superficial submucosal invasion.
EMR was the first treatment alternative to surgery for early gastric cancer. However, EMR is associated with a high recurrence rate (30%) according to some studies.
ESD for early gastric cancers has higher ‘en bloc’ resection rates, histologically complete resection rates, and low recurrence rates. ESD though is associated with longer operative times.
Duodenum:
The use of endoscopic resection in the duodenum and the small bowel is limited because of a high risk of perforations. EMR standard or piecemeal resections can be used for superficial lesions with perforation rates less than 5%.
Colon:
EMR represents a highly effective treatment for lesions of the colon less than 20mm in diameter. Piecemeal EMR for larger lesions reduces the quality and reliability of histopathological findings.
In the rectum, the indications for ESD may be extended for all large (>20mm), non-granular (NG) or granular lesions, or mixed laterally spreading tumors (LSTs) (>20-30mm).
ESD can be considered for the removal of colonic and rectal lesions with a high suspicion of limited submucosal invasion, which is based on two main criteria, namely a depressed morphology and an irregular or non-granular surface pattern, particularly if the lesions are larger than 20 mm.
Summary:
EMR should be the first option for the following:
- superficial lesion in Barrett’s esophagus;
- small gastric lesion
N Fukami
Lecture
3 years ago
436 views
21 likes
0 comments
29:26
Respective indications of EMR and ESD
Endoscopy has increased the detection of early neoplastic lesions of the gastrointestinal tract (GIT) known as gastrointestinal superficial lesions.
Endoscopic resection is adequate in patients with early gastrointestinal cancer with limited or completely nil submucosal involvement. Endoscopic resections are mainly used for high- and low-grade dysplasia. Most lesions can be treated using endoscopic mucosal resection (EMR), however unsuitable for lesions greater than 20mm in size. Endoscopic submucosal dissection (ESD) allows to achieve an ‘en bloc’ resection of the lesions, irrespective of the size of the tumor.
Esophagus:
Endoscopic resection is indicated for esophageal cancers with no risk of lymph node invasion. The size of the lesion is the main criterion for the choice of the procedure.
Barrett’s esophagus: EMR is the gold standard for endoscopic excision in Barrett’s esophagus; the main limitation is piecemeal resection with EMR, which makes histopathological assessment difficult, and the risk of recurrence and residual tumor is high. ESD should be considered for lesions greater than 15mm, poorly lifting tumors, and those at risk for submucosal invasion.
Stomach:
The lesions which should be considered for endoscopic resection because of a very low risk of lymph node metastasis are the following:
- non-invasive neoplasia (dysplasia) independently of size;
- intramucosal differentiated-type adenocarcinoma, without ulceration (size ≤2cm absolute indication, >2cm expanded indication);
- intramucosal differentiated-type adenocarcinoma, with ulcer, size ≤3cm (expanded indication);
- intramucosal undifferentiated-type adenocarcinoma, size ≤2cm (expanded indication);
- differentiated-type adenocarcinoma with superficial submucosal invasion.
EMR was the first treatment alternative to surgery for early gastric cancer. However, EMR is associated with a high recurrence rate (30%) according to some studies.
ESD for early gastric cancers has higher ‘en bloc’ resection rates, histologically complete resection rates, and low recurrence rates. ESD though is associated with longer operative times.
Duodenum:
The use of endoscopic resection in the duodenum and the small bowel is limited because of a high risk of perforations. EMR standard or piecemeal resections can be used for superficial lesions with perforation rates less than 5%.
Colon:
EMR represents a highly effective treatment for lesions of the colon less than 20mm in diameter. Piecemeal EMR for larger lesions reduces the quality and reliability of histopathological findings.
In the rectum, the indications for ESD may be extended for all large (>20mm), non-granular (NG) or granular lesions, or mixed laterally spreading tumors (LSTs) (>20-30mm).
ESD can be considered for the removal of colonic and rectal lesions with a high suspicion of limited submucosal invasion, which is based on two main criteria, namely a depressed morphology and an irregular or non-granular surface pattern, particularly if the lesions are larger than 20 mm.
Summary:
EMR should be the first option for the following:
- superficial lesion in Barrett’s esophagus;
- small gastric lesion
Laparoscopic distal gastrectomy with Billroth II reconstruction for peptic ulcer obstruction
This live surgery video demonstrates a laparoscopic distal gastrectomy with Billroth II reconstruction in a patient with pyloric stenosis which was caused by peptic ulcer. Treatment using balloon dilatation failed. The fibrotic area of the duodenal ulcer was approached by fine dissection and ligation of right gastro-epiploic and right gastric vessels. The dissection was performed around the duodenum until an adequate margin could be obtained in the healthy portion of the distal duodenum. The duodenum was then transected by means of a stapler. A relatively large dilated stomach including the antrum and part of the gastric body was transected, and a Billroth II gastrojejunostomy was performed.
HK Yang
Surgical intervention
4 years ago
3561 views
157 likes
0 comments
21:58
Laparoscopic distal gastrectomy with Billroth II reconstruction for peptic ulcer obstruction
This live surgery video demonstrates a laparoscopic distal gastrectomy with Billroth II reconstruction in a patient with pyloric stenosis which was caused by peptic ulcer. Treatment using balloon dilatation failed. The fibrotic area of the duodenal ulcer was approached by fine dissection and ligation of right gastro-epiploic and right gastric vessels. The dissection was performed around the duodenum until an adequate margin could be obtained in the healthy portion of the distal duodenum. The duodenum was then transected by means of a stapler. A relatively large dilated stomach including the antrum and part of the gastric body was transected, and a Billroth II gastrojejunostomy was performed.
Gastric GIST: minimally invasive surgical modalities
Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor, and the stomach is the most frequent location (50-60%). Gastric GIST presents as a submucosal tumor and is often found incidentally. Submucosal tumors greater than 2cm are indicated for resection. Indication for laparoscopic surgery is not strictly determined by the size, but whether surgery can follow resection principles, 1) R0 resection with histologically negative margins, 2) all efforts are made to prevent tumor rupture. Wedge resection using a linear stapler, also called “exogastric resection” is effective in most cases. However, the operator should pay attention to align the direction of the linear stapler “transversely” to the long axis of the stomach, otherwise it can cause gastric lumen narrowing after resection, especially in case of a relatively large tumor with endophytical growth. Endoscopy is very useful to identify and define tumor resection margins for endophytic tumor, and the “eversion” technique is one option to reduce the amount of normal mucosa resection. GIST cases located at the posterior wall of the upper stomach are technically challenging, and transgastric or intragastric techniques are suggested as good surgical options for such tumors. Laparoscopic or endoscopic “coring out” techniques can be dangerous, because of the high risk of tumor rupture and gastric wall perforation, which can cause peritoneal seeding when both take place simultaneously.
SH Kong
Lecture
3 years ago
2141 views
121 likes
1 comment
22:10
Gastric GIST: minimally invasive surgical modalities
Gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor, and the stomach is the most frequent location (50-60%). Gastric GIST presents as a submucosal tumor and is often found incidentally. Submucosal tumors greater than 2cm are indicated for resection. Indication for laparoscopic surgery is not strictly determined by the size, but whether surgery can follow resection principles, 1) R0 resection with histologically negative margins, 2) all efforts are made to prevent tumor rupture. Wedge resection using a linear stapler, also called “exogastric resection” is effective in most cases. However, the operator should pay attention to align the direction of the linear stapler “transversely” to the long axis of the stomach, otherwise it can cause gastric lumen narrowing after resection, especially in case of a relatively large tumor with endophytical growth. Endoscopy is very useful to identify and define tumor resection margins for endophytic tumor, and the “eversion” technique is one option to reduce the amount of normal mucosa resection. GIST cases located at the posterior wall of the upper stomach are technically challenging, and transgastric or intragastric techniques are suggested as good surgical options for such tumors. Laparoscopic or endoscopic “coring out” techniques can be dangerous, because of the high risk of tumor rupture and gastric wall perforation, which can cause peritoneal seeding when both take place simultaneously.
Endoscopic biliary stones extraction using a forward viewing standard gastroscope in a patient with altered anatomy (partial gastrectomy with Billroth II reconstruction)
Endoscopic retrograde cholangiography in case of altered anatomy such as partial gastrectomy with Billroth II reconstruction has a success rate of 85% due to different factors such as failure to cross the anastomosis and the presence of an important length of afferent loop with a high risk of jejunal perforation at (or near) the anastomotic site while advancing the duodenoscope. The use of a front-view scope is the safest and could be used theoretically. However, the lack of elevator, the inability to see the papilla in a direct view, and the limited number of catheters available for cannulation and therapeutic procedures in the standard gastroscope with the 2.8mm working channel, can make this kind of procedure quite challenging. In this video, we present a case of successful biliary stone extraction in a patient with Billroth II reconstruction using a standard 2.8mm working channel front-viewing scope.
Gf Donatelli, BM Vergeau, B Meduri
Surgical intervention
4 years ago
880 views
14 likes
0 comments
04:47
Endoscopic biliary stones extraction using a forward viewing standard gastroscope in a patient with altered anatomy (partial gastrectomy with Billroth II reconstruction)
Endoscopic retrograde cholangiography in case of altered anatomy such as partial gastrectomy with Billroth II reconstruction has a success rate of 85% due to different factors such as failure to cross the anastomosis and the presence of an important length of afferent loop with a high risk of jejunal perforation at (or near) the anastomotic site while advancing the duodenoscope. The use of a front-view scope is the safest and could be used theoretically. However, the lack of elevator, the inability to see the papilla in a direct view, and the limited number of catheters available for cannulation and therapeutic procedures in the standard gastroscope with the 2.8mm working channel, can make this kind of procedure quite challenging. In this video, we present a case of successful biliary stone extraction in a patient with Billroth II reconstruction using a standard 2.8mm working channel front-viewing scope.
Laparoscopic management of intra-abdominal fish bone mimicking acute cholecystitis
This video shows a female patient of 62 years, presenting with acute upper abdominal pain with fever and vomiting for five days. Clinically, she presented with features of acute cholecystitis.
Blood examination revealed leukocytosis with normal liver function tests. Abdominal ultrasonography showed edema of the gallbladder wall with pericholecystic collection, cholelithiasis and signs of acute cholecystitis.
Under antibiotic cover, the patient was subjected for single-port laparoscopic cholecystectomy using the EK glove port. Due to dense and stubborn adhesions, the procedure was converted to conventional 3-port surgery.
The duodenum was found adherent to the infundibulum of the gallbladder with a fish bone and pus within it. A 3.3cm long fish bone perforated the duodenum, produced abscess and mimicked acute cholecystitis.
The fish bone was extracted, perforation was repaired and cholecystectomy was performed.
E Khiangte, I Newme, P Phukan
Surgical intervention
7 years ago
2862 views
24 likes
0 comments
07:27
Laparoscopic management of intra-abdominal fish bone mimicking acute cholecystitis
This video shows a female patient of 62 years, presenting with acute upper abdominal pain with fever and vomiting for five days. Clinically, she presented with features of acute cholecystitis.
Blood examination revealed leukocytosis with normal liver function tests. Abdominal ultrasonography showed edema of the gallbladder wall with pericholecystic collection, cholelithiasis and signs of acute cholecystitis.
Under antibiotic cover, the patient was subjected for single-port laparoscopic cholecystectomy using the EK glove port. Due to dense and stubborn adhesions, the procedure was converted to conventional 3-port surgery.
The duodenum was found adherent to the infundibulum of the gallbladder with a fish bone and pus within it. A 3.3cm long fish bone perforated the duodenum, produced abscess and mimicked acute cholecystitis.
The fish bone was extracted, perforation was repaired and cholecystectomy was performed.
Tips 'n tricks: successful ERCP in the presence of periampullary diverticula
Duodenal diverticula are found in approximately 10-20% of patients undergoing Endoscopic Retrograde Cholangio-Pancreatography (ERCP).
Usually, these diverticula lie within 2cm of the major duodenal papilla and are called juxtapapillary diverticula. They are mostly acquired and their incidence increases with age.
Juxtapapillary diverticula have often been associated with mechanical compression and they are also involved in Oddi’s sphincter dysfunction. The presence of juxtapapillary diverticula is known to influence the outcome of ERCP procedure by making it more difficult and causing some complications like bleeding. Various techniques have been advised for a more successful ERCP outcome
In this video, four cases of duodenal diverticula are presented to provide tips and tricks for the successful cannulation of the CBD and management of periampullary bleeding in case they occur.
Gf Donatelli, P Dhumane, S Perretta, B Dallemagne, J Marescaux
Surgical intervention
8 years ago
2086 views
12 likes
0 comments
09:19
Tips 'n tricks: successful ERCP in the presence of periampullary diverticula
Duodenal diverticula are found in approximately 10-20% of patients undergoing Endoscopic Retrograde Cholangio-Pancreatography (ERCP).
Usually, these diverticula lie within 2cm of the major duodenal papilla and are called juxtapapillary diverticula. They are mostly acquired and their incidence increases with age.
Juxtapapillary diverticula have often been associated with mechanical compression and they are also involved in Oddi’s sphincter dysfunction. The presence of juxtapapillary diverticula is known to influence the outcome of ERCP procedure by making it more difficult and causing some complications like bleeding. Various techniques have been advised for a more successful ERCP outcome
In this video, four cases of duodenal diverticula are presented to provide tips and tricks for the successful cannulation of the CBD and management of periampullary bleeding in case they occur.
Small sphincterotomy and balloon sphincteroplasty for extraction of a common bile duct stone in a patient with juxtapapillary diverticulum
Duodenal diverticula have a prevalence of 9 to 32%. Usually, they are within 2cm of the major duodenal papilla and for that are called juxtapapillary diverticula. They are acquired and their incidence increases with age. Biliary and pancreatic disease is often associated with juxtapapillary diverticula, in particular common bile duct stones. They are directly associated with the outcome of Endoscopic Retrograde Cholangio-Pancreatography (due to the complexity of cannulation) and with an increased rate of complications, in particular bleeding. Various techniques are described to increase the success rate, such as clip-assisted biliary cannulation, endoscopic ultrasound-guided bile duct access, main pancreatic duct stent placement followed by pre-cut biliary sphincterotomy. The success rate, independently of these techniques, varies from 61% to 95%.
In this video, we show a case of a patient with angiocholitis secondary to choledocholithiasis, and several cardiovascular co-morbidities, having the papilla of Vater on the edge of a diverticulum. A small sphincterotomy was performed as shown and then bleeding risk was evaluated (the patient being on anticoagulants) and because of the important size of the impacted stone, a sphincteroplasty with dilatation of the papilla with a balloon expanded to 15mm was performed, along with stone extraction using a Dormia basket.
The patient was discharged on postoperative day 2 with normal liver function tests and no inflammation.
Gf Donatelli, C Callari, S Perretta, B Dallemagne
Surgical intervention
9 years ago
1329 views
19 likes
0 comments
05:08
Small sphincterotomy and balloon sphincteroplasty for extraction of a common bile duct stone in a patient with juxtapapillary diverticulum
Duodenal diverticula have a prevalence of 9 to 32%. Usually, they are within 2cm of the major duodenal papilla and for that are called juxtapapillary diverticula. They are acquired and their incidence increases with age. Biliary and pancreatic disease is often associated with juxtapapillary diverticula, in particular common bile duct stones. They are directly associated with the outcome of Endoscopic Retrograde Cholangio-Pancreatography (due to the complexity of cannulation) and with an increased rate of complications, in particular bleeding. Various techniques are described to increase the success rate, such as clip-assisted biliary cannulation, endoscopic ultrasound-guided bile duct access, main pancreatic duct stent placement followed by pre-cut biliary sphincterotomy. The success rate, independently of these techniques, varies from 61% to 95%.
In this video, we show a case of a patient with angiocholitis secondary to choledocholithiasis, and several cardiovascular co-morbidities, having the papilla of Vater on the edge of a diverticulum. A small sphincterotomy was performed as shown and then bleeding risk was evaluated (the patient being on anticoagulants) and because of the important size of the impacted stone, a sphincteroplasty with dilatation of the papilla with a balloon expanded to 15mm was performed, along with stone extraction using a Dormia basket.
The patient was discharged on postoperative day 2 with normal liver function tests and no inflammation.
Laparoscopic management of gangrenous perforated cholecystitis
Laparoscopic cholecystectomy is the gold standard for symptomatic cholecystolithiasis. Technical maturation and advances in instrumentation have enabled the application of this procedure for acute cholecystitis.
This video demonstrates the surgical approach to performing a laparoscopic cholecystectomy in an older male patient with acute cholecystitis and who has had a previous laparotomy for vascular surgery. The surgeon uses a French approach standing between the patient's legs while he optical trocar is placed supraumbilically, 3cm to the right of the midline in order to avoid the adhesions caused by the previous surgery.
An ischemic gallbladder with necrotic area and infundibular perforation was found.
J D'Agostino, J Marescaux
Surgical intervention
10 years ago
4180 views
88 likes
0 comments
05:58
Laparoscopic management of gangrenous perforated cholecystitis
Laparoscopic cholecystectomy is the gold standard for symptomatic cholecystolithiasis. Technical maturation and advances in instrumentation have enabled the application of this procedure for acute cholecystitis.
This video demonstrates the surgical approach to performing a laparoscopic cholecystectomy in an older male patient with acute cholecystitis and who has had a previous laparotomy for vascular surgery. The surgeon uses a French approach standing between the patient's legs while he optical trocar is placed supraumbilically, 3cm to the right of the midline in order to avoid the adhesions caused by the previous surgery.
An ischemic gallbladder with necrotic area and infundibular perforation was found.
Laparoscopic common bile duct exploration: choledochotomy approach
The description of the laparoscopic common bile duct exploration: choledochotomy approach covers all aspects of the surgical procedure used for the management of common bile duct stones.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration and exposure, dissection, intraoperative cholangiography, laparoscopic ultrasonography, choledochotomy, stone extraction, common bile duct closure.
Consequently, this operating technique is well standardized for the management of this condition.
D Bacal, JC Berthou, D Mutter, I Jourdan
Operative technique
16 years ago
3860 views
216 likes
0 comments
Laparoscopic common bile duct exploration: choledochotomy approach
The description of the laparoscopic common bile duct exploration: choledochotomy approach covers all aspects of the surgical procedure used for the management of common bile duct stones.
Operating room set up, position of patient and equipment, instruments used are thoroughly described. The technical key steps of the surgical procedure are presented in a step by step way: exploration and exposure, dissection, intraoperative cholangiography, laparoscopic ultrasonography, choledochotomy, stone extraction, common bile duct closure.
Consequently, this operating technique is well standardized for the management of this condition.