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A young lady with dysphagia and GIST after a complicated sleeve gastrectomy for morbid obesity
A 34 year-old woman was referred to us for persistent dysphagia and retrosternal chest pain, aggravated by eating. Two years earlier, she underwent a laparoscopic sleeve gastrectomy for morbid obesity.
Her operation was complicated by septic shock due to an esophagogastric fistula with subphrenic abscesses, and on postoperative day 20, she underwent a laparotomy, abscess debridement and drainage, splenectomy and application of cyanoacrylate-based glue, followed by endoscopic positioning of a self-expandable partially coated prosthesis.
Three weeks afterwards, her prosthesis was replaced with a self-expandable fully coated prosthesis due to persistent leak. This prosthesis was finally removed after 7 weeks.
One year after her operation, at gastroscopy, a 25mm submucosal nodule covered with an ulcerated mucosa was found in the proximal antrum. Biopsy was negative, and endoscopic ultrasonography was suggestive of GIST.
She underwent an esophageal manometry, which was indicative of esophagogastric junction outflow obstruction. Her barium swallow test showed a delayed esophageal emptying due to the narrowing and twisting of the proximal part of the stomach. Her abdominal MRI was normal.
An exploratory laparoscopy was indicated for adhesiolysis and removal of the antral lesion.
Total duration of the operation was 3 hours. Her postoperative course was uneventful and she was discharged on postoperative day 6.
Her postoperative swallow study showed the easy passage of the contrast agent with no leaks. The patient completely recovered from her symptoms, and remained asymptomatic after 30 months. Final histology of her lesion evidenced a foreign body granuloma.
S Greco, M Giulii Capponi, M Lotti, M Khotcholava
Surgical intervention
27 days ago
403 views
1 like
1 comment
14:14
A young lady with dysphagia and GIST after a complicated sleeve gastrectomy for morbid obesity
A 34 year-old woman was referred to us for persistent dysphagia and retrosternal chest pain, aggravated by eating. Two years earlier, she underwent a laparoscopic sleeve gastrectomy for morbid obesity.
Her operation was complicated by septic shock due to an esophagogastric fistula with subphrenic abscesses, and on postoperative day 20, she underwent a laparotomy, abscess debridement and drainage, splenectomy and application of cyanoacrylate-based glue, followed by endoscopic positioning of a self-expandable partially coated prosthesis.
Three weeks afterwards, her prosthesis was replaced with a self-expandable fully coated prosthesis due to persistent leak. This prosthesis was finally removed after 7 weeks.
One year after her operation, at gastroscopy, a 25mm submucosal nodule covered with an ulcerated mucosa was found in the proximal antrum. Biopsy was negative, and endoscopic ultrasonography was suggestive of GIST.
She underwent an esophageal manometry, which was indicative of esophagogastric junction outflow obstruction. Her barium swallow test showed a delayed esophageal emptying due to the narrowing and twisting of the proximal part of the stomach. Her abdominal MRI was normal.
An exploratory laparoscopy was indicated for adhesiolysis and removal of the antral lesion.
Total duration of the operation was 3 hours. Her postoperative course was uneventful and she was discharged on postoperative day 6.
Her postoperative swallow study showed the easy passage of the contrast agent with no leaks. The patient completely recovered from her symptoms, and remained asymptomatic after 30 months. Final histology of her lesion evidenced a foreign body granuloma.
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
7 years ago
1848 views
24 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.
Unusual cause of new onset persistent dysphagia after Nissen fundoplication
Persistent troublesome dysphagia develops in a small percentage of patients after Nissen fundoplication. Mild transient solid food dysphagia is an unavoidable side-effect of the operation. However, severe persistent dysphagia is probably related to poor patient selection, inadequate preoperative evaluation or technical errors, in most cases, excessively tight or long fundoplication. If dysphagia persists after dilatation, an outflow obstruction different to too tight or too long a wrap should be suspected as in this case. Re-operation may be needed if evidence of a poorly constructed wrap is apparent during the evaluation.
B Dallemagne, J Marescaux
Surgical intervention
10 years ago
613 views
34 likes
0 comments
18:38
Unusual cause of new onset persistent dysphagia after Nissen fundoplication
Persistent troublesome dysphagia develops in a small percentage of patients after Nissen fundoplication. Mild transient solid food dysphagia is an unavoidable side-effect of the operation. However, severe persistent dysphagia is probably related to poor patient selection, inadequate preoperative evaluation or technical errors, in most cases, excessively tight or long fundoplication. If dysphagia persists after dilatation, an outflow obstruction different to too tight or too long a wrap should be suspected as in this case. Re-operation may be needed if evidence of a poorly constructed wrap is apparent during the evaluation.
Laparoscopic re-operation for severe dysphagia following fundoplication and prosthetic reinforcement of the hiatus
Complications related to prosthetic hiatoplasty for hiatal hernia repair are more common than previously reported with no apparent relationship between mesh type and mesh configuration. The aim of this video is to show a case of mesh repair complication.
A 50-year-old woman presented with severe dysphagia and important weight loss one year after redo laparoscopic Nissen fundoplication with prosthetic crural repair. At re-operation, important esophageal stenosis and angulation was found arising from the key-hole-shaped polypropylene mesh with pseudodiverticular dilatation of the distal esophagus. The esophagus was freed from the dense fibrotic capsule surrounding the prosthesis and a myotomy was performed.
B Dallemagne, S Perretta, J Marescaux
Surgical intervention
10 years ago
386 views
10 likes
0 comments
19:50
Laparoscopic re-operation for severe dysphagia following fundoplication and prosthetic reinforcement of the hiatus
Complications related to prosthetic hiatoplasty for hiatal hernia repair are more common than previously reported with no apparent relationship between mesh type and mesh configuration. The aim of this video is to show a case of mesh repair complication.
A 50-year-old woman presented with severe dysphagia and important weight loss one year after redo laparoscopic Nissen fundoplication with prosthetic crural repair. At re-operation, important esophageal stenosis and angulation was found arising from the key-hole-shaped polypropylene mesh with pseudodiverticular dilatation of the distal esophagus. The esophagus was freed from the dense fibrotic capsule surrounding the prosthesis and a myotomy was performed.
Peroral endoscopic myotomy of a suspected type III achalasia with a double scope control
A 59-year-old woman was referred to our unit for progressive dysphagia and chest pain associated with heartburn and chest fullness. A nutcracker esophagus was suspected at the HD manometry and the patient was scheduled for a peroral endoscopic myotomy (POEM). The procedure started with an esophagogastroduodenal series (EGDS), which showed abnormal contractions of the distal esophagus and increased resistance at the level of the esophagogastric junction (EGJ) with a high suspicion of type III achalasia. The tunnel was started 12cm above the EGJ in a 5 o’clock position. After submucosal injection, a mucosal incision was made with a new triangle-tip (TT) knife equipped with water jet facility. The access to the submucosa was gained and a submucosal longitudinal tunnel was created until the EGJ, dissecting the submucosal fibers with the TT knife. The myotomy was performed by completely dissecting the circular muscular layer muscle fibers using swift coagulation. To assess the extension of the myotomy just at the level of the EGJ, a “double scope control” was performed by inserting a pediatric scope, which confirmed the presence of the mother scope light in the esophagus. The submucosal tunnel and the myotomy were then extended together for 1 to 2cm. A second check with the pediatric scope showed the presence of the mother scope light in the correct position above the EGJ. The mucosal incision site was finally closed using multiple endoclips.
H Inoue, RA Ciurezu, M Pizzicannella, F Habersetzer
Surgical intervention
3 months ago
286 views
2 likes
0 comments
25:51
Peroral endoscopic myotomy of a suspected type III achalasia with a double scope control
A 59-year-old woman was referred to our unit for progressive dysphagia and chest pain associated with heartburn and chest fullness. A nutcracker esophagus was suspected at the HD manometry and the patient was scheduled for a peroral endoscopic myotomy (POEM). The procedure started with an esophagogastroduodenal series (EGDS), which showed abnormal contractions of the distal esophagus and increased resistance at the level of the esophagogastric junction (EGJ) with a high suspicion of type III achalasia. The tunnel was started 12cm above the EGJ in a 5 o’clock position. After submucosal injection, a mucosal incision was made with a new triangle-tip (TT) knife equipped with water jet facility. The access to the submucosa was gained and a submucosal longitudinal tunnel was created until the EGJ, dissecting the submucosal fibers with the TT knife. The myotomy was performed by completely dissecting the circular muscular layer muscle fibers using swift coagulation. To assess the extension of the myotomy just at the level of the EGJ, a “double scope control” was performed by inserting a pediatric scope, which confirmed the presence of the mother scope light in the esophagus. The submucosal tunnel and the myotomy were then extended together for 1 to 2cm. A second check with the pediatric scope showed the presence of the mother scope light in the correct position above the EGJ. The mucosal incision site was finally closed using multiple endoclips.
Heller's cardiomyotomy for achalasia
Achalasia stems from Greek and means “a” (not) and “khálasis” (relaxation).
Idiopathic megaesophagus (achalasia) is an esophageal primary motor irregularity. It is characterized by the absence of esophageal peristalsis, together with incomplete relaxation of the lower esophageal sphincter after swallowing.
Differential diagnosis must be made between Chagas disease and esophageal squamous cell carcinoma. The incidence rate ranges from 0.5 to 1 per 100,000 persons-years of study. Although there are several theories, the etiology remains unknown.
The first clinical description was made by Sir Thomas Wills (1672). He used to treat the disease via dilation with a sponge attached to a whalebone. Arthur Hertz was the first to name the disease “achalasia”. Ernest Heller performed the first successful esophagectomy in 1913. Zaaijer was the first to describe the anterior myotomy in 1923.
Other therapeutic procedures include botulinum toxin injection into the lower esophageal sphincter. It has transient effects and patients can develop tolerance to the injections. Another option is endoscopic hydropneumatic dilation, which should be fluoroscopically-guided. When it fails, the efficacy of other therapeutic options decreases. The most serious complication is esophageal perforation.
The diagnostic criteria are based on endoscopic findings. Endoscopy reveals there are food remains as well as esophageal dilation, and decreased motility. X-ray exams show esophageal dilation and narrowing of the lower esophageal sphincter. Manometric findings show decreased esophageal motility, increased lower esophageal sphincter pressure, and incomplete relaxation of the lower esophageal sphincter.
The patient was operated on. Since there was no hiatal hernia, laparoscopic Toupet fundoplication was chosen, based on its efficacy in preventing reflux, as well as in keeping the myotomy free of a wrap.
G Lozano Dubernard, R Gil-Ortiz Mejía, B Rueda Torres, NS Gómez Peña-Alfaro
Surgical intervention
27 days ago
1370 views
9 likes
2 comments
12:40
Heller's cardiomyotomy for achalasia
Achalasia stems from Greek and means “a” (not) and “khálasis” (relaxation).
Idiopathic megaesophagus (achalasia) is an esophageal primary motor irregularity. It is characterized by the absence of esophageal peristalsis, together with incomplete relaxation of the lower esophageal sphincter after swallowing.
Differential diagnosis must be made between Chagas disease and esophageal squamous cell carcinoma. The incidence rate ranges from 0.5 to 1 per 100,000 persons-years of study. Although there are several theories, the etiology remains unknown.
The first clinical description was made by Sir Thomas Wills (1672). He used to treat the disease via dilation with a sponge attached to a whalebone. Arthur Hertz was the first to name the disease “achalasia”. Ernest Heller performed the first successful esophagectomy in 1913. Zaaijer was the first to describe the anterior myotomy in 1923.
Other therapeutic procedures include botulinum toxin injection into the lower esophageal sphincter. It has transient effects and patients can develop tolerance to the injections. Another option is endoscopic hydropneumatic dilation, which should be fluoroscopically-guided. When it fails, the efficacy of other therapeutic options decreases. The most serious complication is esophageal perforation.
The diagnostic criteria are based on endoscopic findings. Endoscopy reveals there are food remains as well as esophageal dilation, and decreased motility. X-ray exams show esophageal dilation and narrowing of the lower esophageal sphincter. Manometric findings show decreased esophageal motility, increased lower esophageal sphincter pressure, and incomplete relaxation of the lower esophageal sphincter.
The patient was operated on. Since there was no hiatal hernia, laparoscopic Toupet fundoplication was chosen, based on its efficacy in preventing reflux, as well as in keeping the myotomy free of a wrap.
Laparoscopic management of small bowel obstruction and ileo-ileal intussusception
Meckel’s diverticulum is the most common congenital anomaly of the digestive tract, found in 2 to 3% of the population. It is usually detected in children. In adults, symptoms vary, and diagnosis is therefore uneasy to establish. The most common infectious complications include obstructions and bleedings, which account for approximately one third of overall complications. Obstructions may be caused by intussusception or by a band.
This video demonstrates a case of a 49-year-old male patient, who necessitated an emergency surgical procedure for the management of a small bowel obstruction induced by the presence of Meckel’s diverticulum and intussusception. Due to an underlying necrosis, a resection and an anastomosis of the small bowel were performed.
D Kadoche, M Ignat, D Mutter, J Marescaux
Surgical intervention
5 months ago
616 views
4 likes
0 comments
08:22
Laparoscopic management of small bowel obstruction and ileo-ileal intussusception
Meckel’s diverticulum is the most common congenital anomaly of the digestive tract, found in 2 to 3% of the population. It is usually detected in children. In adults, symptoms vary, and diagnosis is therefore uneasy to establish. The most common infectious complications include obstructions and bleedings, which account for approximately one third of overall complications. Obstructions may be caused by intussusception or by a band.
This video demonstrates a case of a 49-year-old male patient, who necessitated an emergency surgical procedure for the management of a small bowel obstruction induced by the presence of Meckel’s diverticulum and intussusception. Due to an underlying necrosis, a resection and an anastomosis of the small bowel were performed.
Robotic Heller myotomy with Dor fundoplication for esophageal achalasia
Achalasia is an esophageal motility disorder characterized by an incomplete or absent esophagogastric junction (EGJ) relaxation associated with loss of peristalsis or uncoordinated contractions of the esophageal body in response to swallowing. All available treatments for achalasia are palliative, directed towards the elimination of the outflow resistance caused by abnormal lower esophageal sphincter (LES) function and aiming to improve the symptoms related to esophageal stasis, such as dysphagia and regurgitation. Laparoscopic Heller myotomy with partial fundoplication is the current standard of care for the treatment of achalasia. It is associated with symptom improvement or relief in about 90% of patients. However, it is a challenging procedure with the potential risk of esophageal perforation reported in up to 10% of cases. Interestingly, laparoscopic myotomy has some limitations which depend on the laparoscopic technique (bidimensional vision, poor range of movement) and on the surgeon’s experience. Recently, the use of the robotic technology has been proposed claiming that it might reduce intraoperative esophageal perforation rates and improve postoperative quality of life after Heller myotomy, mainly due to the 3D view and enhanced dexterity of the surgeon. Despite significant improvements in surgical treatment, the length of myotomy is still a matter of debate to date. Substantially, although some authors proposed a limited myotomy on the lower esophagus preserving a small portion of the LES to prevent postoperative reflux, most authors recommended a myotomy extending 4 to 6cm on the esophagus and 1 to 2cm on the gastric side. In this video, we performed a 6cm long esophagogastric myotomy, with a 2.5cm proximal extension above the Z-line (endoscopically recognized) and a 3.5cm distal extension below the same landmark. In a previous experimental study with intraoperative computerized manometry, we observed that myotomy of the esophageal portion of the LES (without dissection of the gastric fibers) did not lead to any significant variation in sphincteric pressure. Instead, the dissection of the gastric fibers for at least 2 to 2.5cm on the anterior gastric wall created a significant modification of the LES pressure profile. This may be due to the interruption of the anterior portion of gastric semicircular clasp and sling fibers, with consequent loss of their hook properties on the LES pressure profile.
L Marano, A Spaziani, G Castagnoli
Surgical intervention
1 year ago
1522 views
7 likes
0 comments
08:13
Robotic Heller myotomy with Dor fundoplication for esophageal achalasia
Achalasia is an esophageal motility disorder characterized by an incomplete or absent esophagogastric junction (EGJ) relaxation associated with loss of peristalsis or uncoordinated contractions of the esophageal body in response to swallowing. All available treatments for achalasia are palliative, directed towards the elimination of the outflow resistance caused by abnormal lower esophageal sphincter (LES) function and aiming to improve the symptoms related to esophageal stasis, such as dysphagia and regurgitation. Laparoscopic Heller myotomy with partial fundoplication is the current standard of care for the treatment of achalasia. It is associated with symptom improvement or relief in about 90% of patients. However, it is a challenging procedure with the potential risk of esophageal perforation reported in up to 10% of cases. Interestingly, laparoscopic myotomy has some limitations which depend on the laparoscopic technique (bidimensional vision, poor range of movement) and on the surgeon’s experience. Recently, the use of the robotic technology has been proposed claiming that it might reduce intraoperative esophageal perforation rates and improve postoperative quality of life after Heller myotomy, mainly due to the 3D view and enhanced dexterity of the surgeon. Despite significant improvements in surgical treatment, the length of myotomy is still a matter of debate to date. Substantially, although some authors proposed a limited myotomy on the lower esophagus preserving a small portion of the LES to prevent postoperative reflux, most authors recommended a myotomy extending 4 to 6cm on the esophagus and 1 to 2cm on the gastric side. In this video, we performed a 6cm long esophagogastric myotomy, with a 2.5cm proximal extension above the Z-line (endoscopically recognized) and a 3.5cm distal extension below the same landmark. In a previous experimental study with intraoperative computerized manometry, we observed that myotomy of the esophageal portion of the LES (without dissection of the gastric fibers) did not lead to any significant variation in sphincteric pressure. Instead, the dissection of the gastric fibers for at least 2 to 2.5cm on the anterior gastric wall created a significant modification of the LES pressure profile. This may be due to the interruption of the anterior portion of gastric semicircular clasp and sling fibers, with consequent loss of their hook properties on the LES pressure profile.
Giant hiatal hernia: pleural incision helping defect closure without tension
Incidence of hiatal hernias (HH) increases with age. Approximately 60% of persons aged over 50 have a HH. Most of them are asymptomatic patients and may be discovered incidentally; others may be symptomatic and their presentation differs depending on hernia type.
We present the case of a 65-year-old woman, complaining of abdominal pain and vomiting. CT-scan showed a giant hiatal sliding hernia with almost the whole stomach in an intrathoracic position. Surgery was put forward to the patient for HH correction and Nissen procedure and she accepted it.
Although a uniform definition does not exist, a giant HH is considered a hernia which includes at least 30% of the stomach in the chest. Usually, a giant HH is a type III hernia with a sliding and paraesophageal component, and consequently patients may complain of pain, heartburn, dysphagia, and vomiting. Surgery ordinarily includes four steps: hernia sac dissection and resection, esophageal mobilization, crural repair, and fundoplication. To prevent tension due to a large hiatus, relaxation of the diaphragmatic crura can be associated with the use of a mesh. However, mesh use is still a matter of debate because of severe associated complications, such as erosions requiring gastric resection. In this case, we decided to deliberately make a pleural incision, in order to reduce tension preventing the use of a mesh with all of its potential complications. This procedure, already described by some authors, is not associated with respiratory complications because of the difference in abdominal and respiratory pressures observed in laparoscopic surgery. The patient progressed favorably and was discharged asymptomatically on postoperative day 2.
C Viana, M Lozano, D Poletto, T Moreno, C Varela, A Toscano
Surgical intervention
11 months ago
3396 views
9 likes
1 comment
15:27
Giant hiatal hernia: pleural incision helping defect closure without tension
Incidence of hiatal hernias (HH) increases with age. Approximately 60% of persons aged over 50 have a HH. Most of them are asymptomatic patients and may be discovered incidentally; others may be symptomatic and their presentation differs depending on hernia type.
We present the case of a 65-year-old woman, complaining of abdominal pain and vomiting. CT-scan showed a giant hiatal sliding hernia with almost the whole stomach in an intrathoracic position. Surgery was put forward to the patient for HH correction and Nissen procedure and she accepted it.
Although a uniform definition does not exist, a giant HH is considered a hernia which includes at least 30% of the stomach in the chest. Usually, a giant HH is a type III hernia with a sliding and paraesophageal component, and consequently patients may complain of pain, heartburn, dysphagia, and vomiting. Surgery ordinarily includes four steps: hernia sac dissection and resection, esophageal mobilization, crural repair, and fundoplication. To prevent tension due to a large hiatus, relaxation of the diaphragmatic crura can be associated with the use of a mesh. However, mesh use is still a matter of debate because of severe associated complications, such as erosions requiring gastric resection. In this case, we decided to deliberately make a pleural incision, in order to reduce tension preventing the use of a mesh with all of its potential complications. This procedure, already described by some authors, is not associated with respiratory complications because of the difference in abdominal and respiratory pressures observed in laparoscopic surgery. The patient progressed favorably and was discharged asymptomatically on postoperative day 2.
Laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction for a terminal achalasia
Introduction: Idiopathic achalasia is the most frequent esophageal motility disorder. Generally, treatment is the "palliation" of symptoms and improvement in quality of life. Although Heller myotomy is the standard treatment, achieving good results in 90 to 95% of cases, esophagectomy is required in 5 to 10% of cases.
The authors present a case of a laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction in a woman with long-term achalasia and megaesophagus.
Clinical case: A 54-year-old woman, with a previous history of a "psychological eating disorder", was referred to the Emergency Department. She complained of epigastric pain and dysphagia. A thoraco-abdominal CT-scan was requested and revealed a dilated, tortuous, sigmoid esophagus, filled with food content, with no identifiable mass causing obstruction. The patient was admitted to hospital and further study was performed --esophagogastroscopy and esophageal manometry - which confirmed the diagnosis of achalasia with esophageal aperistalses.
The patient was proposed a laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction.
No complications were reported in the postoperative period, and discharge was possible on postoperative day 7. Six months later, an esophagram showed adequate contrast passage and progression.
Discussion/Conclusion: Esophagectomy as a primary treatment of achalasia might be considered if severe symptomatic (dysphagia, regurgitation), anatomical (megaesophagus) or functional (esophagus aperistalses) disorders are contraindications to a more conservative approach.
AM Pereira, J Magalhães, R Ferreira de Almeida, G Gonçalves, M Nora
Surgical intervention
1 year ago
3383 views
289 likes
0 comments
09:29
Laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction for a terminal achalasia
Introduction: Idiopathic achalasia is the most frequent esophageal motility disorder. Generally, treatment is the "palliation" of symptoms and improvement in quality of life. Although Heller myotomy is the standard treatment, achieving good results in 90 to 95% of cases, esophagectomy is required in 5 to 10% of cases.
The authors present a case of a laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction in a woman with long-term achalasia and megaesophagus.
Clinical case: A 54-year-old woman, with a previous history of a "psychological eating disorder", was referred to the Emergency Department. She complained of epigastric pain and dysphagia. A thoraco-abdominal CT-scan was requested and revealed a dilated, tortuous, sigmoid esophagus, filled with food content, with no identifiable mass causing obstruction. The patient was admitted to hospital and further study was performed --esophagogastroscopy and esophageal manometry - which confirmed the diagnosis of achalasia with esophageal aperistalses.
The patient was proposed a laparoscopic transhiatal esophagectomy with Akiyama tube reconstruction.
No complications were reported in the postoperative period, and discharge was possible on postoperative day 7. Six months later, an esophagram showed adequate contrast passage and progression.
Discussion/Conclusion: Esophagectomy as a primary treatment of achalasia might be considered if severe symptomatic (dysphagia, regurgitation), anatomical (megaesophagus) or functional (esophagus aperistalses) disorders are contraindications to a more conservative approach.
Surgical approach to intragastric migrated hiatal mesh
Mesh use in the laparoscopic repair of hiatal hernia is associated with fewer recurrences. However, it may cause some complications such as dysphagia, stenosis or even erosion with esophageal or gastric migration.
A 61-year-old woman with a large type III hiatal hernia underwent a laparoscopic Toupet fundoplication with closure of the hiatal crura with a dual U-shaped mesh.
She was symptom-free for 1 year, subsequently developing dysphagia and weight loss. An esophagogastric barium test revealed minimal contrast passage and endoscopy showed partial intragastric mesh migration.
The patient was submitted to a laparoscopic removal of migrated mesh with a transgastric approach. Hiatus inspection demonstrated significant fibrosis, with plication integrity and no evidence of recurrent hernia. A gastrotomy was performed allowing to identify and remove a migrated intra-gastric mesh. Careful evaluation did not show any gastric fistula and pressure test with methylene blue showed no evidence of leak.
This unusual approach avoided hiatus dissection, decreasing the risks of local complications such as perforation and bleeding. The patient had no postoperative complications, recovered well, and remained asymptomatic.
A Trovão, L Costa, M Costa, R Ferreira de Almeida, M Nora
Surgical intervention
1 year ago
649 views
106 likes
0 comments
09:55
Surgical approach to intragastric migrated hiatal mesh
Mesh use in the laparoscopic repair of hiatal hernia is associated with fewer recurrences. However, it may cause some complications such as dysphagia, stenosis or even erosion with esophageal or gastric migration.
A 61-year-old woman with a large type III hiatal hernia underwent a laparoscopic Toupet fundoplication with closure of the hiatal crura with a dual U-shaped mesh.
She was symptom-free for 1 year, subsequently developing dysphagia and weight loss. An esophagogastric barium test revealed minimal contrast passage and endoscopy showed partial intragastric mesh migration.
The patient was submitted to a laparoscopic removal of migrated mesh with a transgastric approach. Hiatus inspection demonstrated significant fibrosis, with plication integrity and no evidence of recurrent hernia. A gastrotomy was performed allowing to identify and remove a migrated intra-gastric mesh. Careful evaluation did not show any gastric fistula and pressure test with methylene blue showed no evidence of leak.
This unusual approach avoided hiatus dissection, decreasing the risks of local complications such as perforation and bleeding. The patient had no postoperative complications, recovered well, and remained asymptomatic.
Minimally invasive management of an epiphrenic diverticulum
We present the case of a 65-year-old gentleman who was referred to our department with long standing symptoms of dysphagia, reflux, and regurgitation. An esophagogastroduodenoscopy (EGD) was initially performed to evaluate his symptoms and showed food residue in the esophagus and a wide-necked epiphrenic diverticulum extending from 38 to 41cm with superficial ulceration within it. The esophagogastric junction was at 45cm and appeared tight, which was consistent with the appearance of achalasia. A subsequent barium swallow and manometric studies confirmed the endoscopic findings. A minimally invasive laparoscopic approach was adopted for trans-hiatal dissection and diverticulectomy. Heller’s myotomy combined with an anti-reflux procedure was also performed to deal with the underlying achalasia as the cause of this pulsion diverticulum. The patient’s postoperative recovery was uneventful with complete resolution of his symptoms.
WT Butt, M Arumugasamy
Surgical intervention
1 year ago
1142 views
60 likes
0 comments
08:19
Minimally invasive management of an epiphrenic diverticulum
We present the case of a 65-year-old gentleman who was referred to our department with long standing symptoms of dysphagia, reflux, and regurgitation. An esophagogastroduodenoscopy (EGD) was initially performed to evaluate his symptoms and showed food residue in the esophagus and a wide-necked epiphrenic diverticulum extending from 38 to 41cm with superficial ulceration within it. The esophagogastric junction was at 45cm and appeared tight, which was consistent with the appearance of achalasia. A subsequent barium swallow and manometric studies confirmed the endoscopic findings. A minimally invasive laparoscopic approach was adopted for trans-hiatal dissection and diverticulectomy. Heller’s myotomy combined with an anti-reflux procedure was also performed to deal with the underlying achalasia as the cause of this pulsion diverticulum. The patient’s postoperative recovery was uneventful with complete resolution of his symptoms.
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
1334 views
112 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 enucleation of a horseshoe-shaped leiomyoma of the distal esophagus
This is the case of a 17-year-old girl, complaining of weight loss and dysphagia. In the preoperative work-up, gastroscopy and endoscopic ultrasonography revealed a 3-4cm multilobulated submucosal mass. Computed tomography and MRI showed a distal esophageal mass of 4cm in diameter. Fine needle aspiration biopsy was compatible with a leiomyoma. The patient was admitted to hospital for surgery, and a laparoscopic transhiatal enucleation of the esophageal leiomyoma was performed. The patient was placed in a gynecologic position, with the surgeon standing between the patient’s legs. The first assistant stood on the right side of the patient and the second assistant on the left. The procedure was performed using 5 trocars. The phrenoesophageal membrane was divided. The distal esophagus was circumferentially mobilized. Dissection was started by separating the layer over the tumor. Blunt dissection was preferred. The use of energy devices discouraged to prevent any delayed mucosal burn injury. The leiomyoma was completely enucleated. Esophageal muscle layers were closed. The postoperative period was uneventful. This video demonstrates technical details of a laparoscopic enucleation of a hoseshoe-shaped leiomyoma of the distal esophagus.
K Karabulut, S Usta, E Sahin, Z Cetinkaya
Surgical intervention
1 year ago
615 views
43 likes
0 comments
11:21
Laparoscopic enucleation of a horseshoe-shaped leiomyoma of the distal esophagus
This is the case of a 17-year-old girl, complaining of weight loss and dysphagia. In the preoperative work-up, gastroscopy and endoscopic ultrasonography revealed a 3-4cm multilobulated submucosal mass. Computed tomography and MRI showed a distal esophageal mass of 4cm in diameter. Fine needle aspiration biopsy was compatible with a leiomyoma. The patient was admitted to hospital for surgery, and a laparoscopic transhiatal enucleation of the esophageal leiomyoma was performed. The patient was placed in a gynecologic position, with the surgeon standing between the patient’s legs. The first assistant stood on the right side of the patient and the second assistant on the left. The procedure was performed using 5 trocars. The phrenoesophageal membrane was divided. The distal esophagus was circumferentially mobilized. Dissection was started by separating the layer over the tumor. Blunt dissection was preferred. The use of energy devices discouraged to prevent any delayed mucosal burn injury. The leiomyoma was completely enucleated. Esophageal muscle layers were closed. The postoperative period was uneventful. This video demonstrates technical details of a laparoscopic enucleation of a hoseshoe-shaped leiomyoma of the distal esophagus.
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
957 views
33 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.
Laparoscopic Roux-en-Y gastric bypass redo after sleeve gastrectomy associated with intrathoracic sleeve migration
Sleeve gastrectomy is a standard procedure in bariatric surgery nowadays. However, common contraindications involve the presence of gastroesophageal reflux and hiatal hernia. Here, we present the case of a morbidly obese female patient with a past surgical history of a Nissen fundoplication reversed in 2012 because of dysphagia. A sleeve gastrectomy had been performed 2 years ago complicated by an intrathoracic migration and gastric twist as discovered in the preoperative control followed by dysphagia, reflux, and vomiting. A conversion to a Roux-en-Y gastric bypass has been decided upon.
L Marx, S Tzedakis, HA Mercoli, S Perretta, D Mutter, J Marescaux
Surgical intervention
4 years ago
1585 views
47 likes
1 comment
09:21
Laparoscopic Roux-en-Y gastric bypass redo after sleeve gastrectomy associated with intrathoracic sleeve migration
Sleeve gastrectomy is a standard procedure in bariatric surgery nowadays. However, common contraindications involve the presence of gastroesophageal reflux and hiatal hernia. Here, we present the case of a morbidly obese female patient with a past surgical history of a Nissen fundoplication reversed in 2012 because of dysphagia. A sleeve gastrectomy had been performed 2 years ago complicated by an intrathoracic migration and gastric twist as discovered in the preoperative control followed by dysphagia, reflux, and vomiting. A conversion to a Roux-en-Y gastric bypass has been decided upon.
Laparoscopic gastrostomy in a patient with esophageal squamous cell carcinoma
Percutaneous endoscopic gastrostomy (PEG) and self-expanding endoscopic prosthesis are considered to be the "gold standard" for patients with neurological or oncologic diseases, which do not allow feeding per os. When they fail, surgical gastrostomy is considered. Recent data suggest that the laparoscopic approach may be better regarding early complications as compared to PEG.
We present the case of an 81-year-old male patient diagnosed with squamous cell carcinoma of the esophagus. The patient presented with total dysphagia. The attempt of placing a self-expanding endoscopic prosthesis was unsuccessful. The patient was then proposed for the placement of a feeding laparoscopic gastrostomy. The postoperative period was uneventful and the patient was discharged on day two.
Surgical gastrostomy is associated with frequent complications, such as erythema, chronic suppuration, migration and complications associated with surgical access. Laparoscopic access and technical details of the procedure allowed to reduce such complications and to perform the main steps under direct visual control, making it very safe and easily reproducible.
A Gomes, D Luis, T Carneiro, C Veiga
Surgical intervention
3 years ago
1959 views
58 likes
0 comments
06:40
Laparoscopic gastrostomy in a patient with esophageal squamous cell carcinoma
Percutaneous endoscopic gastrostomy (PEG) and self-expanding endoscopic prosthesis are considered to be the "gold standard" for patients with neurological or oncologic diseases, which do not allow feeding per os. When they fail, surgical gastrostomy is considered. Recent data suggest that the laparoscopic approach may be better regarding early complications as compared to PEG.
We present the case of an 81-year-old male patient diagnosed with squamous cell carcinoma of the esophagus. The patient presented with total dysphagia. The attempt of placing a self-expanding endoscopic prosthesis was unsuccessful. The patient was then proposed for the placement of a feeding laparoscopic gastrostomy. The postoperative period was uneventful and the patient was discharged on day two.
Surgical gastrostomy is associated with frequent complications, such as erythema, chronic suppuration, migration and complications associated with surgical access. Laparoscopic access and technical details of the procedure allowed to reduce such complications and to perform the main steps under direct visual control, making it very safe and easily reproducible.