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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
2 years ago
678 views
44 likes
2 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.
Laparoscopic transhiatal resection of horseshoe-shaped leiomyoma of the thoracic esophagus
This is the case of a 36-year-old woman with symptoms which have been present for 18 months. Her main symptoms were the following: difficulty to swallow food accompanied by retrosternal discomfort. Upper endoscopy performed on September 29, 2011 found an extrinsic compression of the esophageal wall located 28cm away from the upper dental arcade with a mucosa which appeared to be normal. That extrinsic compression goes until 33cm from the upper dental arcade. The patient was evaluated by a gastroenterologist who performed an echo-endoscopy on March 7, 2012. The gastroenterologist observed a heterogeneous hypo-echoic mass coming from the muscular layer, 25 to 33cm away from the esophagus. The diagnosis of esophageal leiomyoma was established. The patient was admitted to hospital for surgery, and a laparoscopic transhiatal resection of the esophageal leiomyoma was performed on May 22, 2012.
This case is essential because it shows the excision of a horseshoe-shaped leiomyoma of the thoracic esophagus. In addition, it shows a transfixing stitch, which is performed to exert traction on the tumor.
DU Castro Nuñez
Surgical intervention
5 years ago
771 views
4 likes
0 comments
10:18
Laparoscopic transhiatal resection of horseshoe-shaped leiomyoma of the thoracic esophagus
This is the case of a 36-year-old woman with symptoms which have been present for 18 months. Her main symptoms were the following: difficulty to swallow food accompanied by retrosternal discomfort. Upper endoscopy performed on September 29, 2011 found an extrinsic compression of the esophageal wall located 28cm away from the upper dental arcade with a mucosa which appeared to be normal. That extrinsic compression goes until 33cm from the upper dental arcade. The patient was evaluated by a gastroenterologist who performed an echo-endoscopy on March 7, 2012. The gastroenterologist observed a heterogeneous hypo-echoic mass coming from the muscular layer, 25 to 33cm away from the esophagus. The diagnosis of esophageal leiomyoma was established. The patient was admitted to hospital for surgery, and a laparoscopic transhiatal resection of the esophageal leiomyoma was performed on May 22, 2012.
This case is essential because it shows the excision of a horseshoe-shaped leiomyoma of the thoracic esophagus. In addition, it shows a transfixing stitch, which is performed to exert traction on the tumor.
LIVE INTERACTIVE SURGERY: Barrett's esophagus treatment using BARRX™ radiofrequency ablation (RFA) system
Barrett’s esophagus is a metaplastic change in the lining mucosa of the esophagus in response to chronic GERD. The hallmark of specialized Barrett’s epithelium is mucus-secreting goblet cells (intestinal metaplasia). There is an increased risk of adenocarcinoma with intestinal metaplasia. BARRX™ is a new treatment option for Barrett’s esophagus which uses Radio frequency energy and minimizes the risk of developing cancer.
Radio frequency energy is delivered via a catheter to the esophagus, lasts less than a second and creates superficial injury to the mucosa.
Principle: To deliver high power (approx. 300 Watts) in a short period of time. This will allow the depth of penetration to ablate the epithelium and the muscularis mucosa without injuring the submucosa. Overall results are excellent with elimination of dysplasia in 80% of patients and stricture rate to less than 6%.
Side effects: chest pain following the procedure, which can be treated with analgesics.
Bleeding, infection, and perforation requiring surgery are some of the rare complications.
Follow-up: endoscopy at 3 months and ablation repeated if required.
LL Swanström, V Wong
Surgical intervention
4 years ago
389 views
14 likes
0 comments
11:15
LIVE INTERACTIVE SURGERY: Barrett's esophagus treatment using BARRX™ radiofrequency ablation (RFA) system
Barrett’s esophagus is a metaplastic change in the lining mucosa of the esophagus in response to chronic GERD. The hallmark of specialized Barrett’s epithelium is mucus-secreting goblet cells (intestinal metaplasia). There is an increased risk of adenocarcinoma with intestinal metaplasia. BARRX™ is a new treatment option for Barrett’s esophagus which uses Radio frequency energy and minimizes the risk of developing cancer.
Radio frequency energy is delivered via a catheter to the esophagus, lasts less than a second and creates superficial injury to the mucosa.
Principle: To deliver high power (approx. 300 Watts) in a short period of time. This will allow the depth of penetration to ablate the epithelium and the muscularis mucosa without injuring the submucosa. Overall results are excellent with elimination of dysplasia in 80% of patients and stricture rate to less than 6%.
Side effects: chest pain following the procedure, which can be treated with analgesics.
Bleeding, infection, and perforation requiring surgery are some of the rare complications.
Follow-up: endoscopy at 3 months and ablation repeated if required.
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
8 years ago
3372 views
74 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.
Thoracoscopic enucleation of a middle esophagus leiomyoma
Leiomyoma is the most frequent esophageal benign tumor. It represents 70% of these tumors and 1 to 8% of all esophageal tumors. The most frequent location is the distal esophagus. The majority of cases are asymptomatic and are discovered by chance in endoscopic or radiologic examinations. An endoscopic or surgical treatment can be applied in symptomatic cases (mainly dysphagia), basically depending on its size.
We present a thoracoscopic enucleation of a milddle esophagus leiomyoma in a 41-year-old woman. The operation was performed using a thoracoscopic approach. The patient was placed in a prone decubitus position. The tumor was enucleated by myotomy with subsequent suturing of the muscular gap through three trocars. There were no complications. After 48 hours postoperatively, a water-soluble contrast gastroduodenal study revealed normal passage through the esophageal lumen. The pathologist's diagnosis was esophageal leiomyoma.
F Ochando Cerdan, JM Fernandez Cebrian, L Vega Lopez
Surgical intervention
6 years ago
1315 views
19 likes
0 comments
16:15
Thoracoscopic enucleation of a middle esophagus leiomyoma
Leiomyoma is the most frequent esophageal benign tumor. It represents 70% of these tumors and 1 to 8% of all esophageal tumors. The most frequent location is the distal esophagus. The majority of cases are asymptomatic and are discovered by chance in endoscopic or radiologic examinations. An endoscopic or surgical treatment can be applied in symptomatic cases (mainly dysphagia), basically depending on its size.
We present a thoracoscopic enucleation of a milddle esophagus leiomyoma in a 41-year-old woman. The operation was performed using a thoracoscopic approach. The patient was placed in a prone decubitus position. The tumor was enucleated by myotomy with subsequent suturing of the muscular gap through three trocars. There were no complications. After 48 hours postoperatively, a water-soluble contrast gastroduodenal study revealed normal passage through the esophageal lumen. The pathologist's diagnosis was esophageal leiomyoma.
Collis Nissen fundoplication in a patient with Barrett's esophagus
This video demonstrates a laparoscopic Collis esophageal lengthening procedure in a 65-year-old man with a 15-year history of typical GERD symptoms and Barrett’s esophagus. The identification and surgical management of the short esophagus are discussed as well as the technical steps required for a Collis gastroplasty. Given that the most common mode of failure of a laparoscopic Nissen fundoplication is herniation of the fundoplication into the chest, as our experience increases, we recognize that reduction of the gastroesophageal junction below the diaphragmatic hiatus without tension is problematic and foreshortening of the esophagus is a real entity. Patients who have Barrett’s esophagus must be considered at risk for having a short esophagus.
B Dallemagne, S Perretta, J Marescaux
Surgical intervention
9 years ago
3695 views
89 likes
2 comments
17:25
Collis Nissen fundoplication in a patient with Barrett's esophagus
This video demonstrates a laparoscopic Collis esophageal lengthening procedure in a 65-year-old man with a 15-year history of typical GERD symptoms and Barrett’s esophagus. The identification and surgical management of the short esophagus are discussed as well as the technical steps required for a Collis gastroplasty. Given that the most common mode of failure of a laparoscopic Nissen fundoplication is herniation of the fundoplication into the chest, as our experience increases, we recognize that reduction of the gastroesophageal junction below the diaphragmatic hiatus without tension is problematic and foreshortening of the esophagus is a real entity. Patients who have Barrett’s esophagus must be considered at risk for having a short esophagus.
Laparoscopic transhiatal esophagectomy for adenocarcinoma of the lower esophagus
Conventional esophagectomy requires either a laparotomy with a transhiatal dissection or a laparotomy combined with thoracotomy and it is associated with significant morbidity and mortality. In the attempt to decrease morbidity, some surgeons have reported the application of minimally invasive technique of resection of the esophagus. De Paula was the first to report a large series of 48 patients undergoing a total laparoscopic transhiatal esophagectomy (LTH). LTH may be used to treat patients with either benign or malignant esophageal disease because the reconstructive result cervical esophagogastric anastomosis yields good functional outcomes. Here we show the case of a LTH for adenocarcinoma of the lower esophagus.
B Dallemagne, S Perretta, J Marescaux
Surgical intervention
10 years ago
5855 views
163 likes
0 comments
21:14
Laparoscopic transhiatal esophagectomy for adenocarcinoma of the lower esophagus
Conventional esophagectomy requires either a laparotomy with a transhiatal dissection or a laparotomy combined with thoracotomy and it is associated with significant morbidity and mortality. In the attempt to decrease morbidity, some surgeons have reported the application of minimally invasive technique of resection of the esophagus. De Paula was the first to report a large series of 48 patients undergoing a total laparoscopic transhiatal esophagectomy (LTH). LTH may be used to treat patients with either benign or malignant esophageal disease because the reconstructive result cervical esophagogastric anastomosis yields good functional outcomes. Here we show the case of a LTH for adenocarcinoma of the lower esophagus.
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
10 months ago
8352 views
35 likes
4 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.
Proximal gastrectomy with stapled circular esophagogastrostomy: manual purse-string technique
Early tumors of the esophagogastric junction can be managed with a minimally invasive proximal gastrectomy. This operation has recently been reevaluated for early-stage tumors since it offers a good postoperative quality of life with oncological outcomes equivalent to more extended procedures. In this video, we present the case of a 72-year-old man presenting with a 2cm adenocarcinoma of the esophagogastric junction. The clinical stage of the lesion was T1N0. A laparoscopic proximal gastrectomy with stapled circular esophagogastrostomy was decided upon. Five ports were placed. The left trocar incision was enlarged to introduce the circular stapler for the anastomoses and for specimen extraction. The procedure began with a complete abdominal exploration to rule out peritoneal metastases. The gastrocolic and gastrosplenic ligaments were divided with an ultrasonic scalpel. Short splenic vessels were clipped and divided and the greater curvature completely isolated with careful preservation of the gastroepiploic arcade and of the right gastroepiploic artery and vein. Left gastric vessels were divided at their origin with a vascular stapler and the distal esophagus was isolated through the diaphragmatic hiatus. A gastric tube was created with multiple applications of a linear stapler. The anvil of the circular stapler was secured to the esophageal stump with a hand-sewn purse-string suture in order to avoid the overlap of two suture lines. The esophagogastric anastomosis was then achieved with a circular stapler.
C Battiston, D Citterio, L Conti, M Virdis, V Mazzaferro
Surgical intervention
6 months ago
1062 views
19 likes
3 comments
11:43
Proximal gastrectomy with stapled circular esophagogastrostomy: manual purse-string technique
Early tumors of the esophagogastric junction can be managed with a minimally invasive proximal gastrectomy. This operation has recently been reevaluated for early-stage tumors since it offers a good postoperative quality of life with oncological outcomes equivalent to more extended procedures. In this video, we present the case of a 72-year-old man presenting with a 2cm adenocarcinoma of the esophagogastric junction. The clinical stage of the lesion was T1N0. A laparoscopic proximal gastrectomy with stapled circular esophagogastrostomy was decided upon. Five ports were placed. The left trocar incision was enlarged to introduce the circular stapler for the anastomoses and for specimen extraction. The procedure began with a complete abdominal exploration to rule out peritoneal metastases. The gastrocolic and gastrosplenic ligaments were divided with an ultrasonic scalpel. Short splenic vessels were clipped and divided and the greater curvature completely isolated with careful preservation of the gastroepiploic arcade and of the right gastroepiploic artery and vein. Left gastric vessels were divided at their origin with a vascular stapler and the distal esophagus was isolated through the diaphragmatic hiatus. A gastric tube was created with multiple applications of a linear stapler. The anvil of the circular stapler was secured to the esophageal stump with a hand-sewn purse-string suture in order to avoid the overlap of two suture lines. The esophagogastric anastomosis was then achieved with a circular stapler.
Minimally invasive surgery for esophagectomy and tubularized gastric pull-up
The accidental ingestion of caustic agents is a common problem in pediatric emergency units. These agents can cause a series of damage to the upper gastrointestinal tract and can lead to an esophageal stricture. We present the case of a 4-year-old girl who was referred to our hospital for vomiting and hematemesis after ingesting a caustic solution. Physical examination revealed tongue edema and denuded buccal mucosa. Friable mucosa and esophageal ulceration were observed in the endoscopy. The patient was administered omeprazole and a nasogastric tube was placed for a week. Two esophageal strictures were observed after 3 weeks of the ingestion. The patient underwent esophageal dilatation once or twice a month during 21 months depending on the symptoms. Due to the refractory stricture, we decided to perform an esophagectomy and tubularized gastric pull-up by combining thoracoscopy, laparoscopy, and cervicotomy. In addition, we performed a jejunostomy to provide sufficient nutritional support. The patient started feeding on postoperative day 7 and she is currently asymptomatic.
I Cano Novillo, A García Vázquez, F de la Cruz Vigo, B Aneiros Castro
Surgical intervention
11 months ago
1451 views
6 likes
2 comments
12:40
Minimally invasive surgery for esophagectomy and tubularized gastric pull-up
The accidental ingestion of caustic agents is a common problem in pediatric emergency units. These agents can cause a series of damage to the upper gastrointestinal tract and can lead to an esophageal stricture. We present the case of a 4-year-old girl who was referred to our hospital for vomiting and hematemesis after ingesting a caustic solution. Physical examination revealed tongue edema and denuded buccal mucosa. Friable mucosa and esophageal ulceration were observed in the endoscopy. The patient was administered omeprazole and a nasogastric tube was placed for a week. Two esophageal strictures were observed after 3 weeks of the ingestion. The patient underwent esophageal dilatation once or twice a month during 21 months depending on the symptoms. Due to the refractory stricture, we decided to perform an esophagectomy and tubularized gastric pull-up by combining thoracoscopy, laparoscopy, and cervicotomy. In addition, we performed a jejunostomy to provide sufficient nutritional support. The patient started feeding on postoperative day 7 and she is currently asymptomatic.