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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
1 year ago
612 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.
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
4 years ago
755 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
3 years ago
377 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
7 years ago
3327 views
73 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
5 years ago
1277 views
16 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
8 years ago
3569 views
87 likes
0 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.
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
1 day ago
135 views
3 likes
1 comment
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.
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
1 month ago
311 views
3 likes
1 comment
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.
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
1 day ago
40 views
1 like
0 comments
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.
Esophagectomy : Thoracoscopic or robotic?
For esophageal cancer patients, radical esophagolymphadenectomy is the cornerstone of multimodality therapy with a curative intent. However, the percentage of cardiopulmonary complications associated with the transthoracic approach is high. Recent studies have shown that robot-assisted minimally invasive thoraco-laparoscopic esophagectomy (RATE) is at least equivalent to the open transthoracic approach for esophageal cancer in terms of short-term oncological outcomes. In this authoritative lecture, Dr. YK Chao, MD, PhD, presents a comparison between techniques, goes through a review of the literature and provides a single surgeon’s experience with the use of the robot in the management of this disease.
YK Chao
Lecture
5 months ago
94 views
0 likes
0 comments
19:50
Esophagectomy : Thoracoscopic or robotic?
For esophageal cancer patients, radical esophagolymphadenectomy is the cornerstone of multimodality therapy with a curative intent. However, the percentage of cardiopulmonary complications associated with the transthoracic approach is high. Recent studies have shown that robot-assisted minimally invasive thoraco-laparoscopic esophagectomy (RATE) is at least equivalent to the open transthoracic approach for esophageal cancer in terms of short-term oncological outcomes. In this authoritative lecture, Dr. YK Chao, MD, PhD, presents a comparison between techniques, goes through a review of the literature and provides a single surgeon’s experience with the use of the robot in the management of this disease.
Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy
The standard curative treatment for patients with esophageal cancer is perioperative chemotherapy or preoperative chemoradiotherapy followed by open transthoracic esophagectomy (OTE). However, robot-assisted minimally invasive thoracolaparoscopic esophagectomy (RAMIE) resulted in a lower percentage of overall surgery-related and cardiopulmonary complications with lower postoperative pain, better short-term quality of life, and a better short-term postoperative functional recovery as compared to OTE. In this authoritative lecture, Dr. JP Ruurda, MD, PhD addresses his team experience with RAMIE since 2003. He goes through a review of the literature and presents a clinical case describing the operative steps of the robot-assisted minimally invasive thoracolaparoscopic esophagectomy.
JP Ruurda
Lecture
5 months ago
271 views
2 likes
0 comments
26:15
Robot-assisted minimally invasive thoraco-laparoscopic esophagectomy
The standard curative treatment for patients with esophageal cancer is perioperative chemotherapy or preoperative chemoradiotherapy followed by open transthoracic esophagectomy (OTE). However, robot-assisted minimally invasive thoracolaparoscopic esophagectomy (RAMIE) resulted in a lower percentage of overall surgery-related and cardiopulmonary complications with lower postoperative pain, better short-term quality of life, and a better short-term postoperative functional recovery as compared to OTE. In this authoritative lecture, Dr. JP Ruurda, MD, PhD addresses his team experience with RAMIE since 2003. He goes through a review of the literature and presents a clinical case describing the operative steps of the robot-assisted minimally invasive thoracolaparoscopic esophagectomy.
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
9 years ago
5613 views
161 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.
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
1437 views
6 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.
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
3311 views
288 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.
Laparoscopic excision of a horseshoe-shaped leiomyoma of the lower esophagus
Esophageal leiomyomas are approximately 50 times less common than carcinomas, but they represent 80% of benign tumors of the lower esophagus.
An esophageal leiomyoma can be enucleated safely and effectively through minimally invasive surgery. The laparoscopic approach is a conventional option for this kind of tumor (located near or at the esophagogastric (EG) junction). Laparoscopic transhiatal enucleation is a safe and feasible procedure. This video demonstrates all the technical details of a laparoscopic excision of a large horseshoe-shaped leiomyoma of the lower esophagus. A conventional port placement is used to approach the hiatal region.
B Dallemagne, J Marescaux
Surgical intervention
10 years ago
762 views
14 likes
0 comments
13:18
Laparoscopic excision of a horseshoe-shaped leiomyoma of the lower esophagus
Esophageal leiomyomas are approximately 50 times less common than carcinomas, but they represent 80% of benign tumors of the lower esophagus.
An esophageal leiomyoma can be enucleated safely and effectively through minimally invasive surgery. The laparoscopic approach is a conventional option for this kind of tumor (located near or at the esophagogastric (EG) junction). Laparoscopic transhiatal enucleation is a safe and feasible procedure. This video demonstrates all the technical details of a laparoscopic excision of a large horseshoe-shaped leiomyoma of the lower esophagus. A conventional port placement is used to approach the hiatal region.
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
1133 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
1298 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.