monthly focus

surgical intervention video

Résection intragastrique par laparoscopie assistée par endoscopie d'un cancer gastrique précoce

In the minimally invasive approach to a gastric pathology, the association of laparoscopy with endoscopy (also called hybrid or collaborative surgery) emerges as an advanced therapeutic option for the surgical treatment of both benign and malignant intragastric lesions in selected patients. 

We present the case of an elderly patient aged 86 with a serious medical history. She is endoscopically diagnosed with a gastric lesion located in the incisura angularis with a biopsy of high-grade dysplasia/carcinoma “in situ”. 

Given the patient's age and her medical history, the multidisciplinary committee decided to perform a minimally invasive surgery. Submucosal dissection of the lesion using a hybrid approach (intragastric endoscopy/laparoscopy) was proposed. 

The pathological area was marked and stained by endoscopy, followed by intragastric submucosal dissection with laparoscopic instruments assisted by means of endoscopy. 

The surgery went smoothly and the patient could be discharged 48 hours after surgery. 

Final pathological findings reported a well-differentiated tubular adenocarcinoma infiltrating the lamina propria and surgical resection margins free of tumor infiltration (pT1a Nx Mx (TNM 8th Ed. 2017)). 

Endoscopy-assisted laparoscopic intragastric resection of early gastric cancer

Endoscopic sleeve gastroplasty (ESG) is a novel endobariatric procedure with a mechanism of action totally different from the one used for a standard sleeve gastrectomy. An over-the-scope suturing system (OverStitch™, Apollo Endosurgery, Austin, TX) mounted on a dual-channel gastroscope (GIF- 2TH180, Olympus, Center Valley, PA) allowed to place full-thickness sutures in order to obtain gastric volume reduction and shrinking. The number of applied sutures relies on the gastric volume. Sutures are placed starting from the incisura to the fundus that is spared in a U-shaped fashion. A tissue-retracting helix device is used to grab the gastric wall. In this live educational video, Professor Silvana Perretta presented the case of a morbidly obese 38-year-old female patient with a BMI of 36.72kg/m2. 

The procedure was performed with the patient under general anesthesia and carbon dioxide insufflation. An Overtube™ (Apollo Endosurgery, Austin, TX) was placed at the beginning of the procedure to protect the airways, the esophagus, and the hypopharynx. Each purse-string suture consisted of 6 to 8 full-thickness bites starting first on the anterior gastric wall, then on the greater curvature, and the posterior wall and moving backward in the opposite direction. Once completed, the suture was tied and knotted using a cinching device (EndoCinch™). During the live procedure, a complication occurred due to an excessive pressure placed on the EndoCinch™ handle which caused a break of the collar part of the cinch. The management of this complication was achieved by cutting the suture, so that the collar part of the cinch which grasped the mucosa could be detached with a grasper to allow for suture replacement. A total of 4 sutures were applied in order to obtain gastric tubulization. 

Endoscopic sleeve gastroplasty (ESG): live educational procedure with resolution of device-related complication

Gastroplastie en manchon endoscopique :  procédure éducative en direct avec résolution des complications liées au dispositif

video lecture

Résection endoscopique : indications et techniques - Dissection sous-muqueuse endoscopique (ESD)

In this key lecture, Dr. Yahagi outlines indications and techniques of endoscopic resections, and more particularly focuses on endoscopisc submucosal dissection, providing recommendations for beginners.

Endoscopic resection: indications and techniques - Endoscopic Submucosal Dissection (ESD)

In this key lecture, Dr. Petruzziello outlines endoscopic resections, with their indications and techniques, and more specifically focuses on full-thickness resection (FTR) and hybrid techniques. 

Endoscopic resections, indications and techniques - Full-thickness resection (FTR) and hybrid techniques

Résections endoscopiques, indications et techniques - Résection de pleine épaisseur (FTR) et techniques hybrides

Les procédures que tout chirurgien devrait connaître : chirurgie POEM et autres techniques sous-muqueuses

In this key lecture, Dr. Lee Swanström looks into procedures surgeons should know, such as PerOral Endoscopic Myotomy (POEM) and other submucosal surgeries in the treatment of achalasia.

The procedures surgeons should know: POEM and other submucosal surgeries

Études de cas de scénarios chirurgicaux compliqués

In this short presentation, Professor Yen-I Chen, MD, expert in advanced endoscopy and pancreaticobiliary disease at McGill University (Montreal, Canada), introduces 3 video cases of complicated surgical scenarios which were managed endoscopically.

In the first video, he presents the case of a 58 year-old man with a previous history of pancreatic cancer (2016). The patient had had a pancreaticoduodenectomy (Whipple procedure). After 2 years, the patient presented cancer recurrence with septic cholangitis due to gastrojejunostomy obstruction (closed loop obstruction of the afferent limb and also loop obstruction of the efferent limb). 

In the second video, Prof. Chen looks into what can go wrong during endoscopic ultrasound-guided gastrojejunostomy. Previous stent systems required dilatations prior to stent deployment, and here, the video presents a case scenario in which the stent was displaced causing gastric perforation in the abdominal cavity. This complication was managed using a NOTES procedure. 

In the third video, he reports the case of a patient with a previous obstructed duodenal stent which required an endoscopic ultrasound-guided gastrojejunostomy using the Axios stent.

Case studies of complicated surgical scenarios

Dissection endoscopique sous-muqueuse (ESD) du rectum pour grande lésion polypoïde rectale : une procédure éducative en direct 

Endoscopic Submucosal Dissection (ESD) is an endoscopic technique which allows ‘en bloc’ resection of early stage tumors and polyps in the gastrointestinal tract. In this case, Professor Yahagi presents the case of a 67-year-old male patient with an incidental finding of a large rectal polyp during an MRI study. Colonoscopy revealed a 5cm laterally spreading tumor granular type (LST-G) of the rectum, extending to one fourth of the rectal circumference. The ESD was performed with a dual channel gastroscope in retrovision due to the proximity of the LST-G to the anal verge. Glycerol and indigo carmine were injected into the submucosal plane to lift the target lesion. The mucosal incision followed by submucosal dissection was performed with a 1.5mm DualKnife™ (Olympus) using a swift coag electrosurgical setting. Hemostasis of large vessels was performed switching to the forced coag effect. The vascular submucosal network has been carefully assessed. All critical steps are evaluated during the procedure. 

Endoscopic Submucosal Dissection (ESD) of the rectum for a large rectal polypoid lesion: a live educational procedure 

Cholangiopancréatographie rétrograde endoscopique (CPRE) pour extraction de calculs de la voie biliaire principale : une procédure didactique en direct

Dr. Gianfranco Donatelli presents the live case of common bile duct stone extraction in a clinical context of an episode of acute cholangitis and cholecystitis. On CT-scan, a distal common bile duct (CBD) stone was diagnosed with dilatation of the biliary tree. Due to anticoagulation therapy, sphincterotomy could not be immediately performed, and biliary drainage was ensured by means of an initial plastic stent placement prior to the present elective ERCP and stone extraction. Cholecystectomy is to be performed thereafter.

Focus on flexible endoluminal surgery