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Gianfranco DONATELLI

MD
Hôpital Privé des Peupliers
Paris, France
60 vidéos
100.7K vues
13 commentaires
2K J'aime
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Endoscopic internal drainage of gastric fistula after sleeve gastrectomy
Gastric fistula is a major adverse event after sleeve gastrectomy.
In this live instructional video, authors present the case of a 45-year-old woman with a complex postoperative course after sleeve gastrectomy due to a gastric leakage and a twisted stomach. The patient had already been managed with the endoscopic placement of a fully covered metal stent and a percutaneous drainage with no resolution of the fistula.
The first step of the procedure consists in the removal of a 16cm fully covered stent using a grasper. After contrast injection, the leakage and the gastric twist are visualized. Under fluoroscopic control, a 30mm pneumatic dilatation of the twist is obtained. Two double pigtail plastic stents are placed between the stomach and the abscess cavity in order to achieve internal drainage and facilitate the healing process. The percutaneous drainage will be removed one day after the procedure while the plastic stents will be removed after 3 months.
Vidéo chirurgicale
Il y a 1 an
992 vues
6 J'aime
0 commentaire
14:45
Endoscopic internal drainage of gastric fistula after sleeve gastrectomy
Gastric fistula is a major adverse event after sleeve gastrectomy.
In this live instructional video, authors present the case of a 45-year-old woman with a complex postoperative course after sleeve gastrectomy due to a gastric leakage and a twisted stomach. The patient had already been managed with the endoscopic placement of a fully covered metal stent and a percutaneous drainage with no resolution of the fistula.
The first step of the procedure consists in the removal of a 16cm fully covered stent using a grasper. After contrast injection, the leakage and the gastric twist are visualized. Under fluoroscopic control, a 30mm pneumatic dilatation of the twist is obtained. Two double pigtail plastic stents are placed between the stomach and the abscess cavity in order to achieve internal drainage and facilitate the healing process. The percutaneous drainage will be removed one day after the procedure while the plastic stents will be removed after 3 months.
ERCP in a patient with previous subtotal gastrectomy for cancer: hybrid approach with transjejunal access
Endoscopic retrograde cholangiopancreatography (ERCP) in patients with prior gastric surgery (Roux-en-Y gastric bypass, partial or subtotal gastrectomy) is a challenging procedure. Despite technological advances in endoscopy, reaching the duodenum and entering the bile duct remains difficult. Laparoscopic assisted ERCP (LAERCP) allows the duodenum to be accessed through the excluded stomach in case of previous RYGB or through the proximal jejunum in case of gastric resection. The objective of this video is to demonstrate the hybrid approach in a patient with a previous subtotal gastrectomy for gastric cancer.
Vidéo chirurgicale
Il y a 1 an
223 vues
4 J'aime
0 commentaire
12:02
ERCP in a patient with previous subtotal gastrectomy for cancer: hybrid approach with transjejunal access
Endoscopic retrograde cholangiopancreatography (ERCP) in patients with prior gastric surgery (Roux-en-Y gastric bypass, partial or subtotal gastrectomy) is a challenging procedure. Despite technological advances in endoscopy, reaching the duodenum and entering the bile duct remains difficult. Laparoscopic assisted ERCP (LAERCP) allows the duodenum to be accessed through the excluded stomach in case of previous RYGB or through the proximal jejunum in case of gastric resection. The objective of this video is to demonstrate the hybrid approach in a patient with a previous subtotal gastrectomy for gastric cancer.
EUS gastrojejunal anastomosis with HOT AXIOS® stent after Whipple pancreatectomy, filling blind loop through percutaneous transhepatic biliary drainage
A 67-year-old woman underwent a Whipple pancreatectomy for cancer one year earlier. She was readmitted to hospital for abdominal pain and subocclusion with jaundice. CT-scan showed a dilatation of the jejunal stump with associated biliary tree dilatation. Percutaneous biliary transhepatic drainage (PBTHD) was performed and a stenosis was diagnosed in the afferent loop, accountable for subocclusion and secondary jaundice. Two double pigtails were delivered by the interventional radiologist through PBTHD across the jejunal stricture without resolution of symptoms. Biliary drainage was left in place causing patient discomfort. EUS gastrojejunal anastomosis (GJA) using the HOT AXIOS® stent was attempted in order to bypass the stricture. EUS allows to find the jejunal stump, detected by mechanical staple line visualization. Additionally, the blind loop was detected as it was filled up with liquid and contrast through the PBTHD. The HOT AXIOS® stent was delivered without any complications (VIDEO). Afterwards, flow of bile and liquid was observed through the lumen-apposing metal stent (LAMS). PBTHD was immediately removed. Recovery was uneventful and the patient was discharged on a normal diet with no pain on the following day. EUS-GJA via a LAMS is a well-described technique in experts’ hands (Technical review of endoscopic ultrasonography-guided gastroenterostomy in 2017. Itoi T, Baron TH, Khashab MA, et al. Dig Endosc 2017;29:495-502). Special skills and techniques are necessary in order to recognize the exact small bowel loop to puncture (Endoscopic ultrasound-guided gastrojejunostomy with a lumen-apposing metal stent: a multicenter, international experience. Tyberg A, Perez-Miranda M, Sanchez-Ocaña R et al. Endosc Int Open 2016;4:E276-81). In that case, we show that filling this loop using a previous transhepatic access should be considered an alternative in case of alterated anatomy. Also direct EUS transgastric injection of contrast medium in the dilated biliary tree to fill up the jejunal stump could be considered an option to perform GJA by a single operator in a single session after safely recognizing the right loop. In addition, fluoroscopy helps to detect the exact loop puncture site. In conclusion, GJA using a LAMS is feasible, safe and useful, and transhepatic injection of liquid and contrast medium helps to adequately recognize the jejunal stump after biliopancreatic surgery.
Vidéo chirurgicale
Il y a 1 an
243 vues
3 J'aime
0 commentaire
02:30
EUS gastrojejunal anastomosis with HOT AXIOS® stent after Whipple pancreatectomy, filling blind loop through percutaneous transhepatic biliary drainage
A 67-year-old woman underwent a Whipple pancreatectomy for cancer one year earlier. She was readmitted to hospital for abdominal pain and subocclusion with jaundice. CT-scan showed a dilatation of the jejunal stump with associated biliary tree dilatation. Percutaneous biliary transhepatic drainage (PBTHD) was performed and a stenosis was diagnosed in the afferent loop, accountable for subocclusion and secondary jaundice. Two double pigtails were delivered by the interventional radiologist through PBTHD across the jejunal stricture without resolution of symptoms. Biliary drainage was left in place causing patient discomfort. EUS gastrojejunal anastomosis (GJA) using the HOT AXIOS® stent was attempted in order to bypass the stricture. EUS allows to find the jejunal stump, detected by mechanical staple line visualization. Additionally, the blind loop was detected as it was filled up with liquid and contrast through the PBTHD. The HOT AXIOS® stent was delivered without any complications (VIDEO). Afterwards, flow of bile and liquid was observed through the lumen-apposing metal stent (LAMS). PBTHD was immediately removed. Recovery was uneventful and the patient was discharged on a normal diet with no pain on the following day. EUS-GJA via a LAMS is a well-described technique in experts’ hands (Technical review of endoscopic ultrasonography-guided gastroenterostomy in 2017. Itoi T, Baron TH, Khashab MA, et al. Dig Endosc 2017;29:495-502). Special skills and techniques are necessary in order to recognize the exact small bowel loop to puncture (Endoscopic ultrasound-guided gastrojejunostomy with a lumen-apposing metal stent: a multicenter, international experience. Tyberg A, Perez-Miranda M, Sanchez-Ocaña R et al. Endosc Int Open 2016;4:E276-81). In that case, we show that filling this loop using a previous transhepatic access should be considered an alternative in case of alterated anatomy. Also direct EUS transgastric injection of contrast medium in the dilated biliary tree to fill up the jejunal stump could be considered an option to perform GJA by a single operator in a single session after safely recognizing the right loop. In addition, fluoroscopy helps to detect the exact loop puncture site. In conclusion, GJA using a LAMS is feasible, safe and useful, and transhepatic injection of liquid and contrast medium helps to adequately recognize the jejunal stump after biliopancreatic surgery.
Large intradiverticulum endoscopic biliary sphincterotomy
Periampullary duodenal diverticula are observed in 10-20% of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and could well increase ampulla cannulation failure risk, as well as potential complications related to endoscopic sphincterotomy.
Here we report two successful cases of large intradiverticular endoscopic biliary sphincterotomy in the treatment of two different kinds of benign biliary pathologies. The first case was that of a woman with multiple large stones in the common bile duct (CBD). The second case was one of a male patient with cholestasis due to a compression of the distal common bile duct caused by a diverticulum – this condition being known as Lemmel’s syndrome.
Vidéo chirurgicale
Il y a 3 ans
1386 vues
77 J'aime
0 commentaire
05:09
Large intradiverticulum endoscopic biliary sphincterotomy
Periampullary duodenal diverticula are observed in 10-20% of patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and could well increase ampulla cannulation failure risk, as well as potential complications related to endoscopic sphincterotomy.
Here we report two successful cases of large intradiverticular endoscopic biliary sphincterotomy in the treatment of two different kinds of benign biliary pathologies. The first case was that of a woman with multiple large stones in the common bile duct (CBD). The second case was one of a male patient with cholestasis due to a compression of the distal common bile duct caused by a diverticulum – this condition being known as Lemmel’s syndrome.
Successful closure of iatrogenic colonic perforation with Over-The-Scope Clip™ system (OVESCO™) after failed attempt with standard endoscopic clips
Iatrogenic colonic perforation is a rare complication which has been reported in 0.03%-0.8% of cases during diagnostic colonoscopy. The sigmoid colon and the rectosigmoid junction are the most common sites of perforation during diagnostic examination. Successful endoscopic closure of the defect has been reported using standard clips. However, in case of large defects, standard clips are often ineffective. OTSC™ clips are devices which are successfully used to close wall defects up to 25mm. They make it possible to continue the endoscopic procedure after wall defect closure. In this video, we show the successful closure of a sigmoid colonic iatrogenic perforation in a 50-year-old woman by means of the Over The Scope Clip™ system (OVESCO® Endoscopy, Germany) (11/6 t) after failed attempt with standard clips. OVESCO™ was applied with a standard gastroscope using the suction technique by pushing the cap against the edges of the defect. In order to prevent incarceration of adjacent structures a soft aspiration of the omentum was applied and the OVESCO™ was carefully deployed. Carbon dioxide insufflation was used. Antibiotic therapy was started and the patient was discharged 5 days later. In conclusion, the Over The Scope Clip™ (OTSC™) is a safe surgery-sparing tool which allows for a successful iatrogenic perforation closure of the GI tract, performing omentoplasty by means of a suction technique.
Vidéo chirurgicale
Il y a 4 ans
1399 vues
31 J'aime
0 commentaire
02:28
Successful closure of iatrogenic colonic perforation with Over-The-Scope Clip™ system (OVESCO™) after failed attempt with standard endoscopic clips
Iatrogenic colonic perforation is a rare complication which has been reported in 0.03%-0.8% of cases during diagnostic colonoscopy. The sigmoid colon and the rectosigmoid junction are the most common sites of perforation during diagnostic examination. Successful endoscopic closure of the defect has been reported using standard clips. However, in case of large defects, standard clips are often ineffective. OTSC™ clips are devices which are successfully used to close wall defects up to 25mm. They make it possible to continue the endoscopic procedure after wall defect closure. In this video, we show the successful closure of a sigmoid colonic iatrogenic perforation in a 50-year-old woman by means of the Over The Scope Clip™ system (OVESCO® Endoscopy, Germany) (11/6 t) after failed attempt with standard clips. OVESCO™ was applied with a standard gastroscope using the suction technique by pushing the cap against the edges of the defect. In order to prevent incarceration of adjacent structures a soft aspiration of the omentum was applied and the OVESCO™ was carefully deployed. Carbon dioxide insufflation was used. Antibiotic therapy was started and the patient was discharged 5 days later. In conclusion, the Over The Scope Clip™ (OTSC™) is a safe surgery-sparing tool which allows for a successful iatrogenic perforation closure of the GI tract, performing omentoplasty by means of a suction technique.
Diagnosis and treatment of symptomatic common bile duct stones following cholecystectomy by means of EUS and ERCP
A post-cholecystectomy syndrome is a well-known condition, which includes dyspepsia and biliary-like abdominal pain coupled with deterioration of liver enzymes. Biliary factors responsible for a post-cholecystectomy syndrome could be the following: biliary iatrogenic duct strictures, retained stones in the common bile duct (CBD), cystic stump, or even a gallbladder remnant.
The diagnosis of stones is difficult to establish considering that even trans-abdominal ultrasonography has a diagnostic sensitivity of only 27%. Conversely, endoscopic ultrasound (EUS) is a very useful tool to diagnose stones in such situations, allowing to perform subsequent ERCP and stone extraction during the same anesthetic session. Here, we report the case of a 69-year-old man who underwent laparoscopic cholecystectomy and who was referred to us after 24 hours of abdominal colic pain and cholestasis. He underwent EUS, which diagnosed residual common bile duct stones. As a result, treatment was performed by means of ERCP during the same session.
Vidéo chirurgicale
Il y a 5 ans
1617 vues
62 J'aime
0 commentaire
03:26
Diagnosis and treatment of symptomatic common bile duct stones following cholecystectomy by means of EUS and ERCP
A post-cholecystectomy syndrome is a well-known condition, which includes dyspepsia and biliary-like abdominal pain coupled with deterioration of liver enzymes. Biliary factors responsible for a post-cholecystectomy syndrome could be the following: biliary iatrogenic duct strictures, retained stones in the common bile duct (CBD), cystic stump, or even a gallbladder remnant.
The diagnosis of stones is difficult to establish considering that even trans-abdominal ultrasonography has a diagnostic sensitivity of only 27%. Conversely, endoscopic ultrasound (EUS) is a very useful tool to diagnose stones in such situations, allowing to perform subsequent ERCP and stone extraction during the same anesthetic session. Here, we report the case of a 69-year-old man who underwent laparoscopic cholecystectomy and who was referred to us after 24 hours of abdominal colic pain and cholestasis. He underwent EUS, which diagnosed residual common bile duct stones. As a result, treatment was performed by means of ERCP during the same session.
Endoscopic biliary stones extraction using a forward viewing standard gastroscope in a patient with altered anatomy (partial gastrectomy with Billroth II reconstruction)
Endoscopic retrograde cholangiography in case of altered anatomy such as partial gastrectomy with Billroth II reconstruction has a success rate of 85% due to different factors such as failure to cross the anastomosis and the presence of an important length of afferent loop with a high risk of jejunal perforation at (or near) the anastomotic site while advancing the duodenoscope. The use of a front-view scope is the safest and could be used theoretically. However, the lack of elevator, the inability to see the papilla in a direct view, and the limited number of catheters available for cannulation and therapeutic procedures in the standard gastroscope with the 2.8mm working channel, can make this kind of procedure quite challenging. In this video, we present a case of successful biliary stone extraction in a patient with Billroth II reconstruction using a standard 2.8mm working channel front-viewing scope.
Vidéo chirurgicale
Il y a 5 ans
921 vues
14 J'aime
0 commentaire
04:47
Endoscopic biliary stones extraction using a forward viewing standard gastroscope in a patient with altered anatomy (partial gastrectomy with Billroth II reconstruction)
Endoscopic retrograde cholangiography in case of altered anatomy such as partial gastrectomy with Billroth II reconstruction has a success rate of 85% due to different factors such as failure to cross the anastomosis and the presence of an important length of afferent loop with a high risk of jejunal perforation at (or near) the anastomotic site while advancing the duodenoscope. The use of a front-view scope is the safest and could be used theoretically. However, the lack of elevator, the inability to see the papilla in a direct view, and the limited number of catheters available for cannulation and therapeutic procedures in the standard gastroscope with the 2.8mm working channel, can make this kind of procedure quite challenging. In this video, we present a case of successful biliary stone extraction in a patient with Billroth II reconstruction using a standard 2.8mm working channel front-viewing scope.
Single stage diagnosis and treatment by EUS and ERCP of a pancreatic stone causing an acute pancreatitis
Biliopancreatic stones are the ‘primum movens’ of acute pancreatitis. Pure pancreatic stones are rare. However, when present, they are the main cause of acute obstruction of the main pancreatic duct. Conversely, when present in chronic pancreatitis, they are mostly responsible for pancreatic glandular insufficiency. Medical treatment, radiologic evaluation (by MRI or CT-scan), and therapeutic endoscopy constitute the standard of care (SOC).
Here, we report the case of a 25-year-old man, admitted for upper middle abdominal pain and hyperamylasemia, without anomalies in liver function tests, and who underwent biliopancreatic EUS. A pancreatic stone was diagnosed and immediately treated by endoscopic pancreatic sphincterotomy and extraction.
Vidéo chirurgicale
Il y a 5 ans
1210 vues
41 J'aime
0 commentaire
05:10
Single stage diagnosis and treatment by EUS and ERCP of a pancreatic stone causing an acute pancreatitis
Biliopancreatic stones are the ‘primum movens’ of acute pancreatitis. Pure pancreatic stones are rare. However, when present, they are the main cause of acute obstruction of the main pancreatic duct. Conversely, when present in chronic pancreatitis, they are mostly responsible for pancreatic glandular insufficiency. Medical treatment, radiologic evaluation (by MRI or CT-scan), and therapeutic endoscopy constitute the standard of care (SOC).
Here, we report the case of a 25-year-old man, admitted for upper middle abdominal pain and hyperamylasemia, without anomalies in liver function tests, and who underwent biliopancreatic EUS. A pancreatic stone was diagnosed and immediately treated by endoscopic pancreatic sphincterotomy and extraction.
Endoscopic internal drainage (EID) for leaks following sleeve gastrectomy
Leaks following sleeve gastrectomy represent a serious problem for surgeons, since a standardized approach has not yet been established.
Usually laparoscopic exploration is necessary in order to achieve a diagnostic peritoneal lavage, and a surgical drain is left in place proximally to the suture line, at the level of the dehiscence (if visualized), jejunostomy is also frequently performed to ensure enteral alimentation. This treatment however, needs to be combined with an endoscopic treatment, in order to facilitate rapid closure of gastric staple line defects.
In this video we report our Endoscopic Internal Drainage (EID) technique by insertion of double pigtail stents combined for the firsts weeks with enteral nutrition, with the aim to create an internal fistula allowing to quickly remove the surgical drain, and promote the formation of granulation tissue at the level of the dehiscence.
Reference:
Endoscopic internal drainage with enteral nutrition (EDEN) for treatment of leaks following sleeve gastrectomy. Donatelli G, Ferretti S, Vergeau BM, Dhumane P, Dumont JL, Derhy S, Tuszynski T, Dritsas S, Carloni A, Catheline JM, Pourcher G, Dagher I, Meduri B. Obes Surg 2014;24:1400-7.
Vidéo chirurgicale
Il y a 5 ans
971 vues
21 J'aime
0 commentaire
06:33
Endoscopic internal drainage (EID) for leaks following sleeve gastrectomy
Leaks following sleeve gastrectomy represent a serious problem for surgeons, since a standardized approach has not yet been established.
Usually laparoscopic exploration is necessary in order to achieve a diagnostic peritoneal lavage, and a surgical drain is left in place proximally to the suture line, at the level of the dehiscence (if visualized), jejunostomy is also frequently performed to ensure enteral alimentation. This treatment however, needs to be combined with an endoscopic treatment, in order to facilitate rapid closure of gastric staple line defects.
In this video we report our Endoscopic Internal Drainage (EID) technique by insertion of double pigtail stents combined for the firsts weeks with enteral nutrition, with the aim to create an internal fistula allowing to quickly remove the surgical drain, and promote the formation of granulation tissue at the level of the dehiscence.
Reference:
Endoscopic internal drainage with enteral nutrition (EDEN) for treatment of leaks following sleeve gastrectomy. Donatelli G, Ferretti S, Vergeau BM, Dhumane P, Dumont JL, Derhy S, Tuszynski T, Dritsas S, Carloni A, Catheline JM, Pourcher G, Dagher I, Meduri B. Obes Surg 2014;24:1400-7.
Endoscopic extraction of a giant cystic duct stone to treat type I Mirizzi syndrome
Mirizzi syndrome (MS) is characterized by common hepatic duct obstruction due to mechanical compression and surrounding inflammation by a gallstone impacted in the cystic duct (type I) or at the gallbladder neck (type II). Preoperative diagnosis of the syndrome is mandatory and associated with a decrease of complication rate of surgical management. Endoscopic therapies like ERCP with lithotripsy or endoscopic extraction of cystic duct calculi followed by laparoscopic cholecystectomy have been described. Here we report successful endoscopic stone-clearance using double-cannulation and large balloon dilatation of the papilla for giant biliary stone impacted in the cystic duct inserted low in the common hepatic duct causing type I MS.
Bibliographic reference:
Double-cannulation and large papillary balloon dilation: key to successful endoscopic treatment of mirizzi syndrome in low insertion of cystic duct. Donatelli G, Dhumane P, Dallemagne B, Marx L, Delvaux M, Gay G, Marescaux J. Dig Endosc 2012;24:466-9.
Vidéo chirurgicale
Il y a 5 ans
909 vues
13 J'aime
0 commentaire
04:09
Endoscopic extraction of a giant cystic duct stone to treat type I Mirizzi syndrome
Mirizzi syndrome (MS) is characterized by common hepatic duct obstruction due to mechanical compression and surrounding inflammation by a gallstone impacted in the cystic duct (type I) or at the gallbladder neck (type II). Preoperative diagnosis of the syndrome is mandatory and associated with a decrease of complication rate of surgical management. Endoscopic therapies like ERCP with lithotripsy or endoscopic extraction of cystic duct calculi followed by laparoscopic cholecystectomy have been described. Here we report successful endoscopic stone-clearance using double-cannulation and large balloon dilatation of the papilla for giant biliary stone impacted in the cystic duct inserted low in the common hepatic duct causing type I MS.
Bibliographic reference:
Double-cannulation and large papillary balloon dilation: key to successful endoscopic treatment of mirizzi syndrome in low insertion of cystic duct. Donatelli G, Dhumane P, Dallemagne B, Marx L, Delvaux M, Gay G, Marescaux J. Dig Endosc 2012;24:466-9.
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.
Vidéo chirurgicale
Il y a 8 ans
3372 vues
74 J'aime
0 commentaire
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.
Gastric mucosal laceration managed with endoscopic clipping during ESD in a patient with Child Class A liver cirrhosis
Patients with liver cirrhosis present with portal hypertension (PHT), which causes various pathological changes in the entire gastrointestinal tract (from esophagus to anus). In this video, the Mallory Weiss tear (MWT) occurred accidentally during ESD of a gastric antral adenoma in a cirrhotic patient. It was successfully managed by means of endoscopic clipping. The patient had two episodes of retching during endoscopy, which might have contributed to gastric over-distension. With esophagogastroduodenoscopy (EGD) being so commonly performed in cirrhotic patients and ESD being more and more commonly used for treatment of gastric mucosal lesions, this case report should serve as a precautionary reminder in such case scenarios.
Vidéo chirurgicale
Il y a 8 ans
782 vues
11 J'aime
0 commentaire
02:57
Gastric mucosal laceration managed with endoscopic clipping during ESD in a patient with Child Class A liver cirrhosis
Patients with liver cirrhosis present with portal hypertension (PHT), which causes various pathological changes in the entire gastrointestinal tract (from esophagus to anus). In this video, the Mallory Weiss tear (MWT) occurred accidentally during ESD of a gastric antral adenoma in a cirrhotic patient. It was successfully managed by means of endoscopic clipping. The patient had two episodes of retching during endoscopy, which might have contributed to gastric over-distension. With esophagogastroduodenoscopy (EGD) being so commonly performed in cirrhotic patients and ESD being more and more commonly used for treatment of gastric mucosal lesions, this case report should serve as a precautionary reminder in such case scenarios.