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Monthly publications

#June 2013
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Laparoscopic partial fundoplication in a patient with scleroderma and severe GERD
Scleroderma is associated with severe esophageal dysmotility and gastroesophageal reflux disease (GERD). Results after antireflux surgery have been suboptimal due to the profound esophageal dysmotility observed in this disease.

Here, we show the case of a 54-year-old patient with scleroderma and severe GERD. The patient presented with both typical GERD symptoms, persistent cough unresponsive to high dose of PPIs, and dysphagia to solids. Preoperative work-up included high-resolution (HR) manometry, which showed a hypotensive lower esophageal sphincter and severely impaired peristalsis as well as impedance pH monitoring, which confirmed the presence of pathological reflux, mainly acid, occurring mostly at night in a recumbent position.
S Perretta, B Dallemagne, J Marescaux
Surgical intervention
5 years ago
3366 views
35 likes
0 comments
09:11
Laparoscopic partial fundoplication in a patient with scleroderma and severe GERD
Scleroderma is associated with severe esophageal dysmotility and gastroesophageal reflux disease (GERD). Results after antireflux surgery have been suboptimal due to the profound esophageal dysmotility observed in this disease.

Here, we show the case of a 54-year-old patient with scleroderma and severe GERD. The patient presented with both typical GERD symptoms, persistent cough unresponsive to high dose of PPIs, and dysphagia to solids. Preoperative work-up included high-resolution (HR) manometry, which showed a hypotensive lower esophageal sphincter and severely impaired peristalsis as well as impedance pH monitoring, which confirmed the presence of pathological reflux, mainly acid, occurring mostly at night in a recumbent position.
Laparoscopic redo Nissen for failed anterior fundoplication
Nissen fundoplication is the most commonly performed antireflux operation. An alternative is the partial fundoplication, either anterior or posterior to the esophagus, which provides adequate control of reflux. The anterior valve is effective, provided that it is properly constructed. It is not a simple fundic plication but it implies precise dissection parameters to create an effective antireflux mechanism. This video shows a redo fundoplication in a patient with an anterior fundoplication that never controlled GERD, because it was built as a simple fundic plication. This cause of failure is typical in inexperienced surgeons, who are afraid of doing a posterior dissection of the gastroesophageal junction. The video also demonstrates the management of a peri-splenic hemorrhage.
B Dallemagne, S Perretta, J Marescaux
Surgical intervention
5 years ago
1986 views
37 likes
0 comments
31:15
Laparoscopic redo Nissen for failed anterior fundoplication
Nissen fundoplication is the most commonly performed antireflux operation. An alternative is the partial fundoplication, either anterior or posterior to the esophagus, which provides adequate control of reflux. The anterior valve is effective, provided that it is properly constructed. It is not a simple fundic plication but it implies precise dissection parameters to create an effective antireflux mechanism. This video shows a redo fundoplication in a patient with an anterior fundoplication that never controlled GERD, because it was built as a simple fundic plication. This cause of failure is typical in inexperienced surgeons, who are afraid of doing a posterior dissection of the gastroesophageal junction. The video also demonstrates the management of a peri-splenic hemorrhage.
Single incision laparoscopic gastrojejunal bypass with intraoperative ultrasonography for obstructive pancreatic head tumor
Background: Pancreatic head tumors can be diagnosed immediately as symptomatic although the biliary tract is not involved. Single incision laparoscopy can be proposed as a valid option to allow an early beginning of neo-adjuvant chemotherapy.

Video: A 56-year-old man was admitted to hospital for vomiting and weight loss. Preoperative work-up showed the presence of an advanced and obstructive pancreatic head adenocarcinoma, not interesting the biliary tract. A laparoscopic gastro-jejunal bypass with staging laparoscopy, through a transumbilical single-access, was proposed to the patient. The technique consisted in the insertion of an 11mm reusable trocar, two 6mm flexible reusable trocars, and curved reusable instruments according to DAPRI (Karl Storz Endoskope, Tüttlingen, Germany) through the same umbilical incision. The procedure started with the exploration of the parietal peritoneum, lavage of the cavity, opening of the lesser sac for perioperative ultrasonography, and ended with linear mechanical side-to-side gastrojejunostomy.

Results: The obstructive status of the patient resolved during the postoperative course and the patient started neo-adjuvant chemotherapy after 10 days.

Conclusions: Single incision laparoscopic gastrojejunostomy for obstructive pancreatic head tumor, after staging laparoscopy including perioperative ultrasonography, permits the resolution of the clinical status as well as an early beginning of neo-adjuvant chemotherapy.
G Dapri
Surgical intervention
5 years ago
2219 views
54 likes
0 comments
06:40
Single incision laparoscopic gastrojejunal bypass with intraoperative ultrasonography for obstructive pancreatic head tumor
Background: Pancreatic head tumors can be diagnosed immediately as symptomatic although the biliary tract is not involved. Single incision laparoscopy can be proposed as a valid option to allow an early beginning of neo-adjuvant chemotherapy.

Video: A 56-year-old man was admitted to hospital for vomiting and weight loss. Preoperative work-up showed the presence of an advanced and obstructive pancreatic head adenocarcinoma, not interesting the biliary tract. A laparoscopic gastro-jejunal bypass with staging laparoscopy, through a transumbilical single-access, was proposed to the patient. The technique consisted in the insertion of an 11mm reusable trocar, two 6mm flexible reusable trocars, and curved reusable instruments according to DAPRI (Karl Storz Endoskope, Tüttlingen, Germany) through the same umbilical incision. The procedure started with the exploration of the parietal peritoneum, lavage of the cavity, opening of the lesser sac for perioperative ultrasonography, and ended with linear mechanical side-to-side gastrojejunostomy.

Results: The obstructive status of the patient resolved during the postoperative course and the patient started neo-adjuvant chemotherapy after 10 days.

Conclusions: Single incision laparoscopic gastrojejunostomy for obstructive pancreatic head tumor, after staging laparoscopy including perioperative ultrasonography, permits the resolution of the clinical status as well as an early beginning of neo-adjuvant chemotherapy.
Occurrence of a rare complication during laparoscopic sleeve gastrectomy
Nowadays, sleeve gastrectomy is a common procedure frequently performed laparoscopically in the management of morbid obesity. This intervention as proven to be efficient in comparison to laparoscopic Roux-en-Y gastric bypass (LRYGB) regarding weight loss and revision of obesity-related co-morbidities such as diabetes mellitus and high blood pressure. Today, in France, selection of the surgical technique (e.g., sleeve gastrectomy, LRYGB) depends on the patient should preoperative work-up be strictly normal. If not, the surgeon will have to make a decision as to which technique should be used. Postoperative complications related to bariatric surgery are currently well-known (fistula, bleeding, abscess) and are managed in a multidisciplinary way by radiologists, endoscopists and surgeons. Here, we present the case of a rare perioperative complication related to the incidental stapling of the nasogastric tube during gastric division. This complication mainly highlights shortcomings in the interaction between the surgical team and anesthesiologists during placement and retrieval of calibration and nasogastric tubes. In the present case, this complication was immediately demonstrated and it was managed laparoscopically.
L Marx, M Vix, J Marescaux
Surgical intervention
5 years ago
2864 views
25 likes
0 comments
08:29
Occurrence of a rare complication during laparoscopic sleeve gastrectomy
Nowadays, sleeve gastrectomy is a common procedure frequently performed laparoscopically in the management of morbid obesity. This intervention as proven to be efficient in comparison to laparoscopic Roux-en-Y gastric bypass (LRYGB) regarding weight loss and revision of obesity-related co-morbidities such as diabetes mellitus and high blood pressure. Today, in France, selection of the surgical technique (e.g., sleeve gastrectomy, LRYGB) depends on the patient should preoperative work-up be strictly normal. If not, the surgeon will have to make a decision as to which technique should be used. Postoperative complications related to bariatric surgery are currently well-known (fistula, bleeding, abscess) and are managed in a multidisciplinary way by radiologists, endoscopists and surgeons. Here, we present the case of a rare perioperative complication related to the incidental stapling of the nasogastric tube during gastric division. This complication mainly highlights shortcomings in the interaction between the surgical team and anesthesiologists during placement and retrieval of calibration and nasogastric tubes. In the present case, this complication was immediately demonstrated and it was managed laparoscopically.
Laparoscopic total gastrectomy with D2 lymphadenectomy for adenocarcinoma
Total gastrectomy with D2 lymphadenectomy is recommended for T1-T2 gastric cancer.
The laparoscopic approach for this procedure has been validated by extensive clinical randomized trials in Asia, leading to fewer postoperative complications and morbidity and identical oncological outcome.
This video presents a laparoscopic total gastrectomy with D2 lymphadenectomy in a 54-year-old woman presenting with a T1-T2 poorly differentiated adenocarcinoma of the lesser curvature of the stomach. Due to the location of the tumor, lymphadenectomy of stations 10 and 11d are not performed. An original technique of circular eso-jejunal anastomosis is described.
A Talvane Torres de Oliveira, C Lacerda, PA Bertulucci
Surgical intervention
5 years ago
4964 views
77 likes
0 comments
25:53
Laparoscopic total gastrectomy with D2 lymphadenectomy for adenocarcinoma
Total gastrectomy with D2 lymphadenectomy is recommended for T1-T2 gastric cancer.
The laparoscopic approach for this procedure has been validated by extensive clinical randomized trials in Asia, leading to fewer postoperative complications and morbidity and identical oncological outcome.
This video presents a laparoscopic total gastrectomy with D2 lymphadenectomy in a 54-year-old woman presenting with a T1-T2 poorly differentiated adenocarcinoma of the lesser curvature of the stomach. Due to the location of the tumor, lymphadenectomy of stations 10 and 11d are not performed. An original technique of circular eso-jejunal anastomosis is described.
POEM endoscopic treatment of achalasia using the EndoFLIP® (Endolumenal Functional Lumen Imaging Probe) imaging system
This is the case of a 75-year-old lady who presented with recurrent symptoms of dysphagia and regurgitation associated with a significant weight loss due to recurrent achalasia. She developed progressive recurrence after a first surgical treatment by an open Heller myotomy and Dor fundoplication back in 1974. This first operation was complicated by an esophageal perforation which required a thoracotomy to be controlled. Several dilatations were attempted with no significant symptoms improvement. One of the most important aspects of POEM is to ensure that the submucosal tunnel adequately extends into the gastric cardia in order to perform a complete and adequate myotomy. To this aim, proper orientation is key but may be difficult even to the experienced eye of the interventional endoscopist familiar with ESD techniques and dissection planes. Six endoscopic cues that assist with this determination have been identified so far. The most useful cue was deemed to be the characteristic appearance of the submucosal space of the cardia of a slightly different color with a somewhat yellowish hue, more capacious than the esophageal submucosal space with more and larger vessels. Identification of the thick, cord-like circular muscle fibers of the lower esophageal sphincter was deemed as the second most useful cue, and noting a bluish coloration of the cardial mucosa from the colored submucosal injection via a retroflexed luminal view was the third most useful cue. Endoscope insertion length within the submucosal tunnel and the palisading mucosal vessels marking the gastroesophageal junction and visible also from inside the submucosal tunnel were deemed helpful but to a lesser degree. Nevertheless, identification of these endoscopic landmarks is not easy nor always reproducible. Creation of the submucosal tunnel is very sensitive to case difficulty and accounts for the large fluctuations in procedure time. Another area of technique variability involves the orientation of the myotomy. In order to improve the recognition of the essential landmarks, we developed a myotomy technique guided by the EndoFLIP® catheter. EndoFLIP® is a unique physiology test that uses both volumetric assessment and pressure readings to calculate compliance and high pressure zones as well as distensibility changes at the gastroesophageal junction. It allows intraoperative assessment of myotomy completion. The use of this device provides a direct immediate feedback with regards to the efficacy of the myotomy. The EndoFLIP® catheter used in this case (EF-325L) has been specifically modified for the POEM procedure. It differs from the standard EndoFLIP® catheter in that it contains an integrated illuminating LED adjacent to the centre measurement electrode. When the catheter is positioned intraluminally at the gastroesophageal junction and secured to this position taping the distal end to the endothracheal tube, it allows to direct dissection towards the cardia.
S Perretta, LL Swanström, B Dallemagne, J Marescaux
Surgical intervention
5 years ago
2735 views
39 likes
0 comments
07:08
POEM endoscopic treatment of achalasia using the EndoFLIP® (Endolumenal Functional Lumen Imaging Probe) imaging system
This is the case of a 75-year-old lady who presented with recurrent symptoms of dysphagia and regurgitation associated with a significant weight loss due to recurrent achalasia. She developed progressive recurrence after a first surgical treatment by an open Heller myotomy and Dor fundoplication back in 1974. This first operation was complicated by an esophageal perforation which required a thoracotomy to be controlled. Several dilatations were attempted with no significant symptoms improvement. One of the most important aspects of POEM is to ensure that the submucosal tunnel adequately extends into the gastric cardia in order to perform a complete and adequate myotomy. To this aim, proper orientation is key but may be difficult even to the experienced eye of the interventional endoscopist familiar with ESD techniques and dissection planes. Six endoscopic cues that assist with this determination have been identified so far. The most useful cue was deemed to be the characteristic appearance of the submucosal space of the cardia of a slightly different color with a somewhat yellowish hue, more capacious than the esophageal submucosal space with more and larger vessels. Identification of the thick, cord-like circular muscle fibers of the lower esophageal sphincter was deemed as the second most useful cue, and noting a bluish coloration of the cardial mucosa from the colored submucosal injection via a retroflexed luminal view was the third most useful cue. Endoscope insertion length within the submucosal tunnel and the palisading mucosal vessels marking the gastroesophageal junction and visible also from inside the submucosal tunnel were deemed helpful but to a lesser degree. Nevertheless, identification of these endoscopic landmarks is not easy nor always reproducible. Creation of the submucosal tunnel is very sensitive to case difficulty and accounts for the large fluctuations in procedure time. Another area of technique variability involves the orientation of the myotomy. In order to improve the recognition of the essential landmarks, we developed a myotomy technique guided by the EndoFLIP® catheter. EndoFLIP® is a unique physiology test that uses both volumetric assessment and pressure readings to calculate compliance and high pressure zones as well as distensibility changes at the gastroesophageal junction. It allows intraoperative assessment of myotomy completion. The use of this device provides a direct immediate feedback with regards to the efficacy of the myotomy. The EndoFLIP® catheter used in this case (EF-325L) has been specifically modified for the POEM procedure. It differs from the standard EndoFLIP® catheter in that it contains an integrated illuminating LED adjacent to the centre measurement electrode. When the catheter is positioned intraluminally at the gastroesophageal junction and secured to this position taping the distal end to the endothracheal tube, it allows to direct dissection towards the cardia.
Endoscopic subcutaneous approach to components separation for suture closure and underlay mesh reinforcement of central ventral hernias
This video describes the technique for repair of central ventral defects by endoscopic subcutaneous component separation, suture closure of the central ventral defects using V-Loc™ suture and reinforcement of the reconstruction with an underlay composite mesh. Advantages of this approach are the preservation of abdominal wall dynamics with a low recurrence rate and fewer complications usually observed in other complex abdominal reconstructions such as seromas, hematomas, infection, pain, delayed recovery, and undesirable cosmetic results. The video shows the endoscopic subcutaneous component separation technique in detail as well as the identification and closure of the central ventral defect and the underlay placement of a composite mesh. CT-scan images of abdominal wall reconstruction at three months postoperatively are presented. In our first 6 cases, early clinical and CT-scan results were encouraging.
J Daes
Surgical intervention
5 years ago
1599 views
24 likes
0 comments
09:01
Endoscopic subcutaneous approach to components separation for suture closure and underlay mesh reinforcement of central ventral hernias
This video describes the technique for repair of central ventral defects by endoscopic subcutaneous component separation, suture closure of the central ventral defects using V-Loc™ suture and reinforcement of the reconstruction with an underlay composite mesh. Advantages of this approach are the preservation of abdominal wall dynamics with a low recurrence rate and fewer complications usually observed in other complex abdominal reconstructions such as seromas, hematomas, infection, pain, delayed recovery, and undesirable cosmetic results. The video shows the endoscopic subcutaneous component separation technique in detail as well as the identification and closure of the central ventral defect and the underlay placement of a composite mesh. CT-scan images of abdominal wall reconstruction at three months postoperatively are presented. In our first 6 cases, early clinical and CT-scan results were encouraging.