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Monthly publications

#January 2016
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LIVE INTERACTIVE SURGERY: POEM for type 2 achalasia and incidental esophageal leiomyoma
POEM (peroral endoscopic myotomy) is an emerging procedure, which has evolved from the era of NOTES. The most cardinal indication for POEM is achalasia of the cardia. Other indications include diffuse esophageal spasm, jackhammer esophagus, and surgically failed cases.
The steps of POEM include the following: mucosotomy, submucous tunnelling, myotomy, closure of mucosotomy.
The myotomy is started 2 to 3cm distal to the mucosotomy and is continued to the end of the tunnel at 2 to 3cm distally to the gastroesophageal junction (GEJ). A partial myotomy is most commonly performed by means of careful dissection of circular fibers, hence avoiding longitudinal fibers to prevent entry into the mediastinum. The mucosotomy is then closed to prevent any leakage with the use of endoscopic clips or of an endoscopic suturing device. About the EndoFLIP™ (Endolumenal Functional Lumen Imaging Probe) Imaging System: this is a functional endoluminal imaging probe, which helps in the assessment of gastroesophageal junction distensibility and compliance after the procedure.
Complications of POEM:
Inadvertent mucosotomy is the most common complication.
Complications due to insufflation (pneumomediastinum, pneumoperitoneum) can be controlled by using carbon dioxide for insufflation. Esophageal leak is the most dreaded complication with rates ranging from 0 to 5.6%.
H Inoue, S Perretta
Surgical intervention
2 years ago
956 views
32 likes
0 comments
31:42
LIVE INTERACTIVE SURGERY: POEM for type 2 achalasia and incidental esophageal leiomyoma
POEM (peroral endoscopic myotomy) is an emerging procedure, which has evolved from the era of NOTES. The most cardinal indication for POEM is achalasia of the cardia. Other indications include diffuse esophageal spasm, jackhammer esophagus, and surgically failed cases.
The steps of POEM include the following: mucosotomy, submucous tunnelling, myotomy, closure of mucosotomy.
The myotomy is started 2 to 3cm distal to the mucosotomy and is continued to the end of the tunnel at 2 to 3cm distally to the gastroesophageal junction (GEJ). A partial myotomy is most commonly performed by means of careful dissection of circular fibers, hence avoiding longitudinal fibers to prevent entry into the mediastinum. The mucosotomy is then closed to prevent any leakage with the use of endoscopic clips or of an endoscopic suturing device. About the EndoFLIP™ (Endolumenal Functional Lumen Imaging Probe) Imaging System: this is a functional endoluminal imaging probe, which helps in the assessment of gastroesophageal junction distensibility and compliance after the procedure.
Complications of POEM:
Inadvertent mucosotomy is the most common complication.
Complications due to insufflation (pneumomediastinum, pneumoperitoneum) can be controlled by using carbon dioxide for insufflation. Esophageal leak is the most dreaded complication with rates ranging from 0 to 5.6%.
LIVE INTERACTIVE SURGERY: Esophagogastroduodenoscopy (EGD), chromoendoscopy, and BARRX treatment of remaining Barrett's mucosa
Chromoendoscopy is a procedure where dyes are instilled in the gastrointestinal tract at the time of visualization with endoscopy. It enhances the characterization of the tissues. The most common applications are as follows:
- Identification of squamous cell carcinoma or dysplasia;
- Identification of Barrett’s esophagus;
- Detection of early gastric cancer;
- Characterization of colonic polyps;
- Screening.
BARRX™ is a radiofrequency ablation of the metaplastic esophageal mucosa. The concept is to resect the epithelium and the muscularis mucosa without damaging the submucosa. It reduces the risk of developing carcinoma.
E Coron, G Rahmi
Surgical intervention
2 years ago
411 views
20 likes
0 comments
09:12
LIVE INTERACTIVE SURGERY: Esophagogastroduodenoscopy (EGD), chromoendoscopy, and BARRX treatment of remaining Barrett's mucosa
Chromoendoscopy is a procedure where dyes are instilled in the gastrointestinal tract at the time of visualization with endoscopy. It enhances the characterization of the tissues. The most common applications are as follows:
- Identification of squamous cell carcinoma or dysplasia;
- Identification of Barrett’s esophagus;
- Detection of early gastric cancer;
- Characterization of colonic polyps;
- Screening.
BARRX™ is a radiofrequency ablation of the metaplastic esophageal mucosa. The concept is to resect the epithelium and the muscularis mucosa without damaging the submucosa. It reduces the risk of developing carcinoma.
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
2 years ago
364 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.
ERAS, ventilation and anesthesia
Despite steady advances in anesthetic and surgical techniques over the years, postoperative complications remain one of the major drawbacks of surgery, not only for the specific patient involved but also for surgical care team and the health care system in general. The progressive understanding of the physiological basis of surgical injury has been the rationale for the research efforts of interdisciplinary teams, incorporating surgeons, anesthesiologists and nurses, physical therapists and others to minimize surgical stress response and thereby improve outcomes. This presentation will identify the various elements of the enhanced recovery protocol (ERP), understand the physiologic rationalization of enhanced recovery strategy, the role of ventilation and anesthesia on the impact of ERP, ascertain the impact of ERP on improving patient outcome and how to implement ERP in community hospitals or major academic medical centers.
TJ Gan
Lecture
2 years ago
379 views
12 likes
0 comments
34:29
ERAS, ventilation and anesthesia
Despite steady advances in anesthetic and surgical techniques over the years, postoperative complications remain one of the major drawbacks of surgery, not only for the specific patient involved but also for surgical care team and the health care system in general. The progressive understanding of the physiological basis of surgical injury has been the rationale for the research efforts of interdisciplinary teams, incorporating surgeons, anesthesiologists and nurses, physical therapists and others to minimize surgical stress response and thereby improve outcomes. This presentation will identify the various elements of the enhanced recovery protocol (ERP), understand the physiologic rationalization of enhanced recovery strategy, the role of ventilation and anesthesia on the impact of ERP, ascertain the impact of ERP on improving patient outcome and how to implement ERP in community hospitals or major academic medical centers.
Transumbilical single access laparoscopic sleeve gastrectomy plus 1.8mm trocarless grasping forceps
Background: Transumbilical single access laparoscopy (TSAL) has gained interest over the last decade. However, in bariatric surgery, it still remains difficult due to the fact that the umbilicus is not a landmark, and it is frequently localized too far from the operative field. In selected patients, it can be considered and offered.
Video: A 29-year-old morbidly obese woman with a BMI of 40 underwent TSAL sleeve gastrectomy. Two reusable ports and curved reusable instruments according to DAPRI (Karl Storz Endoskope, Tuttlingen, Germany) were placed in the umbilicus. The chosen method to perform sleeve gastrectomy was a medial-to-lateral approach (gastric division followed by greater curvature mobilization), and the resection of the gastric antrum. Gastric division was performed under the control of a long, rigid, 30-degree scope (Karl Storz). To expose the hiatal region and the angle of His, a 1.8mm trocarless grasping forceps according to DAPRI (Karl Storz) was inserted underneath the xiphoid process and placed against the diaphragm below the left liver lobe. Some absorbable sutures between the staple lines were finally placed, and no drain was left into the abdominal cavity. The specimen was removed transumbilically, after joining the three used windows together at the umbilical aponeurosis.
Results: Laparoscopy took 94 minutes and perioperative bleeding was 30cc. Umbilical scar length was 25mm. No postoperative complications were noted and the patient was discharged on postoperative day 4.
Conclusions: TSAL sleeve gastrectomy can be offered to selected obese patients. The use of reusable material and curved tools make it possible not to increase the cost of the procedure due to TSAL, and to establish intracorporeal and extracorporeal working triangulation.
G Dapri
Surgical intervention
2 years ago
1689 views
62 likes
0 comments
08:13
Transumbilical single access laparoscopic sleeve gastrectomy plus 1.8mm trocarless grasping forceps
Background: Transumbilical single access laparoscopy (TSAL) has gained interest over the last decade. However, in bariatric surgery, it still remains difficult due to the fact that the umbilicus is not a landmark, and it is frequently localized too far from the operative field. In selected patients, it can be considered and offered.
Video: A 29-year-old morbidly obese woman with a BMI of 40 underwent TSAL sleeve gastrectomy. Two reusable ports and curved reusable instruments according to DAPRI (Karl Storz Endoskope, Tuttlingen, Germany) were placed in the umbilicus. The chosen method to perform sleeve gastrectomy was a medial-to-lateral approach (gastric division followed by greater curvature mobilization), and the resection of the gastric antrum. Gastric division was performed under the control of a long, rigid, 30-degree scope (Karl Storz). To expose the hiatal region and the angle of His, a 1.8mm trocarless grasping forceps according to DAPRI (Karl Storz) was inserted underneath the xiphoid process and placed against the diaphragm below the left liver lobe. Some absorbable sutures between the staple lines were finally placed, and no drain was left into the abdominal cavity. The specimen was removed transumbilically, after joining the three used windows together at the umbilical aponeurosis.
Results: Laparoscopy took 94 minutes and perioperative bleeding was 30cc. Umbilical scar length was 25mm. No postoperative complications were noted and the patient was discharged on postoperative day 4.
Conclusions: TSAL sleeve gastrectomy can be offered to selected obese patients. The use of reusable material and curved tools make it possible not to increase the cost of the procedure due to TSAL, and to establish intracorporeal and extracorporeal working triangulation.