Monthly publications

A 36-year-old woman came to the attention of the endocrinologist for a recent onset of headache and tachycardia and an US finding of a 1.8cm nodule in the right suprarenal space.
At age 25, she was submitted to an anterior laparoscopic transperitoneal right adrenalectomy for a 5cm pheochromocytoma. At age 33, she underwent laparoscopic cholecystectomy.
The diagnostic work-up revealed raised urinary metanephrine and normetanephrine and an MRI finding of a 1.5cm nodule in the right suprarenal space, with smaller satellite nodules in the retrocaval space.
A surgical revision of the right suprarenal space was indicated and the posterior retroperitoneal approach was chosen, to warrant better reach of the nodules and allow direct exposure of the retrocaval and retrohepatic spaces.
The operative time was 210 minutes. The patient recovered with no major complications and was discharged on her 4th postoperative day. Her symptoms recovered and she was found with lowered metanephrines at follow-up. An 18-FDG PET-CT scan performed 6 months after the operation showed no abnormal metabolic activity within her body.

The objective of this video is to demonstrate a laparoscopic total gastrectomy with D2 lymphadenectomy for antral gastric cancer. The patient we present is a 40 year-old gentleman who presented with epigastric pain. Endoscopy revealed a neoplastic lesion at the gastric antrum. Biopsies confirmed the presence of an adenocarcinoma. This was staged as a T2 lesion and there was no distant metastasis. A total gastrectomy was planned using a total laparoscopic approach. For reconstruction, the authors used a Roux En Y esophagojejunal anastomosis using the transoral delivery of the OrVil® device (Covidien, Mansfield, MA, USA). We also demonstrate how to deal with a positive intraoperative leak test at the end of the procedure.

A 73-year-old male patient, previously submitted to a radical cystoprostatectomy with ileal conduit as urinary diversion for urothelial cancer, was admitted to the emergency department because of stomal tumefaction and malfunction. There was no evidence of oncologic relapse.
CT-scan revealed an abscess in the parastomal area as well as a parastomal hernia. The abscess was treated with percutaneous drainage and antibiotics. In a second time, he was submitted to a laparoscopic correction of the parastomal defect.
The procedure was performed with no-flexible cameras and straight laparoscopic instruments. For defect correction, a laparoscopic intraperitoneal mesh repair (IPOM) technique was used.
No complications were observed and the patient was discharged on postoperative day 6.

Colorectal polyps are the most common type of polyps. Early resection before the polyp undergoes malignant transformation is key to long-term survival and to a favorable prognosis.
Endoscopic submucosal dissection (ESD) has been developed based on endoscopic mucosal resection (EMR) techniques. ESD can be used to resect lesions regardless of size, location, and fibrosis.

Indications for ESD:
- colorectal tumors when EMR is not feasible;
- tumors >20mm in size;
- lateral spreading tumors (non-granular) type;
- lateral spreading tumors (granular type) with a nodule;
- residual and recurrent tumors.

Technique:
- to accurately define the margins;
- to mark the borders;
- to perform a circumferential incision;
- to perform a submucosal dissection.

Complications:
- perforations – 2.4% in colonic ESD;
- bleeding – may be immediate or delayed, occurring after the procedure.
The overall rate of complications is 1.5%.

Endoscopic ultrasound (EUS):
The use of high-frequency EUS is useful to determine the depth of invasion of colorectal lesions. According to some studies, the efficacy of EUS is found to be superior to chromoendoscopy in determining the depth of the tumor.

Colorectal polyps are classified as neoplastic or non-neoplastic. The majority of polyps are small, non-neoplastic, and incidentally found during colonoscopy.
The malignant potential depends on the type of the polyp, size and degree of dysplasia. High grades of dysplasia, polyps greater than 1cm in diameter are associated with an increased risk of malignancy.

An intestinal polyp is a mass of tissue, which arises from the bowel wall and protrudes into the lumen. Polyps may be sessile or pedunculated. The incidence of polyps ranges from 7 to 50%. Polyps are most commonly found in the rectum and sigmoid colon and decrease in frequency towards the caecum.
Symptoms and signs:
Polyps are usually asymptomatic. The most frequent complaint is rectal bleeding, which is usually occult. Abdominal pain and obstruction occur with large polyps. The main concern with polyps is the risk of malignant transformation.
Complications of polypectomy: Common complications following polypectomy are bleeding and infection. The risk of bleeding ranges from 0.2 to 1.2%. When patients are on blood thinners, the risk of bleeding increases to 6.8%.
Advantages and disadvantages of use of prophylactic clips:
Clips can be applied during the procedure itself. They are easy to deploy. No scarring can be observed.
Disadvantages:
They are expensive, and present a risk of perforation and further bleeding.

Traumatic diaphragmatic hernias have been well described after blunt trauma. Diaphragmatic ruptures can occur in up to 0.8 to 7% of blunt abdominal trauma, with large left-sided defects being the most common. If the injury goes unrecognized, progressive herniation of abdominal contents may follow.
We report the case of a diaphragmatic hernia in a 48-year-old woman. The patient reports dyspnea and vomiting after left diaphragmatic node resection (diaphragmatic granuloma) one year ago.
A CT-scan demonstrated a large defect within the left hemi-diaphragm, associated with a herniation of the antrum, body of the stomach, colon, and spleen into the thoracic cavity.
At laparoscopy, a large rupture of the left hemi-diaphragm with a big herniation is shown. The hernia was reduced laparoscopically, and the defect was repaired with interrupted absorbable sutures and reinforced with continuous sutures. An intraperitoneal mesh was placed. The patient recovered uneventfully.
Diagnosis of a traumatic diaphragmatic hernia in the acute setting can be very challenging. In the chronic period, a myriad of symptoms and radiological findings may arise. Plain films, CT-scan, magnetic resonance imaging, and even diagnostic laparoscopy can help with the diagnosis. Laparoscopy is a safe and feasible method to repair traumatic diaphragmatic hernias, especially in the chronic setting, with the advantage of evaluating the entire abdomen and both hemi-diaphragms simultaneously.

Background: Minimally invasive surgery (MIS) has proven to be oncologically feasible and safe. Over the last decade, a new philosophy of MIS reducing abdominal trauma and improving cosmetic results has been made popular. The authors report a three-trocar laparoscopic total gastrectomy combined with a D2 lymphadenectomy for smaller curvature gastric adenocarcinoma.
Video: A 52-year-old woman presenting with a non-differentiated gastric adenocarcinoma at the incisura angularis was admitted to our department. Preoperative work-up showed a T3N+M0 tumor. After neoadjuvant chemotherapy, laparoscopy was scheduled. Three ports (5mm, 12mm, 5mm) were placed in the abdomen. Exposure of the operative field was improved with percutaneous sutures. En-bloc total gastrectomy and omentectomy were performed with a D2 lymphadenectomy, including the nodes of stations 1, 2, 3, 4, 5, 6, 7, 8a, 8p, 9, 10, 11p, 11d, and 12a. A completely manual end-to-side esophagojejunostomy, and a linear mechanical side-to-side jejunojejunostomy were performed, with closure of both mesenteric and mesocolic defects. The specimen was retrieved through a suprapubic access.
Results: Operative time was 4 hours and 45 minutes (anastomosis: 30) and perioperative bleeding amounted to 100cc. The pathological report confirmed the presence of a non-differentiated adenocarcinoma, mucinous, G3, interesting the gastric wall completely, with 63 (4 positive) nodes removed; 7 edition UICC stage: pT4aN2aM0; keratine AE1/AE3 negative, HER2/neu and HER2/CEP17 non-amplified. During the postoperative follow-up, no recurrence was demonstrated at 12 months.
Conclusions: Reduced port laparoscopic surgery provides the same quality of oncologic surgery as conventional multiport laparoscopy. However, a superior cosmesis and a reduced abdominal trauma are offered.

In this key lecture, Dr. de la Rosette focuses on international recommendations for the management of stones (urolithiasis).

In this key lecture, Dr. de la Rosette focuses on percutaneous nephrolithotomy (PCNL), highlighting indications, results, and complications.

In this key lecture, Dr. de la Rosette focuses on ureteroscopy and highlights indications, results, and complications.

In this key lecture, Dr. Christian Saussine focuses on percutaneous nephrolithotomy (PCNL), and more particularly on materials and technique used.

Pre-procedural planning before any endoscopic resection requires the assessment of the lesion. The main criteria which need to be assessed are the following:
- depth of invasion of the lesion;
- lymph node metastasis;
- lateral spread of the tumor;
- pit pattern.
Routine endoscopy is used to assess tumor size. Tumors can be staged with the use of many classifications, and notably the Paris classification.
High-frequency (≥20MHz) endoscopic ultrasonography (EUS) produces an image of the mucosal wall comprising nine separate layers differentiated by their echogenicity. Careful examination of the depth of lesion penetration into the mucosal and submucosal layers is used to determine the risk of lymph node metastases with a greater precision.
Pit pattern can be evaluated by means of magnification on endoscopy.
Kudos classification is used.
Type I: roundish pits
Type II: stellar or papillary pits
Type III S: small roundish or tubular pits (smaller than type I pits)
Type III L: large roundish or tubular pits (larger than type I pits)
Type IV: branch-like or gyrus-like pits
Type V: non-structured pits

Endoscopic mucosal resection (EMR) is a method for treating early gastrointestinal mucosal lesions. The procedure of EMR involves submucosal injection of normal saline or saline with a mix of methylene blue to separate the lesion from the underlying muscle layers. The raised lesions can be completely removed with a snare. EMR is a simple and safe procedure with a small learning curve.
The risk of serious complications such as perforation and bleeding is rare.
The invasion depth of the tumor can be assessed after resection using pathological examination. The recurrence rate is very low (0-3.6%) after resection. EMR is not an appropriate choice for gastrointestinal tumors (size >20mm) as the complete recurrence rate is very low and recurrence after resection is very high.

The benefits of EMR and ESD overrule the complications associated with the procedures. Bleeding, perforations, and submucosal fibrosis are the most common complications encountered during resections.
The risk of bleeding (5-8%) and perforations (

Endoscopy has increased the detection of early neoplastic lesions of the gastrointestinal tract (GIT) known as gastrointestinal superficial lesions.
Endoscopic resection is adequate in patients with early gastrointestinal cancer with limited or completely nil submucosal involvement. Endoscopic resections are mainly used for high- and low-grade dysplasia. Most lesions can be treated using endoscopic mucosal resection (EMR), however unsuitable for lesions greater than 20mm in size. Endoscopic submucosal dissection (ESD) allows to achieve an ‘en bloc’ resection of the lesions, irrespective of the size of the tumor.
Esophagus:
Endoscopic resection is indicated for esophageal cancers with no risk of lymph node invasion. The size of the lesion is the main criterion for the choice of the procedure.
Barrett’s esophagus: EMR is the gold standard for endoscopic excision in Barrett’s esophagus; the main limitation is piecemeal resection with EMR, which makes histopathological assessment difficult, and the risk of recurrence and residual tumor is high. ESD should be considered for lesions greater than 15mm, poorly lifting tumors, and those at risk for submucosal invasion.
Stomach:
The lesions which should be considered for endoscopic resection because of a very low risk of lymph node metastasis are the following:
- non-invasive neoplasia (dysplasia) independently of size;
- intramucosal differentiated-type adenocarcinoma, without ulceration (size ≤2cm absolute indication, >2cm expanded indication);
- intramucosal differentiated-type adenocarcinoma, with ulcer, size ≤3cm (expanded indication);
- intramucosal undifferentiated-type adenocarcinoma, size ≤2cm (expanded indication);
- differentiated-type adenocarcinoma with superficial submucosal invasion.
EMR was the first treatment alternative to surgery for early gastric cancer. However, EMR is associated with a high recurrence rate (30%) according to some studies.
ESD for early gastric cancers has higher ‘en bloc’ resection rates, histologically complete resection rates, and low recurrence rates. ESD though is associated with longer operative times.
Duodenum:
The use of endoscopic resection in the duodenum and the small bowel is limited because of a high risk of perforations. EMR standard or piecemeal resections can be used for superficial lesions with perforation rates less than 5%.
Colon:
EMR represents a highly effective treatment for lesions of the colon less than 20mm in diameter. Piecemeal EMR for larger lesions reduces the quality and reliability of histopathological findings.
In the rectum, the indications for ESD may be extended for all large (>20mm), non-granular (NG) or granular lesions, or mixed laterally spreading tumors (LSTs) (>20-30mm).
ESD can be considered for the removal of colonic and rectal lesions with a high suspicion of limited submucosal invasion, which is based on two main criteria, namely a depressed morphology and an irregular or non-granular surface pattern, particularly if the lesions are larger than 20 mm.
Summary:
EMR should be the first option for the following:
- superficial lesion in Barrett’s esophagus;
- small gastric lesion

In this lecture, Dr. Lehr outlines the various methods of handling the resected specimens. The importance of ‘en bloc’ resection over piecemeal resection is highlighted. ESD specimens are usually resected ‘en bloc’, hence 82% of the resections are R0, and the risk of recurrence is less than 1%.
As for EMR, 48% of specimens are piecemeal. Consequently, an accurate assessment of the resection margin cannot be achieved and the risk of recurrence is greater than 6%.
The true depth of the tumor can only be assessed when the lesion is resected in one piece and with the avoidance of electrocautery injuries inside or at the edges of the lesion. The specimen must be fixed on a Styrofoam or in specialized boxes to prevent it from curling up once put in formalin.
Specimen orientation is essential in order to help the pathologist for proper examination and reporting.

Chromoendoscopy uses the topical application of stains or pigments to improve tissue localization, characterization, or diagnosis during endoscopy. Various stains used are as follows:
- absorptive stains: Lugol’s solution of iodine, methylene blue;
- contrast stains: indigo carmine;
- reactive stains: congo red and phenol red.
The most commonly used stains are iodine and methylene blue.
The other available advanced endoscopic technologies for lesion assessment are magnification endoscopy, confocal endoscopy, and confocal endocytoscopy. This video highlights the various types of mucosal patterns in early cancer seen with the use of high definition and magnification endoscopy.
Narrow band imaging (NBI): this is an imaging technique used in endoscopy where lights of blue or green wavelength are used to enhance the details of the mucosal pattern.

The video highlights various complications associated with endoscopic mucosal dissection. The intraoperative and postoperative management of complications such as bleeding and perforation is outlined in detail.
The use of new technologies for the management of perforations (e.g., use of endoscopic loops, clips, OverStitch™ device) is highlighted. Other complications (e.g., stricture, aspiration pneumonia, venous thrombo-embolism, air embolism) are listed and their management is explained.

In this key lecture, Dr. Wahegaonkar focuses on arthroscopic dorsal capsuloligamentous repair in the management of SLIOL tears.

In this key lecture, Dr. Gras looks into long-term results of arthroscopic replacement of necrotic proximal pole with APSI implant.

In this key lecture, Dr. Liverneaux highlights robotic assisted wrist arthroscopy.

In this key lecture, Dr. Schmelzer-Schmied looks into TFCC reconstruction.

In this key lecture, Dr. Christophe Mathoulin outlines a state-of-the-art presentation on the treatment of arthroscopic scapholunate tear.

In this key lecture, Dr. Messina focuses on scapholunate tears and on the importance of their early diagnosis.

In this key lecture, Dr. Levadoux focuses on interposition in SLAC wrist.