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Silvana PERRETTA

Hôpitaux Universitaires de Strasbourg
Strasbourg, France
MD, PhD
8675 likes
262271 views
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Fourth antireflux procedure in a patient with a BMI of 35: esophagogastric disconnection and Roux-en-Y gastrojejunostomy
We present an esophagogastric disconnection and Roux-en-Y gastrojejunostomy as the fourth antireflux procedure in an obese patient with recurrent severe GERD despite high-dose PPI therapy. After previous Nissen fundoplications and a redo procedure with a partial posterior fundoplication, the patient now presented with an intrathoracic migration of the posterior fundoplication. In these complex redo scenarios in conjunction with a high BMI, the strategy of esophagogastric disconnection and Roux-en-Y reconstruction similarly to obesity surgery is increasingly being used.
B Dallemagne, S Perretta, D Mutter, J Marescaux
Surgical intervention
7 months ago
840 views
350 likes
0 comments
21:18
Fourth antireflux procedure in a patient with a BMI of 35: esophagogastric disconnection and Roux-en-Y gastrojejunostomy
We present an esophagogastric disconnection and Roux-en-Y gastrojejunostomy as the fourth antireflux procedure in an obese patient with recurrent severe GERD despite high-dose PPI therapy. After previous Nissen fundoplications and a redo procedure with a partial posterior fundoplication, the patient now presented with an intrathoracic migration of the posterior fundoplication. In these complex redo scenarios in conjunction with a high BMI, the strategy of esophagogastric disconnection and Roux-en-Y reconstruction similarly to obesity surgery is increasingly being used.
Laparoscopic pancreatectomy with preservation of splenic vessels: a live broadcast from IRCAD America Latina, Barretos, Brazil
In this instructional video, Dr. Bernard Dallemagne demonstrated the main principles and key steps of laparoscopic pancreatectomy with the preservation of splenic vessels (Kimura technique) in a 58-year-old woman with a complex cyst of the body and tail of the pancreas. He briefly described the technical aspects and maneuvers for a better exposure and dissection of the inferior and superior border of the pancreas. He highlighted the tips and tricks for opening the gastrocolic ligament, the identification and dissection of vessels, the mobilization of the pancreas, dissection line reinforcement, and specimen removal.
B Dallemagne, S Perretta
Surgical intervention
10 months ago
4381 views
592 likes
1 comment
38:09
Laparoscopic pancreatectomy with preservation of splenic vessels: a live broadcast from IRCAD America Latina, Barretos, Brazil
In this instructional video, Dr. Bernard Dallemagne demonstrated the main principles and key steps of laparoscopic pancreatectomy with the preservation of splenic vessels (Kimura technique) in a 58-year-old woman with a complex cyst of the body and tail of the pancreas. He briefly described the technical aspects and maneuvers for a better exposure and dissection of the inferior and superior border of the pancreas. He highlighted the tips and tricks for opening the gastrocolic ligament, the identification and dissection of vessels, the mobilization of the pancreas, dissection line reinforcement, and specimen removal.
LIVE INTERACTIVE SURGERY: paraesophageal hernia repair: critical value of extrasaccular approach
Paraesophageal hernia (PEH) repair is a challenging procedure. Repositioning of the herniated stomach and the reduction of the sac from the mediastinum is mandatory in order to decrease the risk of recurrence. The dissection and reduction of the sac must be performed following stepwise and precise dissection rules: it must be carried out outside of the sac, in an anatomical cleavage plane. Recurrence is also related to the type of crural repair performed, some authors advocating the systematic use of prosthetic or biological reinforcement. In this video, we present a PEH repair and cruroplasty protected with an absorbable mesh and contemporary Nissen fundoplication.
B Dallemagne, S Perretta, M Diana, D Mutter, J Marescaux
Surgical intervention
11 months ago
4490 views
435 likes
0 comments
54:47
LIVE INTERACTIVE SURGERY: paraesophageal hernia repair: critical value of extrasaccular approach
Paraesophageal hernia (PEH) repair is a challenging procedure. Repositioning of the herniated stomach and the reduction of the sac from the mediastinum is mandatory in order to decrease the risk of recurrence. The dissection and reduction of the sac must be performed following stepwise and precise dissection rules: it must be carried out outside of the sac, in an anatomical cleavage plane. Recurrence is also related to the type of crural repair performed, some authors advocating the systematic use of prosthetic or biological reinforcement. In this video, we present a PEH repair and cruroplasty protected with an absorbable mesh and contemporary Nissen fundoplication.
LIVE INTERACTIVE SURGERY: thoracoscopic esophageal diverticulectomy and myotomy
A 65-year-old woman was referred to our hospital with complaints of dysphagia. She had a surgical history of cesarean section and cholecystectomy. Esophageal motility examination showed a normal lower esophageal sphincter (LES), and the absence of hiatal hernia and spasm in the distal part of the esophagus. The barium X-ray showed a bulky diverticulum in the middle thoracic esophagus and barium collecting inside the diverticulum without obstruction. The 3D-CT image also showed a giant diverticulum in the middle esophagus. The diverticulum was located below the azygos vein and carina of the bronchus and was sticking out from the middle esophagus in the contralateral side of the thoracic aorta. The diverticulum does not invade other organs. The patient was then proposed for an elective surgery, a thoracoscopic esophageal diverticulectomy and myotomy in a prone position.
B Dallemagne, S Perretta, D Mutter, J Marescaux
Surgical intervention
11 months ago
1081 views
111 likes
0 comments
41:44
LIVE INTERACTIVE SURGERY: thoracoscopic esophageal diverticulectomy and myotomy
A 65-year-old woman was referred to our hospital with complaints of dysphagia. She had a surgical history of cesarean section and cholecystectomy. Esophageal motility examination showed a normal lower esophageal sphincter (LES), and the absence of hiatal hernia and spasm in the distal part of the esophagus. The barium X-ray showed a bulky diverticulum in the middle thoracic esophagus and barium collecting inside the diverticulum without obstruction. The 3D-CT image also showed a giant diverticulum in the middle esophagus. The diverticulum was located below the azygos vein and carina of the bronchus and was sticking out from the middle esophagus in the contralateral side of the thoracic aorta. The diverticulum does not invade other organs. The patient was then proposed for an elective surgery, a thoracoscopic esophageal diverticulectomy and myotomy in a prone position.
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
957 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%.
Upper GI obstruction due to incarcerated recurrent hiatal hernia with mesh repair
This is the case of a 46-year-old woman with a BMI of 43 who presented to our clinic complaining of aphasia. Her past medical history is significant for a hiatal hernia repair and a diaphragmatic mesh reinforcement performed in July 2013. After surgery, she complained of dysphagia even after the three postoperative months, and the upper GI series showed a recurrence of her hiatal hernia. The dysphagia got worse, and in January 2015, a CT-scan showed a complete blockage of the gastroesophageal junction due to the herniation of the stomach. A 5-trocar technique was used, very similar to what we would use for a Nissen fundoplication.
S Perretta, B Dallemagne, D Mutter, J Marescaux
Surgical intervention
2 years ago
797 views
31 likes
0 comments
12:26
Upper GI obstruction due to incarcerated recurrent hiatal hernia with mesh repair
This is the case of a 46-year-old woman with a BMI of 43 who presented to our clinic complaining of aphasia. Her past medical history is significant for a hiatal hernia repair and a diaphragmatic mesh reinforcement performed in July 2013. After surgery, she complained of dysphagia even after the three postoperative months, and the upper GI series showed a recurrence of her hiatal hernia. The dysphagia got worse, and in January 2015, a CT-scan showed a complete blockage of the gastroesophageal junction due to the herniation of the stomach. A 5-trocar technique was used, very similar to what we would use for a Nissen fundoplication.
Type III hiatal hernia: stepwise laparoscopic treatment
The surgical treatment of type III hiatal hernia has been thoroughly standardized in the following order: extrasaccular approach, reduction of the entire sac, and esophageal mobilization in order to restore the esophagogastric anatomy. Although it is recommended to combine this with a fundoplication as most authors do, there is still controversy concerning the closure technique of the diaphragmatic defect. Some experts recommend the reinforcement of this closure by means of a synthetic mesh. It is, however, a method which does not prevent recurrence and which can also bring about complications, which can at times be disastrous. As a result, we privilege reinforcement using an absorbable mesh.
B Dallemagne, S Perretta, S Tzedakis, D Mutter, J Marescaux
Surgical intervention
3 years ago
7395 views
273 likes
1 comment
16:21
Type III hiatal hernia: stepwise laparoscopic treatment
The surgical treatment of type III hiatal hernia has been thoroughly standardized in the following order: extrasaccular approach, reduction of the entire sac, and esophageal mobilization in order to restore the esophagogastric anatomy. Although it is recommended to combine this with a fundoplication as most authors do, there is still controversy concerning the closure technique of the diaphragmatic defect. Some experts recommend the reinforcement of this closure by means of a synthetic mesh. It is, however, a method which does not prevent recurrence and which can also bring about complications, which can at times be disastrous. As a result, we privilege reinforcement using an absorbable mesh.
Laparoscopic Roux-en-Y gastric bypass redo after sleeve gastrectomy associated with intrathoracic sleeve migration
Sleeve gastrectomy is a standard procedure in bariatric surgery nowadays. However, common contraindications involve the presence of gastroesophageal reflux and hiatal hernia. Here, we present the case of a morbidly obese female patient with a past surgical history of a Nissen fundoplication reversed in 2012 because of dysphagia. A sleeve gastrectomy had been performed 2 years ago complicated by an intrathoracic migration and gastric twist as discovered in the preoperative control followed by dysphagia, reflux, and vomiting. A conversion to a Roux-en-Y gastric bypass has been decided upon.
L Marx, S Tzedakis, HA Mercoli, S Perretta, D Mutter, J Marescaux
Surgical intervention
3 years ago
1367 views
46 likes
0 comments
09:21
Laparoscopic Roux-en-Y gastric bypass redo after sleeve gastrectomy associated with intrathoracic sleeve migration
Sleeve gastrectomy is a standard procedure in bariatric surgery nowadays. However, common contraindications involve the presence of gastroesophageal reflux and hiatal hernia. Here, we present the case of a morbidly obese female patient with a past surgical history of a Nissen fundoplication reversed in 2012 because of dysphagia. A sleeve gastrectomy had been performed 2 years ago complicated by an intrathoracic migration and gastric twist as discovered in the preoperative control followed by dysphagia, reflux, and vomiting. A conversion to a Roux-en-Y gastric bypass has been decided upon.
Collis Nissen procedure after lung transplantation and laparoscopic management of mediastinal hematoma
After lung transplantation, GERD causes inflammatory reactions, increasing risks for obliterating bronchiolitis and dysfunctioning graft. Authors first present a laparoscopic Collis Nissen procedure for hiatal hernia and severe esophagitis in a grafted patient. Because of a short esophagus despite extended dissection, a Collis gastroplasty is required. After stapling, cruroplasty is performed, finally followed by a Nissen fundoplication. In case of severe esophagitis, a difficult dissection and inflammatory tissues can lead to more complications such as leak, hemorrhage, slippage, and abscess. Mediastinal hematoma is diagnosed on postoperative day 9, mandating a redo emergency intervention. This rare complication will be managed laparoscopically.
B Dallemagne, S Perretta, HA Mercoli, L Marx, J Marescaux
Surgical intervention
3 years ago
1656 views
58 likes
1 comment
21:07
Collis Nissen procedure after lung transplantation and laparoscopic management of mediastinal hematoma
After lung transplantation, GERD causes inflammatory reactions, increasing risks for obliterating bronchiolitis and dysfunctioning graft. Authors first present a laparoscopic Collis Nissen procedure for hiatal hernia and severe esophagitis in a grafted patient. Because of a short esophagus despite extended dissection, a Collis gastroplasty is required. After stapling, cruroplasty is performed, finally followed by a Nissen fundoplication. In case of severe esophagitis, a difficult dissection and inflammatory tissues can lead to more complications such as leak, hemorrhage, slippage, and abscess. Mediastinal hematoma is diagnosed on postoperative day 9, mandating a redo emergency intervention. This rare complication will be managed laparoscopically.
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.
Gf Donatelli, P Dhumane, S Perretta, BM Vergeau, JL Dumont, T Tuszynski, B Meduri
Surgical intervention
4 years ago
846 views
13 likes
0 comments
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.
Onset of internal hernia after Roux-en-Y gastric bypass: laparoscopic management
Laparoscopic Roux-en-Y gastric bypass (LRYGB) represents the gold standard of treatment for morbidly obese patients. While the laparoscopic approach offers many advantages in terms of fewer wound complications, decreased length of hospital stay, and decreased postoperative pain, certain complications of this operation present difficult clinical problems. The most challenging complication to determine is internal hernia through one of the mesenteric defects.

Internal hernias occur more frequently in LRYGB than in the open procedure. This is a significant clinical problem since internal hernia is the most common cause of small bowel obstruction (SBO) after LRYGB, which can result in ischemia or infarction and often requires a reoperation.

The incidence of SBO after LGBP is reported to be between 1.8 and 9.7%. The most common site of internal hernia after LGBP is at Petersen’s space.
In this video, we present the laparoscopic management of a complete small bowel herniation at Petersen’s space.
A D'Urso, S Perretta, M Vix, D Mutter, J Marescaux
Surgical intervention
4 years ago
1221 views
17 likes
0 comments
11:25
Onset of internal hernia after Roux-en-Y gastric bypass: laparoscopic management
Laparoscopic Roux-en-Y gastric bypass (LRYGB) represents the gold standard of treatment for morbidly obese patients. While the laparoscopic approach offers many advantages in terms of fewer wound complications, decreased length of hospital stay, and decreased postoperative pain, certain complications of this operation present difficult clinical problems. The most challenging complication to determine is internal hernia through one of the mesenteric defects.

Internal hernias occur more frequently in LRYGB than in the open procedure. This is a significant clinical problem since internal hernia is the most common cause of small bowel obstruction (SBO) after LRYGB, which can result in ischemia or infarction and often requires a reoperation.

The incidence of SBO after LGBP is reported to be between 1.8 and 9.7%. The most common site of internal hernia after LGBP is at Petersen’s space.
In this video, we present the laparoscopic management of a complete small bowel herniation at Petersen’s space.
Hybrid laparoscopic transgastric GIST resection
Gastrointestinal Stromal Tumors (GIST) are rare digestive tract tumors with an annual incidence of 6.5 to 14.5 cases per million, accounting for less than 1% of gastrointestinal tumors. They are the most common mesenchymal neoplasms with a biological behavior that is dictated by their size and histological grade and ranging between benign and malignant. They are of particular interest for being the first tumors to have a molecular targeted therapy custom made for them, Imatinib mesylate.

Surgical resection with curative intent is the primary treatment for all patients with localized and potentially resectable GIST. A complete excision of the lesion should be intended and a R0 microscopic limit verified. Minimally invasive procedures are especially of interest in order to achieve the best oncologic and functional results for the patient.

In this video, we present a hybrid endoscopic/laparoscopic excision of a gastric GIST in an elderly and frail patient. Its location in the posterior gastric wall near the lesser curvature made a local excision by laparoscopy uncertain for injury of the coronary gastric vessels. It would be also difficult to evaluate the properness of the resection margin. The procedure was safely performed by a combined surgical team working in parallel laparoscopically and endoscopically. The functional result was excellent and the pathology confirmed the complete R0 resection of the GIST.
S Perretta, D Ntourakis, J Marescaux
Surgical intervention
4 years ago
1784 views
54 likes
0 comments
06:43
Hybrid laparoscopic transgastric GIST resection
Gastrointestinal Stromal Tumors (GIST) are rare digestive tract tumors with an annual incidence of 6.5 to 14.5 cases per million, accounting for less than 1% of gastrointestinal tumors. They are the most common mesenchymal neoplasms with a biological behavior that is dictated by their size and histological grade and ranging between benign and malignant. They are of particular interest for being the first tumors to have a molecular targeted therapy custom made for them, Imatinib mesylate.

Surgical resection with curative intent is the primary treatment for all patients with localized and potentially resectable GIST. A complete excision of the lesion should be intended and a R0 microscopic limit verified. Minimally invasive procedures are especially of interest in order to achieve the best oncologic and functional results for the patient.

In this video, we present a hybrid endoscopic/laparoscopic excision of a gastric GIST in an elderly and frail patient. Its location in the posterior gastric wall near the lesser curvature made a local excision by laparoscopy uncertain for injury of the coronary gastric vessels. It would be also difficult to evaluate the properness of the resection margin. The procedure was safely performed by a combined surgical team working in parallel laparoscopically and endoscopically. The functional result was excellent and the pathology confirmed the complete R0 resection of the GIST.
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
3357 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
1961 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.
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
2719 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.
Laparoscopic stepwise approach of a tumor of the gastroesophageal junction
GISTs are rare neoplasms that account for less than 1% of all gastrointestinal malignancies. GISTs have the capability to become malignant and then metastasize, whereas leiomyomas are almost invariably benign. In clinical practice, preoperative differentiation between GISTs and leiomyomas is usually difficult, even if EUS-guided fine-needle aspiration or trucut biopsy is performed. Leiomyomas are rare in the stomach and duodenum while GIST are more frequent in the stomach.
This patient presented with a 6cm submucosal tumor below the gastroesophageal junction. This video demonstrates the stepwise laparoscopic approach taking into consideration the potentially (pre-)malignant nature of the tumor.
B Dallemagne, S Perretta, S Mandala, J Marescaux
Surgical intervention
5 years ago
1732 views
17 likes
0 comments
26:11
Laparoscopic stepwise approach of a tumor of the gastroesophageal junction
GISTs are rare neoplasms that account for less than 1% of all gastrointestinal malignancies. GISTs have the capability to become malignant and then metastasize, whereas leiomyomas are almost invariably benign. In clinical practice, preoperative differentiation between GISTs and leiomyomas is usually difficult, even if EUS-guided fine-needle aspiration or trucut biopsy is performed. Leiomyomas are rare in the stomach and duodenum while GIST are more frequent in the stomach.
This patient presented with a 6cm submucosal tumor below the gastroesophageal junction. This video demonstrates the stepwise laparoscopic approach taking into consideration the potentially (pre-)malignant nature of the tumor.
Challenges in GERD: Collis fundoplication in a patient with a BMI of 41
Obesity has long been considered a predisposing factor for gastroesophageal reflux. It is also thought to predispose patients to a poorer clinical outcome following antireflux surgery and some authors recommend gastric bypass in obese patient with symptomatic GERD. However, some studies reported that preoperative BMI does not influence the clinical outcome following laparoscopic antireflux surgery and concluded that obesity is not a contraindication for laparoscopic fundoplication (1, 2).
In this video, we present a Collis-Toupet gastroplasty in a woman with a BMI of 41.
References:
1. Winslow ER, Frisella MM, Soper NJ, Klingensmith ME. Obesity does not adversely affect the outcome of laparoscopic antireflux surgery (LARS). Surgical Endoscopy 2003;17:2003-11.
2. Chisholm JA, Jamieson GG, Lally CJ, Devitt PG, Game PA, Watson DI. The effect of obesity on the outcome of laparoscopic antireflux surgery. J Gastrointest Surg 2009;13:1064-70.
B Dallemagne, S Perretta, J Marescaux
Surgical intervention
5 years ago
1519 views
27 likes
0 comments
25:13
Challenges in GERD: Collis fundoplication in a patient with a BMI of 41
Obesity has long been considered a predisposing factor for gastroesophageal reflux. It is also thought to predispose patients to a poorer clinical outcome following antireflux surgery and some authors recommend gastric bypass in obese patient with symptomatic GERD. However, some studies reported that preoperative BMI does not influence the clinical outcome following laparoscopic antireflux surgery and concluded that obesity is not a contraindication for laparoscopic fundoplication (1, 2).
In this video, we present a Collis-Toupet gastroplasty in a woman with a BMI of 41.
References:
1. Winslow ER, Frisella MM, Soper NJ, Klingensmith ME. Obesity does not adversely affect the outcome of laparoscopic antireflux surgery (LARS). Surgical Endoscopy 2003;17:2003-11.
2. Chisholm JA, Jamieson GG, Lally CJ, Devitt PG, Game PA, Watson DI. The effect of obesity on the outcome of laparoscopic antireflux surgery. J Gastrointest Surg 2009;13:1064-70.
Second reoperative antireflux procedure for valve slippage
Redo surgery is technically more demanding than primary fundoplication. In addition, anatomical defects that caused failure may increase technical difficulties. A recent review found that the average success rate after laparoscopic redo operations ranged from 65 to 100 per cent (van Beek D, Auyang E, Soper N. A comprehensive review of laparoscopic redo fundoplication. Surgical Endoscopy: Springer New York; 2010. p 1-7). However, our recent study showed that the failure rate after re-operation is increasing with time, and highlighted the need for accurate preoperative and intraoperative assessment of the causes of failure (Dallemagne B, Arenas Sanchez M, Francart D, Perretta S, Weerts J, Markiewicz S, et al. Long-term results after laparoscopic reoperation for failed antireflux procedures. Br J Surg 2011;98:1581-7). This video shows a third antireflux procedure in a patient presenting with slippage of the fundoplication.
B Dallemagne, S Perretta, J D'Agostino, J Marescaux
Surgical intervention
6 years ago
1379 views
15 likes
0 comments
29:04
Second reoperative antireflux procedure for valve slippage
Redo surgery is technically more demanding than primary fundoplication. In addition, anatomical defects that caused failure may increase technical difficulties. A recent review found that the average success rate after laparoscopic redo operations ranged from 65 to 100 per cent (van Beek D, Auyang E, Soper N. A comprehensive review of laparoscopic redo fundoplication. Surgical Endoscopy: Springer New York; 2010. p 1-7). However, our recent study showed that the failure rate after re-operation is increasing with time, and highlighted the need for accurate preoperative and intraoperative assessment of the causes of failure (Dallemagne B, Arenas Sanchez M, Francart D, Perretta S, Weerts J, Markiewicz S, et al. Long-term results after laparoscopic reoperation for failed antireflux procedures. Br J Surg 2011;98:1581-7). This video shows a third antireflux procedure in a patient presenting with slippage of the fundoplication.
Management of persisting dysphagia after laparoscopic Nissen fundoplication
Dysphagia is a normal observation after fundoplication for GERD. It usually lasts for 4 to 6 weeks and results from esophageal motility disorders related to the esophageal dissection and to the outlet obstruction created by the fundoplication. It is managed by appropriate diet. When dysphagia persists after 3 months, there is some concern and need for objective evaluation. This video shows the management of this type of persisting dysphagia after laparoscopic Nissen fundoplication, during which a big hematoma developed on the wrap. This usually does not lead to any long-term problems but, in this patient, dysphagia persisted over a 3-month period of time and led to re-operation.
B Dallemagne, S Perretta, T Piardi, J Marescaux
Surgical intervention
6 years ago
1783 views
23 likes
0 comments
18:17
Management of persisting dysphagia after laparoscopic Nissen fundoplication
Dysphagia is a normal observation after fundoplication for GERD. It usually lasts for 4 to 6 weeks and results from esophageal motility disorders related to the esophageal dissection and to the outlet obstruction created by the fundoplication. It is managed by appropriate diet. When dysphagia persists after 3 months, there is some concern and need for objective evaluation. This video shows the management of this type of persisting dysphagia after laparoscopic Nissen fundoplication, during which a big hematoma developed on the wrap. This usually does not lead to any long-term problems but, in this patient, dysphagia persisted over a 3-month period of time and led to re-operation.
Laparoscopic repair of giant type 4 paraesophageal hernia
Type 4 giant hiatal hernias are not common. The stomach is herniated, as well as viscera in the mediastinum, colon, spleen, and even sometimes in the pancreas. Repair is challenging for different reasons. This type of hernia is frequent in older and fragile patients. Reduction of the sac from the mediastinum is mandatory and must be carried out following stepwise and precise dissection rules: it has to be done outside of the sac, in an anatomical cleavage plane. Crural repair is challenging and must be tailored on the quality of the diaphragmatic musculature and size of the orifice. Anti-reflux repair must be performed as well. The laparoscopic approach has radically improved the clinical outcome of this procedure in old patients.
B Dallemagne, E Marzano, S Perretta, J Marescaux
Surgical intervention
6 years ago
4622 views
78 likes
0 comments
21:43
Laparoscopic repair of giant type 4 paraesophageal hernia
Type 4 giant hiatal hernias are not common. The stomach is herniated, as well as viscera in the mediastinum, colon, spleen, and even sometimes in the pancreas. Repair is challenging for different reasons. This type of hernia is frequent in older and fragile patients. Reduction of the sac from the mediastinum is mandatory and must be carried out following stepwise and precise dissection rules: it has to be done outside of the sac, in an anatomical cleavage plane. Crural repair is challenging and must be tailored on the quality of the diaphragmatic musculature and size of the orifice. Anti-reflux repair must be performed as well. The laparoscopic approach has radically improved the clinical outcome of this procedure in old patients.
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.
B Dallemagne, S Perretta, Gf Donatelli, J Marescaux
Surgical intervention
6 years ago
3237 views
71 likes
0 comments
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.
Management of transpyloric invagination of a gastrointestinal stromal tumor (GIST)
Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. GISTs are most commonly found in the stomach (40-70%), but can occur in all other parts of the GI tract, with 20 to 40% of GISTs arising in the small intestine and 5 to 15% from the colon and rectum.
They typically grow endophytically, parallel to the bowel lumen, commonly with overlying mucosal necrosis and ulceration. They also vary in size, from a few millimeters to 40cm in diameter. Many GISTs are well defined by a thin pseudo-capsule.
Over 95% of patients present with a solitary primary tumor, and in 10 to 40% of these cases, the tumor directly invades neighboring organs. Gastric GISTs are usually presented with GI bleeding and abdominal pain. However, most patients are symptom-free and the lesions are discovered incidentally during an upper endoscopy performed for other reasons (chronic abdominal pain and intermittent gastric obstruction in this patient).
Surgery remains the mainstay of curative treatment.
Surgical resection of localized gastric GISTs is the preferred treatment modality, as resection of the tumor renders the only chance for cure at this time. Historically, a 1 to 2cm margin was thought to be necessary for an adequate resection. However, more recently, DeMatteo et al. demonstrated that tumor size and not negative microscopic surgical margins determine survival.
It is therefore accepted that the surgical goal should be a complete resection with gross negative margins only.
Given this, wedge resection has been advocated by many investigators for the majority of gastric GISTs.
J D'Agostino, Gf Donatelli, S Perretta, J Marescaux
Surgical intervention
6 years ago
2065 views
19 likes
0 comments
04:15
Management of transpyloric invagination of a gastrointestinal stromal tumor (GIST)
Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. GISTs are most commonly found in the stomach (40-70%), but can occur in all other parts of the GI tract, with 20 to 40% of GISTs arising in the small intestine and 5 to 15% from the colon and rectum.
They typically grow endophytically, parallel to the bowel lumen, commonly with overlying mucosal necrosis and ulceration. They also vary in size, from a few millimeters to 40cm in diameter. Many GISTs are well defined by a thin pseudo-capsule.
Over 95% of patients present with a solitary primary tumor, and in 10 to 40% of these cases, the tumor directly invades neighboring organs. Gastric GISTs are usually presented with GI bleeding and abdominal pain. However, most patients are symptom-free and the lesions are discovered incidentally during an upper endoscopy performed for other reasons (chronic abdominal pain and intermittent gastric obstruction in this patient).
Surgery remains the mainstay of curative treatment.
Surgical resection of localized gastric GISTs is the preferred treatment modality, as resection of the tumor renders the only chance for cure at this time. Historically, a 1 to 2cm margin was thought to be necessary for an adequate resection. However, more recently, DeMatteo et al. demonstrated that tumor size and not negative microscopic surgical margins determine survival.
It is therefore accepted that the surgical goal should be a complete resection with gross negative margins only.
Given this, wedge resection has been advocated by many investigators for the majority of gastric GISTs.
Management of a hiatal hernia during laparoscopic Roux-en-Y gastric bypass: be ready to repair
Here we show the case of a 44-year-old woman with a BMI of 40.5 and a history of gastroesophageal reflux disease. She was presented for a weight reductive surgery evaluation. Preoperative esophagogastroduodenoscopy, barium swallow and esophageal high resolution manometry were performed. They demonstrated a 3cm hiatal hernia as well as a hypotensive lower esophageal sphincter.
The presence of a large hiatal hernia (greater than 5cm) is problematic and may prevent successful weight reductive surgery. Laparoscopic Roux-en-Y gastric bypass is an effective procedure to control symptoms and GERD complications in morbidly obese patients. For this reason, Roux-en-Y gastric bypass is a valid alternative to manage morbidly obese patients with symptomatic hiatal hernia and GERD.
Bsed on the preoperative work-up, decision was made to perform a concomitant paraesophageal hernia repair and a laparoscopic Roux-en-Y gastric bypass.
S Perretta, J Marescaux
Surgical intervention
6 years ago
1765 views
14 likes
0 comments
14:28
Management of a hiatal hernia during laparoscopic Roux-en-Y gastric bypass: be ready to repair
Here we show the case of a 44-year-old woman with a BMI of 40.5 and a history of gastroesophageal reflux disease. She was presented for a weight reductive surgery evaluation. Preoperative esophagogastroduodenoscopy, barium swallow and esophageal high resolution manometry were performed. They demonstrated a 3cm hiatal hernia as well as a hypotensive lower esophageal sphincter.
The presence of a large hiatal hernia (greater than 5cm) is problematic and may prevent successful weight reductive surgery. Laparoscopic Roux-en-Y gastric bypass is an effective procedure to control symptoms and GERD complications in morbidly obese patients. For this reason, Roux-en-Y gastric bypass is a valid alternative to manage morbidly obese patients with symptomatic hiatal hernia and GERD.
Bsed on the preoperative work-up, decision was made to perform a concomitant paraesophageal hernia repair and a laparoscopic Roux-en-Y gastric bypass.
Right colon Dieulafoy's lesion: endoscopic treatment
A 78-year-old man presenting with chronic renal failure was admitted to the emergency department of our hospital for bleeding per rectum.
The hemoglobin level was 10.5 g/dL on admission. Given that the patient was hemodynamically stable, decision was made to perform an upper GI endoscopy and a total colonoscopy the following day after standard bowel preparation. Bleeding recurred during the night with a hemoglobin drop to 6.3g/dL, requiring transfusions of 3 Units of blood.
With no further delay, endoscopy was performed. The gastroscopy was normal but at colonoscopy old blood was visualized in the rectum, the sigmoid, and the left and transverse colon. Additional bright red blood was observed at the level of the right colon.
Gf Donatelli, S Perretta, B Dallemagne
Surgical intervention
7 years ago
1568 views
16 likes
1 comment
02:32
Right colon Dieulafoy's lesion: endoscopic treatment
A 78-year-old man presenting with chronic renal failure was admitted to the emergency department of our hospital for bleeding per rectum.
The hemoglobin level was 10.5 g/dL on admission. Given that the patient was hemodynamically stable, decision was made to perform an upper GI endoscopy and a total colonoscopy the following day after standard bowel preparation. Bleeding recurred during the night with a hemoglobin drop to 6.3g/dL, requiring transfusions of 3 Units of blood.
With no further delay, endoscopy was performed. The gastroscopy was normal but at colonoscopy old blood was visualized in the rectum, the sigmoid, and the left and transverse colon. Additional bright red blood was observed at the level of the right colon.
MRI lymphography for esophageal sentinel node mapping: evolution of a NOTES technique
Introduction: Natural Orifice Transluminal Endoscopic Surgery (NOTES) may render conventionally inaccessible anatomic sites accessible in a truly minimally invasive means. Having developed expertise in esophageal mural tunneling for the purposes of endoscopic Heller’s myotomy, we now cautiously explore the feasibility of a transesophageal technique for sentinel node mapping based on MRI lymphography.
Methods: two non-survival porcine models were used to demonstrate how targeted mediastinal lymph node biopsy could be performed transesophageally by a combination of endoscopic submucosal lymphatic mapping, MRI imaging and NOTES.
First, lymphatic mapping of the area of interest is performed by injecting 2mls of methylene blue submucosally using a standard gastroscope inserted into the distal esophagus. This suspension of small molecular size dye particles is rapidly taken up by the submucosal lymphatic efferents and transported to the first echelon draining lymph nodes which are then detectable by their blue discoloration.
After a few minutes, the endoscope is withdrawn proximally to this injection site and a mucosal incision made 15cm from the EGJ to allow creation of a submucosal tunnel using a biliary soft tipped dilatation balloon. This along with the pressure of endoscopic CO2 insufflation allows a space to be formed within the esophageal wall. A second staggered incision then allows exit of the endoscope into the mediastinum proper. Once in this anatomic space, a careful search is performed for blue discolored lymph nodes whereupon standard endoscopic dissection instruments allows selective lymphadenectomy to be performed and the salient nodes withdrawn to the exterior via to esophagotomy. The small diameter of the scope allows for easy retroflection providing good visualization even of the proximal esophagus. The last step is mucosal clip closure to reinforce the mucosal flap seal. The retrieved nodes were MRI scanned to confirm the presence of gadolinium in the dyed nodes.
In the second animal the mapping was performed as described above but instead of retrieving only the sentinel nodes an en bloc esophagogastrectomy was performed to assess the sentinel nodes basin distribution at MRI.
Results: The operative technique proved readily feasible in all its aspects with blue sentinel nodes being found around the distal esophagus. The gadolinium combined with methylene blue was found in the first draining nodes in both animals.
Conclusions: MRI imaging may provide a new tool for sentinel node basin identification, and if proved sufficiently reliable, may represent a step further towards a solely endoscopic diagnosis and resection of the primary tumor.
S Perretta, M Diana, B Dallemagne, R Cahill, J Marescaux
Surgical intervention
7 years ago
122 views
3 likes
0 comments
02:28
MRI lymphography for esophageal sentinel node mapping: evolution of a NOTES technique
Introduction: Natural Orifice Transluminal Endoscopic Surgery (NOTES) may render conventionally inaccessible anatomic sites accessible in a truly minimally invasive means. Having developed expertise in esophageal mural tunneling for the purposes of endoscopic Heller’s myotomy, we now cautiously explore the feasibility of a transesophageal technique for sentinel node mapping based on MRI lymphography.
Methods: two non-survival porcine models were used to demonstrate how targeted mediastinal lymph node biopsy could be performed transesophageally by a combination of endoscopic submucosal lymphatic mapping, MRI imaging and NOTES.
First, lymphatic mapping of the area of interest is performed by injecting 2mls of methylene blue submucosally using a standard gastroscope inserted into the distal esophagus. This suspension of small molecular size dye particles is rapidly taken up by the submucosal lymphatic efferents and transported to the first echelon draining lymph nodes which are then detectable by their blue discoloration.
After a few minutes, the endoscope is withdrawn proximally to this injection site and a mucosal incision made 15cm from the EGJ to allow creation of a submucosal tunnel using a biliary soft tipped dilatation balloon. This along with the pressure of endoscopic CO2 insufflation allows a space to be formed within the esophageal wall. A second staggered incision then allows exit of the endoscope into the mediastinum proper. Once in this anatomic space, a careful search is performed for blue discolored lymph nodes whereupon standard endoscopic dissection instruments allows selective lymphadenectomy to be performed and the salient nodes withdrawn to the exterior via to esophagotomy. The small diameter of the scope allows for easy retroflection providing good visualization even of the proximal esophagus. The last step is mucosal clip closure to reinforce the mucosal flap seal. The retrieved nodes were MRI scanned to confirm the presence of gadolinium in the dyed nodes.
In the second animal the mapping was performed as described above but instead of retrieving only the sentinel nodes an en bloc esophagogastrectomy was performed to assess the sentinel nodes basin distribution at MRI.
Results: The operative technique proved readily feasible in all its aspects with blue sentinel nodes being found around the distal esophagus. The gadolinium combined with methylene blue was found in the first draining nodes in both animals.
Conclusions: MRI imaging may provide a new tool for sentinel node basin identification, and if proved sufficiently reliable, may represent a step further towards a solely endoscopic diagnosis and resection of the primary tumor.
Collis Nissen fundoplication in a patient with Barrett's esophagus
This video demonstrates a laparoscopic Collis esophageal lengthening procedure in a 65-year-old man with a 15-year history of typical GERD symptoms and Barrett’s esophagus. The identification and surgical management of the short esophagus are discussed as well as the technical steps required for a Collis gastroplasty. Given that the most common mode of failure of a laparoscopic Nissen fundoplication is herniation of the fundoplication into the chest, as our experience increases, we recognize that reduction of the gastroesophageal junction below the diaphragmatic hiatus without tension is problematic and foreshortening of the esophagus is a real entity. Patients who have Barrett’s esophagus must be considered at risk for having a short esophagus.
B Dallemagne, S Perretta, J Marescaux
Surgical intervention
7 years ago
3344 views
86 likes
0 comments
17:25
Collis Nissen fundoplication in a patient with Barrett's esophagus
This video demonstrates a laparoscopic Collis esophageal lengthening procedure in a 65-year-old man with a 15-year history of typical GERD symptoms and Barrett’s esophagus. The identification and surgical management of the short esophagus are discussed as well as the technical steps required for a Collis gastroplasty. Given that the most common mode of failure of a laparoscopic Nissen fundoplication is herniation of the fundoplication into the chest, as our experience increases, we recognize that reduction of the gastroesophageal junction below the diaphragmatic hiatus without tension is problematic and foreshortening of the esophagus is a real entity. Patients who have Barrett’s esophagus must be considered at risk for having a short esophagus.
Laparoscopic redo Nissen for recurrent GERD not responding to PPIs
This video demonstrates a redo laparoscopic Nissen fundoplication in a 34-year-old man with recurrent gastroesophageal reflux symptoms. A first laparoscopic Nissen-Rossetti procedure was performed ten years ago, and was taken down 2 months after surgery for severe dysphagia and important weight loss.
The success rate of laparoscopic Nissen fundoplication depends on the proper creation of a floppy and symmetric wrap together with a suitable crural repair. Most failures and complications due to technical mistakes during antireflux surgeries are related to an incomplete or inadequate intraoperative evaluation of the wrap and crural repair. Development or persistence of dysphagia after fundoplication is among the most common complications occurring in up to 30% of patients. Surgical factors responsible for de novo dysphagia are mainly related to the degree, tightness, length of the fundoplication and technical errors leading to wrap misconstruction -below the anatomical gastroesophageal junction or by a distortion of the esophageal diameter and orientation at the level of the crural repair.
B Dallemagne, S Perretta, J Marescaux
Surgical intervention
7 years ago
1504 views
27 likes
0 comments
09:41
Laparoscopic redo Nissen for recurrent GERD not responding to PPIs
This video demonstrates a redo laparoscopic Nissen fundoplication in a 34-year-old man with recurrent gastroesophageal reflux symptoms. A first laparoscopic Nissen-Rossetti procedure was performed ten years ago, and was taken down 2 months after surgery for severe dysphagia and important weight loss.
The success rate of laparoscopic Nissen fundoplication depends on the proper creation of a floppy and symmetric wrap together with a suitable crural repair. Most failures and complications due to technical mistakes during antireflux surgeries are related to an incomplete or inadequate intraoperative evaluation of the wrap and crural repair. Development or persistence of dysphagia after fundoplication is among the most common complications occurring in up to 30% of patients. Surgical factors responsible for de novo dysphagia are mainly related to the degree, tightness, length of the fundoplication and technical errors leading to wrap misconstruction -below the anatomical gastroesophageal junction or by a distortion of the esophageal diameter and orientation at the level of the crural repair.
Endoscopic extraction of a giant common bile duct stone
The Endoscopic Retrograde Cholangio-Pancreatography (ERCP) has become the gold standard for the treatment of cholelithiasis with a success rate of 95%.
The dimensions of a giant biliary calculus are equal to or bigger than 2cm.
Various endoscopic tools such as the mechanical lithotripsy or extracorporeal shock wave lithotripsy (ESWL) have been described to treat this pathology. Surgery is offered to cases unresolved by endoscopic therapy.
Recently, the sphincteroplasty with a large-size balloon dilatation of the papilla has been described as an option for the endoscopic management of the giant biliary stone.
This is a case of extraction of giant common bile duct calculus using the combination of sphincterotomy and large-size balloon sphincteroplasty.
Gf Donatelli, P Dhumane, S Perretta, B Dallemagne, J Marescaux
Surgical intervention
7 years ago
2732 views
17 likes
0 comments
03:56
Endoscopic extraction of a giant common bile duct stone
The Endoscopic Retrograde Cholangio-Pancreatography (ERCP) has become the gold standard for the treatment of cholelithiasis with a success rate of 95%.
The dimensions of a giant biliary calculus are equal to or bigger than 2cm.
Various endoscopic tools such as the mechanical lithotripsy or extracorporeal shock wave lithotripsy (ESWL) have been described to treat this pathology. Surgery is offered to cases unresolved by endoscopic therapy.
Recently, the sphincteroplasty with a large-size balloon dilatation of the papilla has been described as an option for the endoscopic management of the giant biliary stone.
This is a case of extraction of giant common bile duct calculus using the combination of sphincterotomy and large-size balloon sphincteroplasty.
Tips 'n tricks: successful ERCP in the presence of periampullary diverticula
Duodenal diverticula are found in approximately 10-20% of patients undergoing Endoscopic Retrograde Cholangio-Pancreatography (ERCP).
Usually, these diverticula lie within 2cm of the major duodenal papilla and are called juxtapapillary diverticula. They are mostly acquired and their incidence increases with age.
Juxtapapillary diverticula have often been associated with mechanical compression and they are also involved in Oddi’s sphincter dysfunction. The presence of juxtapapillary diverticula is known to influence the outcome of ERCP procedure by making it more difficult and causing some complications like bleeding. Various techniques have been advised for a more successful ERCP outcome
In this video, four cases of duodenal diverticula are presented to provide tips and tricks for the successful cannulation of the CBD and management of periampullary bleeding in case they occur.
Gf Donatelli, P Dhumane, S Perretta, B Dallemagne, J Marescaux
Surgical intervention
7 years ago
2036 views
10 likes
0 comments
09:19
Tips 'n tricks: successful ERCP in the presence of periampullary diverticula
Duodenal diverticula are found in approximately 10-20% of patients undergoing Endoscopic Retrograde Cholangio-Pancreatography (ERCP).
Usually, these diverticula lie within 2cm of the major duodenal papilla and are called juxtapapillary diverticula. They are mostly acquired and their incidence increases with age.
Juxtapapillary diverticula have often been associated with mechanical compression and they are also involved in Oddi’s sphincter dysfunction. The presence of juxtapapillary diverticula is known to influence the outcome of ERCP procedure by making it more difficult and causing some complications like bleeding. Various techniques have been advised for a more successful ERCP outcome
In this video, four cases of duodenal diverticula are presented to provide tips and tricks for the successful cannulation of the CBD and management of periampullary bleeding in case they occur.
Small sphincterotomy and balloon sphincteroplasty for extraction of a common bile duct stone in a patient with juxtapapillary diverticulum
Duodenal diverticula have a prevalence of 9 to 32%. Usually, they are within 2cm of the major duodenal papilla and for that are called juxtapapillary diverticula. They are acquired and their incidence increases with age. Biliary and pancreatic disease is often associated with juxtapapillary diverticula, in particular common bile duct stones. They are directly associated with the outcome of Endoscopic Retrograde Cholangio-Pancreatography (due to the complexity of cannulation) and with an increased rate of complications, in particular bleeding. Various techniques are described to increase the success rate, such as clip-assisted biliary cannulation, endoscopic ultrasound-guided bile duct access, main pancreatic duct stent placement followed by pre-cut biliary sphincterotomy. The success rate, independently of these techniques, varies from 61% to 95%.
In this video, we show a case of a patient with angiocholitis secondary to choledocholithiasis, and several cardiovascular co-morbidities, having the papilla of Vater on the edge of a diverticulum. A small sphincterotomy was performed as shown and then bleeding risk was evaluated (the patient being on anticoagulants) and because of the important size of the impacted stone, a sphincteroplasty with dilatation of the papilla with a balloon expanded to 15mm was performed, along with stone extraction using a Dormia basket.
The patient was discharged on postoperative day 2 with normal liver function tests and no inflammation.
Gf Donatelli, C Callari, S Perretta, B Dallemagne
Surgical intervention
8 years ago
1309 views
19 likes
0 comments
05:50
Small sphincterotomy and balloon sphincteroplasty for extraction of a common bile duct stone in a patient with juxtapapillary diverticulum
Duodenal diverticula have a prevalence of 9 to 32%. Usually, they are within 2cm of the major duodenal papilla and for that are called juxtapapillary diverticula. They are acquired and their incidence increases with age. Biliary and pancreatic disease is often associated with juxtapapillary diverticula, in particular common bile duct stones. They are directly associated with the outcome of Endoscopic Retrograde Cholangio-Pancreatography (due to the complexity of cannulation) and with an increased rate of complications, in particular bleeding. Various techniques are described to increase the success rate, such as clip-assisted biliary cannulation, endoscopic ultrasound-guided bile duct access, main pancreatic duct stent placement followed by pre-cut biliary sphincterotomy. The success rate, independently of these techniques, varies from 61% to 95%.
In this video, we show a case of a patient with angiocholitis secondary to choledocholithiasis, and several cardiovascular co-morbidities, having the papilla of Vater on the edge of a diverticulum. A small sphincterotomy was performed as shown and then bleeding risk was evaluated (the patient being on anticoagulants) and because of the important size of the impacted stone, a sphincteroplasty with dilatation of the papilla with a balloon expanded to 15mm was performed, along with stone extraction using a Dormia basket.
The patient was discharged on postoperative day 2 with normal liver function tests and no inflammation.
Heller myotomy and intraluminal fundoplication: a NOTES technique
Background and study aims: It is generally accepted that the most effective method of treating achalasia is a surgical myotomy. Nevertheless, if a myotomy alone is performed, reflux may occur in up to 50% of patients. This video demonstrates a transoral incisionless stepwise approach to both esophageal Heller myotomy and partial fundoplication.
Materials and methods: The first step in this experiment consisted in creating the esophageal myotomy. Under general anesthesia, with the pig supine, endoscopy was performed to assess the location of the EGJ. The mucosa on the right postero-lateral esophageal wall was cut with the needle-knife 15cm above the LES. The initial incision was dilated with blunt dissection and the scope eased into the submucosal space. A submucosal tunnel was created with the assistance of CO2 and blunt dissection and extended distally toward the LES. Once the GEJ was clearly identified, the muscular layer was incised in a distal-to-proximal fashion using the IT knife. The scope was then withdrawn back into the lumen and the mucosal flap sealed by the application of endoscopic clips. The adequacy of endoscopic myotomy was evaluated assessing manometric lower esophageal sphincter (LES) profile and postoperative LES pressure fall and evaluated by comparing the EGJ diameter and volume profile before, after and during the division of the esophageal muscular fibers using the Functional Lumen Imaging Probe "endoflip”. The second step of the treatment consisted in building a transoral incisionless fundoplication. Four weeks later, a gastroesophageal valve was created endoscopically using the EsophyX device (EsophyX™, EndoGastric Solutions).
Results: Both Heller myotomy and subsequent endoscopic fundoplication were successfully accomplished with an operative time of 45 min and 20 min respectively. No injury to the esophagus or breach of the esophageal mucosa occurred.
Conclusions: A stepwise transoral incisionless approach to esophageal Heller myotomy and partial fundoplication is feasible in the porcine model.
S Perretta, P Allemann, B Dallemagne, A Lobontiu, D Coumaros, J Marescaux
Surgical intervention
8 years ago
434 views
7 likes
0 comments
04:53
Heller myotomy and intraluminal fundoplication: a NOTES technique
Background and study aims: It is generally accepted that the most effective method of treating achalasia is a surgical myotomy. Nevertheless, if a myotomy alone is performed, reflux may occur in up to 50% of patients. This video demonstrates a transoral incisionless stepwise approach to both esophageal Heller myotomy and partial fundoplication.
Materials and methods: The first step in this experiment consisted in creating the esophageal myotomy. Under general anesthesia, with the pig supine, endoscopy was performed to assess the location of the EGJ. The mucosa on the right postero-lateral esophageal wall was cut with the needle-knife 15cm above the LES. The initial incision was dilated with blunt dissection and the scope eased into the submucosal space. A submucosal tunnel was created with the assistance of CO2 and blunt dissection and extended distally toward the LES. Once the GEJ was clearly identified, the muscular layer was incised in a distal-to-proximal fashion using the IT knife. The scope was then withdrawn back into the lumen and the mucosal flap sealed by the application of endoscopic clips. The adequacy of endoscopic myotomy was evaluated assessing manometric lower esophageal sphincter (LES) profile and postoperative LES pressure fall and evaluated by comparing the EGJ diameter and volume profile before, after and during the division of the esophageal muscular fibers using the Functional Lumen Imaging Probe "endoflip”. The second step of the treatment consisted in building a transoral incisionless fundoplication. Four weeks later, a gastroesophageal valve was created endoscopically using the EsophyX device (EsophyX™, EndoGastric Solutions).
Results: Both Heller myotomy and subsequent endoscopic fundoplication were successfully accomplished with an operative time of 45 min and 20 min respectively. No injury to the esophagus or breach of the esophageal mucosa occurred.
Conclusions: A stepwise transoral incisionless approach to esophageal Heller myotomy and partial fundoplication is feasible in the porcine model.
Emergency endoscopic removal of intragastric balloon for hematemesis and melena
The BioEnterics® Intragastric Balloon (BIB®) System has been developed as a temporary aid to achieve weight loss in obese people that are 40% or more above their optimal weight, in patients who have had unsatisfactory results in their treatment of morbid obesity despite being cared for by a multidisciplinary team, and in superobese patients for whom surgery is often associated with high risks. The BIB® reduces the volume of the stomach and leads to a premature feeling of satiety. The placement and removal of the BIB® is an interventional endoscopic procedure and the balloon is designed to float freely inside the stomach; its size can be changed during the placement.
The technique has absolute contraindications such as voluminous hiatus hernia, abnormalities of the pharynx and esophagus, esophageal varicose veins, use of anti-inflammatory or anti-coagulant drugs, pregnancy and psychiatric disorders. Relative contraindications are esophagitis, ulceration and acute lesions of the gastric mucous membrane. The complications of the BIB® are related to the endoscopic method itself, to sedation and perforation, to its prolonged contact with the mucous membrane and its migration, which may result in esophageal or intestinal obstruction (1). The patients must be clinically supervised during the BIB® placement. Complications and symptoms, such as esophageal injury and vomiting due to BIB® slippage must be described to the patient, along with the possibility that the BIB® may require early endoscopic removal. Since the BIB® works as an artificial bezoar, the patients usually show a maximal reduction in ingestion around the fourth week, and return to normal after 12 weeks.

(1) Mathus-Vliegen EMH. Efficacy of bioenterics intragastric balloon treatment in a prospective 2 years follow-up study. Presented at the Eighth European Congress on Obesity; 1997 Aug. Dublin, Ireland: European Congress on Obesity, 1997.
Gf Donatelli, C Callari, S Perretta, B Dallemagne
Surgical intervention
8 years ago
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Emergency endoscopic removal of intragastric balloon for hematemesis and melena
The BioEnterics® Intragastric Balloon (BIB®) System has been developed as a temporary aid to achieve weight loss in obese people that are 40% or more above their optimal weight, in patients who have had unsatisfactory results in their treatment of morbid obesity despite being cared for by a multidisciplinary team, and in superobese patients for whom surgery is often associated with high risks. The BIB® reduces the volume of the stomach and leads to a premature feeling of satiety. The placement and removal of the BIB® is an interventional endoscopic procedure and the balloon is designed to float freely inside the stomach; its size can be changed during the placement.
The technique has absolute contraindications such as voluminous hiatus hernia, abnormalities of the pharynx and esophagus, esophageal varicose veins, use of anti-inflammatory or anti-coagulant drugs, pregnancy and psychiatric disorders. Relative contraindications are esophagitis, ulceration and acute lesions of the gastric mucous membrane. The complications of the BIB® are related to the endoscopic method itself, to sedation and perforation, to its prolonged contact with the mucous membrane and its migration, which may result in esophageal or intestinal obstruction (1). The patients must be clinically supervised during the BIB® placement. Complications and symptoms, such as esophageal injury and vomiting due to BIB® slippage must be described to the patient, along with the possibility that the BIB® may require early endoscopic removal. Since the BIB® works as an artificial bezoar, the patients usually show a maximal reduction in ingestion around the fourth week, and return to normal after 12 weeks.

(1) Mathus-Vliegen EMH. Efficacy of bioenterics intragastric balloon treatment in a prospective 2 years follow-up study. Presented at the Eighth European Congress on Obesity; 1997 Aug. Dublin, Ireland: European Congress on Obesity, 1997.