Monthly publications

Gastric remnant cancer affects about one in twenty patients who have undergone partial gastrectomy as a treatment for early gastric cancer. In this video, we demonstrate the indications for the procedure, and the outcomes of laparoscopic completion gastrectomy for cancer of the gastric remnant.

Zenker’s diverticulum (ZD) is an abnormal hypopharyngeal pouch often presenting with dysphagia. Treatment is often sought with an invasive surgical management of the diverticulum. Nowadays, treatment is usually provided using a less invasive trans-oral technique with a rigid endoscope. In this authoritative lecture, Dr. Costamagna presents his technique and his experience.

Gastric band erosion is one of the most dreaded complications of this bariatric procedure. Endoscopic removal of a migrated band seems to be an effective and safe method for band erosion. In this key lecture, Dr. Galvao Neto outlines his experience with this endoscopic treatment.

In this key lecture, Dr. Lee Swanström presents the endoscopic approach to benign strictures, leaks and fistulas.

In this key lecture, Dr. Inoue outlines his large experience in endoluminal minimally invasive gastrointestinal procedures.

Roux-en-Y gastric bypass (RYGB) is the gold standard bariatric operation. However, substantial weight regain represents a major concern in late follow-up. In this key lecture, Dr. Galvao Neto defines the current indications for additional procedure after weight regain as well as the different endoscopic approaches available.

Sleeve gastrectomy appears as an easy procedure. However, some complications are challenging to manage, and in particular postopertive fistulas. In this key lecture, Dr. Galvao Neto outlines the endoscopic options for treating this major complication.

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%.

Chromoendoscopy is a procedure where dyes are instilled in the gastrointestinal tract at the time of visualization with endoscopy. It enhances the characterization of the tissues. The most common applications are as follows:
- Identification of squamous cell carcinoma or dysplasia;
- Identification of Barrett’s esophagus;
- Detection of early gastric cancer;
- Characterization of colonic polyps;
- Screening.
BARRX™ is a radiofrequency ablation of the metaplastic esophageal mucosa. The concept is to resect the epithelium and the muscularis mucosa without damaging the submucosa. It reduces the risk of developing carcinoma.

Argon Plasma Coagulation (APC) is an innovative non-invasive endoscopic treatment used to reduce the anastomotic diameter.
Technology: Argon gas is used to deliver evenly distributed thermal energy to a field of tissue close to the probe. The heat which is generated devitalizes, coagulates, desiccates, and shrinks the tissue.
Argon Plasma Coagulation is performed by applications of 0.5 to 2 seconds in duration. The depth of penetration is around 2 to 3mm.
Side effects: gaseous distension, pain, stricture, bleeding, pneumoperitoneum, and rarely perforation.

Barrett’s esophagus is a metaplastic change in the lining mucosa of the esophagus in response to chronic GERD. The hallmark of specialized Barrett’s epithelium is mucus-secreting goblet cells (intestinal metaplasia). There is an increased risk of adenocarcinoma with intestinal metaplasia. BARRX™ is a new treatment option for Barrett’s esophagus which uses Radio frequency energy and minimizes the risk of developing cancer.
Radio frequency energy is delivered via a catheter to the esophagus, lasts less than a second and creates superficial injury to the mucosa.
Principle: To deliver high power (approx. 300 Watts) in a short period of time. This will allow the depth of penetration to ablate the epithelium and the muscularis mucosa without injuring the submucosa. Overall results are excellent with elimination of dysplasia in 80% of patients and stricture rate to less than 6%.
Side effects: chest pain following the procedure, which can be treated with analgesics.
Bleeding, infection, and perforation requiring surgery are some of the rare complications.
Follow-up: endoscopy at 3 months and ablation repeated if required.

In this lecture, Dr. Diemunsch details the application of a rigid videolaryngoscopy flexible fibrescopy intubation under general anesthesia.

Despite steady advances in anesthetic and surgical techniques over the years, postoperative complications remain one of the major drawbacks of surgery, not only for the specific patient involved but also for surgical care team and the health care system in general. The progressive understanding of the physiological basis of surgical injury has been the rationale for the research efforts of interdisciplinary teams, incorporating surgeons, anesthesiologists and nurses, physical therapists and others to minimize surgical stress response and thereby improve outcomes. This presentation will identify the various elements of the enhanced recovery protocol (ERP), understand the physiologic rationalization of enhanced recovery strategy, the role of ventilation and anesthesia on the impact of ERP, ascertain the impact of ERP on improving patient outcome and how to implement ERP in community hospitals or major academic medical centers.

Mitochondrial number and function are altered in response to external stimuli. In this lecture, Dr. Pottecher outlines mitochondrial respiration, dysfunction during sepsis, and protection against infrared radiation (IR).

The insertion of an endotracheal tube and the institution of positive pressure ventilation remain key in intensive care medicine. In this lecture, Dr. Ricard presents this approach and his experience.

Background: Transumbilical single access laparoscopy (TSAL) has gained interest over the last decade. However, in bariatric surgery, it still remains difficult due to the fact that the umbilicus is not a landmark, and it is frequently localized too far from the operative field. In selected patients, it can be considered and offered.
Video: A 29-year-old morbidly obese woman with a BMI of 40 underwent TSAL sleeve gastrectomy. Two reusable ports and curved reusable instruments according to DAPRI (Karl Storz Endoskope, Tuttlingen, Germany) were placed in the umbilicus. The chosen method to perform sleeve gastrectomy was a medial-to-lateral approach (gastric division followed by greater curvature mobilization), and the resection of the gastric antrum. Gastric division was performed under the control of a long, rigid, 30-degree scope (Karl Storz). To expose the hiatal region and the angle of His, a 1.8mm trocarless grasping forceps according to DAPRI (Karl Storz) was inserted underneath the xiphoid process and placed against the diaphragm below the left liver lobe. Some absorbable sutures between the staple lines were finally placed, and no drain was left into the abdominal cavity. The specimen was removed transumbilically, after joining the three used windows together at the umbilical aponeurosis.
Results: Laparoscopy took 94 minutes and perioperative bleeding was 30cc. Umbilical scar length was 25mm. No postoperative complications were noted and the patient was discharged on postoperative day 4.
Conclusions: TSAL sleeve gastrectomy can be offered to selected obese patients. The use of reusable material and curved tools make it possible not to increase the cost of the procedure due to TSAL, and to establish intracorporeal and extracorporeal working triangulation.

This video shows the clinical case of a high-grade serous vaginal adenocarcinoma, FIGO stage I located on the upper third (vaginal vault) and treated by laparoscopy. We performed a radical colpectomy and pelvic lymphadenectomy, with a nerve-sparing approach. This video demonstrates how to perform oncological surgery laparoscopically, decreasing the risk of dissemination. It also highlights several steps of parametrectomy after developing oncological spaces.

Sacrocolpopexy is considered the gold standard in the treatment of pelvic organ prolapse (POP). The technique described may be an alternative to sacrocolpopexy, especially in patients with a difficult access to the promontory. It is indicated for cystocele associated with hysterocele and also for pure hysterocele. The technique is efficient in a uterus-conserving approach, reproducible, and safe.

In this key lecture, Dr. Rösch outlines the current results of some of the most performed endoscopic prcedures.

In this key lecture, Dr. Cohen covers the arthroscopic interposition strategy for basal joint arthritis.

In this key lecture, Dr. Garret focuses on dorsal ganglion, which is more than a normal pathology according to him.

The triangular fibrocartilage complex (TFCC) is often torn during sport injury in torsion.
Sometimes, the foveal attachment of the TFCC is detached. This video shows one of the technique available. The objective is to re-attach the TFCC into the foveal area of the ulna, with the help of an absorbable micro-anchor, using a trick in order to achieve two fixations with only one suture.

In this key lecture, Dr. Atzei outlines TFCC tears looking into classification and treatment.

In this key lecture, Dr. Camus looks into the management of associated lesions in distal radius fractures

In this key lecture, Dr. Ho outlines arthroscopic bone grafting (ABG) in scaphoid non-union.

Although the overall morbidity is lower after a VATS lobectomy than after an open lobectomy, there are some intraoperative complications, some of them serious, which deserve to be known. Dr. Herbert Decaluwe presents these complications and the initial results of a European survey.

As vascular injuries represent the most frequent intraoperative complications of VATS lobectomies, knowing how to prevent and manage them is crucial. Benefiting from such an impressive experience, Dr. Tadasu Kohno presents tips and tricks for thoracoscopic vascular control.

One of the limitations of VATS lobectomies is exposure, as the surgeon cannot use his/her hands and conventional retracting devices. Dr. Dominique Gossot outlines the tricks used during full thoracoscopic lobectomies in order to achieve a perfect exposure.

Approaching the fissure for vascular dissection is considered difficult, especially when it is fused. Dr. William Walker who performs most of his VATS lobectomies with dissection of the fissure exposes every tip for a safe and efficient technique.

Dr. Rene Petersen presents the main steps and technical aspects of thoracoscopic middle lobectomy using an anterior approach.

VATS sleeve lobectomies are still a challenging procedure and are not mastered by many teams. Professor Sanghoon Jheon provides an excellent overview of this technique with amazing pictures.