Gianfranco Donatelli

Transoral endoscopic esophageal myotomy based on esophageal function testing in a survival porcine model

BACKGROUND The most effective treatment of achalasia is Heller myotomy. OBJECTIVE To explore a submucosal endoscopic myotomy technique tailored on esophageal physiology testing and to compare it with the open technique. DESIGN Prospective acute and survival comparative study in pigs (n = 12; 35 kg). SETTING University animal research center. INTERVENTION Eight acute-4 open and 4 endoscopic-myotomies followed by 4 survival endoscopic procedures. MAIN OUTCOME MEASUREMENTS Preoperative and postoperative manometry; esophagogastric junction (EGJ) distensibility before and after selective division of muscular fibers at the EGJ and after the myotomy was prolonged to a standard length by using the EndoFLIP Functional Lumen Imaging Probe (Crospon, Galway, Ireland). RESULTS All procedures were successful, with no intraoperative and postoperative complications. In the survival group, the animals recovered promptly from surgery. Postoperative manometry demonstrated a 50% drop in mean lower esophageal sphincter pressure (LESp) in the endoscopic group (mean preoperative LESp, 22.2 ± 3.3 mm Hg; mean postoperative LESp, 11.34 ± 2.7 mm Hg; P < .005) and a 69% loss in the open procedure group (mean preoperative LESp, 24.2 ± 3.2 mm Hg; mean postoperative LESp, 7.4 ± 4 mm Hg; P < .005). The EndoFLIP monitoring did not show any distensibility difference between the 2 techniques, with the main improvement occurring when the clasp circular fibers were taken. LIMITATIONS Healthy animal model; small sample. CONCLUSION Endoscopic submucosal esophageal myotomy is feasible and safe. The lack of a significant difference in EGJ distensibility between the open and endoscopic procedure is very appealing. Were it to be perfected in a human population, this endoscopic approach could suggest a new strategy in the treatment of selected achalasia patients.

Endoscopic placement of fully covered self expanding metal stents for management of post-operative foregut leaks

BACKGROUND: Fully covered self-expanding metal stent (SEMS) placement has been successfully described for the treatment of malignant and benign conditions. The aim of this study is to evaluate our experience of fully covered SEMS placement for post-operative foregut leaks. MATERIALS AND METHODS: Retrospective analysis was done for indications, outcomes and complications of SEMS placed in homogeneous population of 15 patients with post-operative foregut leaks in our tertiary-care centre from December 2008 to December 2010. Stent placement and removal, clinical and radiological evidence of leak healing, migration and other complications were the main outcomes analyzed. RESULTS: Twenty-three HANAROSTENT® SEMS were successfully placed in 14/15 patients (93%) with post-operative foregut leaks for an average duration of 28.73 days (range=1-42 days) per patient and 18.73 days per SEMS. Three (20%) patients needed to be re-stented for persistent leaks ultimately resulting in leak closure. Total 5/15 (33.33%) patients and 7/23 (30.43%) stents showed migration; 5/7 (71.42%) migrated stents could be retrieved endoscopically. There were mucosal ulceration in 2/15 (13.33%) and pain in 1/15 (6.66%) patients. CONCLUSIONS: Stenting with SEMS seems to be a feasible option as a primary care modality for patients with post-operative foregut leaks.

Transgastric cholecystectomy: From the laboratory to clinical implementation.

After the first report by Kalloo et al on transgastric peritoneoscopy in pigs, it rapidly became apparent that there was no room for an under-evaluated concept and blind adoption of an appealing (r)evolution in minimal access surgery. Systematic experimental work became mandatory before any translation to the clinical setting. Choice and management of the access site, techniques of dissection, exposure, retraction and tissue approximation-sealing were the basics that needed to be evaluated before considering any surgical procedure or study of the relevance of natural orifice transluminal endoscopic surgery (NOTES). After several years of testing in experimental labs, the revolutionary concept of NOTES, is now progressively being experimented on in clinical settings. In this paper the authors analyse the challenges, limitations and solutions to assess how to move from the lab to clinical implementation of transgastric endoscopic cholecystectomy.

The fear of transgastric cholecystectomy: misinterpretation of the biliary anatomy

IntroductionPrevention of injury during cholecystectomy relies on accurate dissection of the cystic duct and artery and avoidance of major biliary and vascular structures. The advent of natural orifice translumenal surgery (NOTES) has led to a new look into the biliary anatomy, especially Calot’s triangle. Here we show the clinical case of a NOTES transgastric cholecystectomy for uncomplicated cholelithiasis, in which misinterpretation of the biliary anatomy occurred.Methods and procedureA 5-mm port was introduced at the umbilicus to ascertain the feasibility of transgastric cholecystectomy and to ensure safe gastrotomy creation and closure. Transgastric access was obtained using a percutaneous endoscopic gastrostomy (PEG)-like technique on the anterior mid body of the stomach to pass a 12-mm gastroscope (Karl Storz, Tuttlingen, Germany). The laparoscope was switched to a grasper for gallbladder retraction. Dissection was started close to the gallbladder using the endoscope at the junction between the infundibulum and what was thought to be the cystic duct. During dissection, the size and the orientation of the cystic duct appeared to be unclear. The decision was made to switch to a laparoscopic view to reorient the dissection plane and clarify the anatomy. At laparoscopy, dissection of the triangle of Calot, although started close to the gallbladder, appeared far too low. The common bile duct had been mistaken for the cystic duct. Once the biliary anatomy was clarified, the vision was switched back to the endoscope, but an additional 2-mm grasper was introduced to improve exposure while cholecystectomy was performed in a standard fashion.ConclusionsSpecific anatomic distortions due to NOTES technique together with the lack of exposure provided by current methods of retraction tend to distort Calot’s triangle by flattening it rather than opening it out. At this stage, whenever the anatomy of the biliary tract is unclear, a temporary “conversion” to a laparoscopic view, more familiar to the surgeon’s eye, is recommended.

Double‐cannulation and large papillary balloon dilation: Key to successful endoscopic treatment of mirizzi syndrome in low insertion of cystic duct

Mirizzi syndrome is a rare cause of benign biliary obstruction and is often predisposed by low insertion of the cystic duct on the common hepatic duct. Through a case series of three patients, we emphasize the importance of double cannulation (cystic duct and hepatic duct) followed by sphincterotomy and large balloon papillary dilatation for successful endoscopic stone clearance in such patients.

Endoscopic intragastric balloon: a bridge toward definitive bariatric surgical management of a morbidly obese patient with situs ambiguous and midgut malrotation (with videos)

d a m t g w i 2 m t o F w Situs ambiguous or heterotaxia, with polysplenia (leftsided isomerism), is a rare anomaly of organ arrangement.1 It is estimated to occur in about 4 per 1 million live births. Most affected persons die by the age of 5 years, mainly because of cardiac anomalies.2 Today, we have various surgical and endoscopic options for weight reduction in morbidly obese patients. Various surgeries in patients with situs inversus have been reported.3,4 We report this case for its extremely rare ocurrence and to emphasize the role of endoscopic balloon lacement as a bridge toward definitive bariatric surgical anagement in difficult cases of morbid obesity in which he laparoscopic approach remains challenging.

Endoscopic Submucosal Dissection With a Novel Traction Method Using a Steerable Grasper A Feasibility Study in a Porcine Model

Introduction. Endoscopic submucosal dissection (ESD) is a technically challenging procedure in which complications and operative times depend on the operator’s expertise as well as on the location and size of the lesion. Good visualization of the submucosal dissection plane is essential to perform a safe and effective ESD. Objectives. To evaluate the feasibility, efficacy, and safety of a novel traction method using an over-the-scope steerable grasper to improve the exposure of the dissection plane during gastric ESD. Results. A total of 24 ESDs were performed without any complications in various locations of porcine stomachs, including antrum, gastric body, and cardia. En bloc complete resections were achieved in all cases. The mean specimen size was 44.92 ± 8.30 mm, mean total procedure time was 29.17 ± 11.27 minutes, and mean dissection time was 15.08 ± 7.21 minutes. The optimal dissection plane could be obtained by controlling the grasper in all cases. Conclusions. Technical feasibility, efficacy, and safety of the over-the-scope steerable grasper technique were demonstrated in order to provide dynamic and controlled traction during ESD at different locations of porcine stomachs.

Drainage of a para-aortic abscess by transrectal endoscopic retroperitoneoscopy (with video)

Retroperitoneoscopy and the transperitoneal approach are well-established for retroperitoneal procedures. Natural orifice transluminal endoscopic surgery (NOTES) is a rapidly evolving mode of surgical access to body cavities. NOTES has been well-demonstrated in animal models and in (sporadic) human cases for various surgeries.1 In this report, we describe the first human case of transrectal endoscopic retroperitoneoscopy for drainage of a paraaortic periprosthetic abscess.

Feasibility of Transumbilical Flexible Endoscopic Preperitoneoscopy (FLEPP) and Its Utility for Inguinal Hernia Repair: Experimental Animal Study

Background and study aims. Various NOTES (natural orifice translumenal endoscopic surgery) hernia repair techniques have been described. The aim of this study was to evaluate the feasibility of a transumibilically introduced conventional double-channel flexible endoscope for performing preperitoneoscopy (FLEPP, flexible endoscopic preperitoneoscopy technique) and to perform totally extraperitoneal (TEP) inguinal hernia meshplasty in an animal model. Material and methods. The study was done in 2 steps on 8 swines weighing 25 to 30 kg each: (1) establishing feasibility of preperitoneal dissection of the inguinal region using a conventional double-channel flexible gastroscope and making bed for mesh placement and (2) placement of a polypropylene mesh in the inguinal region to cover the myopectineal orifice. Results. The flexible endoscope provided good vision and maneuverability to identify preperitoneal structures—namely, the arcuate line, insertion of rectus abdominis on pubis symphysis, inferior epigastric vessels, deep inguinal ring, spermatic cord, pubic symphysis, and psoas muscle—without causing any damage to any of the structures. The spermatic cord could be dissected to identify the vas deference. A 9 × 7 cm2 oval mesh was successfully placed over the myopectineal orifice of Fruchaud with good overlap. Average time required for the complete FLEPP procedure (including mesh placement) was 55 minutes (range 45-90 minutes). Conclusions. This study demonstrates, for the first time, the feasibility of the transumbilical FLEPP technique and its utility for performing TEP inguinal hernia repair with prosthetic mesh placement in a swine model.

Transhepatic metallic stenting for hepaticojejunostomy stricture following laparoscopic cholecystectomy biliary injury: A case of successful 20 years follow-up.

Laparoscopic cholecystectomy is still associated with a considerable rate of biliary injuries and related strictures. Advances in interventional endoscopy and percutaneous techniques have made stenting a preferred treatment modality for the management of these strictures. We report successful 20 years of follow-up of a case of trans-hepatic metallic stenting (2 Gianturco® prostheses, 5 cm long, 2 cm in diameter) done for stenosed hepatico-jejunostomy anastomosis after laparoscopic CBD injury. Percutaneous transhepatic stenting and long-term placement of metallic stents need to be re-evaluated as a minimally invasive definitive treatment option for benign biliary strictures in patients with altered anatomy such as hepatico-jejunostomy or in whom re-operation involves high risk.