Society: SSAT

Classical gastrointestinal anastomoses have been made with sutures and/or metal staples, but have resulted in significant bleeding and leak rates. This video is demonstrating a compression anastomosis using magnets to achieve weight loss and remission of co-morbidities.
A linear magnet was delivered by flexible endoscopic catheter to a point 250 cm proximal to the ileocecal valve, and a second magnet was positioned in the first part of the duodenum; the bowel segments containing the magnets were apposed to initiate gradual incisionless compression. Laparoscopic assistance was used to obtain accurate bowel measurements, obviate tissue interposition, and close mesenteric defects.

Gastrointestinal stromal tumors (GIST) are the most common mesenchymal neoplasms of the gastrointestinal tract with an annual incidence of 10-15 cases per million. Overall, they account for 0.1%-3.0% of all gastrointestinal tumors. GISTs take time to grow and become clinically expressed, therefore they are commonly an incidental finding. They appear throughout the gastrointestinal tract, however the most common site is the stomach followed by the small intestines, and rarely the rectum or esophagus. Gastroesophageal junction (GEJ) GISTs are extremely rare. We present a case of a unique resection, via DaVinci robot, of a GIST at the GEJ in a patient with type IV paraesophageal hernia.

We present a modification to a Laparoscopic Sleeve Gastrectomy (LSG) for the combined treatment of Class II obesity and an epiphrenic esophageal diverticulum in a patient with a relative contra-indication to a gastric bypass. The patient had a BMI of 39, ESRD on hemodialysis awaiting a Renal Transplant. A large epiphrenic diverticulum was found on endoscopy, and UGI Swallow confirmed a right posterolateral diverticulum, with preserved esophageal peristalsis. Technical highlights include hiatal and diverticulum dissection and diverticulectomy, Heller myotomy, Dor Fundoplication and hiatus closure. Lastly, the modified LSG preserving the part of the fundus used for the fundoplication.

Preoperative EndoFLIP was done to characterize the pylorus. The distensibility index (DI), minimum diameter (Dmin), and cross sectional area (CSA) were assessed and recorded at 40 and 50 mL fill volumes. Orise gel was then injected into submucosal space. Mucosal incision was made and submucosal plane was developed with monopolar cautery until duodenal fibers were seen over pyloric ridge. A retrograde circular myotomy was made with cautery. The mucosotomy was closed with running suture. Postoperatively, EndoFLIP was performed at the same site and volumes. The final DI, Dmin, and CSA at 50 mL increased from 6.7 to 7.5 mm2/mmHg (12%), 18.7 to 19.6 mm (5%), and 276 to 303 mm2 (10%) respectively

48 y/o male with several year history of chest discomfort, that became worse in the past 15 months. Postprandial pain was usually 4/10. The cardiac workup was negative for abnormalities.
EGD was normal. The patient had a CT ABD/PELVIS which showed celiac artery narrowing.
Patient had a celiac plexus block which relieved the pain for 4-6 hours .CTA showed moderate to high-grade narrowing of the proximal celiac trunk. Uneventful postoperative course. Denied nausea or vomiting. No further postprandial pain. Tolerated diet progressively. Discharged home on POD 1
Robotic-Assisted MALS release is a safe and effective procedure when significant narrowing of the celiac artery is observed.

We present a 41 year old male with multiple admissions for chronic nausea, emesis, post prandial abdominal pain, and weight loss. Celiac Duplex US and angiography were consistent with MALS revealing elevated peak systolic velocity (PSV) and compression of the celiac artery. Pre operative Duplex US showed elevated PSV that increased during expiration. A robotic approach with ICG was utilized to help delineate vascular anatomy. After median arcuate ligament release, Celiac Duplex US showed decrease in PSV to normal value. Patient had near total relief of symptoms post operatively.

Median arcuate ligament syndrome (MALS) is rare etiology of postpranadial abdominal pain and feeding intolerance. Due to its vague clinical presentation, it is often missed leading to prolong patient suffering prior to accurate diagnosis and treatment.

Median arcuate ligament syndrome is multifactorial encompassing vascular malperfusion due to celiac artery compression and neurogenic symptoms due to celiac ganglion compression. In this case we are describing the utility of robotic assisted surgical interventions to obtain accurate median arcuate release using intra-operative robotic assisted duplex US and Infrared Fluroscence imaging
to ensure adequate celiac artery perfusion.

Patients with clinically severe obesity and GERD have better GERD outcomes with a laparoscopic gastric bypass (LRYGB) when compared to a laparoscopic sleeve gastrectomy (LSG). However, some patients with GERD may have a contraindication to undergo LRYGB and modifications to LSG to include an anti-reflux fundoplication have been used to allow offering a LSG to patients with GERD. In this video we present the key technical aspects of a modified LSG with hiatal hernia repair, a partial posterior 270^o fundoplication, and initial clinical results in 15 patients. Long-term GERD outcomes and potential advantages of a partial fundoplication added to an LSG are still under scrutiny.

Laparoscopy in ACS can prove challenging, compared to the traditional laparotomy. However, in medically complex patients, it may decrease morbidity and shorten recovery. We present a systematic approach to these cases that includes: 1) 4-quadrant evaluation, 2) local irrigation, 3) endoscopic leak test, and 4) wide drainage. We demonstrate the efficacy of this algorithm in 2 case studies.
A 64 yo man with CAD, CKD, and BMI 40 had a 3-cm gastric perforation and underwent a partial gastrectomy without post-op complications. A 78 yo man with Child C cirrhosis, COPD, and pulmonary HTN had a perforated D1 ulcer repaired with an omental patch. His post-op bile leak was successfully managed non-op.

We present a 53 y/o female with morbid obesity (BMI 57) with multiple comorbidities as well as GERD and h/o postprandial epigastric pain. Previous CT showed a left hepatic exophytic mass. Subsequent MRI showed to be a cavernous hemangioma ( approximately 6 cm in diameter). The hemangioma was overlying the GEJ. We planned for a simultaneous laparoscopic liver resection and sleeve gastrectomy. However, during the procedure we also observed a hiatal hernia as well as an umbilical hernia that we repaired simultaneously. We consider that simultaneous advanced complex operations are safe in combination with bariatric surgery, when performed by an experience team in a tertiary care center.

The classic resection techniques including EMR/ESD had always been targeting the mucosa & submucosal layers. But if the muscle layer is involved this is named FTR. Free handed FTR; resecting the lesion first leaving a hole that should be closed.Sometimes closure devices like suturing devices are expensive & not available. we present a simple way that can effectively close a perforation. Purse string suture; in which the endoloop is applied to the edges of the defect with hemoclips & then followed by endoloop closure closing the whole defect perfectly. We demonstrate FRT of a gastric GIST about 2.1x 2.9 cm from the fundus of the stomach &closing the defect with purse string suture.

Mohamed El-Sherbiny

Cairo University Kasr Alainy Faculty of Medicine

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