Silvana Perretta - Academia.edu (original) (raw)

Papers by Silvana Perretta

Surgical Endoscopy, 2020

Background As flexible endoscopy offers many advantages to patients, access to training should be... more Background As flexible endoscopy offers many advantages to patients, access to training should be aggressively encouraged. In 2014, the IRCAD-IHU-Strasbourg launched a year-long university diploma using advanced education methods to offer surgeons and gastroenterologists high-quality, personalized training in flexible endoscopy. This paper describes and critically reviews the first 5 years of the University Diploma in Surgical Endoscopy (UDSE). Methods The UDSE aims to progressively transmit theoretical knowledge, clinical judgment, and practical skills on basic and advanced flexible endoscopy. The 300-h year-long curriculum is composed of 100 h of online lectures with tests, 150 h of clinical rotations and 50 h of hands-on sessions. The hands-on training is delivered through validated mechanical simulators, virtual reality simulators, and specifically designed ex vivo and in vivo animal models. Participants' demographics, training, and clinical experience were recorded. Trainees' evaluations of each online lecture, hands-on training, and clinical rotations were assessed using a Likert scale from 1 (not satisfactory) to 5 (outstanding). Trainees' skill progression was evaluated using the Global Assessment of Gastrointestinal Endoscopic Skills (GAGES) proficiency test. Finally, clinical uptake was surveyed. Results 162 (79.01% males) trainees from 38 countries enrolled and successfully completed the first 5 courses. The vast majority of the trainees were surgeons and 19.14% were gastroenterologist. Sixty-nine (42.59%) participants were residents and 97 (56.79%) had no prior experience in flexible endoscopy. The online lectures, on-site sessions, and clinical rotations were highly appreciated receiving an overall average score of 4.33/5, 4.56/5, 4.43/5, respectively. Trainees' endoscopic skills improved significantly (16.68 vs. 20.53 GAGES scores; p = 0.016). At an average of 18.83 months following the course, 31 alumni (77.50% of repliers) started to use a flexible endoscope in their practice. Conclusions Over its 5-year evolution, the UDSE has proven to be a valid means to ease access to the fundamental knowledge, practical skills, and clinical judgment necessary to achieve proficiency in surgical endoscopy.

Visceral medicine, 2018

important to rule out severe dysmotility such as achalasia and other major motility disorders inc... more important to rule out severe dysmotility such as achalasia and other major motility disorders including severe, symptomatic ineffective oesophageal motility as seen in scleroderma, as well as, on occasion, individuals with very severe reflux disease. 2) Patients presenting with symptom recurrence or dysphagia after fundoplication. Upper GI motility testing with high-resolution manometry (HRM), especially if combined with solid swallows, can rule out 'outlet obstruction' at the esophagogastric junction (EGJ) due to a tight fundoplication, fundoplication slippage or migration, and hiatal hernia recurrence. Reflux studies can also provide objective evidence of persistent (or recurrent) reflux disease if the fundoplication is too loose or has dehisced. 3) Further assessment of patients with dysphagia and unexplained ('non-cardiac') chest pain to rule out achalasia, other motility disorders (e.g. hypercontractile motility), and reflux disease as a cause of symptoms.

World journal of gastrointestinal surgery, Jan 27, 2010

To develop a pure transvaginal access to the retroperitoneum, that is simple, reproducible and us... more To develop a pure transvaginal access to the retroperitoneum, that is simple, reproducible and uses endoscopic material available on the market. From February 2008 to April 2009, 31 pigs were operated on, with 17 as an acute experiment and 14 with a survival protocol. The animals were placed in a supine position and a 12-mm double-channel endoscope (Karl Storz™, Tuttlingen) was used for vision and dissection. During the same time period, the access experiment was reproduced on 3 human cadavers using material similar to that used in the animal model. In the animal model, 37 interventions were done on the kidney, adrenal gland and pancreas. The mean time to fashion the access was 10 min (range 5 to 20 min). No intraoperative death was observed. Two major (5%) intraoperative complications occurred: one hemorrhage on the aorta and one tearing of the right renal vein. Peritoneal laceration was encountered in 5 cases without impairing the planned task. In the survival group, good clinical...

Surgical innovation, 2012

The future of natural orifice transluminal endoscopic surgery lies not just in the reduction of t... more The future of natural orifice transluminal endoscopic surgery lies not just in the reduction of the invasiness of selected surgical procedures, but more in the development of innovative surgical concepts and revisitation of old surgical dogmas. This is particularly true for minimally invasive oesophageal surgery which is still relatively new and therefore an ideal field for improvement as it presents many unanswered questions. Endoluminal and transluminal esophageal endoscopic procedures for both diagnostic and therapeutic purposes have recently been explored. Most impressively perhaps Haruhiro Inoue{H. Inoue, 2010 #191}, has recently reported the first clinical experience of submucosal endoscopic esophageal myotomy for esophageal achalasia with a peroral endoscopic myotomy (POEM). In addition to being a no-scar technique the true innovation and appeal of the POEM procedure is that it specifically targets the circular muscle layers of the LES affected by achalasia, thereby preservin...

British Journal of Surgery, 2009

Background Clinical application of natural orifice transluminal endoscopic surgery is under inves... more Background Clinical application of natural orifice transluminal endoscopic surgery is under investigation. Preliminary results of transvaginal cholecystectomy in women and associated technical issues have been described. The technique and initial results of hybrid transgastric cholecystectomy are now reported. Methods Five patients aged 18–60 years with uncomplicated cholelithiasis underwent transgastric cholecystectomy in a prospective intention-to-treat study that included the option of transparietal assistance (hybrid technique) if needed. The gastrotomy was created under laparoscopic guidance through a 5-mm umbilical trocar, which also served to expose the gallbladder, clip the cystic pedicle and close the gastrotomy. Cholecystectomy was carried out using flexible instruments through the endoscope, alone or in combination with laparoscopic instruments. Results The procedure was successful in all patients with a median operating time of 150 (range 120–180) min. Transparietal assi...

Journal of Minimal Access Surgery, 2012

Surgical Endoscopy, Sep 24, 2008

Natural orifice translumenal endoscopic surgery (NOTES) continues to evolve. This study investiga... more Natural orifice translumenal endoscopic surgery (NOTES) continues to evolve. This study investigated the feasibility and outcome of performing localized sigmoidectomy in its entirety via NOTES. A survival study of five male minipigs (mean weight, 30 kg) was conducted. After anesthesia, a gastrotomy was created by a per os double-channel endoscope, and full peritoneoscopy was performed. A Berci needle then was inserted transparietally to allow maintenance and monitoring of the pneumoperitoneum. Using a transanal probe to facilitate intestinal retraction, the mesentery was dissected with instruments worked through the channels of the transgastric endoscope. The anvil of a circular stapler then was passed per anum into the colon above the point of intended transection. A penetrating transrectal trocar was placed to allow entry of a linear stapler into the peritoneum through a colotomy, and the sigmoid was cross-stapled proximally. The strut of the anvil then was snugged into a colotomy made at this staple line. The specimen was delivered via the anus by a &amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot;pull-through&amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;amp;quot; technique. The distal sigmoidal margin was cross-stapled extracorporeally, ensuring that the colotomy was included within the specimen. Retrograde passage of the circular stapler head per anus allowed colocolonic reanastomosis by its mating with the anvil already in situ. The gastrotomy was closed with a previously validated prosthesis. Postoperatively, all the animals were recovered and monitored for well-being during convalescence. Endoscopy (gastroscopy and sigmoidoscopy), laparoscopy, and laparotomy were performed on postoperative day 14 as follow-up measures. Each operation was satisfactorily completed. The mean operative time was 76 min (range, 44-95 min). All the animals prospered postoperatively. Follow-up examination showed full healing of all anastomoses and gastrotomy sites. There was no evidence of luminal stricturing, peritonitis, or intraabdominal sepsis in any animal. Using this experimental model, colonic resection and reanastomosis can be performed safely within the NOTES format.

Needle holder insert for a medical instrument (60) having a shank (66) whose distal end (68) is a... more Needle holder insert for a medical instrument (60) having a shank (66) whose distal end (68) is angled, with an actuating element (44), with a first stop (22) to which a first side (52) of a medical needle (50) is running can be applied transversely to the actuating element (44), and a barrel member (24) disposed spaced from the first stop (22) and that is configured such that one of the first side (52) (opposite second side 54 the needle (50) is gripped), where (for holding the needle 50) of the stop (22) and the barrel member (24), relatively speaking, (by the actuator 44) towards each other and, (to release the needle 50) are away from one another, wherein from the barrel member (24) protruding a projection (26) toward the stop (22) while holding the needle (50) this engages at least partially, wherein the projection (26) is formed as a nose (28), wherein the stopper (22) two abutment surfaces (46, 48) having an intermediate guide (34) that further comprises a portion (42) of the...

Surgical Innovation, 2011

Segmental colectomy is an ideal procedure for natural orifice transluminal endoscopic surgery (NO... more Segmental colectomy is an ideal procedure for natural orifice transluminal endoscopic surgery (NOTES). Transanal endoscopic approaches have enabled rectosigmoid colectomy through a viscerotomy that is resected with the specimen. To extend NOTES segmental colectomy to the entire colon and beyond, a rectal viscerotomy will have to be safely and effectively closed at the end of the procedure. A new technique for rectal viscerotomy closure using a circular EEA Hemorrhoid and Prolapse Stapler with DST Series Technology (Covidien) is described.

Textbook and Video Atlas, 2012

Surgical Endoscopy, 2008

Sentinel node biopsy is proposed as sufficiently reliable in determining the lymph node status of... more Sentinel node biopsy is proposed as sufficiently reliable in determining the lymph node status of early gastric cancer to justify curtailed resection margins if negative. Its performance by natural orifice transluminal endoscopic surgery (NOTES) could therefore expand the patient cohort able to undergo solely endoscopic resection of their primary. A transvaginal NOTES technique was utilized in six pigs (mean weight 30 kg). The posterior colpotomy and pneumoperitoneum was created by a standard double-channel flexible videoendoscope which was then used to perform peritoneoscopy. Concomitant gastroscopy allowed selection of a site along the greater curvature for lymphatic mapping by submucosal injection of methylene blue (3 ml). Furthermore, torque upon this endoscope allowed the posterior surface of the stomach and retrogastric space to become accessible to the transvaginal endoscope. In surveying the mapping in vivo, the intraperitoneal scope could follow blue-stained efferent lymphatic channels to their first-order draining nodes (i.e., sentinel nodes). Conventional instruments worked down the scope's channels were then used to perform the excisional biopsy. At procedure end, the animals underwent immediate laparotomy to ensure the safety and adequacy of the procedure. Each procedure was technically successful. Colpotomy, pneumoperitoneum, and peritoneoscopy were promptly achieved (mean 8 min). Post injection, blue efferent lymphatic channels were immediately appreciable in every animal. Five animals had sentinel nodes in their retropyloric region while the last mapped cephalad towards the esophagogastric junction. Two animals had alternative drainage channels identifying additional sentinel nodes. All blue nodes were dissected cleanly by the intraperitoneal scope and retrieved intact per vaginam. Mean lymphadenectomy time was 19 min. At laparotomy, there was no hematoma, ongoing hemorrhage, or visceral injury in any pig. There were no residual, missed stained nodes or channels. NOTES sentinel node biopsy for the stomach is technically accomplishable in this experimental model. This proof of concept should encourage serious consideration of its applicability to clinical practice.

Gastrointestinal Endoscopy, 2012

d a m t g w i 2 m t o F w Situs ambiguous or heterotaxia, with polysplenia (leftsided isomerism),... more 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.

Surgical Endoscopy, 2013

Recent advances in interventional endoscopy and NOTES Ò have highlighted the limitations of exist... more Recent advances in interventional endoscopy and NOTES Ò have highlighted the limitations of existing flexible endoscopes. In 2005, IRCAD and KARL-STORZ began a collaborative development to create an interventional endoscopic platform to enable complex endoluminal and transluminal surgery named the ANUBISCOPE Ò. We show the first transvaginal cholecystectomy performed with this endoscopic platform.

Archives of Surgery, 2007

Hypothesis: Natural orifice transluminal endoscopic surgery (NOTES) provides the potential for pe... more Hypothesis: Natural orifice transluminal endoscopic surgery (NOTES) provides the potential for performance of incisionless operations. This would break the physical barrier between bodily trauma and surgery, representing an epical revolution in surgery. Our group at

Journal of Hepato-Biliary-Pancreatic Surgery, 2009

The initial idea behind natural orifice transluminal endoscopic surgery (NOTES) was that of an in... more The initial idea behind natural orifice transluminal endoscopic surgery (NOTES) was that of an incisionless surgery. NOTES cholecystectomy is a good model of human ingenuity and technological advance. NOTES cholecystectomy in a human being was performed at our institution after extensive laboratory work in live pig models. In this process we gained helpful information related to NOTES cholecystectomy. More than 250 cholecystectomies in pigs have been performed. From May 2007 to November 2008 a total of 10 and 6 transvaginal and transgastric human cholecystectomies, respectively, have been performed. The procedure was successful in all patients, with a mean operative time of 120 min. There were no intraoperative or postoperative complications. Patients recovered promptly after surgery and had minor postoperative pain. They were discharged on the second postoperative day. The advantages of laparoscopy appeared to be enhanced by this approach: patients had minor postoperative pain and minimal scarring. This stepwise experience in the cholecystectomy procedure is an important first step in the development of methods and devices to enable the evaluation of potential incisionless NOTES surgery. Additional research and comparison studies are needed for further improvement in order to provide NOTES procedures to a wider range of patients.

Annals of Surgery, 2011

OBJECTIVE The purpose of this report is to evaluate and compare the long-term objective and subje... more OBJECTIVE The purpose of this report is to evaluate and compare the long-term objective and subjective outcome after laparoscopic paraesophageal hernia repair (LPHR). BACKGROUND Short-term symptomatic results of LPHR are often excellent. However, a high recurrence rate is detected at objective radiographic follow-up. METHODS Retrospective review of a prospectively gathered database of consecutive patients undergoing LPHR with and without reinforced crural repair at a single institution. Subjective and objective outcomes were assessed by using a structured symptoms questionnaire, Gastrointestinal Quality-of-Life Index, satisfaction score, and barium esophagogram. RESULTS From September 1991 to September 2005, LPHR was performed in 85 patients (median age, 66 years) with (25 patients) and without (60 patients) reinforced crural repair. Two patients (3%) underwent laparoscopic reoperation, for severe dysphagia and for symptomatic recurrence, respectively. Subjective outcome, available ...

Surgical Innovation

We submit a summary of some of the activities of the IHU-Strasbourg during the initial period of ... more We submit a summary of some of the activities of the IHU-Strasbourg during the initial period of the COVID-19 pandemic. These were presented as part of the coronnavation effort coordinated by Dr Adrian Park. Three initiatives are presented as follows: Protect-Est App, healthcare worker stress, and converted diving mask for ventilation. Two of the 3 projects are still ongoing, and one (Predoict-Est) has been adopted nationally.

Annals of Surgical Oncology

The optimal surgical procedure for duodenal gastrointestinal stromal tumors (D-GISTs) remains poo... more The optimal surgical procedure for duodenal gastrointestinal stromal tumors (D-GISTs) remains poorly defined. Pancreaticoduodenectomy (PD) allows for a wide resection but is associated with a high morbidity rate. The aim of this study was to compare the short- and long-term outcomes of PD versus limited resection (LR) for D-GISTs and to evaluate the role of tumor enucleation (EN). In this retrospective European multicenter cohort study, 100 patients who underwent resection for D-GIST between 2001 and 2013 were compared between PD (n = 19) and LR (n = 81). LR included segmental duodenectomy (n = 47), wedge resection (n = 21), or EN (n = 13). The primary objective was to evaluate disease-free survival (DFS) between the groups, while the secondary objectives were to analyze the overall morbidity and mortality, radicality of resection, and 5-year overall survival (OS) and recurrence rates between groups. Furthermore, the short- and long-term outcomes of EN were evaluated. Baseline characteristics were comparable between the PD and LR groups, except for a more frequent D2 tumor location in the PD group (68.3% vs. 29.6%; p = 0.016). Postoperative morbidity was higher after PD (68.4% vs. 23.5%; p < 0.001). OS (p = 0.70) and DFS (p = 0.64) were comparable after adjustment for D2 location and adjuvant therapy rate. EN was performed more in American Society of Anesthesiologists (ASA) stage III/IV patients with tumors < 5 cm and was associated with a 5-year OS rate of 84.6%, without any disease recurrences. For D-GISTs, LR should be the procedure of choice due to lower morbidity and similar oncological outcomes compared with PD. In selected patients, EN appears to be associated with equivalent short- and long-term outcomes. Based on these results, a surgical treatment algorithm is proposed.