Dr Sorin Cimpean, Digestive Surgeon

07/16/2025

Wilkie's syndrome, also known as Superior Mesenteric Artery (SMA) Syndrome, is a rare condition characterized by the compression of the third portion of the duodenum (the first part of the small intestine) between the superior mesenteric artery and the abdominal aorta. This compression leads to partial or complete obstruction of the duodenum, causing a range of gastrointestinal symptoms. The condition is often associated with a reduced aortomesenteric angle (typically 6–25° compared to the normal 38–56°) and a narrowed aortomesenteric distance (2–8 mm compared to the normal 10–20 mm), primarily due to a loss of the mesenteric fat pad that normally cushions the duodenum.

# Surgical intervention:
Indicated when conservative measures fail, symptoms are severe, or complications (e.g., duodenal stasis, perforation) arise.

Common procedures include:
-Duodenojejunostomy: The most common and effective surgical option, with a success rate of around 90%, involving an anastomosis between the duodenum and jejunum to bypass the obstruction. It can be performed laparoscopically.

-Strong’s procedure: Sectioning the ligament of Treitz to relocate the duodenojejunal junction, though it has a higher failure rate and is typically used in infants.

-Gastrojejunostomy: An alternative but less preferred due to the risk of peptic ulceration.

Here is a postoperative OED image of a patient for whom I performed a Duodenojejunostomy. Very good postoperative outcomes with significant improvement of the symptoms.

07/05/2025

07/04/2025

Gastric Bypass Distalization is a revisional bariatric surgery performed to address weight regain or inadequate weight loss after a primary Roux-en-Y gastric bypass (RYGB). It involves modifying the existing gastric bypass to enhance malabsorption by lengthening the biliopancreatic (BP) limb and shortening the common channel (CC), where nutrient absorption occurs, while maintaining a safe total alimentary limb length (TALL).

- Procedure Overview
The jejunojejunal (JJ) anastomosis is repositioned distally, increasing the BP limb length and reducing the CC which increases malabsorption of calories and nutrients.
Goal: Enhance weight loss by reducing nutrient absorption and potentially resetting gut hormones that regulate hunger and metabolism.

- Indications
Weight regain or failure to achieve >50% excess weight loss (EWL) or a BMI

06/28/2025

In case of large hiatal hernias, mesh is used to strengthen the closure of the hiatal defect, especially in large hernias (>5 cm) or when the crural tissue is weak, as the diaphragm is under constant stress from breathing, which can lead to recurrence rates of 5–30% without reinforcement.

Mesh Types:
-Synthetic Mesh: Durable but carries risks like erosion into the esophagus or stricture. Studies report a 0.8–2.5% complication rate, with severe cases requiring major resection in up to 45% of complications.
-Biologic Mesh: Absorbable, potentially safer, resorbtion over 12–18 months. No major complications have been reported, but long-term data is limited.
-Slowly Absorbable Mesh.

In this case I used a Progrip mesh without oesophageal contact and valve fixation over the mesh to limit the risk of erosion.

06/17/2025

# Oesophageal Ph-impedance monitoring
# Sainte-Anne Saint-Remy
# CHIREC

06/14/2025

In case of chronic gastro-oesophageal reflux disease (GERD) and hiatal hernia the anti-reflux surgery aims to restore the lower esophageal sphincter’s function, preventing reflux and reducing esophageal damage.

A 2020 study in Gut found that successful anti-reflux surgery (e.g., fundoplication) was associated with a lower incidence of esophageal adenocarcinoma compared to medical therapy (PPIs) in patients with Barrett’s esophagus, though the absolute risk reduction was modest.

https://www.cancer.org/cancer/types/esophagus-cancer/causes-risks-prevention/risk-factors.html #:~:text=People%20with%20GERD%20have%20a,on%20to%20develop%20esophageal%20cancer.

06/08/2025

A**l Fistula

An a**l fistula is an abnormal tunnel-like connection between the inside of the a**l ca**l or re**um and the skin near the a**s, typically forming after an a**l abscess.

Causes
- Main Trigger: Infection in an a**l gland leads to an abscess, which bursts or is drained, leaving a persistent tract.
- Other Factors:
- Crohn’s disease or ulcerative colitis.
- Trauma or a**l injury.
- Chronic infections (e.g., tuberculosis, STDs).
- Previous surgery or radiation in the area.

Symptoms
- Ongoing pain near the a**s, worse with sitting, bowel movements, or activity.
- Redness, swelling, or irritation around the a**s.
- Discharge of pus, blood, or foul-smelling fluid from an external opening.
- Fever or chills if infection lingers.
- Rarely, difficulty controlling bowel movements.

Diagnosis
- Physical Exam: visible openings, swelling, or drainage.
- Imaging Tests:
- MRI or endoa**l ultrasound to trace the fistula’s path.
- CT scan for complex cases.

Treatment
- Fistulotomy:
- The tract is cut open to heal from the inside.
- Suits simple fistulas with minimal sphincter involvement.
- Risk: Incontinence.

- Seton Placement:
- A thread is placed through the tract to drain infection and may stay long-term or aid healing.
- Ideal for complex fistulas involving the sphincter.
- Risk: Mild discomfort.

- Cutting Seton:
-A seton is a thread or band (often surgical suture, rubber, or silicone) placed through the fistula tract. A "cutting" seton is tied tightly and periodically tightened to slowly cut through the tissue, allowing the fistula to heal behind it.
- Risk: Incontinence, Pain, Infection

- LIFT (Ligation of Intersphincteric Fistula Tract):
- Tract is tied off and cut between sphincter muscles.
- Good for complex fistulas.
- Risk: Recurrence, low incontinence risk.

- Advancement Flap:
- The internal or***ce is closed and a re**al flap is moved to cover the internal opening.
- Used for complex cases to protect sphincter function.
- Risk: Flap failure, recurrence.

- Fibrin Glue or Plugs:
- Tract is sealed with glue or a bioprosthetic plug.
- Risk: Material dislodging, recurrence.

- Video-Assisted A**l Fistula Treatment (VAAFT)
-The fistula tract is cleaned and cauterized using a unipolar electrode to destroy the lining (fulguration).Debris is removed with an endobrush or curette. The internal opening is closed, typically with sutures (e.g., Vicryl), a stapler, or a cutaneous-mucosal flap, and may be reinforced with cyanoacrylate glue for stability.
- Risk: Recurrence, Infection

- FiLaC (Fistula-tract Laser Closure), it uses a radial-emitting laser fiber to deliver energy into the fistula tract. The laser ablates (burns away) the inner lining of the tract, sealing it and encouraging natural healing.
-Risk: Reccurence

- Supportive Measures:
- Antibiotics: Treat active infection, not a standalone fix.
- Pain Relief
- Sitz Baths: Warm water soaks, 10-15 minutes, 2-3 times daily.
- Lifestyle: High-fiber diet, hydration, stool softeners to reduce straining.

06/08/2025

What is an Inguinal Hernia?
An inguinal hernia occurs when tissue, such as part of the intestine or fat, protrudes through a weak spot in the abdominal wall in the groin area.

Types
- Indirect Inguinal Hernia: Follows the path of the spermatic cord or round ligament through the inguinal ca**l; often congenital (present at birth) but may appear later.
- Direct Inguinal Hernia: Pushes through a weakened area of the abdominal wall, typically acquired due to age, strain, or injury.

Symptoms
- A bulge in the groin or sc***um, often more noticeable when standing, coughing, or lifting.
- Pain or discomfort, especially when bending, lifting, or straining.
- A heavy or dragging sensation in the groin.
- In rare cases, nausea, vomiting, or severe pain if the hernia becomes incarcerated (trapped) or strangulated (blood supply cut off—emergency).

Causes and Risk Factors
- Causes: Weakness in the abdominal wall combined with pressure from lifting, straining, chronic coughing, or constipation.
- Risk Factors:
- Male gender (higher risk)
- Family history
- Aging (muscle weakening)
- Chronic cough (e.g., from smoking)
- Obesity or heavy lifting

Diagnosis
- Physical Exam
- Imaging: Ultrasound, CT scan, or MRI may be used if the diagnosis is unclear or complications are suspected.

Treatment
- Surgical:
- Open Repair: Incision in the groin, tissue pushed back, and wall repaired, often with mesh. Recovery: 2-6 weeks.
- Laparoscopic Repair: Minimally invasive, using small incisions and a camera, often with mesh. Faster recovery (1-2 weeks), good for bilateral or recurrent hernias.

Complications
- Incarceration: Tissue gets trapped, causing pain and swelling.
- Strangulation: Blood supply is cut off, risking tissue death—requires urgent surgery.
- Recurrence: Hernia returns post-surgery (low risk with mesh).
- Chronic pain or infection (post-surgical risks).

When to See a Doctor
- Severe pain, redness, or swelling in the groin.
- Nausea, vomiting, or fever with a hernia.
- A bulge that won’t push back

05/16/2025

Hiatal Hernia After Gastric Sleeve.

Possible Reasons for Developing a Hiatal Hernia After Gastric Sleeve:
* Increased Intra-abdominal Pressure: While weight loss from the sleeve generally reduces this pressure, certain activities or individual anatomy might still contribute.
* Changes in Anatomy: The creation of the gastric sleeve involves altering the stomach's shape and size, which could potentially affect the support structures around the hiatus.
* Surgical Technique: Although surgeons often repair hiatal hernias during the sleeve procedure, the initial repair might not be completely successful, or technical factors during the sleeve could contribute to later development.
* Weight Regain: If a person regains a significant amount of weight after the gastric sleeve, this can increase intra-abdominal pressure again, potentially leading to a hiatal hernia.
* Forceful Vomiting or Straining: Activities that put pressure on the abdomen, like severe coughing, vomiting, or heavy lifting, could potentially contribute.

Symptoms of a Hiatal Hernia After Gastric Sleeve:
The symptoms can be similar to those of a hiatal hernia in general and might sometimes be difficult to distinguish from other post-bariatric surgery issues. They can include:
* Heartburn or acid reflux
* Regurgitation of food or liquids
* Difficulty swallowing (dysphagia)
* Chest pain
* Belching or hiccups
* Bloating
* Feeling full quickly
* Nausea or vomiting
* Less common symptoms like shortness of breath, chronic cough, or sore throat

Diagnosis:
* Upper Endoscopy
* Upper GI Series (Barium Swallow)
* High-Resolution Manometry
* pH Monitoring
* Thoraco- Abdominal CT scan

Treatment:
* Lifestyle Modifications and Medications: Similar to managing GERD, this might include dietary changes (avoiding trigger foods), eating smaller meals, not lying down after eating, elevating the head of your bed, and using antacids or acid-reducing medications (H2 blockers or PPIs).
* Surgical Repair: If symptoms are severe or not well-controlled with medication, surgery to repair the hiatal hernia may be necessary. This can often be done minimally invasively. The repair involves pulling the stomach back down into the abdomen and tightening the opening in the diaphragm. Sometimes, a mesh is used to reinforce the repair.
* Revision Bariatric Surgery: In some cases, particularly if reflux is a significant issue, converting the gastric sleeve to a Roux-en-Y gastric bypass might be considered, as this procedure often has a better outcome for managing reflux.

05/11/2025

How Endometriosis Can Involve the Colon or Re**um:
* Endometrial-like tissue can grow on the surface of the colon or re**um and infiltrate the bowel wall.
* The most frequently affected areas of the bowel are the re**um and sigmoid colon, but other parts like the appendix, cecum, and small bowel can also be involved.
* This growth can cause inflammation, scar tissue (adhesions), and sometimes even partial obstruction.

Symptoms of Colic/ Re**al Involvement in Endometriosis:
* Pain on opening the bowels (dyschezia)
* Pain before, during, or after bowel movements
* Deep pelvic pain during s*x (dyspareunia), as the re**um is near the va**na.
* Abdominal pain, which can be chronic or cyclical (worsening around menstruation).
* Bloating
* Changes in bowel habits, such as:
* Constipation
* Diarrhea
* Alternating constipation and diarrhea
* Increased gas
* Feeling of incomplete evacuation
* Re**al pain
* Re**al bleeding, especially during menstruation (less common).
* Nausea and vomiting (less common, but possible, especially with more significant bowel involvement).
* In rare cases, intestinal obstruction can occur.

Diagnosis:
Diagnosing bowel endometriosis can be challenging as symptoms can overlap with other conditions.
* Detailed Medical History: cyclical nature, the overall medical history, including any history of endometriosis.
* Physical Exam: This may include a pelvic exam and possibly a rectova**nal exam to feel for nodules or thickening.
* Imaging Studies:
* Transva**nal Ultrasound (TVUS)
* Magnetic Resonance Imaging (MRI): Considered a valuable tool for mapping the extent of endometriosis, including bowel involvement.
* Endoscopic Ultrasound: Can help visualize lesions in the re**al wall.
* Colonoscopy: While endometriosis rarely affects the bowel lining that would be seen during a colonoscopy, it may be performed to rule out other bowel conditions. Findings suggestive of endometriosis might be seen in some cases (e.g., external compression, nodularity).
* Laparoscopy with Biopsy

Treatment:
* Pain Management:
* Pain medications.
* Hormonal Therapy: Medications like birth control pills, progestins, GnRH agonists, and aromatase inhibitors can help suppress endometriosis growth and reduce symptoms, including bowel-related pain.
* Dietary Changes: Dietary modifications can help manage bowel symptoms like bloating and altered bowel habits.

* Surgery: Surgical removal of the endometriosis lesions on or in the bowel is often the most effective way to relieve bowel-related symptoms. The type of surgery depends on the location and depth of the endometriosis and may involve:
* Shaving or excision of superficial lesions.
* Disc resection
* Segmental colic or re**al resection with anastomosis.

05/08/2025

Stenosis after a gastric sleeve surgery refers to the narrowing of the gastric sleeve, which can cause difficulty in eating and drinking. It's a potential complication that can occur after this type of bariatric surgery.

Causes: The exact cause isn't always clear, but some factors that may contribute to stenosis include:
* Scarring from the surgery.
* The way the stomach is stapled or sutured.
* Reduced blood flow to the area.
* Ulcers that may form at the surgical connection.
* Twisting or misalignment of the gastric sleeve.

Symptoms:
Symptoms of stenosis can include:
* Nausea and vomiting, especially after eating.
* Difficulty swallowing.
* Feeling full very quickly and for a prolonged time.
* Trouble eating certain foods.
* Abdominal pain or discomfort.
* Regurgitation

Diagnosis:
* Upper endoscopy
* Upper GI series (Barium Swallow): You drink a contrast liquid, and X-rays are taken to see the shape and function of your esophagus, stomach, and duodenum.
* Imaging studies like CT scans may also be used in some cases

The treatment for stenosis after a gastric sleeve surgery typically involves the following options:

1. Endoscopic Dilation: This is the most common first-line treatment.
* In some instances, temporary stents may be placed endoscopically to keep the area open for a period before being removed.

2. Revision Surgery: If endoscopic dilation is not successful or the stenosis recurs, surgical revision may be necessary.
* This could involve revising the existing gastric sleeve (gastric résection and anastomosis, seromyotomy) or converting it to another type of bariatric procedure, such as a Roux-en-Y gastric bypass.

3. Gastric Peroral Endoscopic Myotomy (G-POEM): This is a newer, less invasive endoscopic technique that is being explored for treating certain types of gastric sleeve stenosis, particularly those caused by a twist or angulation of the sleeve.
* Instead of just dilating the stricture, G-POEM involves creating a tunnel in the submucosal layer of the stomach wall and then cutting the muscle fibers in the narrowed area.
* This aims to release the constriction and widen the passage.

04/28/2025

A rectocele (also known as posterior va**nal prolapse) occurs when the wall of tissue separating the re**um from the va**na weakens, allowing the re**um to bulge into the va**na. This can happen due to factors that put pressure on the pelvic floor, such as:
* Vaginal childbirth: Especially repeated deliveries or tearing during birth.
* Aging: Tissues naturally lose elasticity with age.
* Chronic constipation: Straining during bowel movements can weaken the pelvic floor.
* Obesity: Excess weight puts added pressure on pelvic structures.
* Chronic coughing or bronchitis: Persistent coughing increases abdominal pressure.
* Heavy lifting: Repeatedly lifting heavy objects can strain the pelvic floor muscles.
Symptoms
Some women with a rectocele may not experience any symptoms. However, others may have:
* A feeling of pressure or fullness in the va**na or re**um.
* A sensation that something is falling out of the va**na.
* Difficulty having a bowel movement or feeling like the re**um doesn't empty completely.
* The need to press on the va**na or the area between the va**na and re**um to help with bowel movements.
* Constipation.
* Discomfort during s*xual in*******se.
* A soft bulge of tissue that can be felt in or protruding from the va**na.
* Lower back pain.

Diagnosis
The diagnostic of a rectocele is during a pelvic exam.
Imaging tests like a defecography (a special X-ray or MRI during defecation) may be used to assess the size of the rectocele and how well the re**um empties.

Treatment
Treatment for a rectocele depends on the severity of your symptoms.
* Conservative Management: For mild cases or those with few symptoms, treatment may include:
* Pelvic floor exercises (Kegel exercises): To strengthen the muscles that support the pelvic organs.
* Bowel training: To establish regular bowel habits and avoid straining.
* High-fiber diet and adequate fluid intake: To prevent constipation.
* Avoiding heavy lifting and straining.
* Vaginal pessary: A removable silicone device inserted into the va**na to support the bulging tissue.

Surgical Repair: Surgery may be recommended for more severe cases where symptoms significantly impact quality of life and conservative measures haven't provided enough relief.
Surgical options include:
* Posterior colporrhaphy
* Rectopexy