Dr Sorin Cimpean, Digestive Surgeon

19/10/2025

Ventral rectopexy (VR) is a minimally invasive abdominal surgical technique that can effectively treat rectocele—a condition where the re**um bulges into the posterior vaginal wall due to weakened pelvic floor support, often causing symptoms like obstructed defecation syndrome (ODS), constipation, incomplete evacuation, and f***l incontinence. While traditionally used for re**al prolapse, VR addresses rectocele by providing ventral support to the re**um and rectovaginal septum, particularly in cases with associated internal re**al intussusception or multicompartment pelvic floor prolapse.

VR achieves high anatomic success (96-100% correction on imaging) and functional improvement in rectocele, with low recurrence (1-5% at 2-5 years). In a 2025 randomized controlled trial (RCT) of 40 women with anterior rectocele, VR reduced constipation from 17±2.8 to ~8 at 12 months (p

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12/10/2025

The anore**al angle (ARA), also known as the ano-re**al angle, is the anatomical angle formed at the junction between the a**l ca**l and the re**um, specifically between the central axis of the a**l ca**l and a line tangent to the posterior wall of the re**al ampulla. It plays a key role in continence and defecation, as it is influenced by the pubore**alis muscle (part of the levator ani), which helps maintain f***l continence by creating a functional barrier.

Normal Measurements
- At rest:
-Typically averages 95–120 degrees, with a normal range of 70–134 degrees.
-Often wider ( >120°) in symptomatic rectocele due to pelvic floor laxity, though some studies show a sharper angle (e.g., ~100°) if coexisting spasticity is present.

- During squeeze/lift (contraction):
-ARA decreases (sharpens) to facilitate continence.
-In rectocele may widen excessively (e.g., ~120°) compared to normals (~110°), indicating reduced pubore**alis tone.

- During evacuation/defecation:
-ARA opens to 100–140 degrees, allowing passage of stool; the anore**al junction also descends slightly (less than 3.5 cm).
-In rectocele typically fails to widen adequately contributing to incomplete evacuation and symptoms like straining or digital assistance. In contrast, excessive widening (>155°) can occur with severe descent.

Clinical Relevance
Abnormal ARA in rectocele often correlates with obstructed defecation syndrome, coexisting intussusception (40%), or enterocele (13%). Abnormal ARA indicates poor coordination between the pubore**alis and pelvic floor, often requiring biofeedback, pelvic floor therapy, or surgery for correction.

09/10/2025

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29/09/2025

19/09/2025

Great Teambuilding with the Digestive Surgery Team

CHIREC Hospital Group

11/09/2025

Desmoid tumor of the re**us abdominis muscle is a rare, benign (non-cancerous) but locally aggressive fibroblastic tumor that arises from the musculoaponeurotic structures, particularly in the abdominal wall.

-Nature: Benign, non-inflammatory fibroblastic tumor with a tendency for local invasion and recurrence after resection. It accounts for ~0.03% of all neoplasms and has an incidence of 3.7 cases per million per year.

-Demographics: More frequent in women (2:1 ratio), especially between ages 20–40. Often associated with pregnancy, postpartum periods, or hormonal factors like estrogen therapy.

Symptoms
-Presentation: Typically presents as a firm, palpable mass, which may be painless or painful, depending on size and location. Pain may increase as the tumor grows and compresses nearby structures like muscles or nerves.

Diagnosis
-Physical Exam: A firm, fixed mass in the abdominal wall, often in the re**us abdominis muscle.

Imaging:
-Ultrasound: Shows a hypoechoic, well-circumscribed mass with possible vascularity on Doppler.
-CT: Reveals a hypodense or isodense mass with mild enhancement after contrast administration. It may have well-defined or ill-defined margins.
-MRI: Preferred for assessing local tumor extension. Desmoids appear isointense to muscle on T1-weighted images and hyperintense with band-like low-signal areas on T2-weighted images.

Differential Diagnosis: Includes acute hematoma, fibrosarcoma, lymphoma, rhabdomyosarcoma, liposarcoma, leiomyosarcoma, neurofibroma, endometriosis (especially post-cesarean), and metastases.

Treatment

-Observation: Stable, asymptomatic tumors can be monitored with imaging every 3–6 months ("wait-and-see" approach).
-Surgery: The mainstay for symptomatic or invasive abdominal wall desmoids. Complete resection with negative margins is preferred to reduce recurrence (up to 87% in younger patients). Reconstruction with polypropylene mesh or acellular dermal matrix may be needed for large defects to prevent herniation.

Non-Surgical Therapies:
-Radiation Therapy: Used for unresectable tumors or as adjuvant therapy, though less common for abdominal wall tumors.
-Systemic Therapy: Includes chemotherapy, hormonal therapy (e.g., tamoxifen due to estrogen sensitivity), or non-steroidal anti-inflammatory drugs (NSAIDs). Molecular targeted agents are also emerging.

Challenges: High recurrence rates (over 30% in some cases) and difficulty achieving margin-free resection due to local invasion.

Prognosis
-Desmoid tumors do not metastasize but can cause significant morbidity due to local invasion and recurrence.
Recurrence is more likely if surgical margins are positive.

30/08/2025

Candy Cane Syndrome occurs when the blind segment of an gastro-jejunal anastomosis of a Roux-en-Y Gastric Bypass can dilate over time, trapping food, liquid, or debris, which leads to increased intraluminal pressure and symptoms.

# Symptoms:
- Abdominal pain ~68–86% of cases, often epigastric or postprandial).
- Nausea and vomiting ( ~32–43% of cases).
- Acid reflux or heartburn.
- Dysphagia or regurgitation.
- Suboptimal weight loss or weight regain (due to the blind limb acting as a reservoir for food, reducing the restrictive effect of the bypass).
- Early satiety or bloating

# Diagnosis:
-Upper gastrointestinal (GI) series (e.g., barium swallow): Sensitivity is ~63% but improves to >90% for limbs ≥2.5 cm.
-Upper endoscopy: Sensitivity is ~50%.
-Computed tomography (CT) scan: Less sensitive (~29%) but can identify dilated loops or obstructions.

# Treatment
- Surgical resection: symptom resolution in 73–100% of cases
- Endoscopic management: endoscopic septotomy or suturing to close the blind limb
- Dietary changes: In mild cases

22/08/2025

Candy Cane Syndrome (CCS) is a rare complication that can occur after Roux-en-Y gastric bypass (RYGB) or gastrectomy surgeries, where an excessively long blind afferent Roux limb (a redundant segment of small intestine) is left at the gastrojejunostomy or jejunojejunostomy.

Jejuno-jejunal (J-J) intussusception in the context of a stump or blind limb following Roux-en-Y gastric bypass (RYGB) is a rare but serious complication. It occurs when a segment of the jejunum (the small intestine) telescopes into an adjacent segment.

We present case report of a patient who presented both conditions.

Here is the link :
https://www.sgo-iasgo.com/article/candy-cane-syndrome-and-jejuno-jejunal-anastomosis-stump-intussusception-in-a-roux-en-y-gastric-bypass-case-report

16/07/2025

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.

05/07/2025

04/07/2025

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

28/06/2025

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.