Efficacy of endoscopic gastrojejunal bypass in obese Yucatan pigs: a comparative animal study.

BACKGROUND: Natural orifice transluminal endoscopy surgery (NOTES) gastrojejunal anastomosis (GJA) with duodenal exclusion (DE) could be used as a less invasive alternative to surgical gastric bypass. The aim of this study was to compare the efficacy and safety of both methods for bariatric purpose. METHODS: This was a prospective, experimental and comparative study on 27 obese living pigs, comparing 4 groups: GJA alone (group 1, G1), GJA + DE (group 2, G2), surgical gastric bypass (group 3, G3), control group (group 4, G4). GJA was endoscopically performed, using NOTES technic and LAMS, while DE was performed surgically for limb length selection. Animals were followed for 3 months. Primary outcome included technical success and weight change, while secondary endpoints included the rate of perioperative mortality and morbidity, histological anastomosis analysis and biological analysis. RESULTS: Technical success was 100% in each intervention group. No death related to endoscopic procedures occurred in the endoscopic groups, while early mortality (< 1 month) was 57,1% in the surgical group, all due to anastomotic dehiscence. At 3 months, compared to baseline, mean weight change was + 3,1% in G1 (p = 0,46); -14,9% in G2 (p = 0,17); +5,6% in G3 (p = 0,38) and + 25% in G4 (p = 0,029). Histopathological analysis of endoscopic GJA showed complete fusion of different layers without leak or abscess. CONCLUSIONS: Endoscopic GJA with DE provides the efficacy of bypass on weight control in an animal model. Next steps consist of the development of devices to perform exclusively endoscopically limb length selection and DE.

A novel pleural-bladder pump for the management of recurrent malignant pleural effusions: a feasibility animal study.

BACKGROUND: Recurrent malignant pleural effusions (MPE) are common and associated with significant morbidity in cancer patients. A new pump connecting the pleural cavity and the bladder may have application for the management of recurrent MPE. In a pre-clinical study, we investigated the utility of this pump in healthy pigs. METHODS: A novel pump system (Pleurapump® system) was inserted into four pigs under general anaesthesia. A tunnelled-pleural catheter was connected to a subcutaneously implanted pump while the urinary bladder was connected by percutaneous technique. Animals were ventilated mechanically and pump functioning was tested using a range of ventilation parameters and spontaneous breathing. Fluid was added to the pleural space to mimic pleural effusion and to assess the effectiveness of the pump at removing fluid to the bladder. RESULTS: The 'pleurapump' system successfully transported fluid from the pleural cavity to the bladder. Pressure variations caused by respiration and variations in the amount of fluid in the pleural cavity had no impact on the pumping. Pumping stopped when the pleural cavity was drained. CONCLUSION: This pump can be implanted into pigs and successfully removed fluid from the pleural cavity to the bladder and may represent a new treatment for management of recurrent MPE. Evaluation in humans is planned.

Development of a program for teaching practical skills in visceral and digestive surgery by simulation.

Up until 2013 in France, practical training for DES/DESC (advanced level) residents in visceral and digestive surgery was not standardized. Since 2017, the third cycle of medical studies has been restructured around three major thematic axes: academic knowledge, and technical and non-technical skills. The curriculum now includes a practical training program by means of simulation outside the operating theater, and it is structured, uniformized and standardized nationwide. Development of this training program is derived from the deliberations of a national consensus panel working under the umbrella of the French college of visceral and digestive surgery, program presenting a training guide to all future surgeons in the specialty. Four consensus conference sessions bringing together an eight-member commission have led to the drafting of a "Resident's manual for practical teaching in visceral and digestive surgery". As a reference document, the manual details in 272 pages the objectives (phase I), the learning resources for each skill (phase II) and, lastly, the means of evaluation for the cornerstone phases as well as the in-depth phases of an advanced degree (DES) in visceral and digestive surgery. As a complement to the manual, we have conducted a review of the structuring and implementation of the program as of November 2017 on a nationwide scale; the conclusions of the review are detailed at the end of this article.

Prognostic impact of tumour-infiltrating lymphocytes and cancer-associated fibroblasts in patients with pancreatic adenocarcinoma of the body and tail undergoing resection.

BACKGROUND: The prognosis of patients with pancreatic cancer remains poor and novel therapeutic targets are required urgently. Treatment resistance could be due to the tumour microenvironment, a desmoplastic stroma consisting of cancer-associated fibroblasts and tumour-infiltrating lymphocytes (TILs). The aim of the study was to evaluate the prognostic value of TILs and cancer-associated fibroblasts (CAFs) in pancreatic cancer of the body and tail. METHODS: Using tissue microarray from resected left-sided pancreatic cancer specimens, the immunohistochemistry of TILs (cluster of differentiation (CD) 45, CD3, CD4, FoxP3 and CD8), CAFs (vimentin and α-smooth muscle actin (αSMA)) and functional markers (PD-L1 and Ki-67) was examined, and the association with disease-free (DFS) and overall (OS) survival investigated using a computer-assisted quantitative analysis. Patients were classified into two groups, with low or high levels or ratios, using the 75th percentile value as the cut-off. RESULTS: Forty-three patients were included in the study. Their median DFS and OS were 9 and 27 months respectively. A high CD4/CD3 lymphocyte ratio was associated with poorer DFS (8 months versus 11 months for a low ratio) (hazard ratio (HR) 2·23, 95 per cent c.i. 1·04 to 4·61; P = 0·041) and OS (13 versus 27 months respectively) (HR 2·62, 1·11 to 5·88; P = 0·028). A low αSMA/vimentin ratio together with a high CD4/CD3 ratio was correlated with poorer outcomes. No significant association was found between Ki-67, PD-L1 and survival. CONCLUSION: In patients with resected left-sided pancreatic cancer, a tumour microenvironment characterized by a high CD4/CD3 lymphocyte ratio along with a low αSMA/vimentin ratio is correlated with poorer survival.

ANTECEDENTES: El pronóstico del cáncer de páncreas sigue siendo malo y se requieren nuevas dianas terapéuticas de forma urgente. La resistencia al tratamiento podría ser atribuida al microambiente tumoral, un estroma desmoplásico compuesto por fibroblastos asociados al cáncer y linfocitos infiltrantes de tumor. El objetivo del estudio fue evaluar el valor pronóstico de los linfocitos infiltrantes de tumor y de los fibroblastos asociados al cáncer en el cáncer de cuerpo y cola de páncreas. MÉTODOS: Utilizando microarray para el análisis de muestras de tejido obtenidas tras la resección de cáncer de páncreas del lado izquierdo, se realizó inmunohistoquímica de linfocitos infiltrantes de tumor (CD45, CD3, CD4, FoxP3 y CD8), fibroblastos asociados al cáncer (vimentina y actina del músculo liso alfa (αSMA)) y marcadores funcionales (PD-L1 y Ki67), y se investigó la asociación con la supervivencia libre de enfermedad y la supervivencia global. Los resultados se obtuvieron tras un análisis cuantitativo asistido por ordenador. Los pacientes se clasificaron en dos grupos, de bajo y alto riesgo, utilizando el valor del percentil 75 como punto de corte. RESULTADOS: Se incluyeron 43 pacientes en el estudio. En esta población, la mediana de supervivencia libre de enfermedad y de supervivencia global fueron 9 meses y 27 meses, respectivamente. Una alta proporción de linfocitos CD4/CD3 se asoció a peor supervivencia libre de enfermedad (8 meses versus 11 meses; cociente de riesgos instantáneos, hazard ratio, HR 2,2; i.c. del 95% 1,0-4,6; P = 0,041) y supervivencia global (13 meses versus 27 meses; HR 2,6; i.c. del 95% 1,1-5,9; P = 0.028). Una baja proporción αSMA/vimentina junto con una alta proporción CD4/CD3 se correlacionó con peores resultados. No se encontró asociación significativa entre Ki67, PD-L1 y la supervivencia. CONCLUSIÓN: En pacientes con cáncer de páncreas izquierdo resecado, un microambiente tumoral caracterizado por una alta proporción de linfocitos CD4/CD3 junto con una baja proporción de αSMA/vimentina se correlaciona con una peor supervivencia.

Redo ileal pouch-anal anastomosis: outcomes from a case-controlled study.

AIM: To assess short- and long-term outcomes of redo ileal pouch-anal anastomosis (redo-IPAA) for failed IPAA, comparing them with those of successful IPAA. METHOD: This was a case-control study. Data were collected retrospectively from prospectively maintained databases from two tertiary care centres. Patients who had a redo-IPAA between 1999 and 2016 were identified and matched (1:2) with patients who had a primary IPAA (p-IPAA), according to diagnosis, age and body mass index. RESULTS: Thirty-nine redo-IPAAs (16 transanal and 23 abdominal procedures) were identified, and were matched with 78 p-IPAAs. After a mean follow-up of 56 ± 51  (2.6-190) months, failure rates after transanal and abdominal approaches were 50% and 15%, respectively. Reoperation after the transanal approach was higher than after p-IPAA (69% vs 7%; P < 0.001). No differences were noted between the abdominal approach for redo-IPAA and p-IPAA in terms of morbidity (61% for redo-IPAA vs 38% for p-IPAA; P = 0.06), major morbidity (9% vs 8%; P = 0.96), anastomotic leakage (13% vs 10%; P = 0.74), mean daily bowel movements (6 vs 5.5; P = 0.68), night-time bowel movements (1.2 vs 1; P = 0.51), faecal incontinence (13% vs 7%; P = 0.40), urgency (31% vs 27%; P = 0.59), use of anti-diarrhoeal drugs (47% vs 37%; P = 0.70), mean Cleveland Global Quality-of-Life score (7 vs 7; P = 0.83) or sexual function. CONCLUSION: The abdominal approach for redo-IPAA is justified in cases of pouch failure because it achieves functional results comparable with those observed after p-IPAA, without higher postoperative morbidity. The transanal approach should be chosen sparingly.

Colorectal surgery and enhanced recovery: Impact of a simulation-based care pathway training curriculum.

BACKGROUND: The aim was to determine whether a simulation-based care pathway approach (CPA) curriculum could improve compliance for enhanced recovery programs (ERP), and residents' participation in laparoscopic colorectal surgery (LCS). Indeed, trainee surgeons have limited access to LCS as primary operator, and ERP have improved patients' outcomes in colorectal surgery (CS). METHODS: All residents of our department were trained in a simulation-based CPA: perioperative training consisted in virtual patients built according to guidelines in both ERP and CS, whilst intraoperative training involved a virtual reality simulator curriculum. Twenty consecutive patients undergoing CS were prospectively included before (n=10) and after (n=10) the training. All demographic and perioperative data were prospectively collected, including compliance for ERP. Residents' participation as primary operator in LCS was measured. RESULTS: Five residents (PGY 4-7) were enrolled. None had performed LCS as primary operator. Overall satisfaction and usefulness were both rated 4.5/5, usefulness of pre-, post- and intraoperative training was rated 5/5, 4.5/5 and 4/5, respectively. Residents' participation in LCS significantly improved after the training (0% (0-100) vs. 82.5% (10-100); P=0.006). Pre- and intraoperative data were comparable between groups. Postoperative morbidity was also comparable. Compliance for ERP improved at Day 2 in post-training patients (3 (30%) vs. 8 (80%); P=0.035). Length of stay was not modified. CONCLUSIONS: A simulated CPA curriculum to training in LCS and ERP was correctly implemented. It seemed to improve compliance for ERP, and promoted residents participation as primary operator without adversely altering patients' outcomes.

Hollow viscus injury due to blunt trauma: A review.

Blunt abdominal trauma results in injury to the bowel and mesenteries in 3-5% of cases. The injuries are polymorphic including hematoma, seromuscular tear, perforation, and ischemia. They preferentially involve the small bowel and may result in bleeding and/or peritonitis. An urgent laparotomy is necessary if there is evidence of active bleeding or peritonitis at the initial examination, but these situations are uncommon. The main diagnostic challenge is to promptly and correctly identify lesions that require surgical repair. Diagnostic delay exceeding eight hours before surgical repair is associated with increased morbidity and probably with mortality. Because of this risk, the traditional therapeutic approach has been to operate on all patients with suspected bowel or mesenteric injury. However, this approach leads to a high rate of non-therapeutic laparotomy. A new approach of non-operative management (NOM) may be applicable to hemodynamically stable patients with no signs of perforation or peritonitis, and is being increasingly employed. This attitude has been described in several recent studies, and can be applied to nearly 40% of patients. However, there is no consensual agreement on which criteria or combination of clinical and radiological signs can insure the safety of NOM. When NOM is decided upon at the outset, very close monitoring is mandatory with repeated clinical examinations and interval computerized tomography (CT). Larger multicenter studies are needed to better define the selection criteria and modalities for NOM.

Practice patterns in complex ventral hernia repair and place of biological grafts: a national survey among French digestive academic surgeons.

BACKGROUND: Despite the prevalence of complex ventral hernias, there is little agreement on the most appropriate technique or prosthetic to repair these defects, especially in contaminated fields. Our objective was to determine French surgical practice patterns among academic surgeons in complex ventral hernia repair (CVHR) with regard to indications, most appropriate techniques, choice of prosthesis, and experience with complications. METHODS: A survey consisting of 21 questions and 6 case-scenarios was e-mailed to French practicing academic surgeons performing CVHR, representing all French University Hospitals. RESULTS: Forty over 54 surgeons (74%) responded to the survey, representing 29 French University Hospitals. Regarding the techniques used for CVHR, primary closure without reinforcement was provided in 31.6% of cases, primary closure using the component separation technique without mesh use in 43.7% of cases, mesh positioned as a bridge in 16.5% of cases, size reduction of the defect by using aponeurotomy incisions without mesh use in 8.2% of cases. Among the 40 respondents, 36 had experience with biologic mesh. There was a strong consensus among surveyed surgeons for not using synthetic mesh in contaminated or dirty fields (100%), but for using it in clean settings (100%). There was also a strong consensus between respondents for using biologic mesh in contaminated (82.5%) or infected (77.5%) fields and for not using it in clean setting (95%). In clean-contaminated surgery, there was no consensus for defining the optimal therapeutic strategy in CVHR. Infection was the most common complication reported after biologic mesh used (58%). The most commonly reported influences for the use of biologic grafts included literature, conferences and discussion with colleagues (85.0%), personal experience (45.0%) and cost (40.0%). CONCLUSIONS: Despite a lack of level I evidence, biologic meshes are being used by 90% of surveyed surgeons for CVHR. Importantly, there was a strong consensus for using them in contaminated or infected fields and for not using them in clean setting. To better guide surgeons, prospective, randomized trials should be undertaken to evaluate the short- and long-term outcomes associated with these materials in various surgical wound classifications.

[Current and future use of surgical skills simulation in gynecologic resident education: a French national survey]. / Utilisation des simulateurs pour former les internes de chirurgie gynécologique en France : un état des lieux en 2013.

OBJECTIVES: Simulation is a promising method to enhance surgical education in gynecology. The purpose of this study was to provide baseline information on the current use of simulators across French academic schools. MATERIALS AND METHODS: Two questionnaires were created, one specifically for residents and one for professors. Main issues included the type of simulators used and the kind of use made for training purposes. Opinions and agreement about the use of simulators were also asked. RESULTS: Twenty-six percent of residents (258/998) and 24% of professors (29/122) answered the questionnaire. Sixty-five percent of residents (167/258) had experienced simulators. Laparoscopic pelvic-trainers (84%) and sessions on alive pigs (63%) were most commonly used. Residents reported access to simulators most commonly during introductory sessions (51%) and days of academic workshops (38%). Residents believed simulators very useful for training. Professors agreed that simulators should become a required part of residency training, but were less enthusiastic regarding simulation becoming a part of certification for practice. CONCLUSION: Surgical skills simulators are already experienced by a majority of French gynecologic residents. However, the use of these educational tools varies among surgical schools and remains occasional for the majority of residents. There was a strong agreement that simulation technology should be a component of training.

Assessment of team training in management of adverse acute events occurring during cardiopulmonary bypass procedure: a pilot study based on an animal simulation model (Fouilloux, Team training in cardiac surgery).

BACKGROUND: Successful cardiac surgery is highly dependent upon effective and efficient teamwork. Practical training and development will further enhance the team ability to react to a series of low-frequency occurring adverse events during cardiopulmonary bypass (CPB). One of our specialized educational programs focuses on training the whole team. This training is based on an original animal simulation model. The objective of this pilot study was to assess our method of training and learning in an attempt to optimize and improve team management and functioning. METHODS: Four members of the same cardiac surgery team joined our program. They performed a common procedure, with a cardiopulmonary bypass (CPB) circuit set up to produce several adverse incidents. Events management was analyzed and debriefed in technical and non-technical perspectives. RESULTS: Management of the adverse events was significantly improved. Discussion and debriefing time was fundamental in identifying the most appropriate management for each event. Rescue procedures were assimilated and team training was found to be effective, with the time reduced by up to 50% for 3 events and by up to 70% for air embolism. CONCLUSION: Our pilot program is an innovative, low-cost tool for the improvement of the management of adverse events occurring during CPB. It includes the different components of surgical education and training. Such an educational tool might be relevant for training. To confirm those encouraging results, it should be assessed in a larger surgical team panel. Further investigations are required for assessing efficiency in real conditions.

Blunt bowel and mesenteric injuries detected on CT scan: who is really eligible for surgery?

BACKGROUND: There is no consensually accepted approach to the management of blunt bowel and mesenteric injuries. Surgery is required urgently in the case of bowel perforation or haemodynamic instability, but several patients can be treated non-operatively. This study aimed to identify the risk factors for surgery in an initial assessment. METHODS: We retrospectively reviewed the medical charts and computed tomography (CT) scans of adult patients presenting with a blunt abdominal trauma to our centre between the years 2004 and 2011. We included only patients with a CT scan showing suspected injury to the mesentery or bowel. RESULTS: There were 43 patients (33 males and 10 females), with a mean Injury Severity Score (ISS) of 22. The most frequently suspected injuries based on a CT scan were mesenteric infiltrations in 40 (93 %) patients and bowel wall thickening in 22 (51 %) patients. Surgical therapy was required for 23 (54 %) patients. Four factors were independently associated with surgical treatment: a free-fluid peritoneal effusion without solid organ injury [adjusted odds ratio (OR) = 14.4, 95 % confidence interval (CI) [1.9-111]; p = 0.015], a beaded appearance of the mesenteric vessels (OR = 9 [1.3-63]; p = 0.027), female gender (OR = 14.2 [1.3-159]; p = 0.031) and ISS >15 (OR = 6.9 [1.1-44]; p = 0.041). Surgery was prescribed immediately for 11 (26 %) patients and with delay, after the failure of initially conservative treatment, for 12 (28 %) patients. The presence of a free-fluid peritoneal effusion without solid organ injury was also an independent risk factor for delayed surgery (OR = 9.8 [1-95]; p = 0.048). CONCLUSIONS: In blunt abdominal trauma, the association of a bowel and/or mesenteric injury with a peritoneal effusion without solid organ injury on an initial CT scan should raise the suspicion of an injury requiring surgical treatment. Additionally, this finding should lead to a clinical discussion of the benefit of explorative laparotomy to prevent delayed surgery. However, these findings need validation by larger studies.

[Stab wounds in emergency department]. / Les plaies par arme blanche et leur prise en charge aux urgences.

Stab wounds represent the most common cause of penetrating wounds, occurring mainly in case of aggression or suicide attempt. Clinical severity depends on the superficial or penetrating aspect of the wound, its location and damaged organs. Medical management must be known because the vital risk is involved in penetrating wounds. Hemodynamically unstable patients should be operated without delay after performing a chest X-ray and ultrasound Focus assisted sonography for trauma (FAST) to guide the surgery. In the stable patients, the general clinical examination, exploration of the wound and medical imaging detect injuries requiring surgical management. Stab penetrating wounds require close and rapid collaboration between medical teams, tailored to the institution's resources.

Evaluation of feasibility, efficiency and safety of a pure NOTES gastrojejunal bypass with gastric outlet obstruction, in an in vivo porcine model.

INTRODUCTION: Natural orifice transluminal endoscopic surgery (NOTES) gastrojejunal anastomosis (GJA) is a less invasive surgery for bariatric procedures and gastric outlet obstruction. The aim of this study was to evaluate the feasibility, efficacy, and safety of a pure NOTES gastrojejunal bypass using an in vivo porcine model. MATERIAL AND METHODS: A prospective study was performed on nine swine. A double-channel scope was used. The intervention steps were: (i) gastric incision; (ii) peritoneal access; (iii) jejunal loop selection and mobilization into the stomach; (iv) stoma creation within the gastric wall and incision; (v) anastomosis suture and pylorus closure using a T-tag prototype. The animals were assessed clinically for 3 weeks including the weight gain. The patency of the GJA was assessed at necropsy and a histological analysis was performed. RESULTS: We successfully performed all the procedures with a mean (standard deviation [SD]) operative time of 108 (26) minutes. We used a mean of 5.55 (1.30) stitches. There were no intraprocedural adverse events. Five animals survived up till euthanasia at 3 weeks (65 %). These showed a significant difference in weight curves of a loss of 3.2 kg compared with gain of 5.2 kg in a control group. Four pigs died from anastomotic dehiscence complicated by peritonitis. CONCLUSION: Gastrojejunal bypass with a pure NOTES approach is feasible. This procedure is effective, resulting in a patent anastomosis and a significant weight loss. However, the anastomotic dehiscence is a major concern because of its mortality rate, and further studies including improvement of the suturing device and the technique are needed.

[Recurrent pericarditis revealing a systemic sarcoidosis]. / Péricardite récidivante révélant une sarcoïdose systémique.

INTRODUCTION: Sarcoidosis is a systemic granulomatous disorder of unknown cause, mainly involving the lung and the mediastinum. Involvement of the pericardium and peritoneum is rare, but can be the first manifestation of the disease. CASE REPORT: A 55-year-old female patient was followed-up for a recurrent "idiopathic" pericarditis. Diagnostis was challenged when she secondarily presented with enlarged hilar and mediastinal lymph nodes associated with pulmonary "nodules". Imaging with (18)F-FDG positron emission tomography with computed tomography showed multiple hypermetabolic foci in the mediastinum and peritoneum, which suggested a malignant disorder. Finally, histopathological evaluation of the peritoneal nodules revealed a sarcoidosis. A corticosteroid therapy was initiated and disease course was favourable. CONCLUSION: This case report highlights the importance of a unique explanation for a patient presenting with recurrent pericarditis associated with a systemic disease. Although rare, sarcoidosis should be discussed and diagnostic procedures should be performed to obtain histological confirmation.

Ruptured liver cell adenoma in man: great fortune in misfortune.

Liver cell adenoma is mostly known as a tumour affecting women with long-term use of contraceptive hormones. Its incidence in men is very low, and particularly few cases of acute complications are related in the literature. We report the case of a 44-year-old man presenting with a life-threatening rupture of a hepatic tumour, successfully treated in emergency with primary endovascular embolization, followed by hepatectomy, once stabilized. The pathological findings were fortunately consistent with the diagnosis of liver-cell adenoma. To our knowledge, it is the first case reported in a man treated by a combined interventional radiological and surgical approach.

[Risks related to tobacco use in general and intestinal surgery]. / Risques liés au tabagisme en chirurgie générale et digestive.

Peri-operative smoking history is an important risk factor, which is often under-appreciated by surgeons. In the first place, tobacco use predisposes patients to specific pathologies, which may require surgical intervention. Secondarily, smoking has been shown to increase surgical risks of mortality, morbidity and length of hospital stay. Of particular importance in general surgery is the increased risk of anastomotic leak with fistula formation, of deep infections, and of abdominal wall complications (infection and ventral hernia). If the patient can stop smoking prior to surgery, there is a concomitant decrease in post-operative complications. Surgeons should be familiar with the pharmacologic and behavioral interventions, which may help the patient with smoking cessation and should not hesitate to defer elective surgery for four to eight weeks so that the patient may have the full benefit of smoking cessation.

A clampless and sutureless aorto-prosthetic end-to-side anastomotic device: an experimental study.

OBJECTIVES: A feasibility study. METHODS: Eight pigs (all females; mean weight: 29 kg) underwent a conventional transperitoneal aortic approach with implantation of an aorto-prosthetic end-to-side anastomosis using a Clampless device and deployment of a 5-mm polytetrafluoroethylene (PTFE) graft. After proximal ligature, a conventional end-to-end anastomosis was then performed between the graft and the left iliac artery. RESULTS: The first pig died during the procedure due to graft misplacement. The seven other procedures were successful with a mean operative and anastomosis time of 101 min (range: 81-115 min) and 3.35 min (range: 2.25-4.25 min), respectively; mean blood loss was 152 ml (range: 30-235 ml). Another pig with a patent graft died at day 4 as a result of a severe unrelated pneumonopathy. The angiogram performed during the procedure and before sacrifice, at 2 (n=2), 4 (n=2) and 6 weeks (n=2), showed no graft stenosis or thrombosis. Microscopic examination revealed a tissue covering the intraluminal stent, which evolved over time, with no visible endothelial proliferation or inflammation. CONCLUSION: An aorto-prosthetic anastomosis can be performed safely and efficiently with our new clampless and sutureless device. The next step will be a laparoscopic Clampless implantation.