A prospective, randomized trial of esophageal submucosal tunnel closure with a stent versus no closure to secure a transesophageal natural orifice transluminal endoscopic surgery access site

Efficacy and safety of endoscopic submucosal tunnel dissection vs endoscopic submucosal dissection for early superficial upper gastrointestinal precancerous lesions and tumors: A meta-analysis

OBJECTIVE

Endoscopic submucosal tunnel dissection (ESTD) is a new treatment for superficial upper gastrointestinal precancerous lesions and tumors. However, its safety and efficacy for treating these lesions is still uncertain. This meta-analysis aimed to compare the efficacy and safety of ESTD with those of endoscopic submucosal dissection (ESD) in treating early superficial upper gastrointestinal precancerous lesions and tumors.

METHODS

Electronic databases, including EMBASE, PubMed, Cochrane Library and the Web of Science, were systematically searched for articles published up to 1 April 2020. The primary outcomes were complete and en bloc resection rates of the lesions. The secondary outcomes included operation time, speed of dissection, complication and recurrence rates. The Newcastle-Ottawa quality assessment scale was used to evaluate the quality of the studies.

RESULTS

Seven studies were included in the final meta-analysis. The complete and en bloc resection rates of early superficial esophageal lesions as well as the en bloc resection rate of early superficial gastric lesions were similar between the ESTD and ESD groups. Compared with the ESD group, the ESTD group had a higher en bloc resection rate for early superficial gastric lesions. A faster dissection speed was observed in both superficial esophageal and gastric lesions. In gastric lesions, the operation time of the ESTD group was shorter than that of the ESD group, while it did not differ for esophageal lesions. There were no obvious differences in bleeding and perforation rates between the groups.

CONCLUSION

As an endoscopic technique for treating early superficial upper gastrointestinal lesions, ESTD is as safe as and more effective than ESD, especially for gastric lesions.

A multicenter retrospective study of endoscopic submucosal tunnel dissection for large lesser gastric curvature superficial neoplasms

BACKGROUND AND AIM

Endoscopic submucosal tunnel dissection (ESTD) has been used for dissection of esophageal and gastric lesions. However, outcomes of ESTD for large lesions in the lesser gastric curvature had not been acknowledged because previous reports had the limitations of being single-center studies. We aimed to clarify the outcomes of ESTD for large lesser gastric curvature superficial neoplasms and provide our experience to accelerate its application.

METHODS

Between July 2014 and July 2016, 87 patients with early cancer in the lesser gastric curvature treated at six Chinese institutions were enrolled. Our primary outcome was dissection speed. Moreover, both efficacy and safety clinical data were collected and analyzed retrospectively.

RESULTS

All of the 87 patients were found to successfully undergo ESTD or ESD. Of these, 32 underwent ESTD and 55 underwent endoscopic submucosal dissection (ESD). The ESTD group had a higher dissection speed (18.0 mm²/min vs. 7.8 mm²/min, p < 0.01) and was associated with higher en bloc resection rate (100% vs. 87.3%, p = 0.035) and curative resection rate (100% vs. 85.5%, p = 0.024) compared with the ESD group. No perforation or muscular injury occurred in the ESTD group and its intraprocedural bleeding rate was lower (59.4% vs. 100%, p < 0.01) than that of the ESD group.

CONCLUSIONS

In this multicenter retrospective study, outcomes of ESTD were excellent with a higher dissection speed and radical curative rate compared with ESD.

Transtracheal thoracic natural orifice transluminal endoscopic surgery (NOTES) in a swine model

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) has the potential to be the final frontier in minimally invasive procedures in thoracic surgery. In order for thoracic pleural NOTES to 1 day be ready for clinical trials, each step of the procedure must be independently evaluated for both safety and efficacy. The aim of this study was to evaluate the trachea as a portal of entry for thoracic NOTES.

METHODS

Eight 40-kg swine underwent right thoracic pleuroscopy in a survival model. In order to avoid inadvertent injury to the superior vena cava, endobronchial ultrasound was employed to select the location of airway incision. A 7-mm linear incision was then performed at the chosen location using an endoscopic electrocautery needle knife through a therapeutic flexible videobronchoscope. The mediastinal fat and parietal pleura were then dissected with electrocautery, and complete right pleuroscopy was performed. The tracheal and mediastinal portal of entry were then sealed with 1-2 cc of fibrin sealant. The pigs were kept alive for 21 days postoperatively. Postmortem diagnostic bronchoscopy was performed to assess tracheal healing. All tracheal specimens underwent histologic examination for healing and signs of mediastinal infection.

RESULTS

Thoracic NOTES procedures on all eight pigs were successful. There were no intraoperative complications except for one minor bleeding episode within the mediastinal dissection site which stopped spontaneously. Two pigs died from severe laryngospasm in the early postoperative period. Six pigs survived for 21 days post-procedure and experienced uneventful postoperative courses. Postmortem examination demonstrated complete tracheal healing with appropriate scarring in all pigs.

CONCLUSIONS

The trachea appears to be a safe port of entry for thoracic NOTES procedures in a swine model. Smaller tracheal incisions followed by balloon dilatation are associated with less postoperative morbidity and mortality. Tracheal incisions sealed with fibrin sealant healed rapidly and without signs of mediastinal infection. This procedure represents a work in progress and is not yet ready for human trials.

Feasibility and safety of functional cholecystectomy by pure NOTES: a pilot animal study

BACKGROUND

NOTES cholecystectomy has become one of the hottest areas of research. But most of the cases need the assistance of the laparoscope. This study is conducted to evaluate the feasibility and safety of a newly proposed operative method-functional cholecystectomy by pure NOTES.

MATERIALS AND METHODS

The functional cholecystectomy was performed on eight female miniature pigs. An incision was made on the vaginal wall, and an endoscope was inserted into the peritoneal cavity to create a pneumoperitoneum to expose the intra-abdominal viscera, gallbladder, and cystic duct. The cystic duct was isolated and closed with a clip. Then, an injection needle was inserted into the gallbladder to suck up the bile. After the gallbladder was washed with saline, an incision was made on the wall of the gallbladder, and the tip of the endoscope was inserted into the gallbladder cavity. After the endoscope was withdrawn, the gallbladder incision was closed with clips in four pigs and was suspended in the other four pigs. The vaginal incision was closed with clips. All the animals were closely monitored and euthanized 28 days after the procedure. Necropsy was performed.

RESULTS

The functional cholecystectomy was successfully completed in all eight pigs. No severe intraoperative complications occurred. The animals recovered well postoperatively. At necropsy, no macroscopic signs of intraperitoneal infection or bile leakage in the peritoneal cavity were observed, and the clips were still present on the cystic duct in a good position in all cases. The gallbladder incision healed, with no sign of bile leakage or injury to the adjacent organs.

CONCLUSIONS

We successfully performed the functional cholecystectomy by transvaginal approach on pigs, which appears to be feasible, safe, and convenient. Functional cholecystectomy provides a new fitting path to pure NOTES.

Natural orifice transesophageal endoscopic surgery: state of the art

The main goal of Natural Orifice Transluminal Endoscopic Surgery (NOTES) is performing surgery avoiding skin incisions. Theoretical advantages of NOTES include decreased postoperative pain, reduction/elimination of general anesthesia, improved cosmetic outcomes, elimination of skin incision-related complications such as wound infections and hernias, and increased overall patient satisfaction. Although various forms of port creation to accomplish thoracic NOTES procedures have been proposed, transesophageal NOTES has been shown to be the most reliable one. The evolution of endoscopic submucosal transesophageal access resulted in the development of per-oral endoscopic myotomy (POEM), which had a fast transition to clinical practice. The authors present a review of the current state of the art concerning transesophageal NOTES, looking at its potential for diagnostic and therapeutic interventions as well as the hurdles yet to be overcome.

Critical analysis of hot topics in NOTES

Natural orifice transluminal endoscopic surgery (NOTES) has gained a great deal of attention from gastroenterologists and surgeons all over the world since its introduction in 2000. The field of NOTES has advanced tremendously since that time and exciting and well-designed research has been reported. Both randomized controlled trials and results from large national and international registries have been published. Many experimental and clinical studies have discussed transesophageal, transgastric, transvaginal and transrectal access for a variety of NOTES procedures. Transvaginal access has been the most frequently reported NOTES access route in clinical trials. When suitable instruments become available, a true comparison of NOTES with current laparoscopic approaches can be realized.