The Queen's closure: a novel technique for closure of endoscopic gastrotomy for natural-orifice transluminal endoscopic surgery

Endoluminal management of colon perforations during advanced endoscopic procedures

BACKGROUND

Advanced endoscopic procedures are gaining attraction despite a steep learning curve, need for high dexterity, and potential complications. Colonic perforation is the most concerning adverse event during advanced endoscopic procedures. This study presents our experience on endoluminal management of iatrogenic colonic perforations.

METHODS

Patients who underwent advanced endoscopic procedures at a quaternary center from 2016 to 2021 were identified. Patients who had colonic perforations during advanced procedures and treated with endoscopic closure/clipping were included. Retrospective chart review was performed. Figures represent frequency (proportion) or median (interquartile range/range).

RESULTS

There were 22 (2.3%) immediate colonic perforations treated with endoscopic clipping out of 964 advanced endoscopic resections. The median age was 64 (interquartile range = 57-71) years and 50% of the patients were female; 16 (73%) resections were proximal to the splenic flexure. Median polyp size was 36 (20-55) mm. Closure was performed with endoscopic clips in 18 (82%) patients, and over-the-scope clips in 4 patients. Median hospital stay was 0.8 (0-4) days, and 13 (59%) patients were discharged the same day; 2 patients were admitted to the emergency department ≤24 hours of procedure. They underwent subsequent laparoscopic suture repair the same day. No one had segmental colon resection, and there were no complications within postoperative 30 days. Pathology revealed 9 (41%) tubular adenomas, 7 (32%) tubulovillous adenomas, 6 (27%) sessile serrated lesions, and no adenocarcinoma. No recurrence was observed with median follow-up of 24 months (range = 0-90 months).

CONCLUSION

Endoscopic management is an effective treatment approach for the management of iatrogenic colonic perforations.

Suturing techniques with endoscopic clips and special devices after endoscopic resection

Endoscopic submucosal dissection is an established method for complete resection of large and early gastrointestinal tumors. However, methods to reduce bleeding, perforation, and other adverse events after endoscopic resection (ER) have not yet been defined. Mucosal defect closure is often performed endoscopically with a clip. Recently, reopenable clips and large-teeth clips have also been developed. The over-the-scope clip enables complete defect closure by withdrawing the endoscope once and attaching the clip. Other methods involve attaching the clip-line or a ring with an anchor to appose the edges of the mucosal defect, followed by the use of an additional clip for defect closure. Since clips are limited by their grasping force and size, other methods, such as endoloop closure, endoscopic ligation with O-ring closure, and the reopenable clip over-the-line method, have been developed. In recent years, techniques often utilized for full-thickness ER of submucosal tumors have been widely used in full-thickness defect closure. Specialized devices and techniques for defect closure have also been developed, including the curved needle and line, stitches, and an endoscopic tack and suture device. These clips and suture devices are applied for defect closure in emergency endoscopy, accidental perforations, and acute and chronic fistulas. Although endoscopic defect closure with clips has a high success rate, endoscopists need to simplify and promote endoscopic closure techniques to prevent adverse events after ER.

A comparison of two endoscopic closures: over-the-scope clip (OTSC) versus KING closure (endoloop + clips) in a randomized long-term experimental study

BACKGROUND

Both over-the-scope clip (OTSC) and KING (endoloop + clips) closures provide reliable and safe full-thickness endoscopic closure. Nevertheless, OTSC clip demonstrated significantly inferior histological healing in the short-term follow-up.

AIM

To compare OTSC versus KING closure of a perforation with regard to long-term effectiveness and macroscopic and histological quality of healing.

METHODS

We performed a randomized experimental study with 16 mini-pigs (mean weight 43.2 ± 11.2 kg). A standardized perforation was performed on the anterior sigmoid wall. KING closure (n = 8) was attained by approximation of an endoloop fixed to the margins of a perforation with endoclips. OTSC closure (n = 8) was performed by deploying OTSC (OVESCO) over the defect. Pigs underwent a control sigmoidoscopy 8 months after the closure to assess the macroscopic quality of healing. Then, autopsy was performed and the rectosigmoid was sent for histopathological assessment.

RESULTS

All closures were completed successfully without air leaks. The duration of closure was similar in both techniques (OTSC 17.8 ± 7.6 min vs. KING 19.6 ± 8.8 min). At autopsy, all KING closures (100 %) were healed with a flat scar without signs of leakage. Microscopically, no inflammatory changes were observed after KING closure. In the OTSC group, microscopic ulcers were present in two pigs (25 %), cryptal abscesses in three pigs (38 %) and significant neutrophil accumulation in all eight pigs (P < 0.01). Giant cell granulomas, dysplasia or abundant scarification was not observed in either group.

CONCLUSIONS

Both OTSC and KING closures offer a long-term reliable seal of a gastrointestinal perforation without stenosis or fistulas. KING closure provides long-term histologically superior healing.

Closing perforations and postperforation management in endoscopy: esophagus and stomach

Luminal perforation after endoscopy is a dreaded complication that is associated with significant morbidity and mortality, longer and more costly hospitalization, and the specter of potential future litigation. The management of such perforations requires a multidisciplinary approach. Until recently, surgery was required. However, nowadays the endoscopist has a burgeoning armamentarium of devices and techniques that may obviate surgery. This article discusses the approach to endoscopic perforations in the esophagus and stomach.

Comparison in efficacy between pure NOTES peritoneoscopy with small or large endoscope and laparoscopy

OBJECTIVE

To evaluate the efficacy and systematic impact of different sized endoscopes for pure transgastric natural orifice transluminal endoscopic surgery (NOTES) peritoneoscopy relative to laparoscopy.

METHODS

A total of 15 dogs were randomly assigned to the small-sized endoscope (SS), large-sized endoscope (LS) and standard laparoscopy (SL) groups. The procedure time, visualization scores for abdominal organs, gastric incision healing times and procedure-associated complications were recorded. Blood samples were collected at 1 h preoperation and at 1 h, 12 h, 2 days and 7 days postoperation. Serum tumor necrosis factor (TNF)-α and interleukin (IL)-6 levels as well as peripheral white blood cell (WBC) counts were analyzed.

RESULTS

Peritoneoscopy was successfully performed with both pure transgastric NOTES and laparoscopy. The peritoneoscopy required less time to complete in the SL group (44.0 ± 7.0 min) than the LS (83.0 ± 28.9 min) and SS (106.6 ± 81.3 min) groups (P < 0.01), but no statistical difference was observed between the SS and LS groups (P > 0.05). The visualization scores of peritoneal organs among the three groups did not differ significantly (P > 0.05). The gastric incision exhibited satisfactory healing in both the SS and LS groups. Moreover, serum TNF-α and IL-6 levels and WBC counts at each time point were similar among the three groups (P > 0.05).

CONCLUSIONS

Small-sized endoscope is not superior to a large-sized one for pure transgastric NOTES peritoneoscopy. Pure transgastric NOTES is not less invasive or less time-consuming than laparoscopy.

Comparing over-the-scope clip versus endoloop and clips (KING closure) for access site closure: a randomized experimental study

BACKGROUND

A safe technique is essential for successful access site closure in Natural Orifice Translumenal Endoscopic Surgery (NOTES) and for closures of iatrogenic perforations.

AIM

To compare an over-the-scope clip (OTSC) versus an endoloop + endoclips closure technique (KING closure).

METHODS

40 minipigs underwent NOTES peritoneoscopy with liver biopsy. Gastrotomies and rectotomies were closed with OTSC (n = 20; 10× stomach, 10× rectum) or KING closure (n = 20; 10× stomach, 10× rectum). The animals were euthanized 28 days after the procedure. The main outcome variables were technical feasibility, effectiveness, and healing.

RESULTS

Stomach: All but one closure (KING) was successfully completed. The times of closure were similar between the techniques. At necropsy, all access sites were healed. In two animals (1× KING, 1× OTSC), an abscess, probably related to the closure technique, was found. Histologically, transmural healing with muscular bridging was observable in nine pigs for KING versus two pigs for OTSC closure (p = 0.003). Inflammation was present in three pigs for KING versus seven pigs for OTSC closure (p = 0.08). Rectum: All closures were successfully completed. The times of closure were similar between the techniques. At necropsy, all closure sites had healed. Transmural healing with muscular bridging was present in nine pigs for KING versus two pigs for OTSC closure (p = 0.003). Inflammation was present in two pigs for KING versus seven pigs for OTSC closure (p = 0.03). In one animal (OTSC), an enterocolic fistula developed in the proximity of the closure site.

CONCLUSIONS

OTSC and KING closure are comparable closure techniques in terms of technical feasibility and effectiveness. KING closure provides a superior histological outcome compared with OTSC closure.

New laser soldering-based closures: a promising method in natural orifice transluminal endoscopic surgery

BACKGROUND

Complete closure of gastrotomy is the linchpin of safe natural orifice transgastric endoscopic surgery.

OBJECTIVE

To evaluate feasibility and efficacy of a new method of gastrotomy closure by using a sutureless laser tissue-soldering (LTS) technique in an ex vivo porcine stomach.

DESIGN

In vitro experiment.

SETTING

Experimental laboratory.

INTERVENTIONS

Histological analysis and internal and external liquid pressure with and without hydrochloric acid exposure were determined comparing gastrotomy closure with LTS and with hand-sewn surgical sutures.

MAIN OUTCOME MEASUREMENTS

Comparison of LTS and hand-sewn surgical gastrotomy closure. The primary outcome parameter was the internal leak pressure. Secondary parameters were the difference between internal and external leak pressures, the impact of an acid environment on the device, histological changes, and feasibility of endoscopic placement.

RESULTS

The internal liquid leak pressure after LTS was almost twice as high as after hand-sewn surgical closure (416 ± 53 mm Hg vs 229 ± 99 mm Hg; P = .01). The internal leak pressure (416 ± 53 mm Hg) after LTS was higher than the external leak pressure (154 ± 46 mm Hg; P < .0001). An acidic environment did not affect leak pressure after LTS. Endoscopic LTS closure was feasible in all experiments. Histopathology revealed only slight alterations beneath the soldering plug.

LIMITATIONS

In vitro experiments.

CONCLUSIONS

Leak pressure after LTS closure of gastrotomy is higher than after hand-sewn surgical closure. LTS is a promising technique for closure of gastrotomies and iatrogenic perforations. Further experiments, in particular survival studies, are mandatory.

Single loop-and-clips technique (KING closure) for gastrotomy closure after transgastric ovariectomy: a survival experiment

Introduction

A safe closure technique of transluminal access is essential for the widespread application of natural orifice transluminal endoscopic surgery (NOTES).

Aim

To evaluate the feasibility and effectiveness of a novel single loop-and-clips closure technique (KING closure).

Material and methods

An experimental survival study using female laboratory pigs was performed. A gastrotomy was performed using a standard percutaneous endoscopic gastrostomy technique. A peritoneoscopy with an ovariectomy was then performed with a double-channel endoscope, on a total of 14 pigs. Two different techniques of gastrotomy closure were analysed: a loop-and-clips closure technique (n = 7) and a standard closure using endoclips (n = 7). After a follow-up period of 30 days, the animals were euthanized for post-mortem examination.

Results

In the “loop-and-clip” closure group, the correct placement of an endoloop and clips was achieved in all animals. At necropsy, no animal showed signs of an abscess or peritonitis. Histological examination demonstrated a patent full-thickness gastric wall closure without evidence of local complications in all instances. In the “clips” group, the gastrotomy closure was assessed as probably unsafe in three animals. At necropsy 3 (42.9%) abscesses and 1 (14.3%) case of peritonitis were found.

Conclusions

A single loop-and-clips closure technique (KING closure) represents a feasible, simple and effective method of gastric incision closure. It appears to be superior to the standard endoscopic closure technique using clips.

Assessment of a simple, novel endoluminal method for gastrotomy closure in NOTES

BACKGROUND

A reliable method for gastrotomy closure in NOTES will be essential for NOTES to become viable clinically. However, methods using existing and widely available endoscopic accessories have been ineffective. The objective of this study was to evaluate the feasibility and safety of a new simple method for gastric closure (retracted clip-assisted loop closure) that uses existing endoscopic accessories with minor modifications.

METHODS

The retracted clip-assisted loop closure technique involves deploying 3-4 Resolution(®) clips (modified by attaching a 90-cm length of suture to the end of each clip) along the margin of the gastrotomy with one jaw on the serosal surface and the other jaw on the mucosal surface. The suture strings are threaded through an endoloop. Traction is then applied to the strings causing the gastric wall to tent. The endoloop is secured below the tip of the clips, completing a full-thickness gastrotomy closure. The main outcome measures were feasibility, efficacy, and safety of the new retracted clip-assisted loop closure technique for NOTES gastrotomy closure.

RESULTS

An air-tight seal was achieved in 100% (n = 9) of stomachs. The mean leak pressure was 116.3 (±19.4) mmHg.

CONCLUSIONS

The retracted clip-assisted loop closure technique can be used to perform NOTES gastrotomy closure by using existing endoscopic accessories with minor modifications.

A novel flexible endoluminal stapling device for use in NOTES colotomy closure: a feasibility study using an ex vivo porcine model

BACKGROUND

With advances in endoscopic diagnosis of early-stage gastrointestinal pathology, the need to offer minimally invasive treatment is attracting significant interest. It is essential that secure and consistent closure of full-thickness colonic resections and colotomy access be provided in natural orifice translumenal surgery (NOTES). This ex vivo porcine study aimed to evaluate a novel prototype flexible endoscopic stapler device for use in closure of full-thickness colonic defects.

METHODS

A feasibility study using ex vivo porcine colon was undertaken to explore the potential of the prototype stapler to close and seal a colotomy. A standardized linear colotomy was created in 30 colons. The novel flexible endostapler was used to close 20, interrupted hand-sewn sutures to close 5, and a well-validated linear stapler to close 5 of these colotomies. The colons were subsequently subjected to leak pressure testing.

RESULTS

The colotomy closure using the prototype stapler endoluminally required a median time of 280 s. No statistically significant difference in leak pressures between the stapler and the other techniques was described. Although the endostapler without any colotomy was found to have the highest median leak pressures and the interrupted sutures the lowest pressures, no significant difference could be demonstrated (p = 0.52). Furthermore, no significant difference was demonstrated when the closure integrity created by the flexible stapler was compared with that created by the well-validated linear stapler.

CONCLUSION

The results suggest that the flexible endoscopic stapler is an effective device for the safe closure of a visceral defect, which in this feasibility study was equivalent to other well-established techniques. Further studies will focus on in vivo application of the prototype stapling device in the setting of full-thickness colonic resection.

Reliability of gastric access closure with the self-approximating transluminal access technique (STAT) for NOTES

BACKGROUND

STAT, or the self-approximating transluminal access technique, has been previously described and involves the dissection of a submucosal tunnel for peritoneal or mediastinal access from the esophagus and stomach. The objective of this study was to assess the safety and reliability of gastric access and closure in a porcine experience using STAT for natural orifice transluminal endoscopic surgery (NOTES).

METHODS

A review of the experience using STAT access tunnels for intraperitoneal access was performed in 39 female pigs at a university animal lab. All animals underwent a predetermined NOTES surgical procedure using a STAT transgastric access tunnel based on a specific protocol. Details of the procedure, complications, and clinical course were documented. Necropsy was performed at 2 weeks. The main outcome measurements were clinical or necropsy evidence of gastrostomy site leak or inadequate access site closure.

RESULTS

STAT was successful in providing safe peritoneal access in all animals. The width of the tunnel ranged from 1.5 to 5.5 cm and the length was up to 27 cm. There was no evidence of gastrostomy site leak in any animals. One animal required a single laparoscopic suture to help with tunnel closure.

CONCLUSION

STAT provides safe transgastric access and allows secure closure of the gastrotomy site.

Gastrotomy closure with the lock-it system and the Padlock-G clip: a survival study in a porcine model

BACKGROUND AND STUDY AIMS

The success of natural orifice surgery depends on secure closure of the transmural gut opening, so a rapid, secure, and easy-to-place closure method is desirable. Our aim was to determine whether a gastrotomy can be closed safely and effectively from within the stomach in a survival model by using a novel, endoscopically placed device: the Padlock-G system.

PATIENTS AND METHODS

This was a pilot study of 4 survival animals in an animal laboratory setting. Gastrotomies were made in the stomachs of laboratory swine, and the abdomen was explored by using a standard gastroscope. Gastrotomies were then closed by using the Padlock-G system. Survival for 2 or 6 weeks was the primary outcome measurement. Secondary outcomes included ease of use, visual assessment of closure integrity immediately and at necropsy, presence of adhesions, evidence of infection, and histologic appearance at the closure sites.

RESULTS

All animals thrived, ate normally, and gained weight. None developed fever, tachycardia, or signs of peritoneal irritation. Closure-site inspection at necropsy revealed excellent healing, with epithelial growth over the Padlock-G. There were no ulcers, serosal surfaces were tightly closed, and no defects could be seen. There were no signs of peritoneal inflammation, intra-abdominal adhesions, or gastric spillage. Histologic evaluation showed organizing granulation tissue with fibrosis, vascular proliferation, and mild chronic inflammatory infiltrate (i.e., scar).

CONCLUSIONS

The Padlock-G is easy to place, provides a durable closure, and allows survival animals to thrive without adverse sequellae. This device provides a suitable closure system for transgastric NOTES.

Endoscopic closure of GI fistulae by using an over-the-scope clip (with videos)

BACKGROUND

Preclinical studies have demonstrated the over-the-scope clip (OTSC) to be feasible and safe for closure of gastric, duodenal, and colonic perforations. A retrospective clinical study demonstrated the feasibility and preliminary safety of the OTSC for the treatment of GI bleeding and closure of acute GI perforations.

OBJECTIVE

Because the OTSC allows rapid and easy endoscopic organ wall closure, we hypothesized that it might be a useful tool to close GI fistulae.

DESIGN

Case series.

SETTING

Academic medical center.

PATIENTS

Four consecutive patients with GI fistulae.

INTERVENTIONS

In all patients, a 12-mm OTSC, in combination with the dedicated twin grasper, anchor device, or endoscopic suction, was used to facilitate endoscopic closure.

MAIN OUTCOME MEASUREMENTS

In 2 cases, OTSCs allowed complete closure of a posttraumatic esophagopulmonary fistula and a chronic gastrocutaneous fistula. Leak tests and follow-up examination demonstrated complete leakproof closures. In 1 esophagopulmonary fistula and 1 jejunocutaneous fistula, the initial closure attempts using OTSCs were not successful because of chronic fibrotic changes and scarring at the fistula site. Both OTSCs were removed by using an endoscopic grasping forceps. The mean procedure time was 54 minutes (range 24-93 minutes). There were no procedure-related complications.

LIMITATIONS

Small sample size.

CONCLUSIONS

The OTSC seems to be a feasible device to close chronic fistulae of the GI tract. It can achieve leakproof, full-thickness closure of transmural defects. Nevertheless, in circumstances of severe fibrosis and scarring, complete incorporation of the defect into the applicator cap and successful OTSC application might not be possible.

Transgastric endoscopic peritoneoscopy and biopsy for causal diagnosis of ascites: report of 3 cases

AIM: To evaluate the application of transgastric endoscopic peritoneoscopy and biopsy to the causal diagnosis of ascites.

METHODS: Three patients with ascites of unknown origin after routine examinations underwent transgastric endoscopic peritoneoscopy and biopsy for causal diagnosis of ascites.

RESULTS: A definite diagnosis was achieved in all the three patients. They were diagnosed with metastatic peritoneal adenocarcinoma, mucinous borderline tumor and tuberculous peritonitis, respectively. No intraoperative or postoperative complications occurred.

CONCLUSION: Transgastric endoscopic peritoneoscopy is a safe and feasible method for causal diagnosis of ascites.

What are the elements of safe gastrotomy closure in NOTES? A systematic review

INTRODUCTION

The safe closure of the gastrotomy needs to be established before natural orifice translumenal endoscopic surgery (NOTES) can be extended to routine clinical practice. As yet no optimum closure method has been identified.

METHODS

A systematic review of the literature on gastrotomy closure modalities for NOTES up until December 2009 was undertaken. An assessment of each closure modality was determined using specified quantitative and qualitative parameters.

RESULTS

There were 46 studies included in this review describing 20 closure techniques. Some robustly designed experimental studies have now been published particularly in relation to the over-the-scope clip system.

CONCLUSION

Current evidence is experimental and therefore limited, but there appears to be some clarification in the direction of the innovative process in this area outlining favorable characteristics of an ideal system. Based on the studies examined in this review, a standardized assessment method is summarized for future in vivo studies, necessary prior to phase 1 trials.

Natural orifice translumenal endoscopic surgery

PURPOSE OF REVIEW

Since its introduction in 2000, natural orifice translumenal endoscopic surgery (NOTES) has gained a great deal of attention from gastroenterologists and surgeons all over the world. In this article, we will review the progress in the field of NOTES and present the latest publications that provide some answers and solutions to the barriers suggested by the Natural Orifice Surgery Consortium for Assessment and Research white paper.

RECENT FINDINGS

Because of the first human NOTES procedure by Rao and Reddy, more pioneering procedures, including transgastric and transvaginal cholecystectomies, appendectomies, and hernia repairs, have been performed. Although NOTES researchers continue to experiment with new innovative equipment and procedures in the lab, more structured work, including randomized controlled trials, has been published.

SUMMARY

In the last several years, there has been growing interest in NOTES, which has translated into exciting animal research work and publication of randomized controlled trials. Additionally, preliminary NOTES human procedures have been successfully performed. When suitable instruments become available, the subsequent step should be comparing NOTES with current laparoscopic approaches. Superiority or even equality of NOTES to laparoscopic surgery would be the best argument for advancing and integrating implementation into clinical practice.

Endoscopic full-thickness resection and defect closure in the colon

BACKGROUND

Endoscopic full-thickness resection (eFTR) is a minimally invasive method for en bloc resection of GI lesions.

OBJECTIVE

The aim of this pilot study was to evaluate the feasibility of a grasp-and-snare technique for eFTR combined with an over-the-scope clip (OTSC) for defect closure.

DESIGN

Nonsurvival animal study.

SETTING

Animal laboratory.

ANIMALS

Fourteen female domestic pigs.

INTERVENTIONS

The eFTR was performed in porcine colons using a novel tissue anchor in combination with a standard monofilament snare and 14 mm OTSC. In the first group (n = 20), closure of the colonic defects with OTSC was attempted after the resection. In the second group (n = 8), an endoloop was used to secure the resection base before eFTR was performed.

RESULTS

In the first group (n = 20), eFTR specimens ranged from 2.4 to 5.5 cm in diameter. Successful closure was achieved in 9 out of 20 cases. Mean burst pressure for OTSC closure was 29.2 mm Hg (range, 2-90; SD, 29.92). Injury to adjacent organs occurred in 3 cases. Lumen obstruction due to the OTSC closure occurred in 3 cases. In the second group (n = 8), the diameter of specimens ranged from 1.2 to 2.2 cm. Complete closure was achieved in all cases, with a mean burst pressure of 76.6 mm Hg (range, 35-120; SD, 31). Lumen obstruction due to the endoloop closure occurred in one case. No other complications or injuries were observed in the second group.

LIMITATIONS

Nonsurvival setting.

CONCLUSIONS

Colonic eFTR using the grasp-and-snare technique is feasible in an animal model. Ligation of the resection base with an endoloop before eFTR seems to reduce complication rates and improve closure success and leak test results despite yielding smaller specimens.

A novel double-endoloop technique for natural orifice transluminal endoscopic surgery gastric access site closure

BACKGROUND

Effective and safe access site closure is critical for clinical application of natural orifice transluminal endoscopic surgery.

OBJECTIVE

The current study evaluated a simple novel technique of gastrotomy closure.

DESIGN

Feasibility study with a survival animal model.

SETTING

Animal laboratory.

SUBJECTS

Ten female domestic pigs.

INTERVENTIONS

Endoscopic closure of a gastrotomy incision was evaluated in 10 pigs in a survival study. A standard double-channel endoscope was advanced into the peritoneal cavity through an incision made by a needle-knife and an 18-mm dilation balloon. After peritoneoscopy and salpingectomy, gastric closure was performed by using an endoscopic grasper and sequential application of 2 endoloops. After a follow-up period of 1 to 3 weeks, the pigs were killed for postmortem examination.

MAIN OUTCOME MEASUREMENTS

Feasibility, efficiency, and safety of a novel closure technique.

RESULTS

Correct positioning and delivery of endoloops was achieved in all animals in a median time of 17 minutes (range 13-25 minutes). All animals survived without complications. Postmortem examination demonstrated patent full-thickness gastric closure without any evidence of infection.

LIMITATIONS

Feasibility study with a small number of subjects in a porcine model.

CONCLUSION

Double endoloop technique represents a novel, simple, safe, and efficient means of gastric access site closure in natural orifice transluminal endoscopic surgery.

Transgastric cecectomy in canine models: natural orifice transluminal endoscopic surgery (NOTES)

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) for bowel resection is a challenging procedure. We studied the feasibility and safety of NOTES by performing cecectomy in dogs, which is equivalent to simple bowel resection in man.

METHODS

Three dogs underwent transgastric endoscopic cecectomy with laparoscopic assistance. Antibiotics and irrigation were administered as preoperative preparation. A single-channel endoscope was introduced through the stomach into the peritoneal cavity, and the cecum was dissected and ligated with an L-knife and endoloops, respectively. Laboratory blood testing, peritoneal bacterial culture, and radiologic testing were performed perioperatively. Animals underwent autopsies on postoperative day (POD) 14.

RESULTS

All subjects survived surgery and remained alive until POD 14. Mean operative time was 126.6 min. The absence of bacterial infections and anatomic leaks was verified by peritoneal swap culture, blood count, air leak testing, and bowel contrast radiology. However, a temporary mild elevation in white blood cell count was noted. No abscess or sign of infection was observed during autopsy, although adhesion was evident.

CONCLUSIONS

Transgastric endoscopic cecectomy with minimal laparoscopic assistance is a feasible and safe procedure. Cecectomy in dogs is equivalent to procedures such as appendectomy, resection of Meckel's diverticulum, and oophorectomy in man. Natural orifice transluminal endoscopic surgery could prove to be a good optional surgical procedure.