Endoscopic vs. laparoscopic gastrojejunostomy for duodenal obstruction: a randomized study in a porcine model

Endoscopic esophagogastric anastomosis with luminal apposition Axios stent (LAS) approach: a new concept for hybrid "Lewis Santy"

BACKGROUND AND STUDY AIMS

Esophagogastric anastomosis (EGA) has a high risk of leakage. Based upon our experience in endoscopic gastrojejunal anastomosis using LAS, the aim of this study was to verify the technical feasibility and the safety of performing an EGA using a hybrid approach (endoscopic and surgical).

MATERIALS AND METHODS

A pilot prospective study was performed on 8 survival pigs. The procedure was carried out in 2 stages: (i) surgical step consisting of an esogastrectomy by laparotomy with separated suture of the esophagus and stomach; (ii) endoscopic esophagogastric anastomosis using the LAS. The first 2 pigs allowed for the setting of the 2 steps procedure, and 6 were included in the study for assessing the efficacy and safety of the procedure with a 3-week survival course. The primary endpoint was morbidity and mortality.

RESULTS

All procedures were successfull. The mean operative time was 98 minutes, with a mean endoscopic time of 46 minutes. Three early deaths occurred within the first weeks, unrelated to the LAS anastomosis. At 3 weeks, endoscopic assessment followed by necropsy demonstrated the right position and the endoscopic removability of the stent with good patency of the esophagogastric anastomosis, without leakage of the endoscopic suture. Pathological examination confirmed the patency of the anastomosis with fusion of mucosal and muscle layers.

CONCLUSION

Endoscopic esophagogastric anastomosis with LAS is feasible and reproducible, without anastomotic leakage. It could be a new alternative to perform safe anastomoses, as part of a hybrid approach (surgical and endoscopic).

Endoscopic Devices for Obesity

The obesity epidemic, recognized by the World Health Organization in 1997, refers to the rising incidence of obesity worldwide. Lifestyle modification and pharmacotherapy are often ineffective long-term solutions; bariatric surgery remains the gold standard for long-term obesity weight loss. Despite the reported benefits, it has been estimated that only 1% of obese patients will undergo surgery. Endoscopic treatment for obesity represents a potential cost-effective, accessible, minimally invasive procedure that can function as a bridge or alternative intervention to bariatric surgery. We review the current endoscopic bariatric devices including space occupying devices, endoscopic gastroplasty, aspiration technology, post-bariatric surgery endoscopic revision, and obesity-related NOTES procedures. Given the diverse devices already FDA approved and in development, we discuss the future directions of endoscopic therapies for obesity.

Natural orifice transluminal endoscopic surgery gastroenterostomy with a biflanged lumen-apposing stent: first clinical experience (with videos)

BACKGROUND

We established feasibility and safety for natural orifice transluminal endoscopic surgery (NOTES) GI anastomosis with a lumen-apposing stent in live pigs. This approach was performed in 3 patients.

OBJECTIVE

Creation of a NOTES gastroduodenal anastomosis in patients.

DESIGN

Case series.

SETTING

Two tertiary-care referral centers at large academic hospitals in France and in the United States.

PATIENTS

Patients with refractory benign duodenal stenosis and malignant duodenal obstruction.

INTERVENTION

NOTES GI anastomosis with a lumen-apposing stent.

MAIN OUTCOME MEASUREMENTS

Disappearence of gastric outlet obstruction.

RESULTS

All 3 procedures were technically successful and uneventful, except 1 minor adverse event. There were no instances of stent occlusion or migration during follow-up. All patients resumed a normal diet.

LIMITATIONS

Small case series.

CONCLUSION

NOTES gastroenteric anastomosis is feasible and safe in humans. A prospective pilot study is warranted.

Gastrojejunostomy by pure natural orifice transluminal endoscopic surgery using a newly designed anastomosing metal stent in a porcine model

BACKGROUND

The accepted palliative treatment for malignant gastric outlet obstruction (GOO) is surgical bypass or placement of self-expandable metal stents. We developed a safe and simple natural orifice transluminal endoscopic surgery (NOTES) technique for gastrojejunostomy using a fully covered, anastomosing metal stent in a porcine model.

METHODS

Under general anesthesia, 11 pigs underwent gastrojejunostomy with a 4 cm length anastomosing metal stent. After gastrotomy formation using a needle knife, the jejunum was drawn into the stomach with alligator forceps. A jejunotomy was then performed in the gastric cavity, which was followed by deployment of an anastomosing metal stent under fluoroscopic guidance. Next, the first portion of the duodenum was resected by an endoscopic linear stapler via laparoscopy, thereby creating the model of GOO. Oral feeding was resumed 24 h after the procedure, and animals were euthanized at 1, 2, and 4 weeks after the operation.

RESULTS

Side-to-side gastrojejunostomy was successfully completed through NOTES in 10/11 animals. Ten pigs stayed healthy until the planned sacrifice. The mean gastrojejunostomy procedure time was 41 min (range 15-94 min). By postmortem examination, anastomoses were still intact without intraperitoneal necrosis or adhesion. Histological examination revealed adequate submucosal apposition in all ten experimental pigs undergoing successful endoscopic gastrojejunostomy.

CONCLUSION

Creating a gastrojejunostomy by NOTES using an anastomosing metal stent seems to be a safe, feasible, durable, and reproducible method for GOO.

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.

Gastrojejunal Anastomosis Exclusively Using the "NOTES" Technique in Live Pigs: A Feasibility and Reliability Study

INTRODUCTION

Natural orifice transluminal endoscopic surgery (NOTES) could reduce procedure-associated morbidity and mortality. The aim of this study was to determine the feasibility of performing a simple model of gastrojejunal anastomosis in a living porcine model exclusively using NOTES.

METHODS

It was a prospective experimental animal study concerning pigs weighing between 25 and 30 kg. Endoscopies were performed using a double-channel gastroscope. A preliminary phase allowed for the development of the technique on 3 animals that were immediately euthanized. The experimental phase included the implementation of a gastrojejunal anastomosis in 9 animals. Antibiotic therapy was continued for 7 days with gradual feeding. Surviving animals were euthanized after 3 weeks. Anastomosis permeability in each animal was confirmed by opacification, endoscopy, and histopathological analysis. The main outcome measurements were the feasibility and animal survival at 3 weeks postsurgery.

RESULTS

The entire procedure was performed on 9 animals (4 males and 5 females). Anastomosis required 4.7 ± 1.2 stitches (range 4-7). The average total length of the procedure was 143 ± 50.8 minutes (range 87-225 minutes). One bleeding, 2 suture dehiscences, and a poor stomach incision were the immediate complications endoscopically resolved. At 3 weeks, 5 animals had survived. Three animals died as a result of anastomotic leakage confirmed at necropsy and histopathology. In the surviving animals, histology confirmed permeable anastomoses with collagen scar tissue and continuity of the mucosa and mucosa muscle layers.

CONCLUSION

Successful gastrojejunal anastomosis by NOTES is technically feasible but is subject to a learning curve.