Flexible endoscopic single-incision extraperitoneal implant and fixation of peritoneal dialysis catheter: proof of concept in the porcine model

BACKGROUND

Peritoneal dialysis (PD) catheters placed in the pelvic space without anchoring present a high rate of migration. We aimed to assess the feasibility of a single-incision approach, using a flexible endoscopic preperitoneal tunneling for catheter implantation and fixation.

MATERIALS AND METHODS

Eight pigs were involved in this experimental study. A 2/0 Vicryl loop was sutured at the tip of a PD catheter. In 4 pigs, a 1.5 cm incision was made on the left paramedian line and the parietal peritoneal layer was identified by splitting rectal muscles. A gastroscope was inserted in the incision and advanced in the extraperitoneal space. An exit hole was made in the peritoneum over the low pelvic cavity. A guidewire was left in the abdominal cavity, and the PD catheter was inserted over the guidewire. The endoscope was inserted in the tunnel again, and endoscopic clips were deployed over the Vicryl loop to fix the catheter. In 4 pigs, the PD catheter was inserted laparoscopically using a two-port approach. The catheter's tip was fixed with laparoscopic clips on the Vicryl loop. A strain test to assess the force required to detach clips was performed using a digital dynamometer.

RESULTS

Operative time for flexible endoscopic tunneling was longer when compared to the laparoscopic implant (29.5 ± 4.43 vs. 22.7 ± 2.51 min). Mean force to displace the catheter was similar after flexible endoscopic fixation when compared to laparoscopic clip fixation (5.57 N ± 2.76 vs. 4.15 N ± 1.76).

CONCLUSIONS

Flexible endoscopic extraperitoneal tunneling allows for minimally invasive single-incision PD catheter placement and fixation.

[Laparoscopic reconstruction in traumatic rupture of the diaphragm]

The authors report the case of a 63-year-old patient who was polytraumatized in a motor vehicle accident and suffered multiple traumatic injuries. Chest and pelvic fractures as well as left-sided diaphragmatic rupture with associated omentum herniation were diagnosed on CT scan. None of the injuries required urgent surgical intervention. After 10 days supportive therapy, elective laparoscopic reconstruction of the diaphragmatic hernia was performed. The authors discuss the role of laparoscopic diaphragm reconstruction.

Mucosal excision and suturing for obesity and GERD

BACKGROUND

Suture and staple-based endoluminal devices for gastroesophageal reflux disease (GERD) and obesity have failed to demonstrate long-term efficacy.

OBJECTIVE

To demonstrate the feasibility of mucosal excision and full-thickness suture apposition of the excision beds to create sufficient scar tissue formation at the gastroesophageal junction for the intraluminal treatment of GERD or obesity.

DESIGN

Survival animal experiments.

PATIENTS

Seven mongrel dogs. Interventions. Under general endotracheal anesthesia, a Barostat test was performed on 4 dogs. A mucosal excision device was introduced through the esophagus into the proximal stomach. Two to 4 mucosal excisions were performed on all dogs at or just below the gastroesophageal junction and the mucosal pieces were removed. After hemostasis, an intraluminal suturing instrument was introduced and either 2 or 4 sutures were placed through the excision beds to bring them into apposition. These were tied and the suture strands cut. All dogs were survived for 2 months. End-term endoscopies were performed, and a repeat Barostat procedure was performed on the animals undergoing an antireflux procedure. After euthanasia the stomachs were explanted, examined, photographed, and sectioned for histologic examination.

RESULTS

All dogs survived without complication. In the 4 GERD dogs, the Barostat studies demonstrated a significant decrease in gastroesophageal junction compliance. In the 3 dogs undergoing the obesity procedure, the gastric outlet apposition to a 6-mm endoscope was satisfactory with full insufflation and the desired scarring was seen on histologic examination.

CONCLUSION

It is possible to create adequate gastroesophageal junction scarring for the treatment of GERD and obesity. A clinical pilot study will be initiated.

The "AMID" hernia and skin stapler for Lichtenstein hernia repair: a pilot study

BACKGROUND

The Lichtenstein hernia repair is a widely accepted and durable treatment option for groin hernias, but acute and chronic postoperative pain for inguinal hernia repair remains a significant issue. The aim of this study was to demonstrate the benefit of a novel hernia stapler on acute postoperative pain after a Lichtenstein hernia repair.

METHODS

A prospective double-arm single-center trial was conducted. Nine patients underwent a Lichtenstein hernia repair using the AMID Stapler (group 1), and another 9 patients underwent a sutured Lichtenstein hernia repair (group 2). Preoperative and postoperative pain was measured on a visual analogue scale (VAS). The intraoperative pain management was either local with sedation, spinal, or general anesthesia. All patients received a local anesthesia preemptively independent of the main anesthetic method. Medication usage, pain, and any procedure related adverse event were documented on postoperative days 1, 2, 3, 4, 5, 6, 7, and 30.

RESULTS

There was no significant difference in demographic data, type or size of hernia, or in baseline pain severity between groups. No intraoperative or postoperative complications occurred. The VAS cumulative average (±standard deviation) pain score during the first postoperative week was 126 (±9.3) and 162 (±9.4) in group 1 and group 2, respectively (P = .38). Patients in group 1 took significantly less pain medication on days 1, 2, and 3 (P < .0001, P = .004, P = .02, respectively), and there was a trend toward a lower average analgesic demand during the entire first postoperative week: 11 (±0.54) doses in group 1 and 15.4 (±0.18) doses in group 2 (P = .07).

CONCLUSION

The Lichtenstein hernia repair using the AMID Stapler is simple and safe and resulted in lower acute postoperative pain and lower analgesic consumption as compared with the sutured Lichtenstein hernia repair. A multicenter clinical trial with a large sample size is needed to more accurately study pain reduction.

Initial experience with Barrett's strip endoscopic mucosal excision: a new Barrett's excision device

BACKGROUND

Barrett's mucosa resection techniques are time consuming, often difficult to perform, and used with varying success. This report describes the authors' results with a new device and technique for strip endoscopic mucosal resection (SEMR) using a cold excision blade.

METHODS

A retrospective review of ex vivo and in vivo animal and human esophagi experiments was conducted to develop the essential design characteristics of a transoral strip mucosal excision device. Depth, size, shape, and technique of excision were serially evaluated.

RESULTS

The SEMR device allows precise capsule positioning with satisfactory excision size and depth in ex vivo and in vivo experiments. A total of 10 excisions were performed on five normal ex vivo cadaveric human esophagi. The specimens ranged in size from 3×2.5 to 2.5×2.2 cm. The average specimen thickness was 0.297 mm. For 147 (99.8%) of 150 fields of examination, muscularis mucosa was included. Six additional in vivo experiments demonstrated device safety and feasibility.

CONCLUSION

Satisfactory excision depth was reproducible. Further animal survival experiments and clinical trials will define the role of the SEMR device for patients with Barrett's esophagus.