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Wang ZJ, Li SY, Zhang YH, Chen Y, Zhang PP, Li ZS, Bai Y, Wang D. Endoscopic closure of large colonic perforations with a novel endoscopic clip device: An animal study (with videos). J Gastroenterol Hepatol 2019; 34:2152-2157. [PMID: 31318990 DOI: 10.1111/jgh.14787] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/31/2019] [Accepted: 07/10/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND AIM An endoscopic clip device was newly designed to accomplish the closure of large gastrointestinal defects. The aim of this study was to determine the feasibility and efficacy of this device in an ex vivo experimental setting. METHODS This prospective study was conducted in porcine colons (n = 5). A large (3-4 cm) linear full-thickness incision was created using a scalpel externally. The device was used for endoscopic closure. The procedure time, number of clips, and success rate of closure were determined. RESULTS Ten defects were created in five porcine colons (two incisions in each specimen). Successful closure was achieved in all defects. The mean procedure time was 24.30 ± 4.42 min, the mean leak pressure is 28.30 ± 9.49 mmHg, and the mean number of additional conventional hemostatic clips used was 5.10 ± 0.99. CONCLUSIONS The results indicated that this clip achieved the convenient and reliable closure of large defects in the colon wall in an ex vivo porcine model and seems to be a promising option for closing large gastrointestinal perforations.
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Affiliation(s)
- Zhi-Jie Wang
- Department of Gastroenterology, Gongli Hospital, Second Military Medical University, Shanghai, China.,Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Shi-Yu Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yan-Hui Zhang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yan Chen
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Ping-Ping Zhang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yu Bai
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Dong Wang
- Department of Gastroenterology, Gongli Hospital, Second Military Medical University, Shanghai, China.,Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
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Liu CY, Lin CS, Liu CC. Asian perspectives in thoracic surgery: clinical innovation in Taiwan. J Thorac Dis 2016; 8:S606-12. [PMID: 27651935 DOI: 10.21037/jtd.2016.08.64] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The development of minimally-invasive surgery of the thorax began in the 1990s, but not until the recent decade did we see dramatic improvements in patient care and refinement of technique. The current generation has witnessed the evolution from traditional thoracotomy, to a single-port, non-intubated thoracoscopic approach. The investigation of subxiphoid single-port, transumbilical approach, and natural orifice transluminal endoscopic surgery (NOTES) in animal model are also undergoing. In Taiwan, several talented young surgeons have vigorously devoted their ideas and innovations to this field, making the Taiwan surgical society vivid and prosperous. The desire to improve, and willingness to change are the foundation of those surgeons. Providing better patient care is their impetus to strive for improvement. This article provides an account of how minimally-invasive thoracic surgery has evolved in recent years, and what clinical innovations have been developed by the Taiwan surgical society.
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Affiliation(s)
- Chao-Yu Liu
- Division of Thoracic Surgery, Department of Surgery, Far Eastern Memorial Hospital, New Taipei City, Taiwan;; School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Chen-Sung Lin
- School of Medicine, National Yang-Ming University, Taipei, Taiwan;; Division of Thoracic Surgery, Feng-Yuan Hospital, Ministry of Health and Welfare, Taichung City, Taiwan
| | - Chia-Chuan Liu
- Division of Thoracic Surgery, Department of Surgery, Koo-Foundation Sun Yat-sen Cancer Center, Taipei, Taiwan
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Zhang L, Zhang W, Hou SC. Nutritional support in inflammatory bowel disease. Shijie Huaren Xiaohua Zazhi 2015; 23:5427-5434. [DOI: 10.11569/wcjd.v23.i34.5427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Inflammatory bowel disease (IBD), including Crohn's disease (CD) and ulcerative colitis (UC), is a group of autoimmune diseases mainly characterized by chronic inflammation in the small and large intestine. The incidence and prevalence of IBD are high and stable. Since IBD is characterized by the wide range of lesions, recurrence, long duration, severe gastrointestinal symptoms and metabolic change, IBD patients often have nutritional disorders. The drug use and surgical operation in the process of IBD treatment will further aggravate nutritional disorders. Therefore, proper nutrition support in IBD is of great value and significance for the recovery and prognosis of the disease.
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Yip HC, Chiu PWY. Recent advances in natural orifice transluminal endoscopic surgery†. Eur J Cardiothorac Surg 2015; 49 Suppl 1:i25-30. [PMID: 26494866 DOI: 10.1093/ejcts/ezv364] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 09/03/2015] [Indexed: 12/11/2022] Open
Abstract
Natural orifice transluminal endoscopic surgery (NOTES) has emerged as one of the most exciting areas in the field of minimally invasive surgery during the last decade. NOTES comprises a wide spectrum of procedures from various natural accesses such as transgastric or transvaginal routes, and different direct-target or distant-target organs. Since polypectomy was first performed in 1955, major advances in technology and refinement of endoscopic technique have allowed endoscopic surgeons to perform complex endoscopic interventions such as endoscopic submucosal dissection. Recognizing the safety and feasibility of submucosal tunnelling and mucosal closure, endoscopic resection beyond the level of mucosa has been increasingly reported. One of these procedures, peroral endoscopic myotomy for achalasia, has gained much popularity and excellent results have been published comparable with that of traditional Heller's cardiomyotomy. Submucosal tunnelling endoscopic resection has also been reported for tumours situated in the muscular layer of the gastrointestinal tract. To overcome the difficulty of intestinal closure after NOTES, researchers have collaborated with the industry in developing different endoscopic suturing devices such as the Eagle Claw (Olympus Medical Systems, Tokyo, Japan) and Overstitch™ (Apollo Endosurgery, Austin TX, USA). These devices allow precise and secure suture application with the ordinary flexible endoscope, achieving tissue approximation similar to open surgical suturing. To further expand the potential of NOTES, investigators had also developed multitasking platforms enabling the performance of surgical procedures of even higher complexity. Recently, a novel endoscopic robotic system 'Master and Slave Transluminal Endoscopic Robot' (MASTER) has been developed. Early results of endoscopic resection utilizing this system have been encouraging, allowing both experts and novices in endoscopy to perform difficult endoscopic resection with a high degree of flexibility.
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Affiliation(s)
- Hon-chi Yip
- Department of Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Philip Wai-yan Chiu
- Department of Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China Department of Surgery, Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong, China
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Verlaan T, Voermans RP, van Berge Henegouwen MI, Bemelman WA, Fockens P. Endoscopic closure of acute perforations of the GI tract: a systematic review of the literature. Gastrointest Endosc 2015; 82:618-28.e5. [PMID: 26005015 DOI: 10.1016/j.gie.2015.03.1977] [Citation(s) in RCA: 77] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 03/25/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgical repair of endoscopic perforations of the GI tract used to be the standard, but immediate, secure endoscopic closure has become an attractive alternative treatment with the potential to reduce morbidity and mortality. OBJECTIVE We aimed to perform a systematic review of the medical literature on endoscopic closure of acute iatrogenic perforations of the GI tract. DESIGN A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. SETTING Available medical literature from 1966 through November 2013. PATIENTS Patients with an acute perforation after an endoscopic procedure that was closed endoscopically. INTERVENTIONS Endoscopic closure of an acute perforation of the GI tract. MAIN OUTCOME MEASUREMENTS Clinically successful endoscopic closure. RESULTS In our search, we identified 726 studies, 702 of which had to be excluded. Twenty-four cohort studies (21 retrospective, 3 prospective) were included in the analysis. No randomized trials were identified. Overall, the methodological quality was low. The 24 studies included described 466 acute perforations in which endoscopic closure was attempted. Successful endoscopic closure was achieved in 419 cases (89.9%; 95% CI, 87%-93%). Successful closure was achieved in 90.2% (n = 359; 95% CI, 87%-93%) of cases by using endoclips, in 87.8% (n = 58; 95% CI, 78%-95%) by using the over-the-scope-clip, and in 100% (n = 2) by using a metal stent. LIMITATIONS Low methodological quality of included studies. CONCLUSION This systematic review suggests that endoscopic perforation closure is a safe and effective alternative for surgical intervention in selected cases; however, the overall methodological quality was low. Prospective, true consecutive studies are needed to define the definitive role of endoscopic closure of perforations.
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Affiliation(s)
- Tessa Verlaan
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Willem A Bemelman
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Schmidt A, Meier B, Caca K. Endoscopic full-thickness resection: Current status. World J Gastroenterol 2015; 21:9273-9285. [PMID: 26309354 PMCID: PMC4541380 DOI: 10.3748/wjg.v21.i31.9273] [Citation(s) in RCA: 57] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/04/2015] [Revised: 05/16/2015] [Accepted: 07/03/2015] [Indexed: 02/06/2023] Open
Abstract
Conventional endoscopic resection techniques such as endoscopic mucosal resection or endoscopic submucosal dissection are powerful tools for treatment of gastrointestinal neoplasms. However, those techniques are restricted to superficial layers of the gastrointestinal wall. Endoscopic full-thickness resection (EFTR) is an evolving technique, which is just about to enter clinical routine. It is not only a powerful tool for diagnostic tissue acquisition but also has the potential to spare surgical therapy in selected patients. This review will give an overview about current EFTR techniques and devices.
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Bhardwaj N. Will NOTES ever become noticed? ANZ J Surg 2015; 85:204-5. [PMID: 25996005 DOI: 10.1111/ans.12812] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Liu L, Chiu PWY, Lam PK, Poon CCY, Lam CCH, Ng EKW, Lai PBS. Effect of local injection of mesenchymal stem cells on healing of sutured gastric perforation in an experimental model. Br J Surg 2015; 102:e158-68. [PMID: 25627130 DOI: 10.1002/bjs.9724] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Revised: 09/03/2014] [Accepted: 10/27/2014] [Indexed: 01/08/2023]
Abstract
BACKGROUND Mesenchymal stem cells are proposed to facilitate repair of organ injuries. The aim of this study was to investigate whether local injection of mesenchymal stem cells could accelerate healing of sutured gastric perforations. METHODS Sutured gastric perforations in rats were treated either with local injection of mesenchymal stem cells (injected MSC group) or by topically spraying with fibrin glue containing mesenchymal stem cells (sprayed MSC group). Controls were treated by local injection of saline or topical spray of fibrin glue without mesenchymal stem cells. Healing of sutured gastric perforations was assessed on days 3, 5 and 7. RESULTS Local injection of mesenchymal stem cells significantly promoted the healing of gastric perforations, with the highest pneumatic bursting pressure (mean(s.e.m.) 112·3(30·2) mmHg on day 5 versus 71·2(17·4) mmHg in saline controls; P = 0·001), minimal wound adhesions, and lowest incidence of wound dehiscence (3, 6, 5 and 1 animal on day 5 in control, fibrin, sprayed MSC and injected MSC groups respectively; n = 10 per group) and abdominal abscess (2, 2, 1 and no animals respectively on day 5). Histological examination showed that gastric perforations in the injected MSC group displayed reduced inflammation, and increased granulation and re-epithelialization. Sutured gastric perforations in the injected MSC group showed decreased expression of interleukin 6, and increased expression of transforming growth factor β1 and epithelial proliferating cell nuclear antigen, compared with the other groups. CONCLUSION Local injection of mesenchymal stem cells was more effective than topical application, and enhanced the healing of sutured gastric perforations by an anti-inflammatory process, enhanced cellular proliferation and earlier onset of granulation. Surgical relevance Abnormal healing of gastric perforation may cause morbidity and increase the risk of death. Adipose tissue-derived mesenchymal stem cells have been found to promote the healing of organ injuries through cellular differentiation and secretion of cytokines that stimulate cellular proliferation and angiogenesis, and suppress inflammation. This study explored the therapeutic potential of such mesenchymal stem cells for promotion of the healing of sutured gastric perforations. Mesenchymal stem cells delivered by local injection significantly enhanced the healing of gastric perforations with reduced severity of wound adhesion, and a decreased incidence of wound dehiscence and abdominal abscess. The increased expression of transforming growth factor β1, proliferating cell nuclear antigen and reduced level of interleukin 6 provide evidence for enhancement of the healing process. Engrafted mesenchymal stem cells expressed α-smooth muscle actin as a marker of myofibroblasts. This preclinical study indicates that local injection of allogeneic adipose tissue-derived mesenchymal stem cells may have a potential therapeutic role in enhancing the healing of peptic ulcer disease and prevention of ulcer-related complications.
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Affiliation(s)
- L Liu
- Department of Surgery, Hong Kong; Chow Tai Fook-Cheng Yu Tung Surgical Stem Cell Research Centre, Faculty of Medicine, Chinese University of Hong Kong, Hong Kong; Department of General Surgery, Anhui Provincial Hospital Affiliated to Anhui Medical University, Hefei, Anhui, China
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Endoluminal flexible endoscopic suturing for minimally invasive therapies. Gastrointest Endosc 2015; 81:262-9.e19. [PMID: 25440675 DOI: 10.1016/j.gie.2014.09.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 09/03/2014] [Indexed: 12/12/2022]
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Kobayashi M, Sumiyama K, Ban Y, Dobashi A, Ohya TR, Aizawa D, Hirooka S, Nakajima K, Tajiri H. Closure of iatrogenic large mucosal and full-thickness defects of the stomach with endoscopic interrupted sutures in in vivo porcine models: are they durable enough? BMC Gastroenterol 2015; 15:5. [PMID: 25608558 PMCID: PMC4308917 DOI: 10.1186/s12876-015-0230-5] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2014] [Accepted: 01/12/2015] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND In this study, we evaluated the technical feasibility of mucosal approximation of large ulcers via an endoscopic suturing system after endoscopic submucosal dissection (ESD), assessed the durability of these sutures, and compared this technique with serosal apposition of full-thickness gastric wall defects using the same device. METHODS Post-ESD ulcers were closed with mucosal apposition in 7 pigs, and endoscopic full-thickness resection (EFTR) defects were closed with serosal apposition in 3 pigs. Pigs recovered for 1 week; they were then euthanized and necropsies were performed. RESULTS Primary defect closure was achieved in 85.7% of the post-ESD closures and in 100% of the post-EFTR closures (p = 0.67). All pigs survived for 1 week. At necropsy, sutures had loosened in the post-ESD animals, although only minor deformity of the ulcer edges was observed in all repaired post-ESD ulcers. Meanwhile, all of the post-EFTR defect closures were sustained for 1 week. CONCLUSIONS Primary closure of post-therapeutic defects can be accomplished using the device. Inverted serosal apposition provides a more durable and reliable repair than everted mucosal apposition.
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Affiliation(s)
- Masakuni Kobayashi
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Kazuki Sumiyama
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Yamato Ban
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Akira Dobashi
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Tomohiko Richard Ohya
- Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Daisuke Aizawa
- Department of Pathology, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Shinichi Hirooka
- Department of Pathology, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
| | - Kiyokazu Nakajima
- Division of Next Generation Endoscopic Intervention, Osaka University, 2-2, Yamadaoka, Suita, Osaka, 565-0871, Japan.
| | - Hisao Tajiri
- Division of Gastroenterology & Hepatology, Department of Internal Medicine, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan. .,Department of Endoscopy, The Jikei University School of Medicine, 3-25-8, Nishi-shimbashi, Minato-ku, Tokyo, 105-8461, Japan.
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Mori H, Kobara H, Fujihara S, Nishiyama N, Ayaki M, Yachida T, Okano K, Suzuki Y, Masaki T. Pure endoscopic full-thickness resection with peritoneoscopy and omentectomy. J Dig Dis 2014; 15:96-101. [PMID: 24734304 DOI: 10.1111/1751-2980.12110] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To investigate surgical procedures for pure endoscopic full-thickness resection (EFTR) using a flexible endoscope and a prototype of a full thickness suturing device in animal experiments. METHODS Six beagles were divided into two groups: sutured with over-the-scope-clip (OTSC group, n = 3) and with a prototype of the double-arm bar suturing system (DBSS group, n = 3). The peritoneoscopy, omentectomy and EFTR procedures were performed through the transgastric route. We examined the surgical procedures required to accomplish pure EFTR and survival rates of these dogs after EFTR. RESULTS The duodenal balloon occlusion method maintained a sufficient endoscopic view during peritoneoscopy. Grooves of 10-mm wide were created around the tumor down to the third layer for treating all blood vessels and adding landmark for full-thickness resection lines. Using the muscle layer thin-cutting method, hyaluronic acid was locally injected into the muscle layer and fine incisions were made. Creating tiny perforations provided safe access to the abdominal cavity. Although it was difficult to suture the resected site safely in the OTSC group, the DBSS prototype was useful and reliable for closing there section sites with 3-0 absorbable thread. After EFTR there were no complications in the DBSS group and the dogs were in good health on POD 30, whereas in the OTSC group two dogs died due to dehiscence and gastric juice leaks. Postmortem examinations showed abscess around the suturing sites and two OTSC were detached from the suturing sites. CONCLUSIONS Pure EFTR is feasible with DBSS when systematic methods are established. The high safety of full-thickness resection suturing will permit their clinical application in the near future.
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Raju GS. Endoscopic clip closure of gastrointestinal perforations, fistulae, and leaks. Dig Endosc 2014; 26 Suppl 1:95-104. [PMID: 24373001 DOI: 10.1111/den.12191] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 09/17/2013] [Indexed: 02/06/2023]
Abstract
Development of endoscopic devices to close perforations has certainly revolutionized endoscopy. Immediate closure of perforations eliminates the need for surgery, which allows us to push the limits of endoscopic surgery from the mucosal plane to deep submucosal layers and eventually transmurally. The present article focuses on endoscopic closure devices, closure techniques, followed by a review of animal and clinical studies on endoscopic closure of perforations.
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Affiliation(s)
- Gottumukkala S Raju
- Department of Gastroenterology, Hepatology, and Nutrition, University of Texas MD Anderson Cancer Center, Houston, USA
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Yi SW, Chung MJ, Jo JH, Lee KJ, Park JY, Bang S, Park SW, Song SY. Gastrojejunostomy by pure natural orifice transluminal endoscopic surgery using a newly designed anastomosing metal stent in a porcine model. Surg Endosc 2014; 28:1439-46. [PMID: 24380992 DOI: 10.1007/s00464-013-3371-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2013] [Accepted: 11/29/2013] [Indexed: 12/20/2022]
Abstract
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.
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Affiliation(s)
- Seung Woo Yi
- Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Korea
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Mori H, Kobara H, Fujihara S, Nishiyama N, Rafiq K, Oryu M, Fujiwara M, Suzuki Y, Masaki T. Feasibility of pure EFTR using an innovative new endoscopic suturing device: the Double-arm-bar Suturing System (with video). Surg Endosc 2013; 28:683-90. [PMID: 24202707 DOI: 10.1007/s00464-013-3266-z] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 10/06/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic full-thickness resection (EFTR) requires a reliable full-thickness suturing device and an endoscopic counter-traction device to prevent the collapse of the digestive tract. OBJECTIVE The present study aimed to assess the reliability of newly developed flexible endoscopy suturing devices and the feasibility of pure EFTR. METHODS A total of 30 EFTRs were performed and allocated to three groups (N = 10 for each group). The full-thickness sutures were placed using over-the-scope clips (OTSCs), hand-sewn sutures, or the Double-arm-bar Suturing System (DBSS). Air leak tests were conducted in the three groups. The times required for the placement of one OTSC suture and single-stitch simple interrupted sutures (hand-sewn and DBSS sutures, respectively) were also compared. RESULTS All 30 full-thickness sutures were completely and successfully placed. Regarding the air leak tests, the Mann-Whitney U test showed significant differences between OTSC and hand-sewn sutures (p = 0.003). There was also a significant difference between OTSC and DBSS sutures (p = 0.023). There was no significant difference between hand-sewn and DBSS sutures (p = 0.542). A significant difference was found in the suture time for single-stitch simple interrupted sutures among the OTSC, hand-sewn, and DBSS sutures. The Mann-Whitney U test revealed a significant difference between OTSC and hand-sewn sutures (p = 0.0001). There was no significant difference between OTSC and DBSS sutures (p = 0.533), while a significant difference was found between hand-sewn and DBSS sutures (p = 0.0001). CONCLUSIONS Pure EFTR is feasible if the mechanical counter traction system is used to expand a small operative field and DBSS is used to make full-thickness sutures. The high safety of full-thickness resection and full-thickness suturing allows for clinical applications of this method.
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Affiliation(s)
- Hirohito Mori
- Department of Gastroenterology and Neurology, Kagawa University, 1750-1 Ikenobe, Miki, Kita, Kagawa, 761-0793, Japan,
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Liu L, Chiu PWY, Teoh AYB, Lam CCH, Ng EKW, Lau JYW. Endoscopic suturing is superior to endoclips for closure of gastrotomy after natural orifices translumenal endoscopic surgery (NOTES): an ex vivo study. Surg Endosc 2013; 28:1342-7. [DOI: 10.1007/s00464-013-3280-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Accepted: 10/06/2013] [Indexed: 12/17/2022]
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Liu L, Chiu PWY, Reddy N, Ho KY, Kitano S, Seo DW, Tajiri H. Natural orifice transluminal endoscopic surgery (NOTES) for clinical management of intra-abdominal diseases. Dig Endosc 2013; 25:565-77. [PMID: 23967798 DOI: 10.1111/den.12154] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2013] [Accepted: 07/04/2013] [Indexed: 12/20/2022]
Abstract
Clinical research on natural orifice transluminal endoscopic surgery (NOTES) has been increasingly reported over the past 5 years and more than 1200 patients have received various NOTES procedures. The present article reviews the clinical practice of NOTES for the treatment of intra-abdominal diseases, and was carried out through systematic search with specific keywords in major databases for NOTES-related clinical literature. The last date of the search was 15 August, 2012. Transvaginal cholecystectomy is the commonest NOTES procedure reported, and its clinical feasibility and safety was established through prospective case series and randomized trials. There is a regional difference in NOTES development with the majority of NOTES fromCaucasian countries being transvaginal cholecystectomy and most reports from Asian countries being NOTES-related procedures. Safe closure of gastrointestinal access remains challenging, and novel endoscopic instruments are essential to enhance future development of NOTES.
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Affiliation(s)
- Liu Liu
- Department of Surgery, Chinese University of Hong Kong, Hong Kong, China
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Feasibility of full-thickness gastric resection using master and slave transluminal endoscopic robot and closure by Overstitch: a preclinical study. Surg Endosc 2013; 28:319-24. [PMID: 23990156 DOI: 10.1007/s00464-013-3149-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 07/22/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastric submucosal tumors are often treated by laparoscopic wedge resection. This study aimed to examine the feasibility of gastric full-thickness resection through a totally endoscopic approach using the master and slave transluminal endoscopic robot (MASTER), and closure of the luminal defect with an endoscopic suturing device. METHODS The operation was performed in two live porcine models under general anesthesia. First, the anterior wall of the stomach was slung to the abdominal wall using a percutaneous suturing device. An imaginary 5-cm lesion was marked using a needle knife. After the initial mucosal incision was made using an IT knife, the MASTER was introduced through a long overtube. A circumferential mucosal incision was completed with the MASTER to expose the muscularis propria which was grasped and incised to the serosal layer by electrocautery applied through the hook of the MASTER. The full-thickness resection of the gastric wall was completed with retraction using the grasper and dissection using the hook. While the defect was being created, the luminal space was maintained with traction of the percutaneous sutures. The defect was closed with suture plication using an Apollo Overstitch device. RESULTS Two full-thickness gastric resections were performed in two nonsurvival porcine models (body weight = 30 and 35 kg, respectively) using the MASTER. The total procedure time was 56 min for the first model and 70 min for the second model. The luminal view was maintained during the whole procedure, and there was no damage to surrounding organs throughout the whole procedure. The gastric defects were closed successfully using Overstitch, with satisfactory gastric distension and no gas leakage afterward. CONCLUSION The current experiment demonstrated the feasibility and safety of a totally endoscopic approach for the treatment of gastric submucosal tumors: full-thickness resection with the MASTER and successful closure of the defect using Overstitch.
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Chiu PW, Ho LK, Reddy N, Seo DW, Tajiri H. Asia Pacific NOTES: Where are we? GASTROINTESTINAL INTERVENTION 2013. [DOI: 10.1016/j.gii.2013.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
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Teoh AYB, Chiu PWY, Chan SM, Wong TCL, Lau JYW, Ng EKW. Direct incision versus submucosal tunneling as a method of creating transgastric accesses for natural orifice transluminal endoscopic surgery (NOTES) peritoneoscopy: randomized controlled trial. Dig Endosc 2013; 25:281-7. [PMID: 23368513 DOI: 10.1111/j.1443-1661.2012.01390.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2012] [Accepted: 08/27/2012] [Indexed: 02/08/2023]
Abstract
AIM The optimal approach for creating accesses for transgastric peritoneoscopy is still uncertain. The present study aims to assess the feasibility of carrying out transgastric submucosal tunnel (SMT) peritoneoscopy and to determine whether this approach improves or restricts access to various sectors within the peritoneal cavity. METHODS This was a randomized comparative study carried out in an in-vivo survival porcine model. Sixty-six beads in six swine were visualized and touched via gastrotomies created by either direct incision (DI) or SMT. The influence of the type of gastrotomy on improving or restricting access to particular sites within the peritoneal cavity for natural orifice transluminal endoscopic surgery (NOTES) peritoneoscopy was compared. The main outcome measurements were localization score of beads, overall procedural time, morbidities and mortalities. RESULTS A significantly higher mean (SD) localization score was observed in peritoneoscopies carried out in the DI group (P < 0.001). Both the visualization and the touching scores were significantly better with the DI technique, and the overall yield of NOTES peritoneoscopy with DI and SMT were 72.73% and 60.6%, respectively (P = 0.043). Significantly more beads that were not touched in the SMT group were located in the sub-phrenic area (P = 0.013). The overall procedural time was significantly shorter in the DI group (P = 0.004). No major morbidities or mortalities occurred in any procedures. CONCLUSIONS SMT resulted in lower visualization and touching scores for transgastric NOTES peritoneoscopy. Alternate methods to improve the diagnostic yield to the sub-phrenic area are required.
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Affiliation(s)
- Anthony Yuen Bun Teoh
- Division of Upper Gastrointestinal Surgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
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Song TJ, Seo DW, Kim SH, Park DH, Lee SS, Lee SK, Kim MH. The Performance of Multiple Transgastric Procedures Using the Natural Orifice Transluminal Endoscopic Surgery Technique: Is Pure NOTES Satisfactory? Gut Liver 2012; 6:457-63. [PMID: 23170150 PMCID: PMC3493726 DOI: 10.5009/gnl.2012.6.4.457] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2011] [Revised: 03/07/2012] [Accepted: 03/16/2012] [Indexed: 12/21/2022] Open
Abstract
Background/Aims Although several groups have demonstrated the usefulness of natural orifice transluminal endoscopic surgery (NOTES), there is still concern about frequent serious adverse events. We performed this study to determine the technical feasibility and safety of pure NOTES with a transgastric approach in a porcine model from the endoscopist's point of view. Methods Diagnostic peritoneoscopy, liver biopsy, salpingo-oophorectomy, and Fallopian tube ligation with a transgastric approach using a two-channel therapeutic endoscope were performed in 10 healthy female minipigs. These procedures were performed in two acute models and eight survival models in consecutive order. Results The technical success rate was 100% for peritoneoscopy (10/10), liver biopsy (5/5), salpingo-oophorectomy (10/10), and Fallopian tube ligation (10/10). Eight cases of adverse events occurred, including one case of splenic injury, one case of bleeding after liver biopsy, two cases of small bowel adhesion after salpingo-oophorectomy, two cases of hematoma at the salphingo-oophorectomy site, and two cases of partial dehiscence at the gastric closure site. The gastric puncture site was closed with seven to eight hemoclips in four cases and two hemoclips and an endoloop in four cases. Conclusions The use of pure NOTES for peritoneoscopy, liver biopsy, salpingo-oophorectomy, and Fallopian tube ligation may be technically feasible, but considerable adverse events can occur during or after the procedure. Further studies utilizing specialized techniques overcome several limitations of pure NOTES are therefore necessary.
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Affiliation(s)
- Tae Jun Song
- Department of Internal Medicine, Inje University Ilsan Paik Hospital, Goyang, Korea
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Banerjee S, Barth BA, Bhat YM, Desilets DJ, Gottlieb KT, Maple JT, Pfau PR, Pleskow DK, Siddiqui UD, Tokar JL, Wang A, Song LMWK, Rodriguez SA. Endoscopic closure devices. Gastrointest Endosc 2012; 76:244-51. [PMID: 22658920 DOI: 10.1016/j.gie.2012.02.028] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 02/17/2012] [Indexed: 02/08/2023]
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Bogni S, Ortner MA, Vajtai I, Jost C, Reinert M, Dallemagne B, Frenz M. New laser soldering-based closures: a promising method in natural orifice transluminal endoscopic surgery. Gastrointest Endosc 2012; 76:151-8. [PMID: 22726474 DOI: 10.1016/j.gie.2012.03.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2011] [Accepted: 03/05/2012] [Indexed: 12/17/2022]
Abstract
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.
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Affiliation(s)
- Serge Bogni
- Department of Biomedical Photonics, Institute of Applied Physics, University of Bern, Bern, Switzerland
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Single loop-and-clips technique (KING closure) for gastrotomy closure after transgastric ovariectomy: a survival experiment. Wideochir Inne Tech Maloinwazyjne 2012; 7:233-9. [PMID: 23362421 PMCID: PMC3557733 DOI: 10.5114/wiitm.2011.28870] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2012] [Revised: 03/29/2012] [Accepted: 04/23/2012] [Indexed: 12/21/2022] Open
Abstract
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.
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Wang J, Zhang L, Wu W. Current progress on natural orifice transluminal endoscopic surgery (NOTES). Front Med 2012; 6:187-94. [PMID: 22570129 DOI: 10.1007/s11684-012-0198-2] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2011] [Accepted: 03/26/2012] [Indexed: 12/21/2022]
Abstract
Natural orifice transluminal endoscopic surgery (NOTES) has received considerable interest in recent years as a novel surgical technique. Here, we aim to review the current progress on NOTES, particularly focusing on the advantages and complications related to NOTES, the recent advances of surgical approaches, new instruments for closure of the natural orifice incision, and the newly developed platform for NOTES. Finally, we make a prediction of the conceivable applications of NOTES on human subjects.
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Affiliation(s)
- Junqing Wang
- Department of General Surgery, Shanghai Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200025, China
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Efficacy and safety of transgastric closure in natural orifice transluminal endoscopic surgery using the OTSC system and T-bar sutures: a survival study in a porcine model. Surg Endosc 2012; 26:2950-4. [PMID: 22549373 DOI: 10.1007/s00464-012-2290-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2011] [Accepted: 03/29/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND In natural orifice transluminal endoscopic surgery (NOTES), procedures are performed with an endoscope passed through a natural orifice. One of the most important factors that will determine the future of transgastric NOTES is obtaining a reliable closure of the access site. The aim of this study was to determine the efficacy and safety of transgastric closure using the over-the-scope clip (OTSC) system or T-bar sutures. METHODS We performed a survival study that included 15 pigs. A standardized transgastric approach to the peritoneal cavity and a peritoneoscopy were performed. The gastrotomy was closed using the OTSC system or T-bar sutures. The gastrotomy closure was tested for leaks with the methylene blue test. All animals were observed for 2 weeks before they were sacrificed and necropsy was performed. Histopathological examination of tissue samples retrieved from the access sites was performed. RESULTS There were no perioperative complications. The methylene blue test did not demonstrate any leakage of fluid. Necropsy after 2 weeks confirmed completeness of gastric closure in all animals with full-thickness healing and no spillage of gastric contents into the peritoneal cavity. No differences between the OTSC system and T-bar sutures were observed. CONCLUSION We observed no differences between the efficacy and safety of the OTSC system and those of T-bar sutures used in closing gastric incisions in NOTES. Both methods are safe and effective.
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Azadani A, Jonsson H, Park PO, Bergström M. A randomized trial comparing rates of abdominal contamination and postoperative infection among natural orifice transluminal endoscopic surgery, laparoscopic surgery, and open surgery in pigs. Gastrointest Endosc 2012; 75:849-55. [PMID: 22284088 DOI: 10.1016/j.gie.2011.11.039] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2011] [Accepted: 11/30/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Bacterial contamination of the abdominal cavity and infectious complications have been debated concerning transgastric natural orifice transluminal endoscopic surgery (NOTES) procedures. OBJECTIVE The aim of this study was to compare bacterial contamination of the abdominal cavity and clinically relevant infections after open, laparoscopic, and transgastric NOTES procedures. DESIGN Randomized survival study in a porcine model. SETTING Animal laboratory at a university hospital. INTERVENTION Thirty pigs were randomized to open, laparoscopic, or transgastric NOTES uterine horn resection under sterile conditions. Bacterial cultures were obtained from the pelvic area immediately at entry of the abdominal cavity and just before closure. The left uterine horn was dissected and ligated. The animals survived for 4 weeks. At necropsy, bacterial culture was obtained from the pelvic area. MAIN OUTCOME MEASUREMENTS Perioperative: operation time and incision length, bacterial growth in abdominal samples. Postoperative: infections or complications, weight gain. Necropsy: signs of peritonitis or infection, abdominal bacterial growth. RESULTS Procedure time was significantly longer for transgastric NOTES. At the start of the procedure, 4 of the NOTES animals showed positive cultures, but only 1 showed positive cultures at the end. No open surgery or laparoscopic surgery animals showed positive cultures at these time points. At necropsy, none of the animals in the NOTES group showed bacterial growth, whereas 4 open surgery animals and 3 laparoscopic surgery animals had positive cultures. Four of these animals (2 from each group) had concurrent wound infections. LIMITATIONS Small sample size and lack of power calculation. CONCLUSION This study indicates that clinically relevant infections are rare after transgastric NOTES procedures despite evidence of bacterial contamination and longer operating times.
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Affiliation(s)
- Asghar Azadani
- Department of Surgery, Sahlgrenska University Hospital, Östra, Gothenburg, Sweden
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Antoniou SA, Bartsch DK. NOTES: Current Status and Recent Developments. VISZERALMEDIZIN 2012. [DOI: 10.1159/000346150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Chen WH, Chu Y, Wu YC, Liu CY, Yuan HC, Ko PJ, Liu YH. Endoscopic closure of a tracheal access site using bioglue after transtracheal thoracoscopy in a nonsurvival canine model. Eur Surg Res 2011; 48:26-33. [PMID: 22189409 DOI: 10.1159/000334281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 07/20/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVES An ideal wound closure device would repair the wound with minimal complexity. In this report, we describe a simple wound closure method using BioGlue sealant. METHOD Eleven canines underwent transtracheal pericardial window creation under endoscopic guidance for natural orifice transluminal endoscopic surgery (NOTES). The tracheal wound was closed using BioGlue sealant. The integrity of the wound was assessed by determining the amount of air leaking under mechanical ventilation. RESULTS Transtracheal thoracic exploration and pericardial window creation was successful for all of the canines, and adequate wound closure was achieved in 10 of the canines. There was 1 case of NOTES-related death arising from misplacement of the endotracheal tube in the left lower lobar bronchus. This caused a collapse of the left upper lobe and ventilatory failure. Minor lung injuries occurred in 3 canines and minor mediastinal bleeding was encountered in 1 canine during the creation of the access site. CONCLUSION BioGlue sealant was found to be effective in sealing the tracheal wound in all but 1 of the canines. This study demonstrates that the use of the sealant is a simple and efficient means of endoscopically closing the tracheal access site in NOTES.
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Affiliation(s)
- W-H Chen
- Laboratory Animal Center, Department of Surgery, Chang Gung Memorial Hospital, Linko, Chang Gung University, Guei-Shan Shiang, Taiwan, ROC
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Azadani A, Bergström M, Dot J, Abu-Suboh-Abadia M, Armengol-Miró JR, Park PO. A new in vivo method for testing closures of gastric NOTES incisions using leak of the closure or gastric yield as endpoints. J Laparoendosc Adv Surg Tech A 2011; 22:46-50. [PMID: 22145609 DOI: 10.1089/lap.2011.0387] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND We developed a non-survival in vivo model for testing of gastric natural orifice translumenal endoscopic surgery (NOTES) closures based on the gastric yield pressure. The aim of this study was to test our model comparing different endoscopic closure techniques with surgical closure of a NOTES gastric incision. METHODS Laparotomy was performed in 30 pigs. One tube for air inflation and one manometry tube were inserted into the stomach via the pylorus, which was closed gas-tight, and the abdominal wall was closed. The stomach was inflated with air, and the gastroesophageal yield pressure was measured. A gastroscopy was performed, and a standard NOTES access was created followed by randomization to closure by surgical suturing, T-tags, Padlock-G over-the-scope (OTS)-clips, OVESCO OTS-clips, and traditional clips. All closures were tested twice with air insufflation. Gastric yield pressure or leak pressure of each closure was recorded. RESULTS The mean baseline gastric yield pressure was 80.5 mm Hg. Post-closure yield pressure was 79.9 mm Hg. Leak test results after closure were as follows: surgery, 0/6 leaked; T-tags, 1/6 leaked before reaching yield pressure (56 mm Hg); Padlock-G, 2/5 leaked (71.5 mm Hg); OVESCO OTS-clips, 3/6 leaked (27.2 mm Hg); and traditional clips, 5/6 leaked (27.2 mm Hg). TAS T-tags and surgical closures leaked significantly less than the other groups (P=.01). Traditional clips and OVESCO OTS-clips leaked at significantly lower pressures than the other three groups (P=.007). CONCLUSION This in vivo model using leak of the closure or the gastric yield pressure as endpoints for testing of the closure strength of a NOTES gastric access site seems to be reproducible. Our results support closure with T-tags and Padlock-G-clips over OVESCO OTS-clips and standard endoscopic clips.
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Affiliation(s)
- Asghar Azadani
- Department of Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
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Junquera F, Martínez-Bauer E, Miquel M, Fort M, Gallach M, Brullet E, Campo R. OVESCO: un sistema prometedor de cierre endoscópico de las perforaciones del tracto digestivo. GASTROENTEROLOGIA Y HEPATOLOGIA 2011; 34:568-72. [DOI: 10.1016/j.gastrohep.2011.05.007] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/14/2011] [Accepted: 05/18/2011] [Indexed: 02/09/2023]
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Soweid A, Yaghi S, Kobeissy A, El Majzoub N, Khreiss M, Alaeddine M, Ayoub C, Seoud M, Matar G, Jamali F. Natural orifice transluminal endoscopic surgery (NOTES): assessment of peritoneal bacterial load after intraperitoneal antimicrobial wash and evaluation of hemodynamic changes in a porcine model. MINIM INVASIV THER 2011; 21:265-70. [PMID: 21919809 DOI: 10.3109/13645706.2011.607828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
AIMS Natural orifice transluminal endoscopic surgery (NOTES) is a promising newly developed procedure; however, it is associated with many complications. The main aim of our study is to assess whether peritoneal wash with antibiotics decreases the bacterial load contamination related to the transgastric approach. METHODS Ten female farm pigs underwent transgastric peritoneoscopy with fallopian tubal ligation. Five pigs were randomized to antibiotic wash of the peritoneal cavity and five to placebo. All animals were given one intravenous dose of antibiotic before the procedure. Hemodynamic variables were continuously monitored throughout the procedure. The next day, peritoneal cultures were taken. The fallopian tubes were inspected to determine the success of ligation and the gastric incision sites were assessed for leakage. RESULTS No significant difference was noted between the antibiotic peritoneal wash group and the placebo group in terms of peritoneal bacterial load with respective median colony-forming units per ml (CFU/ml) of 0 [0; 1] vs. 0 [0; 4], p = 0.637. No clinically significant hemodynamic changes were noted during the procedure. CONCLUSIONS The results of our study indicate that NOTES carries minimal risk of peritoneal bacterial contamination, regardless of the use of intraperitoneal antibiotics, and is not associated with hemodynamic compromise.
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Affiliation(s)
- Assaad Soweid
- Department of Internal Medicine, American University of Beirut Medical Center, Beirut, Lebanon
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Teoh AYB, Chiu PWY, Lau JYW, Ng EKW. Randomized comparative trial of a novel one-step needle sphincterotome versus direct incision and balloon dilation used to create gastrotomies for natural orifice translumenal endoscopic surgery (NOTES) in the porcine model. Surg Endosc 2011; 25:3116-21. [PMID: 21487882 DOI: 10.1007/s00464-011-1653-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2010] [Accepted: 02/20/2011] [Indexed: 01/09/2023]
Affiliation(s)
- Anthony Yuen Bun Teoh
- Division of Upper Gastrointestinal Surgery, Department of Surgery, Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong SAR, China
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Guarner-Argente C, Córdova H, Martínez-Pallí G, Navarro-Ripoll R, Rodríguez-d’Jesús A, Miguel CRD, Beltrán M, Fernández-Esparrach G. Gastrotomy closure with a new tissue anchoring device: A porcine survival study. World J Gastroenterol 2011; 17:1732-8. [PMID: 21483634 PMCID: PMC3072638 DOI: 10.3748/wjg.v17.i13.1732] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Revised: 12/01/2010] [Accepted: 12/08/2010] [Indexed: 02/06/2023] Open
Abstract
AIM: To evaluate the feasibility, reproducibility and efficacy of a new tissue anchoring device in a porcine survival model.
METHODS: Gastrotomies were performed using a needle-knife and balloon dilator in 10 female Yorkshire pigs weighing 30-35 kg. Gastric closure was attempted using a new tissue anchoring device. The tightness of the closure was confirmed by means of air insufflation and the ability to maintain gastric distension with stability in peritoneal pressure measured with a Veress needle. All animals were monitored daily for signs of peritonitis and sepsis over 14 d. During necropsy, the peritoneal cavity and the gastric access site were examined.
RESULTS: Transgastric access, closure and 14 d survival was achieved in all pigs. The mean closure time was 18.1 ± 19.2 min and a mean of 2.1 ± 1 devices were used. Supplementary clips were necessary in 2 cases. The closure time was progressively reduced (24.8 ± 13.9 min in the first 5 pigs vs 11.4 ± 5.9 min in the last 5, P = NS). At necropsy, the gastric access site was correctly closed in all cases with all brace-bars present. One device was misplaced in the mesocolon. Minimal adhesions were observed in 3 pigs and signs of mild peritonitis and adhesions in one.
CONCLUSIONS: The use of this new tissue anchoring device in porcine stomachs is feasible, reproducible and effective and requires a short learning curve.
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Shabbir A, Liang S, Lomanto D, Ho KY, So JBY. Closure of gastrotomy in natural orifice transluminal endoscopic surgery: a feasibility study using an ex vivo model comparing endoloop with endoclip. Dig Endosc 2011; 23:130-4. [PMID: 21429017 DOI: 10.1111/j.1443-1661.2010.01047.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Closure of access site is one of the key issues that will determine the development of natural orifice transluminal endoscopic surgery. Our study was designed to compare the effectiveness of gastrotomy closure using endoloop and endoclip with hand-sewn closure as a control. METHODS Gastrotomy was carried out on 24 ex vivo porcine stomachs and the gastrotomies were randomized to be closed with either hand-sewn, endoloop or endoclip techniques. A 2 cm gastrotomy was created with a needle knife and sphincterotome and the defects closed thereafter. We measured the time to closure of gastrotomy and the pressure at which the closure leaked. RESULTS Three endoloops were required for all the closures in the endoloop group. In the endoclip group, the mean (range) number of endoclips used was 10 (8-13). There was no difference in the median closure times between endoloop 28 (16-58) min and endoclip 30 (21-40) min; however, time for hand-sewn closure was much shorter (3-5 min). All stomachs were successfully distended with air without leak at the end of the procedure and none experienced fluid leak. The endoclip closure endured a significantly higher median (range) pressure of 72.5 mmHg (15-80 mmHg) before leaking compared to that of an endoloop 25 mmHg (15-37 mmHg) (P < 0.001). The hand-sewn gastrotomy leaked at pressure of 95 mmHg (75-130 mmHg). The majority of air leaks were from the wound site. In the endoclip group, two leaks were noted at the clip bite site. CONCLUSION In a bench-top model, endoclips seem to be better for gastrotomy closure because of their potential to endure relatively higher pressure without any prolongation of application time. Animal survival studies are needed to explore technical and wound-closure-related problems arising as a result of use of endoclips and endoloops for gastrotomy closure.
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Affiliation(s)
- Asim Shabbir
- Department of Surgery University Surgical Centre, National University Hospital, Singapore
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Desilets DJ, Romanelli JR, Earle DB, Chapman CN. Gastrotomy closure with the lock-it system and the Padlock-G clip: a survival study in a porcine model. J Laparoendosc Adv Surg Tech A 2011; 20:671-6. [PMID: 20687850 DOI: 10.1089/lap.2010.0076] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- David J Desilets
- Division of Gastroenterology, Department of Medicine, Baystate Medical Center, Tufts University School of Medicine, Springfield, Massachusetts 01199, USA.
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Liu YH, Chu Y, Liu CY, Liu HP, Wu YC, Hsieh MJ, Liu HP. Feasibility of the transtracheal approach for the thoracic cavity in a large animal model. Surg Endosc 2010; 25:1652-8. [PMID: 20953881 DOI: 10.1007/s00464-010-1401-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2010] [Accepted: 09/03/2010] [Indexed: 01/11/2023]
Abstract
BACKGROUND The aim of this study was to evaluate the performance of a novel transtracheal endoscopic technique for thoracic evaluation and intervention in a large animal model. METHODS In 12 animals (6 pigs and 6 dogs) under general anesthesia, a tracheal incision was made on the right lateral wall of the lower trachea and used as an entrance for thoracic evaluation and intervention. Postoperative follow-up included endoscopy at 1 and 2 weeks after surgery and necropsy at 2 weeks after surgery. RESULTS Transtracheal opening and thoracic exploration were achieved in all animals. Four animals (3 pigs and 1 dog) died as a result of complications from the procedure. At the follow-up endoscopy, healing at the tracheal opening region was noted in seven animals. CONCLUSIONS The transtracheal approach to the thoracic cavity is technically feasible in both porcine and canine models (4/12 animals died). The canine model is perhaps more suitable than the porcine model for the study of the transtracheal approach to the thoracic cavity.
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Affiliation(s)
- Yun-Hen Liu
- Laboratory Animal Center, Department of Surgery, Chang Gung Memorial Hospital at Linko, Chang Gung University, No. 5, Fu-Shing Street, Guei-Shan Shiang, 333, Tao-Yuan, Taiwan, ROC
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Teoh AYB, Chiu PWY, Ng EKW. Current developments in natural orifices transluminal endoscopic surgery: An evidence-based review. World J Gastroenterol 2010; 16:4792-9. [PMID: 20939107 PMCID: PMC2955248 DOI: 10.3748/wjg.v16.i38.4792] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Tremendous advances have been made in recent years addressing the key obstacles to safe performance and introduction of human natural orifice transluminal endoscopic surgery (NOTES). Animal studies have focused on identifying optimal solutions to these obstacles, in particular methods of creating transluminal access, safe closure of the point of access, and development of a multitasking platform with dedicated instruments. Whether the performance data generated from these animal studies can be reproduced in humans has yet to be determined. Reports of human NOTES procedures are emerging, and the possibility of accomplishing human NOTES based on existing technology has been demonstrated. However, dedicated platforms and devices are still lacking to allow for pure NOTES procedures, and whether NOTES can deliver the postulated benefits of earlier recovery and improved cosmesis remains uncertain.
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Sodergren MH, Coomber R, Clark J, Karimyan V, Athanasiou T, Teare J, Yang GZ, Darzi A. What are the elements of safe gastrotomy closure in NOTES? A systematic review. Surg Innov 2010; 17:318-31. [PMID: 20829216 DOI: 10.1177/1553350610381089] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
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.
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Affiliation(s)
- Mikael H Sodergren
- Department of Biosurgery and Surgical Technology, Imperial College London, London, UK.
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Voermans RP, van Berge Henegouwen MI, Bemelman WA, Fockens P. Hybrid NOTES transgastric cholecystectomy with reliable gastric closure: an animal survival study. Surg Endosc 2010; 25:728-36. [PMID: 20721586 PMCID: PMC3044824 DOI: 10.1007/s00464-010-1242-4] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2009] [Accepted: 02/27/2010] [Indexed: 12/21/2022]
Abstract
Background Secure transluminal closure remains the most fundamental barrier to safe translation of transgastric natural orifice transluminal endoscopic surgery (NOTES) procedures to humans. Obtaining optimal critical view of safety (CVS) is a prerequisite to performing cholecystectomy avoiding common bile duct injury. Objectives (1) To evaluate feasibility and safety of hybrid transgastric NOTES cholecystectomy. (2) To evaluate feasibility and reliability of gastrotomy closure using a novel Over-The-Scope-Clip (OTSC; Ovesco) in survival porcine experiments. Methods Laparoscopic access to the abdominal cavity was obtained by two 2-mm and one umbilical optical trocar(s). Gastric access was created by balloon dilatation of a needle knife puncture up to 18 mm. Exposure of CVS was obtained and evaluated by aid of a 2-mm device. Subsequently the cystic duct and artery were clipped endoscopically. After laparoscopic dissection the specimen was extracted via the stomach. The gastrotomy was closed endoscopically using the OTSC. Necropsy was performed after 10 days with inspection of gastrotomy and peritoneal cavity for complications. Experiments were planned in 3 acute and 16 survival pigs. Main outcome parameters were documented exposure of CVS, successful cholecystectomy and closure, uncomplicated survival and histology-confirmed full-thickness closure. Results In all 16 survival experiments CVS was obtained satisfactorily and hybrid cholecystectomy was successfully performed [100%; 95% confidence interval (CI): 81–100%]. Transgastric closure was endoscopically successful in all experiments in mean time of 7 min [standard deviation (SD) 3 min]. At necropsy 10 days after surgery there were no signs of (infectious) complications. Histology confirmed full-thickness healing with 100% success (95% CI: 81–100%). Conclusion Hybrid transgastric NOTES cholecystectomy is feasible, safe and results in optimal CVS. Use of OTSC for gastrotomy closure is feasible, reliable and results in histology-proven full-thickness closure in survival porcine experiments. Electronic supplementary material The online version of this article (doi:10.1007/s00464-010-1242-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Rogier P. Voermans
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Willem A. Bemelman
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, The Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, P.O. Box 22700, 1100 DE Amsterdam, The Netherlands
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Chukwumah C, Zorron R, Marks JM, Ponsky JL. Current Status of Natural Orifice Translumenal Endoscopic Surgery (NOTES). Curr Probl Surg 2010; 47:630-68. [DOI: 10.1067/j.cpsurg.2010.04.002] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
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Dallemagne B, Perretta S, Allemann P, Donatelli G, Asakuma M, Mutter D, Marescaux J. Transgastric cholecystectomy: From the laboratory to clinical implementation. World J Gastrointest Surg 2010; 2:187-92. [PMID: 21160872 PMCID: PMC2999242 DOI: 10.4240/wjgs.v2.i6.187] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2009] [Revised: 03/30/2010] [Accepted: 05/06/2010] [Indexed: 02/06/2023] Open
Abstract
After the first report by Kalloo et al on transgastric peritoneoscopy in pigs, it rapidly became apparent that there was no room for an under-evaluated concept and blind adoption of an appealing (r)evolution in minimal access surgery. Systematic experimental work became mandatory before any translation to the clinical setting. Choice and management of the access site, techniques of dissection, exposure, retraction and tissue approximation-sealing were the basics that needed to be evaluated before considering any surgical procedure or study of the relevance of natural orifice transluminal endoscopic surgery (NOTES). After several years of testing in experimental labs, the revolutionary concept of NOTES, is now progressively being experimented on in clinical settings. In this paper the authors analyse the challenges, limitations and solutions to assess how to move from the lab to clinical implementation of transgastric endoscopic cholecystectomy.
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Affiliation(s)
- Bernard Dallemagne
- Bernard Dallemagne, Silvana Perretta, Pierre Allemann, Gianfranco Donatelli, Mitsuhiro Asakuma, Didier Mutter, Jacques Marescaux, Department of Digestive and Endocrine Surgery, Pôle Hépato-Digestif, University Hospital of Strasbourg and IRCAD, 67091 Strasbourg Cedex, France
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Chiu PWY. Natural orifices transluminal endoscopic surgery: Current development and future implications. SURGICAL PRACTICE 2010. [DOI: 10.1111/j.1744-1633.2010.00505.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Hucl T, Benes M, Kocik M, Krak M, Maluskova J, Kieslichova E, Oliverius M, Spicak J. A novel double-endoloop technique for natural orifice transluminal endoscopic surgery gastric access site closure. Gastrointest Endosc 2010; 71:806-11. [PMID: 20170912 DOI: 10.1016/j.gie.2009.10.058] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2009] [Accepted: 10/27/2009] [Indexed: 12/18/2022]
Abstract
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.
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Affiliation(s)
- Tomas Hucl
- Department of Hepatology and Gastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
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Transgastric cecectomy in canine models: natural orifice transluminal endoscopic surgery (NOTES). Surg Endosc 2010; 24:2387-92. [PMID: 20354869 DOI: 10.1007/s00464-010-0959-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2009] [Accepted: 11/15/2009] [Indexed: 12/21/2022]
Abstract
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.
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Phee SJ, Ho KY, Lomanto D, Low SC, Huynh VA, Kencana AP, Yang K, Sun ZL, Chung SCS. Natural orifice transgastric endoscopic wedge hepatic resection in an experimental model using an intuitively controlled master and slave transluminal endoscopic robot (MASTER). Surg Endosc 2010; 24:2293-8. [DOI: 10.1007/s00464-010-0955-8] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2009] [Accepted: 10/06/2009] [Indexed: 12/11/2022]
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Chiu PWY, Wai Ng EK, Teoh AYB, Lam CCH, Lau JYW, Sung JJY. Transgastric endoluminal gastrojejunostomy: technical development from bench to animal study (with video). Gastrointest Endosc 2010; 71:390-3. [PMID: 20004893 DOI: 10.1016/j.gie.2009.09.019] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2009] [Accepted: 09/21/2009] [Indexed: 12/17/2022]
Abstract
BACKGROUND Gastrojejunal anastomosis is commonly performed for palliative management of malignant gastric outlet obstruction and bariatric surgery. Natural orifice transluminal endoscopic surgery revolutionized the surgical approach to intra-abdominal surgery. This study explored the possibility of performing gastrojejunostomy (GJ) by using a hybrid natural orifice transluminal endoscopic surgery approach. OBJECTIVE To develop a surgical technique for the performance of transgastric endoscopic GJ (TGEJ) in a porcine model. DESIGN Prospective series of animal experiments. SETTING University hospital animal laboratory. ANIMALS Thirteen female domestic pigs. INTERVENTIONS With the animals under general anesthesia, the endoscope is passed through the gastrotomy and a segment of small bowel is retrieved into the stomach. An enterotomy is then created, and an EndoGIA stapler is introduced through an intragastric port and passed between the small bowel and stomach wall. A GJ is formed after firing of the EndoGIA stapler. The pigs are allowed to resume their diet 1 day after the operation and are allowed to survive for 2 weeks before they are euthanized. The patency of the GJ is confirmed with a repeat endoscopy, contrast study, and postmortem examination. RESULTS A total of 13 TEGJs were performed, 11 of which were successful. The mean operative time was 53.6 +/- 45.7 minutes. The mean time for gastrotomy was 4.7 minutes, and that for GJ was 42.5 minutes. One TEGJ was converted to open surgery because of malpositioning of the intragastric port, and the other failed because the enterotomy was too extensive. Ten of 11 pigs survived for 2 weeks, and endoscopic examination with contrast study confirmed that all the gastrojejunostomies were patent. On postmortem examination, the average size of the GJ was 30 mm. LIMITATIONS The length between duodenojejunal flexure and the site chosen to perform the GJ could not be determined. CONCLUSIONS TEGJ is technically feasible with a patent and sizable anastomosis.
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Affiliation(s)
- Philip Wai Yan Chiu
- Department of Surgery, Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin NT, People's Republic of China
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Sherwinter DA, Gupta A, Cummings L, Eckstein JG. Evaluation of a modified circular stapler for use as a viscerotomy formation and closure device in natural orifice surgery. Surg Endosc 2009; 24:1456-61. [DOI: 10.1007/s00464-009-0800-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2009] [Accepted: 10/09/2009] [Indexed: 11/29/2022]
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Rolanda C, Lima E, Silva D, Moreira I, Pêgo JM, Macedo G, Correia-Pinto J. In vivo assessment of gastrotomy closure with over-the-scope clips in an experimental model for varicocelectomy (with video). Gastrointest Endosc 2009; 70:1137-45. [PMID: 19647246 DOI: 10.1016/j.gie.2009.04.054] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Accepted: 04/24/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastrotomy closure remains the major limiting factor for human translation of transgastric surgery; the over-the-scope clip (OTSC) system was proposed as a possibility for this purpose. Transgastric access is good for a pelvic approach, making varicocelectomy a possible indication for natural orifice transluminal endoscopic surgery (NOTES). OBJECTIVE To evaluate the reliability of the OTSC system in vivo after transgastric testicular vessel ligation (varicocelectomy model). DESIGN There were 3 experimental groups (5 animals in each): groups 1 and 3, gastrotomy dilation up to 18 mm, surgery was performed with a double-channel endoscope; group 2, gastrotomy dilation up to 13 mm, surgery was performed with a single-channel endoscope. SETTING Surgical Sciences Research Domain, Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal. INTERVENTIONS Bilateral testicular vessel ligation by transgastric access. Gastrotomy closed with the largest version of OTSC system (12 mm): a single clip in groups 1 and 2, and 2 clips in group 3. Animals were monitored for 2 weeks, killed, and submitted for necropsy. MAIN OUTCOME MEASUREMENTS Adequacy of closure and healing after the use of the OTSC system. Statistical analysis. RESULTS Vessel ligation was easily achieved in all groups. Although differences in the complication rate did not reach statistical significance (P = .099), there was a clear tendency for a better prognosis in groups 2 and 3 than group 1. In fact, only 2 animals from group 1 had complications related to incomplete gastrotomy closure. LIMITATIONS Small number of animals per group; nonrandomized study. CONCLUSIONS The OTSC system was shown to be easy and efficient for gastrotomy closure in a survival experimental model of varicocelectomy, when correctly matching the gastrotomy size with the clip size and/or number.
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Affiliation(s)
- Carla Rolanda
- Life and Health Sciences Research Institute, School of Health Sciences, University of Minho, Braga, Portugal
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Liu M. Recent advances in endoscopic therapy for diagnostic and therapeutic endoscopy-associated perforations of the digestive tract. Shijie Huaren Xiaohua Zazhi 2009; 17:3123-3127. [DOI: 10.11569/wcjd.v17.i30.3123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
As diagnostic and therapeutic endoscopy is more widely applied in clinical practice, endoscopy-associated perforations of the digestive tract have become more and more common. Among patients with endoscopy-associated perforations, few can be cured by conservative therapy, and the majority need to undergo laparoscopic or surgical operations to avoid serious consequences. However, the development of new medical instruments makes it possible to effectively and promptly manage endoscopy-related perforations via endoscopic suturing and closure.
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