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Wang K, Xu Q, Xia L, Sun J, Shen K, Liu H, Xu L, Li R. Diagnosis and treatment of gallbladder polypoid lesions: Current practices and future prospects. Chin Med J (Engl) 2024:00029330-990000000-00979. [PMID: 38420780 DOI: 10.1097/cm9.0000000000003019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Indexed: 03/02/2024] Open
Abstract
ABSTRACT Gallbladder polypoid lesions (GPLs) refer to any elevated lesion of the mucosal surface of the gallbladder wall, and the prevalence is estimated to be between 0.9% and 12.1%. GPLs include benign polyps and malignant polyps. Benign polyps are further classified as non-neoplastic polyps and neoplastic polyps. Cholesterol polyps are the most common benign polyps and adenocarcinoma is the main type of malignant polyp. Hepatitis B virus infection, liver function abnormalities, dyslipidemia, and obesity are the main risk factors for GPLs. Studies of biological mechanisms have focused on malignant gallbladder polyps, the development of which is regulated by hormone levels in vivo , gut microbiota, inflammation, oxidative stress, Salmonella typhimurium , and related molecules. Diagnostic modalities include chemical examination and imaging examination, with imaging examination currently being the mainstay. Treatment of patients with GPLs is based on the presence or absence of symptoms, age, size of the polyps, tendency of the polyp to increase, and risk factors for symptomatic malignancy to determine whether surgery should be performed.
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Affiliation(s)
- Kun Wang
- Department of Gastroenterology, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu 215026, China
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Gonzalez JM, Bonin EA, Vanbiervliet G, Garnier E, Berdah S, Matthes K, Barthet M. Evaluation of feasibility, efficiency and safety of a pure NOTES gastrojejunal bypass with gastric outlet obstruction, in an in vivo porcine model. Endosc Int Open 2013; 1:31-8. [PMID: 26135510 PMCID: PMC4440371 DOI: 10.1055/s-0033-1353686] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 12/05/2013] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Natural orifice transluminal endoscopic surgery (NOTES) gastrojejunal anastomosis (GJA) is a less invasive surgery for bariatric procedures and gastric outlet obstruction. The aim of this study was to evaluate the feasibility, efficacy, and safety of a pure NOTES gastrojejunal bypass using an in vivo porcine model. MATERIAL AND METHODS A prospective study was performed on nine swine. A double-channel scope was used. The intervention steps were: (i) gastric incision; (ii) peritoneal access; (iii) jejunal loop selection and mobilization into the stomach; (iv) stoma creation within the gastric wall and incision; (v) anastomosis suture and pylorus closure using a T-tag prototype. The animals were assessed clinically for 3 weeks including the weight gain. The patency of the GJA was assessed at necropsy and a histological analysis was performed. RESULTS We successfully performed all the procedures with a mean (standard deviation [SD]) operative time of 108 (26) minutes. We used a mean of 5.55 (1.30) stitches. There were no intraprocedural adverse events. Five animals survived up till euthanasia at 3 weeks (65 %). These showed a significant difference in weight curves of a loss of 3.2 kg compared with gain of 5.2 kg in a control group. Four pigs died from anastomotic dehiscence complicated by peritonitis. CONCLUSION Gastrojejunal bypass with a pure NOTES approach is feasible. This procedure is effective, resulting in a patent anastomosis and a significant weight loss. However, the anastomotic dehiscence is a major concern because of its mortality rate, and further studies including improvement of the suturing device and the technique are needed.
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Affiliation(s)
- J.-M. Gonzalez
- Department of Gastroenterology, Public Assistance Hospitals of Marseille, North Hospital, Marseille, France,Department of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States,Corresponding author Dr. Jean-Michel Gonzalez, MD Laboratory Dana 506Department of GastroenterologyBeth Israel Deaconess Medical CenterHarvard Medical SchoolBoston, MAUnited States
| | - E. A. Bonin
- Department of Gastroenterology, Public Assistance Hospitals of Marseille, North Hospital, Marseille, France
| | - G. Vanbiervliet
- Department of Endoscopy, University Hospital of Nice, Nice, France
| | - E. Garnier
- Aix-Marseille University, CERC, Faculty of Medicine, Marseille, France
| | - S. Berdah
- Department of Digestive Surgery, Public Assistance Hospitals of Marseille, Marseille, France
| | - K. Matthes
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - M. Barthet
- Department of Gastroenterology, Public Assistance Hospitals of Marseille, North Hospital, Marseille, France
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Vanbiervliet G, Gonzalez JM, Bonin EA, Garnier E, Giusiano S, Saint Paul MC, Berdah S, Barthet M. Gastrojejunal Anastomosis Exclusively Using the "NOTES" Technique in Live Pigs: A Feasibility and Reliability Study. Surg Innov 2013; 21:409-18. [PMID: 24253256 DOI: 10.1177/1553350613508016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Natural orifice transluminal endoscopic surgery (NOTES) could reduce procedure-associated morbidity and mortality. The aim of this study was to determine the feasibility of performing a simple model of gastrojejunal anastomosis in a living porcine model exclusively using NOTES. METHODS It was a prospective experimental animal study concerning pigs weighing between 25 and 30 kg. Endoscopies were performed using a double-channel gastroscope. A preliminary phase allowed for the development of the technique on 3 animals that were immediately euthanized. The experimental phase included the implementation of a gastrojejunal anastomosis in 9 animals. Antibiotic therapy was continued for 7 days with gradual feeding. Surviving animals were euthanized after 3 weeks. Anastomosis permeability in each animal was confirmed by opacification, endoscopy, and histopathological analysis. The main outcome measurements were the feasibility and animal survival at 3 weeks postsurgery. RESULTS The entire procedure was performed on 9 animals (4 males and 5 females). Anastomosis required 4.7 ± 1.2 stitches (range 4-7). The average total length of the procedure was 143 ± 50.8 minutes (range 87-225 minutes). One bleeding, 2 suture dehiscences, and a poor stomach incision were the immediate complications endoscopically resolved. At 3 weeks, 5 animals had survived. Three animals died as a result of anastomotic leakage confirmed at necropsy and histopathology. In the surviving animals, histology confirmed permeable anastomoses with collagen scar tissue and continuity of the mucosa and mucosa muscle layers. CONCLUSION Successful gastrojejunal anastomosis by NOTES is technically feasible but is subject to a learning curve.
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Affiliation(s)
- Geoffroy Vanbiervliet
- University of Nice Sophia-Antipolis, Nice, France University Hospital of Nice, Nice, France Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR/Aix-Marseille University, France
| | - Jean-Michel Gonzalez
- Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR/Aix-Marseille University, France Public Assistance Hospitals of Marseille, Marseille, France
| | - Eduardo Aimore Bonin
- Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR/Aix-Marseille University, France Public Assistance Hospitals of Marseille, Marseille, France
| | - Emmanuelle Garnier
- Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR/Aix-Marseille University, France
| | - Sophie Giusiano
- Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR/Aix-Marseille University, France Public Assistance Hospitals of Marseille, Marseille, France
| | | | - Stéphane Berdah
- Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR/Aix-Marseille University, France Public Assistance Hospitals of Marseille, Marseille, France
| | - Marc Barthet
- Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR/Aix-Marseille University, France Public Assistance Hospitals of Marseille, Marseille, France
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Brescia A, Masoni L, Gasparrini M, Nigri G, Cosenza UM, Dall'Oglio A, Pancaldi A, Mari FS. Laparoscopic assisted transvaginal cholecystectomy: single centre preliminary experience. Surgeon 2012. [PMID: 23182808 DOI: 10.1016/j.surge.2012.09.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023]
Abstract
BACKGROUND Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a new approach that allows abdominal surgery to be performed through a natural orifice such as the oral cavity, vagina or rectum. We present our preliminary experience of laparoscopic assisted transvaginal cholecystectomy (LATC). METHODS Women affected by cholelithiasis, age below 65 years, BMI under 30, ASA I or II, previous full-term pregnancies, and without previous abdominal surgery underwent LATC. Patients' biographic data, operative time, intraoperative and postoperative complications were collected. RESULTS We performed 21 LATCs. Median operative time was 58 min. There were no intraoperative complications. The postoperative course was uneventful in all patients. At 1 year there were no complications and no impaired sexual activity. CONCLUSIONS The results of NOTES are promising, but currently only hybrid NOTES can be safely performed. LATC seems to guarantee better cosmetic results, less postoperative pain, faster mobilization and shorter hospitalization than laparoscopic cholecystectomy.
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Affiliation(s)
- Antonio Brescia
- Department of Medical and Surgical Sciences and Translational Medicine, St. Andrea Hospital, School of Medicine and Psychology, University Sapienza of Rome, Rome, Italy.
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Liu BR, Kong LJ, Song JT, Liu W, Yu H, Dou QF. Feasibility and safety of functional cholecystectomy by pure NOTES: a pilot animal study. J Laparoendosc Adv Surg Tech A 2012; 22:740-5. [PMID: 22970657 DOI: 10.1089/lap.2012.0154] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
BACKGROUND NOTES cholecystectomy has become one of the hottest areas of research. But most of the cases need the assistance of the laparoscope. This study is conducted to evaluate the feasibility and safety of a newly proposed operative method-functional cholecystectomy by pure NOTES. MATERIALS AND METHODS The functional cholecystectomy was performed on eight female miniature pigs. An incision was made on the vaginal wall, and an endoscope was inserted into the peritoneal cavity to create a pneumoperitoneum to expose the intra-abdominal viscera, gallbladder, and cystic duct. The cystic duct was isolated and closed with a clip. Then, an injection needle was inserted into the gallbladder to suck up the bile. After the gallbladder was washed with saline, an incision was made on the wall of the gallbladder, and the tip of the endoscope was inserted into the gallbladder cavity. After the endoscope was withdrawn, the gallbladder incision was closed with clips in four pigs and was suspended in the other four pigs. The vaginal incision was closed with clips. All the animals were closely monitored and euthanized 28 days after the procedure. Necropsy was performed. RESULTS The functional cholecystectomy was successfully completed in all eight pigs. No severe intraoperative complications occurred. The animals recovered well postoperatively. At necropsy, no macroscopic signs of intraperitoneal infection or bile leakage in the peritoneal cavity were observed, and the clips were still present on the cystic duct in a good position in all cases. The gallbladder incision healed, with no sign of bile leakage or injury to the adjacent organs. CONCLUSIONS We successfully performed the functional cholecystectomy by transvaginal approach on pigs, which appears to be feasible, safe, and convenient. Functional cholecystectomy provides a new fitting path to pure NOTES.
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Affiliation(s)
- Bing-Rong Liu
- Department of Gastroenterology and Hepatology, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
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Randomized clinical trial of single-incision versus conventional laparoscopic cholecystectomy: short-term operative outcomes. Surg Laparosc Endosc Percutan Tech 2012; 21:311-3. [PMID: 22002264 DOI: 10.1097/sle.0b013e31822cfacd] [Citation(s) in RCA: 60] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
BACKGROUND Single-incision laparoscopic surgery may reduce the complications of port site and postoperative pain. The improved cosmetic result also may improve the satisfaction of patients who have undergone surgery. METHODS The study enrolled 108 patients who consecutively underwent laparoscopic cholecystectomy by the same surgeons and randomly divided them into single-incision laparoscopic cholecystectomy (SILC) and conventional laparoscopic cholecystectomy (CLC) groups. Demographic data and short-term operative outcomes were collected and compared. RESULTS A total of 57 and 51 patients received SILC and CLC, respectively, from May to August 2010 at our institution. No significant difference was found with respect to demographic data including age, sex, and body mass index between the 2 groups. Similarly, short-term operative outcomes such as postoperative complications, length of stay, and visual analog pain score did not differ between the 2 groups. However, the incision of SILC (21.6 ± 2.4) was shorter than that of CLC (30.8 ± 2.6) (P=0.032). CONCLUSIONS SILC seems to be a safe and feasible technique. It can be undertaken without the expense of added postoperative complication and operative time and provides patients with a minimal apparent scar.
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Satgunam S, Miedema B, Whang S, Thaler K. Transvaginal cholecystectomy without laparoscopic support using prototype flexible endoscopic instruments in a porcine model. Surg Endosc 2012; 26:2331-8. [PMID: 22361735 DOI: 10.1007/s00464-012-2185-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2010] [Accepted: 07/04/2011] [Indexed: 12/31/2022]
Abstract
BACKGROUND Transvaginal cholecystectomy with laparoscopic assistance has been performed safely in humans. The next goal was to develop a natural orifice transluminal endoscopic surgery (NOTES) technique to perform cholecystectomy without laparoscopic instruments using one flexible endoscope and flexible accessories. The aim of the study was to test the feasibility of the procedure in a survival porcine model. METHODS Cholecystectomies were attempted in five 88-130-lb. pigs with a planned 2-week survival. Prototype flexible instruments (NOTES Toolbox, Ethicon Endo-Surgery, Inc.) were used to aid in access, dissection, and removal of the gallbladder via the transvaginal route. RESULTS Cholecystectomy could be completed without abdominal incision using prototype instruments in four out of five pigs. The cystic duct could be exposed with a flexible hook knife and clips applied. The steerable trocar improved stability and the precision of the dissection. The critical view was established in all five pigs. Dissection of the gallbladder off the liver bed was imprecise resulting in gallbladder perforation in all pigs and liver hemorrhage in two. At necropsy, all clips on the cystic duct were secure and no bile leak, bowel injury, or adhesions were present. CONCLUSIONS NOTES cholecystectomy without laparoscopic support is feasible but challenging using prototype flexible endoscopic devices. A prototype clip applier was effective in controlling the cystic duct. Further improvements in instrument design to ensure precision and safety are needed before flexible devices should be used for pure NOTES procedures in humans.
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Affiliation(s)
- Shean Satgunam
- Department of Surgery, University of Missouri, One Hospital Drive, Columbia, MO 65212, USA
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Donatsky AM, Andersen L, Nielsen OL, Holzknecht BJ, Vilmann P, Meisner S, Jørgensen LN, Rosenberg J. Pure natural orifice transluminal endoscopic surgery (NOTES) with ultrasonography-guided transgastric access and over-the-scope-clip closure: a porcine feasibility and survival study. Surg Endosc 2012; 26:1952-62. [PMID: 22237757 DOI: 10.1007/s00464-011-2135-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2011] [Accepted: 12/13/2011] [Indexed: 12/16/2022]
Abstract
BACKGROUND Most natural orifice transluminal endoscopic surgery (NOTES) procedures to date rely on the hybrid technique with simultaneous laparoscopic access to protect against access-related complications and to achieve adequate triangulation for dissection. This is done at the cost of the potential benefits of this new minimally invasive technique. This study aimed to evaluate the feasibility and safety of a transgastric (TG) pure-NOTES procedure in a diagnostic setting. METHODS A TG pure-NOTES procedure with endoscopic ultrasonograpy (EUS)-guided access and over-the-scope-clip (OTSC) closure was performed for 10 pigs in a survival and feasibility study. A full macroscopic necropsy with subsequent histologic evaluation was performed on postoperative day (POD) 14. The outcome parameters were uncomplicated follow-up assessment, survival, intraoperative complications, intraabdominal pathology, macroscopic full-thickness closure, and histology-proven full-thickness healing of the gastrotomy. RESULTS An uncomplicated postoperative course was reported for 9 of the 10 pigs, and survival was reported for all 10 pigs. For all the pigs, EUS-guided access was performed successfully with a median duration of 25 min (range, 12-62 min) and without intraoperative complications or access-related lesions at necropsy. An OTSC closure was achieved with a median duration of 11 min (range, 3-28 min). The OTSC provided immediate closure, but according to the authors' definition of a full-thickness healing evaluated by histologic examination, this was not achieved in any of the cases. Although all the animals survived until POD 14, intraabdominal chronic abscesses were present in 3 of the 10 pigs at necropsy. CONCLUSIONS The EUS-guided TG access proved to be feasible without access-related complications. Although OTSC provided an immediate closure, the histopathology raised concerns regarding the risk of perforation. Together with the high risk of intraabdominal infection, TG pure-NOTES is not yet ready for routine clinical practice.
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Affiliation(s)
- Anders Meller Donatsky
- Department of Surgical Gastroenterology, Herlev Hospital, University of Copenhagen, Herlev Ringvej 75, 2730 Herlev, Denmark.
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Transgastric pure-NOTES peritoneoscopy and endoscopic ultrasonography for staging of gastrointestinal cancers: a survival and feasibility study. Surg Endosc 2011; 26:1629-36. [PMID: 22179468 DOI: 10.1007/s00464-011-2082-6] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Accepted: 11/11/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Human natural orifice transluminal endoscopic surgery (NOTES) has mainly been based on simultaneous laparoscopic assistance (hybrid NOTES), forgoing the theoretical benefits of the NOTES technique. This is due to a lack of NOTES-specific instruments and endoscopes, making pure-NOTES procedures difficult and time consuming. An area where pure NOTES could be adopted at its present stage of development is minimally invasive staging of gastrointestinal (GI) cancer. The aim of this study is to evaluate the feasibility of combining transgastric (TG) pure-NOTES peritoneoscopy and intraperitoneal endoscopic ultrasonography (ip-EUS) with intraluminal EUS (il-EUS) for peritoneal evaluation. METHODS This was a feasibility and survival study where il-EUS followed by ip-EUS and peritoneoscopy was performed in 10 pigs subjected to TG pure NOTES. A score was given with regard to achieved visualisation of predefined anatomical structures. Survival was assessed at postoperative day (POD) 14. RESULTS All animals survived until POD 14. Median total procedural time was 94 min (range 74-130 min). Median time for il-EUS, ip-EUS and peritoneoscopy was 11 min (range 7-14 min), 13 min (range 8-20 min) and 10 min (range 6-23 min). Il-EUS, ip-EUS and peritoneoscopy resulted in a score of 15/15 points (range 14-15 points), 6/9 points (range 1-8 points) and 12/13 points (range 8-13 points). CONCLUSIONS TG pure-NOTES peritoneoscopy and ip-EUS combined with il-EUS is feasible and provides sufficient peritoneal evaluation. The technique could have potential for minimally invasive staging of GI cancers.
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Love KM, Durham CA, Meara MP, Mays AC, Bower CE. Single-incision laparoscopic cholecystectomy: a cost comparison. Surg Endosc 2010; 25:1553-8. [PMID: 20976478 DOI: 10.1007/s00464-010-1433-z] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Accepted: 09/27/2010] [Indexed: 01/27/2023]
Abstract
BACKGROUND Single-incision laparoscopic cholecystectomy (SILC) should not cost more or less than traditional laparoscopic cholecystectomy (LC). METHODS Retrospective cost data were collected from the accounting records of a single institution. A direct comparison of LC and SILC was conducted. Data on the SILC cases converted to LC were included. The total operating room (OR) cost (actual cost to the hospital for equipment, time, and personnel) and the total OR charges (total derived from the OR cost plus a margin to cover overhead costs beyond material costs) were examined. The total hospital charges (OR charges plus hospital charges accrued in the perioperative period) also were included. Descriptive statistics were used to analyze the data, with p values less than 0.05 considered statistically significant. RESULTS Over a period of 19 months, 116 cases of minimally invasive cholecystectomy were evaluated. Of the 116 patients, 48 underwent LC during the first half of that period, and 68 patients underwent SILC during the second half of that period. Nine of the single-incision procedures were converted to traditional LC, for a 13% conversion rate. The groups were well matched from a demographics standpoint, with no significant differences in age, gender, body mass index (BMI), diagnoses, American Society of Anesthesiology (ASA) class, or payment. Comparison of all attempted SILCs, including those converted, with all LCs showed no significant difference in cost category totals. A significant difference among all cost variables was found when SILCs were compared with SILCs that required conversion to LC. A significant difference among the cost variables also was found when LCs were compared with converted SILCs. CONCLUSION The cost for SILC did not differ significantly from that for LC when standard materials were used and the duration of the procedure was considered. Converted cases were significantly more expensive than completed SILC and LC cases.
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Affiliation(s)
- Katie M Love
- Department of Surgery, East Carolina University Brody School of Medicine, Pitt County Memorial Hospital, 600 Moye Boulevard, Greenville, NC 27834, USA.
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A review of 130 humans enrolled in transgastric NOTES protocols at a single institution. Surg Endosc 2010; 25:1004-11. [DOI: 10.1007/s00464-010-1369-3] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2010] [Accepted: 09/03/2010] [Indexed: 12/21/2022]
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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: 1.2] [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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Whang SH, Satgunam S, Miedema BW, Thaler K. Transvaginal cholecystectomy by using a prototype flexible clip applier. Gastrointest Endosc 2010; 72:351-7. [PMID: 20674623 DOI: 10.1016/j.gie.2010.02.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2009] [Accepted: 02/23/2010] [Indexed: 12/10/2022]
Abstract
BACKGROUND Currently, no endoscopic clips have been proven to be effective in ligating the cystic duct in natural orifice transluminal endoscopic surgery (NOTES) hybrid cholecystectomy. OBJECTIVE To determine the safety and feasibility of a prototype endoscopic flexible clip applier, which is the only flexible device that deploys a zero-gap clip. DESIGN Pilot study in a survival porcine model. Necropsy was performed at 2 weeks postprocedure. SETTING University of Missouri animal laboratory, Columbia, Missouri. INTERVENTION Transvaginal cholecystectomy was performed on 6 survival pigs using the NOTES Toolbox 1.0. MAIN OUTCOME MEASUREMENTS Safety and feasibility of the described instrument. Investigators were asked to fill out a standardized, blinded questionnaire on the ease of use and functionality of the flexible clip applier. RESULTS Clipping of the cystic duct was achieved with the flexible clip applier in all 6 pigs. The mean time for completion of clipping of the cystic duct was 9 minutes. Multiple attempts were required to successfully fire the clip in 2 of 6 pigs. We were unable to visualize the tip of the clip before deployment. Difficulty releasing the clip from the applier once fired and challenges in clip loading were encountered. The clips were visualized in place at necropsy, with no bile leakage, evidence of infection, or injury to surrounding structures seen in any cases. LIMITATIONS Preclinical animal model. CONCLUSION The prototype flexible clip applier showed adequate safety and was feasible in clipping the cystic duct in all animals. Design efforts to improve clip visualization, loading, and release are underway.
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Affiliation(s)
- Susan H Whang
- Department of General Surgery, University of Missouri, Columbia, Missouri 65212, USA
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Nau P, Anderson J, Needleman B, Ellison EC, Melvin WS, Hazey JW. Endoscopic peritoneal access and insufflation: natural orifice transluminal endoscopic surgery. Gastrointest Endosc 2010; 71:485-9. [PMID: 20003968 DOI: 10.1016/j.gie.2009.09.032] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2009] [Accepted: 09/25/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND Diagnostic transgastric endoscopic peritoneoscopy is a safe model for exploration of the peritoneum. Endoscopic insufflation of the peritoneal cavity has not been validated in humans. We report here our experience with pneumoperitoneum established endoscopically with a laparoscopic insufflator. DESIGN Pneumoperitoneum was established with a laparoscopic insufflator through the biopsy channel of the gastroscope. Intra-abdominal pressure was measured with a transfascial Veress needle and compared with endoscopic values. The gastrotomy was used in the creation of the gastric pouch. PATIENTS Twenty patients undergoing laparoscopic Roux-en-Y gastric bypass participated in the study. Ten had undergone no previous surgery, whereas the other 10 patients had a history of abdominal procedures. INTERVENTIONS Diagnostic transgastric endoscopic peritoneoscopy was performed through a gastrotomy created endoscopically without laparoscopic visualization. MAIN OUTCOME MEASUREMENTS Diagnostic findings, operating times, and clinical course were recorded. RESULTS The average time for transgastric access was 9.6 minutes. This did not vary in patients with previous surgery (P = .3). Endoscopic insufflation was successful in all patients. The mean endoscopic and laparoscopic pressures were 9.80 and 9.75 mm Hg, respectively (P = .9). In no patients were there limitations to visualization of the abdomen. Adhesions were noted in 80% and 10% of patients with and without a history of surgery, respectively (P = .005). There were no complications related to transgastric passage of the endoscope or exploration of the peritoneal cavity. CONCLUSIONS Although limited by the small sample size in this study, we believe that transgastric access may be considered as an alternative approach to peritoneal insufflation and provides a safe alternative for exploration of the abdomen. Endoscopic insufflation through the biopsy channel by using a laparoscopic insufflator seems to be an effective and safe method for establishing pneumoperitoneum.
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Affiliation(s)
- Peter Nau
- Division of General Surgery and the Center for Minimally Invasive Surgery, The Ohio State University School of Medicine and Public Health, Columbus, Ohio, USA
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Koyanagi T, Motomura S. Transumbilical single-incision laparoscopic surgery: application to laparoscopically assisted vaginal hysterectomy. Arch Gynecol Obstet 2010; 283:305-9. [PMID: 20084387 DOI: 10.1007/s00404-010-1358-8] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2009] [Accepted: 01/05/2010] [Indexed: 10/20/2022]
Abstract
PURPOSE Transumbilical single-incision laparoscopic surgery has been used more frequently in general surgery to reduce the invasiveness of traditional laparoscopy. However, few reports of single-incision laparoscopic surgery have been described in the field of gynecology. We used single-incision laparoscopic surgery to laparoscopically assisted vaginal hysterectomy (LAVH). We performed single-incision LAVH in ten patients and compared the operative results with the conventional multiport, multi-incision LAVH. METHODS We began applying single-incision LAVH in July 2009 and completed this method for uterine myoma in ten cases. Operative time, weight of resected uterus, and body mass index (BMI) were recorded and compared to those of conventional multiport LAVH. RESULTS Comparative outcomes of single-incision LAVH versus conventional multiport LAVH were as follows. The mean operative time was 76 ± 15.5 versus 71.4 ± 21.7 min (P = 0.57). The mean weight of resected uterus was 366.3 ± 144 versus 354 ± 95.5 g (P = 0.85). BMI was 23.3 ± 2.75 versus 22.2 ± 3.76 kg/m(2) (P = 0.52). No significant difference was observed between single incision and conventional LAVH. CONCLUSIONS Single-incision LAVH can be undertaken safely and with similar operative results to conventional multiport LAVH. We consider that it is a promising alternative method for the treatment of some patients with uterine myomas as incision-free gynecological operation.
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Affiliation(s)
- Takahiro Koyanagi
- Department of Obstetrics and Gynecology, Yanagawa Hospital, Yanagawa, Japan.
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Nau P, Anderson J, Yuh B, Muscarella P, Christopher Ellison E, Happel L, Narula VK, Melvin WS, Hazey JW. Diagnostic transgastric endoscopic peritoneoscopy: extension of the initial human trial for staging of pancreatic head masses. Surg Endosc 2010; 24:1440-6. [PMID: 20054581 DOI: 10.1007/s00464-009-0797-4] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2009] [Accepted: 11/15/2009] [Indexed: 12/15/2022]
Abstract
BACKGROUND The validity of natural orifice transluminal endoscopic surgery (NOTES) was confirmed in a human trial of 10 patients undergoing diagnostic transgastric endoscopic peritoneoscopy (DTEP) for staging of pancreatic head masses. This report is an update with 10 additional patients in the series and includes bacterial contamination data. METHODS The patients in this human trial were scheduled to undergo diagnostic laparoscopy for abdominal staging of a pancreatic head mass. A second surgeon, blinded to the laparoscopic findings, performed a transgastric endoscopic peritoneoscopy (TEP). The findings of laparoscopic exploration were compared with that those of the TEP. Diagnostic findings, operative times, and clinical course were recorded. Bacterial contamination data were collected for the second cohort of 10 patients. Bacterial samples were collected from the scope before use and the abdominal cavity before and after creation of the gastrotomy. Samples were assessed for bacterial counts and species identification. Definitive care was rendered based on the findings from laparoscopy. RESULTS In this study, 20 patients underwent diagnostic laparoscopy followed by DTEP. The average time for completion of diagnostic laparoscopy was 10 min compared with 21 min for TEP. The experience acquired during the initial 10 procedures translated to a 7-min decrease in TEP time for the second 10 cases. For 19 of the 20 patients, DTEP corroborated laparoscopic findings for surgical decision making. One endoscopic and five laparoscopic biopsies were performed. Pancreaticoduodenectomy was performed for 14 patients and palliative gastrojejunostomy for 6 patients. No cross-contamination of the peritoneum or infectious complications were noted. No significant complications related to either the endoscopic or laparoscopic approach occurred. CONCLUSIONS This study supports the authors' previous conclusions that the transgastric approach to diagnostic peritoneoscopy is feasible, safe, and accurate. The lack of documented bacterial contamination further supports the use of this technique. Technical issues, including intraabdominal manipulation and gastric closure, require further investigation.
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Affiliation(s)
- Peter Nau
- Division of General Surgery, The Ohio State University School of Medicine and Public Health, 410 West 10th Avenue, Columbus, OH 43210-1228, USA
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Sánchez-Margallo FM, Asencio Pascual JM, Del Carmen Tejonero Alvarez M, Sánchez Hurtado MA, Pérez Duarte FJ, Usón Gargallo J, Sánchez-Gijón SP. [Training design and improvement of technical skills in the transvaginal cholecystectomy (NOTES)]. Cir Esp 2009; 85:307-13. [PMID: 19376505 DOI: 10.1016/j.ciresp.2009.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Accepted: 02/17/2009] [Indexed: 01/15/2023]
Abstract
INTRODUCTION The current surgical scenario of the surgery through natural orifices or <<no-scar surgery>> requires acquiring new technical skills by the surgeon. We introduce the initial experience of the Minimally Invasive Surgery Centre Jesús Usón (MISCJU) in the design and setting-up of a surgical training programme using the the natural orifices approach for the acquisition of surgical skills and abilities, based on the preliminary trials in simulators and a pig model. MATERIAL AND METHODS After initial training, using a laparoscopic pelvic-trainer, 7 female pigs, with weights between 35-40 kg, were operated on. The transvaginal approach was completed using a one-channel gastroscope in all the animals. After accessing the abdomen, the abdominal cavity was explored, and the surgery was concluded with the endoscopic cholecystectomy. RESULTS Endoscopic cholecystectomy was successfully completed in 6 cases. In one of the animals, the procedure was stopped because of technical problems regarding the endoscope leaning to one end. The average surgical time was 107.14 min (range, 80-150 min). The transvaginal approach enabled the abdominal to be explored and the dissection, ligature and section of the cystic duct and the cystic artery. After cholecystectomy, the gallbladder was extracted through the vagina. After the procedure necropsy did not reveal intra-abdominal lesions or intraoperative complications. CONCLUSIONS The pure transvaginal cholecystectomy is a feasible and reproducible procedure in the animal model. A systematized training model, which includes physiopathology knowledge as well as technical knowledge, in order to translate these procedures to the clinical practice in a safe way, is needed.
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Nesargikar PN, Jaunoo SS. Natural orifice translumenal endoscopic surgery (N.O.T.E.S). Int J Surg 2009; 7:232-6. [PMID: 19371796 DOI: 10.1016/j.ijsu.2009.04.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2009] [Revised: 03/19/2009] [Accepted: 04/01/2009] [Indexed: 12/15/2022]
Abstract
Natural orifice translumenal endoscopic surgery (N.O.T.E.S) is a technique that allows access to the peritoneal cavity through natural orifices (oral, rectal, vaginal, vesical) without passing through the anterior abdominal wall. Rapid strides have been made in developing this technique, especially in animal models. Majority of research work in this field is originating from USA, while human clinical trials are being reported from India and Southern America. Morbidly obese patients and ITU patients are two target groups where N.O.T.E.S if implemented, will have the highest potential and bearing. With increasing evidence of safe practice in human models, questions on indications and feasibility of practice need to be addressed by rigorous research, strong evidence and collaboration between surgical centers worldwide.
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Affiliation(s)
- P N Nesargikar
- Keele School of Medicine, University Hospital of North Staffordshire, UK.
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Laparoendoscopic single site (LESS) cholecystectomy. J Gastrointest Surg 2009; 13:188-92. [PMID: 19031097 DOI: 10.1007/s11605-008-0735-0] [Citation(s) in RCA: 138] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2008] [Accepted: 10/14/2008] [Indexed: 01/31/2023]
Abstract
INTRODUCTION The journey from conventional "open" operations to truly "minimally invasive" operations naturally includes progression from operations involving multiple trocars and multiple incisions to operations involving access through the umbilicus alone. Laparoscopic operations through the umbilicus alone, laparoendoscopic single site surgery (LESS), offer improved cosmesis and hopes for less pain and improved recovery. This study was undertaken to evaluate our initial experience with LESS cholecystectomy and to compare our initial experience to concurrent outcomes with more conventional multiport, multi-incision laparoscopic cholecystectomy. METHODS All patients referred for cholecystectomy over a 6-month period were offered LESS. Outcomes, including blood loss, operative time, complications, and length of stay were recorded. Outcomes with our first LESS cholecystectomies were compared to an uncontrolled group of concurrent patients undergoing multiport, multi-incision laparoscopic cholecystectomy at the same hospital by the same surgeon. RESULTS Twenty-nine patients of median age 50 years undergoing LESS cholecystectomy from November 2007 until May 2008 were compared to 29* patients, median age 48 years, undergoing standard multiport, multiple-incision laparoscopic cholecystectomy over the same time period. Median operative time for patients undergoing LESS cholecystectomy was 72 min and was not different from that of patients undergoing multiport, multi-incision laparoscopic cholecystectomy (p = 0.81). Median length of hospital stay was 1.0 day for patients undergoing LESS cholecystectomy and was not different from patients undergoing standard laparoscopic cholecystectomy (p = 0.46). Operative estimated blood loss was less than 100 cc for all patients. No patients undergoing attempted LESS cholecystectomy had conversions to "open" operations; two patients had an additional trocar(s) placed distant from the umbilicus to aid in exposure. Three patients undergoing LESS cholecystectomy had complications: two were troubled by pain control and another had urinary retention. CONCLUSIONS LESS cholecystectomy is a safe and effective alternative to standard laparoscopic cholecystectomy. It can be undertaken without the expense of added operative time and provides patients with minimal, if any, apparent scarring. We believe LESS cholecystectomy will be driven by consumer demand, and therefore, laparoscopic surgeons will need to become proficient with LESS procedures.
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Sodergren MH, Clark J, Athanasiou T, Teare J, Yang GZ, Darzi A. Natural orifice translumenal endoscopic surgery: critical appraisal of applications in clinical practice. Surg Endosc 2009; 23:680-7. [PMID: 19118425 DOI: 10.1007/s00464-008-0278-1] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2008] [Revised: 10/14/2008] [Accepted: 11/24/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND Natural orifice translumenal endoscopic surgery (NOTES), with its focus on eliminating incision-related complications, promises to revolutionize the way surgery is performed. This study aimed to summarize the clinical applications of NOTES for humans, outline the techniques used, and discuss the complications and limitations of current techniques. METHODS A literature search was performed using PubMed and Medline search tools to review the extent and outcomes of human procedures undertaken using the NOTES technique in its pure form or as a hybrid procedure reported until July 2008. The end points were the types of operation performed, the approach and technique used for each operation, and the procedure-related complications and technical limitations. RESULTS This review considered 16 publications reporting on 49 human subjects. All the studies except three used hybrid NOTES procedures, with varying amounts of transabdominal assistance. Three transvaginal cholecystectomies, one transvaginal appendectomy, and eight transgastric appendectomies have been performed using a pure NOTES technique. To date, 15 NOTES transvaginal cholecystectomies and 10 NOTES appendectomies (8 transgastric and 2 transvaginal) are reported. Other procedures including peritoneoscopy and sigmoid colectomy are described. Three cases of minor morbidity are reported and no mortality. CONCLUSIONS Although initial human results seem encouraging, it is important that this research be conducted in a way that minimizes bad publicity and describes both favorable and adverse outcomes. Robust trials must be conducted at established centers with appropriate experience and institutional board ethical review to allow safe introduction of this novel technique, with adequate and expedient reporting of serious adverse events. The limitations of the current tools and methods are discussed, and suggestions are made for further improvements in the technology to facilitate NOTES operations.
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Affiliation(s)
- Mikael H Sodergren
- Department of Biosurgery and Surgical Technology, Imperial College London, Academic Surgical Unit, 10th Floor QEQM, St. Mary's Hospital, South Wharf Road, London W2 1NY, UK.
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