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Guan X, Liu Z, Longo A, Cai JC, Tzu-Liang Chen W, Chen LC, Chun HK, Manuel da Costa Pereira J, Efetov S, Escalante R, He QS, Hu JH, Kayaalp C, Kim SH, Khan JS, Kuo LJ, Nishimura A, Nogueira F, Okuda J, Saklani A, Shafik AA, Shen MY, Son JT, Song JM, Sun DH, Uehara K, Wang GY, Wei Y, Xiong ZG, Yao HL, Yu G, Yu SJ, Zhou HT, Lee SH, Tsarkov PV, Fu CG, Wang XS. International consensus on natural orifice specimen extraction surgery (NOSES) for colorectal cancer. Gastroenterol Rep (Oxf) 2019; 7:24-31. [PMID: 30792863 PMCID: PMC6375350 DOI: 10.1093/gastro/goy055] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2018] [Accepted: 12/26/2018] [Indexed: 12/19/2022] Open
Abstract
In recent years, natural orifice specimen extraction surgery (NOSES) in the treatment of colorectal cancer has attracted widespread attention. The potential benefits of NOSES including reduction in postoperative pain and wound complications, less use of postoperative analgesic, faster recovery of bowel function, shorter length of hospital stay, better cosmetic and psychological effect have been described in colorectal surgery. Despite significant decrease in surgical trauma of NOSES have been observed, the potential pitfalls of this technique have been demonstrated. Particularly, several issues including bacteriological concerns, oncological outcomes and patient selection are raised with this new technique. Therefore, it is urgent and necessary to reach a consensus as an industry guideline to standardize the implementation of NOSES in colorectal surgery. After three rounds of discussion by all members of the International Alliance of NOSES, the consensus is finally completed, which is also of great significance to the long-term progress of NOSES worldwide.
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Affiliation(s)
- Xu Guan
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Bejing, China
| | - Zheng Liu
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Bejing, China
| | - Antonio Longo
- Department of Coloproctology and Pelvic Diseases, Humanitas Gavazzeni, Bergamo, Italy
| | - Jian-Chun Cai
- Department of Gastrointestinal Surgery, Zhongshan Hospital of Xiamen University, Xiamen, China
| | | | - Lu-Chuan Chen
- Department of Abdominal Surgery, Fujian Medical University Cancer Hospital, Fuzhou, China
| | - Ho-Kyung Chun
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | | | - Sergey Efetov
- Colorectal Surgery Department, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Ricardo Escalante
- Universidad Central de Venezuela, Centro Medico Loira, Caracas, Venezuela
| | - Qing-Si He
- Department of General Surgery, Shandong University Qilu Hospital, Jinan, China
| | - Jun-Hong Hu
- Department of General Surgery, Huaihe Hospital of Henan University, Kaifeng, China
| | - Cuneyt Kayaalp
- Department of Gastrointestinal Surgery, Inonu University, Malatya, Turkey
| | - Seon-Hahn Kim
- Department of Surgery, Korea University Anam Hospital, Korea University College of Medicine, Seoul, South Korea
| | - Jim S Khan
- Department of Colorectal Surgery, Portsmouth Hospitals NHS Trust, Queen Alexandra Hospital, Portsmouth, UK
| | - Li-Jen Kuo
- Division of Colorectal Surgery, Taipei Medical University Hospital, Taipei, Taiwan, China
| | - Atsushi Nishimura
- Department of Surgery, Nagaka Chuo General Hospital, Nagaoka City, Japan
| | | | - Junji Okuda
- Innovation Unit / Colorectal Cancer, Osaka Medical College Hospital Cancer Center, Osaka, Japan
| | - Avanish Saklani
- Department of GI Surgical Oncology, Tata Memorial Hospital, Mumbai, India
| | - Ali A Shafik
- Department of Colorectal Surgery, Cairo University, Cairo, Egypt
| | - Ming-Yin Shen
- Department of Surgery, China Medical University Hospital, Taichung, Taiwan, China
| | - Jung-Tack Son
- Department of Surgery, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Jun-Min Song
- Department of Anorectal Surgery, First Affiliated Hospital, Zhengzhou University, Zhengzhou, China
| | - Dong-Hui Sun
- Department of Gastric and Colorectal Surgery, Jilin University First Hospital, Changchun, China
| | - Keisuke Uehara
- Division of Surgical Oncology, Nagoya University Graduate School of Medicine, Nagoya, Japan
| | - Gui-Yu Wang
- Department of Colorectal Cancer Surgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Ye Wei
- Department of General Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Zhi-Guo Xiong
- Department of Gastrointestinal Surgery, Hubei Provincial Cancer Hospital, Wuhan, China
| | - Hong-Liang Yao
- Department of General Surgery, The Second Xiangya Hospital, Central South University, Changsha, China
| | - Gang Yu
- Department of Surgery, People's Hospital of Linzi District, Affiliated to Binzhou Medical College, Zibo, China
| | - Shao-Jun Yu
- Department of Surgical Oncology, The Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Hai-Tao Zhou
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Bejing, China
| | - Suk-Hwan Lee
- Department of Surgery, Kyung Hee University Hospital at Gangdong, Kyung Hee University School of Medicine, Seoul, South Korea
| | - Petr V Tsarkov
- Clinic of Colorectal and Minimally Invasive Surgery, Sechenov First Moscow State Medical University, Moscow, Russia
| | - Chuan-Gang Fu
- Department of Gastrointestinal Surgery, Shanghai East Hospital, Tongji University School of Medicine, Shanghai, China
| | - Xi-Shan Wang
- Department of Colorectal Surgery, National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Bejing, China
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Lee DJK, Tan KY. Endoscopic surgery - exploring the modalities. World J Gastrointest Surg 2015; 7:326-334. [PMID: 26649156 PMCID: PMC4663387 DOI: 10.4240/wjgs.v7.i11.326] [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] [Received: 04/19/2015] [Revised: 09/09/2015] [Accepted: 10/08/2015] [Indexed: 02/07/2023] Open
Abstract
The adoption of endoscopic surgery continues to expand in clinical situations with the recent natural orifice transluminal endoscopic surgery technique enabling abdominal organ resection to be performed without necessitating any skin incision. In recent years, the development of numerous devices and platforms have allowed for such procedures to be carried out in a safer and more efficient manner, and in some ways to better simulate triangulation and surgical tasks (e.g., suturing and dissection). Furthermore, new novel techniques such as submucosal tunneling, endoscopic full-thickness resection and hybrid endo-laparoscopic approaches have further widened its use in more advanced diseases. Nevertheless, many of these new innovations are still at their pre-clinical stage. This review focuses on the various innovations in endoscopic surgery, with emphasis on devices and techniques that are currently in human use.
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Ellrichmann M, Dhar S, Hadeler KG, Seehusen F, Cuming T, Feßler AT, Niemann H, Schwarz S, Fritscher-Ravens A. Risk of infection after iatrogenic perforation of the gut wall? Evaluation of preventive strategies in a randomized controlled animal trial. Surg Endosc 2015; 30:3077-88. [PMID: 26487224 DOI: 10.1007/s00464-015-4600-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2015] [Accepted: 09/23/2015] [Indexed: 10/22/2022]
Abstract
BACKGROUND Interventional endoscopies entail a risk of infection secondary to perforation of the luminal wall. Thereby, bacteria may be introduced into the sterile environment of the peritoneal cavity (PC). Limited data are available regarding the efficacy of prophylactic anti-infective treatments. The aim of the study was to examine the efficacy/safety of anti-infective means in the prevention of infection by interventional endoscopies in a randomized controlled animal trial. METHODS Forty pigs were randomized to: 1: control; 2: oral lavage; 3: gastric lavage; 4: oral/gastric lavage; 5: i.m. antibiotics. Lavage was performed with Octenisept prior to the operation. After gastric wall perforation, peritoneoscopy was performed. Before the procedure, after closure and prior to autopsy, intraabdominal lavage for bacterial culture was taken using mini-laparoscopy. At autopsy, macroscopic appearance of the PC was scored. Lavage fluids were grown to identify/quantify bacterial load. Concentration of intraperitoneal bacteria at autopsy was defined as main outcome parameter. RESULTS No major complications occurred in any of the procedures. Bacterial load of the PC at autopsy was significantly reduced with antibiotics compared to all other groups, whereas it did not differ between the lavage groups and control. Macroscopic scoring of the PC showed significant lower rate of intraabdominal abscesses in the antibiotic group compared to the lavage groups and control (p < 0.01). CONCLUSION Only antibiotic prophylaxis is effective for the prevention of infection after iatrogenic perforation of the gastrointestinal wall. There was no difference between any form of lavage and the control group. Further studies in humans are required to prove these animal data.
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Affiliation(s)
- Mark Ellrichmann
- Interdisciplinary Endoscopy and Experimental Endoscopy Unit, Department of Medicine I, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany.
| | - Shantiswaroop Dhar
- Interdisciplinary Endoscopy and Experimental Endoscopy Unit, Department of Medicine I, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
| | - Klaus-Gerd Hadeler
- Institute for Farm Animal Genetics, Friedrich Loeffler Institute (FLI), Mariensee, Germany
| | - Frauke Seehusen
- Department of Pathology, University Veterinary Medicine, Hannover, Germany
| | - Tamzin Cuming
- Department of Surgery, Homerton University Hospital, London, UK
| | - Andrea T Feßler
- Institute for Farm Animal Genetics, Friedrich Loeffler Institute (FLI), Mariensee, Germany
| | - Heiner Niemann
- Institute for Farm Animal Genetics, Friedrich Loeffler Institute (FLI), Mariensee, Germany
| | - Stefan Schwarz
- Institute for Farm Animal Genetics, Friedrich Loeffler Institute (FLI), Mariensee, Germany
| | - Annette Fritscher-Ravens
- Interdisciplinary Endoscopy and Experimental Endoscopy Unit, Department of Medicine I, University Hospital Schleswig-Holstein, Campus Kiel, Arnold-Heller-Str. 3, 24105, Kiel, Germany
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Liu XZ, Fan J, Zhang YQ, Xu MJ, Zhao DB. Single-incision or conventional laparoscopic adjustable gastric banding: A systematic review. MINIM INVASIV THER 2015; 25:62-9. [PMID: 26471295 DOI: 10.3109/13645706.2015.1096288] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
INTRODUCTION Single-incision laparoscopic surgery (SILS) in gastric banding (SI-LAGB) has been reported to be a safe and technically feasible procedure among various operating methods. However, there is little evidence with regard to the question whether SI-LAGB has more advantages and should be recommended compared with conventional LAGB (CLAGB). Thus, this study was performed to assess the safety and efficacy of SI-LAGB. MATERIAL AND METHODS A computerized search of the electronic databases PubMed and EMBASE was performed. Data regarding operative parameters, postoperative recovery parameters, follow-up time, percentage of excess weight loss, and postoperative complication were pooled and analyzed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses recommendations. RESULTS Ten comparative studies including 2,073 patients (1,038 patients who received SI-LAGB and 1,035 patients who received CLAGB) were included and analyzed. Compared with CLAGB, a similar weight loss could be obtained using SI-LAGB. The postoperative complications of SI-LAGB were within the acceptable range, but one study reported one perioperative death. SI-LAGB required a longer operative time. Other outcome variables, such as blood loss, days of hospitalization, pain score, and hospitalization costs, were not significantly different between the two groups. CONCLUSIONS SI-LAGB might be a safe and effective alternative to C-LAGB when performed by experienced surgeons, but available data do not allow to give a definitive answer and randomized controlled trials are needed.
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Affiliation(s)
- Xing-Zhen Liu
- a The First Department of Recovery , Hangzhou Sanatorium of Nanjing Military Command Region , Hangzhou , China.,c Department of Rheumatology , Changhai Hospital, The Second Military Medical University , Shanghai , China
| | - Jie Fan
- a The First Department of Recovery , Hangzhou Sanatorium of Nanjing Military Command Region , Hangzhou , China
| | - You-Qin Zhang
- a The First Department of Recovery , Hangzhou Sanatorium of Nanjing Military Command Region , Hangzhou , China
| | - Mao Jin Xu
- b Department of Endocrinology , Changhai Hospital, The Second Military Medical University , Shanghai , China
| | - Dong-Bao Zhao
- c Department of Rheumatology , Changhai Hospital, The Second Military Medical University , Shanghai , China
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Donatsky AM, Andersen L, Nielsen OL, Meisner S, Jørgensen LN, Rosenberg J, Vilmann P. Gastrotomy Healing After Transgastric Peritoneoscopy: A Randomized Study in a Pig Model. J Laparoendosc Adv Surg Tech A 2015; 25:747-54. [PMID: 26275155 DOI: 10.1089/lap.2015.0271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Reliable closure and infection prevention are the main barriers for implementation of pure transgastric peritoneoscopy. The primary aim of this study was to assess healing of over the scope clip (OTSC) closed gastrotomies. MATERIALS AND METHODS Pure transgastric peritoneoscopy was performed in 7 pigs. The pigs were randomized to 14 or 28 postoperative days (POD) of follow-up. Decontamination of the access route was performed before instrumentation. A full necropsy was performed. Closure was evaluated with histopathological examination of excised gastrorrhaphies. RESULTS Three pigs were allowed 14 POD of follow-up, and 4 pigs were allowed 28 POD of follow-up. Survival was achieved in 6 of the 7 animals; 1 pig was euthanized due to diffuse peritonitis. Based on our definition, full-thickness healing had only been achieved in a single pig allowed 28 POD. With respect to clinical relevancy, full-thickness healing was deemed achieved in 4 of 6 pigs completing follow-up and in all pigs allowed and surviving 28 POD. Access required repeated punctures and the use of several endoscopic instruments. CONCLUSIONS Full-thickness healing of the gastrotomy was only found in a single case when adhering to the per protocol definition. Endoscopic ultrasonography-guided access was difficult. It lacks reproducibility and needs refinement. Despite a combined decontamination regimen, infectious complications still occurred.
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Affiliation(s)
- Anders Meller Donatsky
- 1 Department of Surgery, Hvidovre Hospital, University of Copenhagen , Hvidovre, Denmark
| | - Luise Andersen
- 2 Department of Pathology, Roskilde Hospital, University of Copenhagen , Roskilde, Denmark
| | - Ole Lerberg Nielsen
- 3 Department of Veterinary Disease Biology, Faculty of Health and Medical Sciences, University of Copenhagen , Frederiksberg, Denmark
| | - Søren Meisner
- 4 Digestive Disease Center, Bispebjerg Hospital, University of Copenhagen , Copenhagen, Denmark
| | | | - Jacob Rosenberg
- 5 Department of Surgery, Herlev Hospital, University of Copenhagen , Herlev, Denmark
| | - Peter Vilmann
- 5 Department of Surgery, Herlev Hospital, University of Copenhagen , Herlev, Denmark
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Xu B, Xu B, Zheng WY, Ge HY, Wang LW, Song ZS, He B. Transvaginal cholecystectomy vs conventional laparoscopic cholecystectomy for gallbladder disease: A meta-analysis. World J Gastroenterol 2015; 21:5393-5406. [PMID: 25954114 PMCID: PMC4419081 DOI: 10.3748/wjg.v21.i17.5393] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/20/2014] [Revised: 11/29/2014] [Accepted: 01/05/2015] [Indexed: 02/06/2023] Open
Abstract
AIM: To compare the results of transvaginal cholecystectomy (TVC) and conventional laparoscopic cholecystectomy (CLC) for gallbladder disease.
METHODS: We performed a literature search of PubMed, EMBASE, Ovid, Web of Science, Cochrane Library, Google Scholar, MetaRegister of Controlled Trials, Chinese Medical Journal database and Wanfang Data for trials comparing outcomes between TVC and CLC. Data were extracted by two authors. Mean difference (MD), standardized mean difference (SMD), odds ratios and risk rate with 95%CIs were calculated using fixed- or random-effects models. Statistical heterogeneity was evaluated with the χ2 test. The fixed-effects model was used in the absence of statistically significant heterogeneity. The random-effects model was chosen when heterogeneity was found.
RESULTS: There were 730 patients in nine controlled clinical trials. No significant difference was found regarding demographic characteristics (P > 0.5), including anesthetic risk score, age, body mass index, and abdominal surgical history between the TVC and CLC groups. Both groups had similar mortality, morbidity, and return to work after surgery. Patients in the TVC group had a lower pain score on postoperative day 1 (SMD: -0.957, 95%CI: -1.488 to -0.426, P < 0.001), needed less postoperative analgesic medication (SMD: -0.574, 95%CI: -0.807 to -0.341, P < 0.001) and stayed for a shorter time in hospital (MD: -1.004 d, 95%CI: -1.779 to 0.228, P = 0.011), but had longer operative time (MD: 17.307 min, 95%CI: 6.789 to 27.826, P = 0.001). TVC had no significant influence on postoperative sexual function and quality of life. Better cosmetic results and satisfaction were achieved in the TVC group.
CONCLUSION: TVC is safe and effective for gallbladder disease. However, vaginal injury might occur, and further trials are needed to compare TVC with CLC.
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Park YH, Kim KT, Bae JB, Kim HH. Transvaginal and transrectal natural orifice translumenal endoscopic surgery nephrectomy in a porcine survival model: comparison with conventional laparoscopic nephrectomy. J Endourol 2014; 29:351-6. [PMID: 25350081 DOI: 10.1089/end.2014.0309] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
PURPOSE We analyzed the technical feasibility, physiological influence, and safety of transvaginal (TV) and transrectal (TR) natural orifice translumenal endoscopic surgery (NOTES) nephrectomy compared with conventional laparoscopic surgery in a porcine survival model. METHODS Fifteen female pigs (32.8-37.2 kg) were randomly assigned to undergo TV NOTES (n=5), TR NOTES (n=5), or conventional laparoscopic nephrectomy (n=5). Postoperatively, all animals were observed for global health status during the recovery from anesthesia. Variable laboratory parameters and inflammatory cytokines were compared among the groups during the entire experimental period. Postmortem examination was performed 1 week after operation for assessment of abdominal complications and cultures for microorganisms. RESULTS All experiments were completed successfully without insertion of an extra port or conversion to laparoscopic or open surgery. Although mean operative times were longer in TV and TR NOTES groups than in the conventional laparoscopy group (61 vs 84 vs 24 min, P<0.001), there were no signs of visceral injury or peritonitis on postmortem examination. None of the laboratory parameters, including white blood cell count, tumor necrosis factor-α, interleukin (IL)-1, and IL-6 differed among the groups during the entire experimental period. CONCLUSIONS TV and TR NOTES nephrectomy could be completed successfully with similar physiologic influence to those of conventional laparoscopic nephrectomy in a porcine survival model.
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Affiliation(s)
- Yong Hyun Park
- 1 Department of Urology, The Catholic University of Korea , Seoul St. Mary's Hospital, Seoul, Korea
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Emhoff IA, Lee GC, Sylla P. Future directions in surgery for colorectal cancer: the evolving role of transanal endoscopic surgery. COLORECTAL CANCER 2014. [DOI: 10.2217/crc.14.8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
SUMMARY The morbidity associated with radical surgery for rectal cancer has launched a revolution in increasingly less-invasive methods of resection, including a recent resurgence in transanal endoscopic surgical approaches. The next evolution in transanal surgery for rectal cancer is natural orifice translumenal endoscopic surgery (NOTES). To date, 14 series of transanal NOTES total mesorectal excision (TME) for rectal cancer have been published (n = 76). Overall, the intraoperative and postoperative complication rates of 8 and 28%, respectively, compare favorably to those expected from laparoscopic and open TME. Short-term follow-up after NOTES TME has yielded no cancer recurrence in average-risk patients. High-risk patients have cancer recurrence rates similar to those after laparoscopic TME. Overall, these early data support transanal NOTES TME as a safe and viable alternative to conventional TME. Advances in instrumentation, surgical expertise and neoadjuvant treatment may expand current indications for NOTES even further.
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Affiliation(s)
- Isha Ann Emhoff
- Department of Surgery, Division of Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman Street, Wang 460, Boston, MA 02114, USA
| | - Grace Clara Lee
- Department of Surgery, Division of Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman Street, Wang 460, Boston, MA 02114, USA
| | - Patricia Sylla
- Department of Surgery, Division of Gastrointestinal Surgery, Massachusetts General Hospital, 15 Parkman Street, Wang 460, Boston, MA 02114, USA
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Upper GI natural orifice translumenal endoscopic surgery: what is new? Eur Surg 2013. [DOI: 10.1007/s10353-013-0240-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Sun G, Yang Y, Zhang X, Li W, Wang Y, Zhang L, Tang P, Kong J, Zhang R, Meng J, Wang X. Comparison of gastrotomy closure modalities for natural orifice transluminal surgery: a canine study. Gastrointest Endosc 2013; 77:774-83. [PMID: 23453129 DOI: 10.1016/j.gie.2012.12.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 12/17/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Reliable closure of the gastrotomy after transgastric natural orifice transluminal endoscopic surgery (NOTES) remains unresolved. OBJECTIVE To compare the technical aspects and clinical and histologic outcomes of NOTES gastrotomy closure techniques. DESIGN Experimental study. SETTING Animal laboratory. PATIENTS Thirty-four dogs, 14 for nonsurvival study and 20 for survival study. INTERVENTIONS The animals randomly received different gastrotomy closures after NOTES: endoclip, omentoplasty, over-the-scope-clip (OTSC), and hand-suturing. MAIN OUTCOME MEASUREMENTS Procedure time, closure strength, survival, postoperative adverse events, and histologic evaluation of wound healing. RESULTS Omentoplasty and OTSC groups needed shorter procedure times and fewer clips than the endoclip group. The endoclip and omentoplasty groups generated similar leakage pressures (34.5 ± 2.6 vs 42.2 ± 4.1 mm Hg, P > .05), both lower than OTSC and hand-suturing groups (81.5 ± 2.1 and 87.0 ± 3.0 mm Hg, respectively, P < .001). Of the 20 animals in the survival study (all 4 groups), only 2 of 6 in the endoclip group were killed prematurely due to sepsis. Necropsy revealed the OTSC group reached a 100% clip retention rate, higher than the endoclip (47.9%) and omentoplasty groups (44.4%, P < .05) rates. Complete healing, defined as intact and continuous gastric layers microscopically, was seen in 83.3% of animals (5 of 6) in the omentoplasty group, comparable with OTSC (4 of 6, 66.7%, P = .500) but higher than the endoclip group (1 of 6, 16.7%, P = .04). LIMITATIONS Animal study. CONCLUSIONS Omentoplasty is easier and safer for NOTES gastrotomy closure than endoclips and offers safety profile and efficacy similar to OTSC and hand-suturing.
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Affiliation(s)
- Gang Sun
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
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Beuran M, Negoi I, Paun S, Lobontiu A, Filipoiu F, Moldoveanu A, Negoi R, Hostiuc S. Natural orifice translumenal endoscopic surgery (NOTES) second-look peritoneoscopy for staging of limited peritoneal carcinomatosis. Med Hypotheses 2013; 80:745-9. [PMID: 23562285 DOI: 10.1016/j.mehy.2013.03.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2012] [Revised: 02/12/2013] [Accepted: 03/03/2013] [Indexed: 11/17/2022]
Abstract
BACKGROUND Over the past decades, staging laparoscopy evolved as a useful tool in multimodality treatment of patients with abdominal malignancies, especially for detection of incurable peritoneal and liver metastasis. Natural orifice translumenal endoscopic surgery (NOTES) is a new, evolving technique which represents the next logical progression in minimally invasive surgery and has theoretical advantages in comparison with standard laparoscopic surgery. A review of the current literature revealed a continuous increasing number of fundamental and clinical studies addressing NOTES approach in multimodal management of oncologic patients. Technical possibility to use this new minimally invasive approach for oncological resection of abdominal malignancies was proved by some investigators. HYPOTHESIS NOTES can be used as an alternative method for staging patients with limited peritoneal carcinomatosis and may have better results compared to current imaging techniques for small diameter metastatic disease. CONCLUSIONS With the continuous development of the NOTES techniques and technology, the second-look peritoneoscopy by NOTES may become an alternative method for staging in patients with peritoneal carcinomatosis. Nevertheless, NOTES is at a very early stage of its development, and its implementation in oncologic surgery should be made very caution, and only after careful evaluation.
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Affiliation(s)
- Mircea Beuran
- General Surgery Department, Emergency Hospital of Bucharest, University of Medicine and Pharmacy Carol Davila Bucharest, Romania
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Fuchs KH, Meining A, von Renteln D, Fernandez-Esparrach G, Breithaupt W, Zornig C, Lacy A. Euro-NOTES Status Paper: from the concept to clinical practice. Surg Endosc 2013; 27:1456-67. [PMID: 23543284 DOI: 10.1007/s00464-013-2870-2] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Accepted: 02/01/2013] [Indexed: 02/08/2023]
Abstract
BACKGROUND The concept of natural orifice transluminal endoscopic surgery (NOTES) consists of the reduction of access trauma by using a natural orifice access to the intra-abdominal cavity. This could possibly lead to less postoperative pain, quicker recovery from surgery, fewer postoperative complications, fewer wound infections, and fewer long-term problems such as hernias. The Euro-NOTES Foundation has organized yearly meetings to work on this concept to bring it safely into clinical practice. The aim of this Euro-NOTES status update is to assess the yearly scientific working group reports and provide an overview on the current clinical practice of NOTES procedures. METHODS After the Euro-NOTES meeting 2011 in Frankfurt, Germany, an analysis was started regarding the most important topics of the European working groups. All prospectively documented information was gathered from Euro-NOTES and D-NOTES working groups from 2007 to 2011. The top five topics were analyzed. RESULTS The statements of the working group activities demonstrate the growing information and changing insights. The most important selected topics were infection issue, peritoneal access, education and training, platforms and new technology, closure, suture, and anastomosis. The focus on research topics changed over time. The principle of hybrid access has overcome the technical and safety limitations of pure NOTES. Currently the following NOTES access routes are established for several indications: transvaginal access for cholecystectomy, appendectomy and colon resections; transesophageal access for myotomy; transgastric access for full-thickness small-tumor resections; and transanal/transcolonic access for rectal and colon resections. CONCLUSIONS NOTES and hybrid NOTES techniques have emerged for all natural orifices and were introduced into clinical practice with a good safety record. There are different indications for different natural orifices. Each technique has been optimized for the purpose of finding a safe and realistic solution to perform the procedure according to the specific indication.
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Affiliation(s)
- K H Fuchs
- Department of Surgery, AGAPLESION-Markus-Krankenhaus, Wilhelm-Epstein-Str. 4, Frankfurt, Germany.
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Navarro-Ripoll R, Martínez-Pallí G, Guarner-Argente C, Córdova H, Martínez-Zamora MA, Comas J, Rodríguez de Miguel C, Beltrán M, Rodríguez-D'Jesús A, Hernández-Cera C, Llach J, Balust J, Fernández-Esparrach G. On-demand endoscopic CO2 insufflation with feedback pressure regulation during natural orifice transluminal endoscopic surgery (NOTES) peritoneoscopy induces minimal hemodynamic and respiratory changes. Gastrointest Endosc 2012; 76:388-95. [PMID: 22817790 DOI: 10.1016/j.gie.2011.10.015] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Accepted: 10/11/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Endoscopic insufflation has been associated with marked increase in intra-abdominal pressure (IAP) and hemodynamic and respiratory changes during transgastric surgery. OBJECTIVE To investigate the hemodynamic and respiratory effects during intraperitoneal cavity exploration through 3 different natural orifice transluminal endoscopic surgery (NOTES) access locations compared with laparoscopy. DESIGN AND SETTING Survival experiments using 40 female pigs randomized to transgastric, transcolonic, transvaginal, and laparoscopic peritoneoscopy. INTERVENTIONS On-demand endoscopic insufflation of CO(2) with feedback pressure regulation was used in NOTES with a maximum pressure of 14 mm Hg. In the laparoscopy group, the IAP was maintained at 14 mm Hg. NOTES procedures were performed by an endoscopist (with the assistance of a gynecologist in the transvaginal group and a second endoscopist in the transgastric and transrectal groups) and laparoscopy by 2 surgeons. MAIN OUTCOME MEASUREMENTS Invasive hemodynamic and respiratory data. Blood samples were drawn for gas analyses. RESULTS All experiments except one in the transrectal group were completed. The IAP was significantly lower in all NOTES groups compared with the laparoscopy group. A significant increase in mean systemic arterial blood pressure was observed in the laparoscopy group at 15 and 30 minutes of intraperitoneal cavity exploration, but it remained unchanged during all NOTES procedures. An increase in airway pressures was observed at 15 and 30 minutes of peritoneoscopy in the animals undergoing laparoscopy, whereas those parameters remained unchanged in the NOTES groups. The laparoscopy group showed a significant impairment in pulmonary gas exchange (decrease in Pao(2), increase in Paco(2), and decrease in arterial pH) after 30 minutes of peritoneoscopy, whereas only a slight increase in Paco(2) was observed in the transrectal and transvaginal groups. LIMITATIONS Healthy animal model. CONCLUSION On-demand endoscopic insufflation of CO(2) with feedback pressure regulation can minimize the risk of hemodynamic and respiratory compromise caused by acute changes in IAP.
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Affiliation(s)
- Ricard Navarro-Ripoll
- Anesthesiology Department, Hospital Clinic, University of Barcelona, Barcelona, Spain
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Perry KA, Shah N, Memark V, Nau P, Needleman BJ, Hazey JW. Specialized instrumentation facilitates stable peritoneal access, gastric decompression, and visualization during transgastric endoscopic peritoneoscopy. Surg Innov 2012; 20:268-72. [PMID: 22858574 DOI: 10.1177/1553350612456101] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
PURPOSE The lack of high-fidelity instrumentation has impeded the development and implementation of natural orifice transluminal endoscopic surgery (NOTES). A steerable flexible trocar (SFT), a rotary access needle (RAN), and an articulating needle knife were developed as components of a flexible instrument set to facilitate transgastric peritoneal access and transluminal abdominal procedures. This cohort study aimed to assess the safety, feasibility, and efficacy of these devices during transgastric peritoneoscopy. METHODS Ten morbidly obese patients undergoing laparoscopic Roux-en-Y gastric bypass participated in the study. Following laparoscopic access, transgastric peritoneal access was established using the SFT and RAN, and transgastric peritoneoscopy performed. NOTES adhesiolysis was performed in 2 patients with significant intra-abdominal adhesions due to prior surgery. Outcome measures included time to enter the peritoneal cavity, ability to visualize each quadrant of the abdomen, ability to perform adhesiolysis, and complications. RESULTS Ten patients with a median body mass index as stated in table 1 of 47.5 kg/m(2) were enrolled. Successful transgastric access was achieved in 8 of the 10 patients. One procedure was aborted because of difficulty creating the gastrotomy. Another procedure was aborted because of the difficult passage of the device through the oropharynx. An upper esophageal laceration occurred in one patient. Transgastric peritoneal access required 17.4 ± 5.5 minutes, and peritoneoscopy averaged 24.7 ± 7.6 minutes. The 4 abdominal quadrants were visualized and were accessible with the endoscope in all patients. CONCLUSIONS The SFT and RAN facilitate transgastric peritoneal access and visualization of difficult-to-reach areas of the peritoneum. These devices provide advanced instrumentation for transgastric NOTES procedures; however, care must be taken during the transoral insertion to avoid complications.
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Affiliation(s)
- Kyle A Perry
- The Ohio State University Medical Center, Columbus, OH, USA
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Natural orifice translumenal endoscopic surgery in humans: a review. Minim Invasive Surg 2012; 2012:189296. [PMID: 22720153 PMCID: PMC3375094 DOI: 10.1155/2012/189296] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 03/06/2012] [Indexed: 12/21/2022] Open
Abstract
Natural orifice translumenal endoscopic surgery (NOTES) had its origins in numerous small animal studies primarily examining safety and feasibility. In human trials, safety and feasibility remain at the forefront; however, additional logistic, practical, and regulatory requirements must be addressed. The purpose of this paper is to evaluate and summarize published studies to date of NOTES in humans. The literature review was performed using PUBMED and MEDLINE databases. Articles published in human populations between 2007 and 2011 were evaluated. A review of this time period resulted in 48 studies describing procedures in 916 patients. Transcolonic and transvesicular procedures were excluded. The most common procedure was cholecystectomy (682, 75%). The most common approach was transvaginal (721, 79%). 424 procedures (46%) were pure NOTES and 491 (54%) were hybrid NOTES cases. 127 (14%) were performed in the United States of America and 789 (86%) were performed internationally. Since 2007, there has been major development in NOTES in human populations. A preponderance of published NOTES procedures were performed internationally. With further development, NOTES may make less invasive surgery available to a larger human population.
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Arain NA, Rondon L, Hogg DC, Cadeddu JA, Bergs R, Fernandez R, Scott DJ. Magnetically anchored camera and percutaneous instruments maintain triangulation and improve cosmesis compared with single-site and conventional laparoscopic cholecystectomy. Surg Endosc 2012; 26:3457-66. [PMID: 22648118 DOI: 10.1007/s00464-012-2354-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2012] [Accepted: 04/17/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND This study evaluated operative outcomes and ergonomics for a magnetic camera (MAGS) used in conjunction with percutaneous instruments [percutaneous surgical set (PSS)] compared with single-site laparoscopic (SSL) and conventional laparoscopic (LAP) cholecystectomy techniques. METHODS Four surgical trainees each performed three porcine cholecystectomies using three randomized techniques including MAGS/PSS, SSL, and LAP. The operative outcomes, procedure-specific ratings (1-5 scale; 1 = superior), workload (1-10 scale; 1 = superior), and global impressions (1-10 scale; 10 = superior) were recorded. Comparisons used analysis of variance (ANOVA) on ranks (Kruskal-Wallis), and p values lower than 0.05 were considered significant. RESULTS The operative outcomes were similar except for significantly higher blood loss with SSL (16.3 ± 10.3) versus LAP (2.8 ± 1.5; p < 0.05) but not with MAGS/PSS (4.8 ± 3.8). Several inadvertent tissue-damaging events occurred with SSL but not with MAGS/PSS or LAP. The incision was significantly shorter with MAGS/PSS (29.3 ± 2.8 mm) and SSL (29.3 ± 2.5 mm) than with LAP (48.0 ± 3.6 mm; p < 0.05). Compared with SSL (3.6 ± 0.5), the procedure-specific ratings significantly favored MAGS/PSS (2.8 ± 0.4) and LAP (1.7 ± 0.2; p < 0.05). Ergonomics and technical challenges both were rated significantly inferior with SSL (4.3 ± 1.0 and 3.8 ± 0.5, respectively) versus LAP (1.5 ± 0.6 and 2.0 ± 0.8, respectively; p < 0.05) but not with MAGS/PSS (2.5 ± 1.0 and 3.0 ± 0.8, respectively). Both MAGS/PSS (4.5 ± 0.5) and SSL (4.8 ± 1.0) were associated with a significantly greater workload than LAP (2.5 ± 0.6; p < 0.05). Global impression ratings were significantly higher for LAP (8.7 ± 1.3) versus SSL (5.8 ± 2.0; p < 0.05) but not for MAGS/PSS (7.1 ± 1.8). Cosmesis was significantly better with MAGS/PSS (9.5 ± 0.6) versus LAP (6.5 ± 2.4; p < 0.05) but not with SSL (8.8 ± 1.3). CONCLUSION The MAGS/PSS technique allows better triangulation and fewer technical difficulties than SSL and better cosmesis than LAP. Further development of these devices is warranted.
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Affiliation(s)
- Nabeel A Arain
- Department of Surgery, The University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9156, USA.
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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: 1.1] [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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Affiliation(s)
- Mouen A Khashab
- Department of Medicine and Division of Gastroenterology and Hepatology, The Johns Hopkins Medical Institute, Baltimore, Maryland 21287, 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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Arain NA, Cadeddu JA, Best SL, Roshek T, Chang V, Hogg DC, Bergs R, Fernandez R, Webb EM, Scott DJ. A randomized comparison of laparoscopic, magnetically anchored, and flexible endoscopic cameras in performance and workload between laparoscopic and single-incision surgery. Surg Endosc 2011; 26:1170-80. [PMID: 22044976 DOI: 10.1007/s00464-011-2013-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2011] [Accepted: 10/11/2011] [Indexed: 11/24/2022]
Abstract
BACKGROUND This study aimed to evaluate the surgeon performance and workload of a next-generation magnetically anchored camera compared with laparoscopic and flexible endoscopic imaging systems for laparoscopic and single-site laparoscopy (SSL) settings. METHODS The cameras included a 5-mm 30° laparoscope (LAP), a magnetically anchored (MAGS) camera, and a flexible endoscope (ENDO). The three camera systems were evaluated using standardized optical characteristic tests. Each system was used in random order for visualization during performance of a standardized suturing task by four surgeons. Each participant performed three to five consecutive repetitions as a surgeon and also served as a camera driver for other surgeons. Ex vivo testing was conducted in a laparoscopic multiport and SSL layout using a box trainer. In vivo testing was performed only in the multiport configuration and used a previously validated live porcine Nissen model. RESULTS Optical testing showed superior resolution for MAGS at 5 and 10 cm compared with LAP or ENDO. The field of view ranged from 39 to 99°. The depth of focus was almost three times greater for MAGS (6-270 mm) than for LAP (2-88 mm) or ENDO (1-93 mm). Both ex vivo and in vivo multiport combined surgeon performance was significantly better for LAP than for ENDO, but no significant differences were detected for MAGS. For multiport testing, workload ratings were significantly less ex vivo for LAP and MAGS than for ENDO and less in vivo for LAP than for MAGS or ENDO. For ex vivo SSL, no significant performance differences were detected, but camera drivers rated the workload significantly less for MAGS than for LAP or ENDO. CONCLUSION The data suggest that the improved imaging element of the next-generation MAGS camera has optical and performance characteristics that meet or exceed those of the LAP or ENDO systems and that the MAGS camera may be especially useful for SSL. Further refinements of the MAGS camera are encouraged.
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Affiliation(s)
- Nabeel A Arain
- Department of Surgery, Southwestern Center for Minimally Invasive Surgery, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9156, USA
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Abstract
Natural orifice transluminal endoscopic surgery (NOTES) has gained a great deal of attention from gastroenterologists and surgeons all over the world since its introduction in 2000. The field of NOTES has advanced tremendously since that time and exciting and well-designed research has been reported. Both randomized controlled trials and results from large national and international registries have been published. Many experimental and clinical studies have discussed transesophageal, transgastric, transvaginal and transrectal access for a variety of NOTES procedures. Transvaginal access has been the most frequently reported NOTES access route in clinical trials. When suitable instruments become available, a true comparison of NOTES with current laparoscopic approaches can be realized.
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Disinfection of the Access Orifice in NOTES: Evaluation of the Evidence Base. DIAGNOSTIC AND THERAPEUTIC ENDOSCOPY 2011; 2011:245175. [PMID: 21785559 PMCID: PMC3138109 DOI: 10.1155/2011/245175] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/31/2011] [Accepted: 05/02/2011] [Indexed: 12/14/2022]
Abstract
Introduction. Appropriate prevention of infection is a key area of research in natural orifice translumenal endoscopic surgery (NOTES), as identified by the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR). Methods. A review of the literature was conducted evaluating the evidence base for access orifice preparation/treatment in NOTES procedures in the context of infectious complications. Recommendations based on the Oxford Centre for Evidence-Based Medicine guidelines were made. Results. The most robust evidence includes several experimental randomised controlled trials assessing infectious complications in the transgastric approach to NOTES. Transvaginal procedures are long established for accessing the peritoneal cavity following disinfection with antiseptic. Only experimental case series for transcolonic and transvesical approaches are described. Conclusion. Grade C recommendation requiring no preoperative preparation can be made for the transgastric approach. Antiseptic irrigation is recommended for transvaginal (grade C) NOTES access, as is current practice. Further human trials need to be conducted to corroborate the current evidence base for transgastric closure. It is important that future trials are conducted in a methodologically robust fashion, with emphasis on clinical outcomes and standardisation of enterotomy closure and postoperative therapy.
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Matthes K, Thakkar SJ, Lee SH, Gromski MA, Lim RB, Janschek J, Jones SB, Jones DB, Chuttani R. Development of a pancreatic tumor animal model and evaluation of NOTES tumor enucleation. Surg Endosc 2011; 25:3191-7. [PMID: 21487862 DOI: 10.1007/s00464-011-1686-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2010] [Accepted: 03/07/2011] [Indexed: 02/06/2023]
Abstract
BACKGROUND Laparoscopic distal pancreatectomy is associated with high morbidity and mortality. NOTES tumor enucleation may provide an alternative to laparoscopic distal pancreatectomy. The goal of this study was to determine the feasibility of NOTES tumor creation and enucleation as a multidisciplinary approach. METHODS A linear-array endoscopic ultrasound (EUS) endoscope was used to inject a thermosensitive ABA triblock polymer mixed with methylene blue through the stomach wall and into the distal pancreas using a 22-gauge EUS needle. Due to its thermosensitive character, the polymer solidifies in response to body temperature, creating an artificial tumor. Seventeen swine underwent NOTES transgastric pancreatic tumor enucleation. Nine nonsurvival animals were sacrificed immediately after the NOTES procedure, with subsequent necropsy. Eight survival animals were observed for up to 16 days after the procedure, subsequently sacrificed, followed by necropsy. RESULTS The procedure was performed successfully in all 17 pigs studied, 9/9 nonsurvival (100%) and 8/8 survival (100%) animals, using a pure NOTES approach without any laparoscopic ports. Complications included two esophageal dissections (1 in nonsurvival group, 1 in survival group) caused by the introduction of the endoscopic overtube (2/17, 12%), unrelated to the actual surgical procedure. In the survival animals, there were two small splenic lacerations caused during retraction with the endoscopic forceps, for which hemostasis was achieved prior to closure of the gastrotomy (2/7, 29%). At necropsy of the animals, there was sufficient closure of 15/17 gastrotomy sites (88%). CONCLUSIONS The creation of artificial pancreatic tumors via EUS guidance is feasible. Pancreatic tumor enucleation using a transgastric NOTES approach is technically feasible and could be an alternative to laparoscopic distal pancreatectomy with further development. Further adoption and adaptation of this technique will require the development of more sophisticated specialized tools to improve the safety profile of the procedure.
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Affiliation(s)
- Kai Matthes
- Department of Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA 02215, USA.
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The Second SAGES/ASGE White Paper on natural orifice transluminal endoscopic surgery: 5 years of progress. Surg Endosc 2011; 25:2441-8. [PMID: 21359881 DOI: 10.1007/s00464-011-1605-5] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2011] [Accepted: 02/01/2011] [Indexed: 12/24/2022]
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