Transgastric large-organ extraction: the initial human experience

Comparison of stapled versus stapleless sleeve gastrectomy with natural orifice specimen extraction (NOSE)

Background

Sleeve gastrectomy is a stapler dependent bariatric procedure. A stapleless sleeve gastrectomy can be necessary for certain circumstances.

Aims

Here, we aimed to show whether laparoscopic stapleless sleeve gastrectomy with natural orifice specimen extraction (NOSE) can be an alternative procedure to stapled sleeve gastrectomy.

Patients and Methods

In the stapleless group (n = 6), no staplers were used and after vertical resection of the stomach by energy devices, the stomach remnant was closed by two rows of intracorporeal sutures. The resected specimen was removed through the mouth using an endoscopic snare. In the stapler group (n = 7), sleeve gastrectomy was carried out with linear stapler under the guidance of 36 Fr bougie. The specimens were extracted from the left upper quadrant trocar site.

Results

A total of 13 patients were compared (stapleless = 6 and stapled group = 7). All the sleeve gastrectomies were completed laparoscopically. The operative time was longer at 200 minutes (range 120-300) versus 120 minutes, (range 90-200) p = 0.07) and the amount of bleeding was higher at 100 ml (range 50-200) versus 30 ml (range 10-50) (p = 0.004) in the stapleless group. Leakage and gastrointestinal bleeding were seen in the stapleless group but no complications were found in the stapler group. No statistically significant difference was found between the metabolic outcomes of the two groups after the operation (p > 0.05). Decrease in BMI at similar rates was observed in 5 postoperative year (stapleless group: 35 kg/m² (range 31-39) versus stapled group: 36.5 kg/m² (range 31-39), p > 0.05).

Conclusion

Laparoscopic stapleless sleeve gastrectomy with natural orifice specimen extraction has longer procedure time, more blood loss and complications.

Mini-laparoscopic adrenalectomy with transgastric specimen extraction

We aimed to describe the initial experience of mini-laparoscopic adrenalectomy combined with transgastric specimen extraction and to assess its safety and feasibility. We used only 5-mm trocars, three ports for left adrenalectomy and four for right. Intraoperative gastroscopy was performed for specimen extraction through the mouth via an endoscopic snare. The gastrotomy was closed intracorporeally. Demographic, perioperative and pathological data were analyzed. There were 16 patients (12 females) with the mean age of 46.5 ± 11.3 years and half of them had previous abdominal surgeries. The median operative time was 150 (45-432) min with a median blood loss of 88 (0-350) ml. The median oral intake time was 2 (1-4) days and the median length of hospital stay was 2 (2-5) days. There was no mortality and extraction-related complication. Histopathological median tumor length, width and depth were 3 cm, 2.15 cm, and 1.9 cm, respectively. The median specimen length, width and depth were 6.25 cm, 4 cm, and 2.2 cm, respectively. Mini-laparoscopic adrenalectomy combined with transgastric specimen extraction is a safe and feasible surgical technique. It provides a less invasive surgery and may also have some benefits on wound-related complications and cosmesis.

Extraction bags provide no benefit when compared to unprotected lateral stomach extraction during laparoscopic sleeve gastrectomy

BACKGROUND

Currently, no evidence compares outcomes for techniques utilizing surgical specimen extractions bags versus unprotected extraction.

METHODS

Evaluation of sleeve gastrectomies performed at two high-volume centers. Cases where an extraction bag was used (+EB) were compared to bag-less extraction (-EB). Outcomes included operative contamination, surgical site infections and extraction-site hernias.

RESULTS

674 patients were evaluated (417 in the +EB group and 257 in the -EB group). Preoperative characteristics were similar between groups. There was a trend toward shorter operative times with the -EB group (-EB = 100 min vs + EB = 106 min, p = 0.07). Gross spillage was documented as a contaminated case in 0.4% of -EB cases compared to 1.2% in +EB cases (p = 0.51). Two superficial infections were appreciated (1.2% = +EB vs 0.7% = -EB, p = 0.7) with one post-operative abscess in the -EB group (p = 0.61). One post-operative hernia was seen in each group (p = 0.62).

DISCUSSION

Bag-less extraction is a safe, resource conscious method that may potentially decreased operative time.

Comparison of laparoscopic sleeve gastrectomy leak rates in five staple-line reinforcement options: a systematic review

Background

Staple-line leaks following laparoscopic sleeve gastrectomy (LSG) remain a concerning complication. Staple-line buttressing is largely adopted as an acceptable reinforcement but data regarding leaks have been equivocal. This study compared staple-line leaks in five reinforcement options during LSG: no reinforcement (NO-SLR), oversewing (suture), nonabsorbable bovine pericardial strips (BPS), tissue sealant or fibrin glue (Seal), or absorbable polymer membrane (APM).

Methods

This systematic review study of articles published between 2012 and 2016 regarding LSG leak rates aligned with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Variables of interest included leak rates, bleeding, and complications in addition to surgical and population parameters. An independent Fisher’s exact test was used to compare the number of patients with and without leaks for the different reinforcement options.

Results

Of the 1633 articles identified, 148 met inclusion criteria and represented 40,653 patients. Differences in age (older in APM; p = 0.001), starting body mass index (lower in Suture; p = 0.008), and distance from pylorus (closer in BPS; p = 0.04) were observed between groups, but mean bougie size was equivalent. The overall leak rate of 1.5% (607 leaks) ranged from 0.7% for APM (significantly lower than all groups; p ≤ 0.007 for next lowest leak rate) to 2.7% (BPS).

Conclusions

This systematic review of staple-line leaks following LSG demonstrated a significantly lower rate using APM staple-line reinforcement as compared to oversewing, use of sealants, BPS reinforcement, or no reinforcement. Variation in surgical technique may also contribute to leak rates.

Electronic supplementary material

The online version of this article (10.1007/s00464-019-06782-2) contains supplementary material, which is available to authorized users.

Hybrid transgastric appendectomy is feasible but does not offer advantages compared with laparoscopic appendectomy: Results from the transgastric appendectomy study

BACKGROUND

Very few transgastric procedures, the original objective of natural orifice translumenal surgery, have been reported in the international Natural Orifice Translumenal Surgery registers. In addition, most cases were controlled mainly by laparoscopy. To show the feasibility of hybrid transgastric appendectomy and to compare results with laparoscopic a prospective, nonrandomized study was conducted.

METHODS

From October 2010 to May 2013, patients with acute appendicitis were screened. If the patients met the inclusion criteria, transgastric appendectomy was offered. If the patient decided on laparoscopy, the consenting patients took part in the observational part of the study. The transgastric appendectomy procedure was controlled completely by the gastroscope, although a 3 mm grasper was used to tauten the appendix. Demographic and clinical parameters were collected. Quality of life and pain were measured with a Short Form-8 questionnaire and the Visual Analogue Scale.

RESULTS

Of the 273 patients who underwent an appendectomy, 65 agreed to take part in this study. Out of these, 30 (46.15%) underwent transgastric appendectomy and 35 (53.85%) underwent laparoscopy. No intraoperative complications were recorded. The operation duration rate was greater in the transgastric appendectomy group (94.5 minutes vs 69 minutes; P < .001). Conversions to open appendectomy and complications were the same. There were no differences in pain preoperatively or postoperatively. In both the transgastric appendectomy and laparoscopic groups, the quality of life of all the subscales increased markedly after successful resection of the pathology.

CONCLUSION

These preliminary results demonstrate the feasibility of transgastric appendectomy. The postoperative course and quality of life are comparable with laparoscopic appendectomy, but no improvement due to transgastric appendectomy could be demonstrated.

Comparison of two specimen retrieval techniques in laparoscopic sleeve gastrectomy: what is the role of endobag?

BACKGROUND

Laparoscopic sleeve gastrectomy (LSG) has become a popular stand-alone treatment for morbid obesity. However, removal of the gastric specimen could be a challenging step due to its large size relative to the width of the trocar site.

OBJECTIVES

We aimed to compare a simplified retrieval technique for extraction of the gastric specimen without an endobag with conventionally performed specimen retrieval using an endobag.

METHODS

A case-control study was conducted recruiting patients undergoing LSG. Patient's demographics, preoperative characteristics, intra-operative, and postoperative variables were compared between the two groups according to the technique of gastric specimen removal.

RESULTS

A total of 193 patients (60.6% female) were enrolled into case (n = 100) and control groups (n = 93). Mean ± SD age and BMI of patients were 35.64 ± 11.84 years and 47.28 ± 8.22 Kg/m², respectively with no significant difference between groups. Median (25th, 75th inter-quartile), extraction time was significantly reduced in the non-endobag group compared to the endobag group (3.5 [2.5-4.5] min vs. 6.5 [3.4-8.2] min, p = 0.03).Patients of both groups had similar intra-operative and trocar site complications (hernia and wound infection) (3% for endobag group and 3.3 % for non-endobag group). The median (25-75% [IQR]) LOS was also comparable between endobag and non-endobag patients (3[2-3] vs. 3[2-4] days, p = 0.84). No difference was observed between the two groups for weight loss and comorbidity resolution.

CONCLUSION

Non-endobag technique for gastric specimen retrieval is safe and feasible with substantial saving in operative time and comparable intra-operative and postoperative outcomes to the conventional retrieval technique.

Minimizing the Access Trauma of Laparoscopic Sleeve Gastrectomy: the Transoral Specimen Extraction Technique

BACKGROUND

Laparoscopic sleeve gastrectomy has become a popular stand-alone procedure among bariatric surgeons. Recently, Natural Orifice Specimen Extraction laparoscopic surgery has been introduced to avoid minilaparotomy, possibly reducing postoperative pain, hospital stay, and improving QoL and cosmetics. Operative steps and preliminary results of NOSE sleeve gastrectomy are described and reported.

METHODS

Five patients underwent NOSE LSG from November 2014 to March 2015. Selection criteria were as follows: age <60 years, ASA score ≤III, BMI <50. Operative steps are the same of standard LSG, but the stomach transection that starts higher on the greater curvature. A 2–3 cm width opening is created on the exceeding antrum and the resected stomach sutured to the calibration probe tip, which is pull back allowing transoral specimen extraction. The exceeding antrum is stapler-trimmed, allowing breach closure and completion of tubulization.

RESULTS

Mean age was 41.6 years (median 43), average weight was 123.6 Kg (median 114), mean BMI 43.6 Kg/m2 (median 44). Mean operation time was 72 min (median 75). Mean and median postoperative stay were 4.6 and 5. No intraoperative nor postoperative complications occurred. Postoperative day 1 mean and median VAS pain score at were 1.4 and 1, respectively. Follow-up ranged 1–5 months (mean and median 3), average weight loss was 19.8 Kg (median 19), and excess weight loss 36.2 % (median 32 %).

CONCLUSIONS

NOSE LSG potential advantages are as follows: improved cosmetics, decreased postoperative pain, possible incisional hernia rate reduction. No objective data are available to confirm these theoretical benefits; larger observational studies and RCTs are mandatory before clinical validation.

[Reducing invasiveness of laparoscopic surgery using natural orifices and abdominal wall defects for extraction of the specimen]

INTRODUCTION

Due to significant technical evolution complex surgeries can be performed laparoscopically nowadays. However, laparotomy is needed frequently for the extraction of the specimen, which decreases the advantages of laparoscopy.

AIM

The aim of the authors was to analyse and present their experience on the use of natural orifices and abdominal wall defects for extraction of the surgical specimen.

METHOD

From 2009 the authors used natural orifices (stomach, vagina, rectum) when viscerotomy was an obligate part of laparoscopic surgery and, in a special gastrointestinal laparoscopic operation, the gate of the inguinal hernia for specimen extraction.

RESULTS

In 3 patients benign lesions of the stomach were extracted using gastroscope. In 6 patients with bowel endometriosis, in whom the wall of the vagina was completely infiltrated, the resected bowel was extracted transvaginally, and in 5 patients transrectal extraction of the specimen was performed. In 2 patients the inguinal hernia was used for the surgical specimen extraction after laparoscopic sigmoid resection, and in one patient a single-port was inserted into the gate of the hernia during laparoscopic cholecystectomy. Complications occurred only after transvaginal specimen extraction (rectovaginal fistula in 2 patients).

CONCLUSIONS

Use of natural orifices and abdominal wall defects for surgical specimen extraction further decreases the invasiveness of laparoscopic surgery, if indications made appropriately.

Euro-NOTES Status Paper: from the concept to clinical practice

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.