The advancing art and science of endoscopy

Endoscopic luminal stenting: Current applications and future perspectives

Endoscopic luminal stenting (ELS) represents a minimally invasive option for the management of malignant obstruction along the gastrointestinal tract. Previous studies have shown that ELS can provide rapid relief of symptoms related to esophageal, gastric, small intestinal, colorectal, biliary, and pancreatic neoplastic strictures without compromising cancer patients’ overall safety. As a result, in both palliative and neoadjuvant settings, ELS has largely surpassed radiotherapy and surgery as a first-line treatment modality. Following the abovementioned success, the indications for ELS have gradually expanded. To date, ELS is widely used in clinical practice by well-trained endoscopists in managing a wide variety of diseases and complications, such as relieving non-neoplastic obstructions, sealing iatrogenic and non-iatrogenic perforations, closing fistulae and treating post-sphincterotomy bleeding. The abovementioned development would not have been achieved without corresponding advances and innovations in stent technology. However, the technological landscape changes rapidly, making clinicians’ adaptation to new technologies a real challenge. In our mini-review article, by systematically reviewing the relevant literature, we discuss current developments in ELS with regard to stent design, accessories, techniques, and applications, expanding the research basis that was set by previous studies and highlighting areas that need to be further investigated.

Development of a Nurse-Led Competency-Based Program for Therapeutic Endoscopy: The Formation of the Nurse Product Procedure Group

Therapeutic endoscopy is emerging as an innovating alternative to gastroenterology surgery. Due to the increase in new technologies, endoscopy clinical staff require ongoing education to develop safe, competent practice for new equipment and supplies. Maintaining competencies with new equipment and supplies can be challenging. This article illustrates the development and implementation of a continuous educational program for endoscopy clinical staff at a major academic medical center. An initial needs assessment of staff education and competency led to the multidisciplinary plan for continuous education. Development of the Nurse Product Procedure Group enabled endoscopy staff to standardize care and maintain competency in advanced therapeutic procedures. The Nurse Product Procedure Group offers various pathways of learning to meet clinical staff's individual learning needs. Over a 5-year span of implementation, staff satisfaction of education and resources improved. Key implementation elements of the Nurse Product Procedure Group include monthly staff education, resource development, multidisciplinary collaboration, cost savings, outreach education, and external collaboration with national and international gastroenterology professional organizations and societies.

The effect of pasireotide on intestinal anastomotic healing with and without whole-body irradiation in a rat model

OBJECTIVE

To examine pasireotide's effect on intestinal anastomotic healing under physiological conditions and following preoperative whole-body irradiation.

MATERIAL AND METHODS

Forty-five male Wistar rats received an ileoileal end-to-end anastomosis. Group 1 (Co, n = 9) served as control. Group 2 (SOM, n = 10) received pasireotide (60 mg/kg) 6 days preoperatively. Group 3 (R-Co, n = 13) was subjected to 8 Gy whole-body irradiation 4 days preoperatively. Finally, group 4 (R-SOM, n = 13) received pasireotide 6 days preoperatively and whole-body irradiation 4 days preoperatively. On postoperative day 4, anastomotic bursting pressure, histology, IGF-1 staining, and collagen density were examined.

RESULTS

Mortality was higher in irradiated animals (30.8% vs. 5.3%, p = 0.021), and anastomotic bursting pressure was significantly lower (median, R-Co = 83 mmHg; R-SOM = 101 mmHg; Co = 149.5 mmHg; SOM = 169 mmHg). Inflammation measured by leukocyte infiltration following irradiation was reduced (p = 0.023), and less collagen was observed, though this was not statistically significant. Bursting pressure did not significantly differ between Co and SOM and between R-Co and R-SOM animals respectively. Semi-quantitative scoring of IGF-1, fibroblast bridging, or collagen density did not reveal significant differences among the groups.

CONCLUSION

Whole-body irradiation decreases the quality of intestinal anastomotic wound healing and increases mortality. Pasireotide does not significantly lessen this detrimental effect.

Cumulative sum: a proficiency metric for basic endoscopic training

BACKGROUND

As work hour restrictions increasingly limit some operative experiences, personalized evaluative methods are needed. We prospectively assessed the value of cumulative sum (Cusum) to measure proficiency with percutaneous endoscopic gastrostomy (PEG) among surgical trainees.

MATERIALS AND METHODS

Nine postgraduate year 1 surgery residents each underwent a 1-month rotation dedicated to endoscopy. Procedure durations for all PEG insertions were recorded prospectively. Criteria for task failure included need for attending takeover or procedure duration >10 min. Cusum parameters were defined a priori, with acceptable and unacceptable failure rates of 5% and 15%, respectively. Concurrently, expert endoscopists blinded to Cusum results evaluated trainee proficiency weekly using a multicategory, five-point Likert-scale survey.

RESULTS

Nine surgical residents performed an average of 21 PEGs each. Expert evaluations and Cusum analyses identified eight and seven participants who attained proficiency after a median of 11.5 and 12 cases, respectively. For four of the residents who achieved proficiency by Cusum criteria, eventual relapses to inadequate performance were identified. These relapses were not detected by expert evaluation. Six participants who attained proficiency by both metrics performed a combined 32 superfluous cases, which could have been redistributed to poor-performing trainees.

CONCLUSIONS

Although lacking the granular insight of expert evaluations, Cusum analysis is more sensitive to relapses of subproficient performance. Adding Cusum analysis to expert evaluations can provide longitudinal, formative feedback and promote efficient redistribution of operative experiences.

An alternative system for transvaginal removal of dermoid cyst and a comparative study with laparoscopy

The objective was to introduce a new system for transvaginal removal of ovarian cyst and to evaluate its feasibility. With a new transvaginal system, ultrasound-assisted culdotomy, and laparoscopy supported cystectomy if vaginal procedure failed. The authors conducted a retrospective review in which 35 cases using new vaginal ovarian cystectomy were compared with 40 cases of laparoscopic cystectomy for the treatment of dermoid cyst. All cystectomies were completed without conversion to laparotomy and complications. In a case from vaginal group, laparoscopy was required. No differences existed in operating time, hemoglobin decrease, and C-reactive protein value between groups. Laparoscopically supported vaginal ovarian cystectomy with ultrasound-guided culdotomy was equivalent to laparoscopic cystectomy as to invasiveness and preserved the option of a completely vaginal approach. When a presumed benign dermoid cyst is located in cul-de-sac, this operation may represent a preferable alternative to an exclusively laparoscopic or exclusively vaginal ovarian cystectomy.

The use of endoscopic hemoclips for postoperative anastomotic bleeding

With the availability of endoscopy and its inherent use as a diagnostic and therapeutic modality, many surgeons and gastroenterologists are able to use this tool to remedy a wide range of gastrointestinal pathologies. The literature is replete with anecdotal endoscopic therapeutic strategies ranging from epinephrine injection, to use of cautery or argon plasma coagulation. This case report highlights the use of endoscopic hemoclips which were successfully applied in the acute postoperative period for a bleeding vessel at a fresh anastomotic site. The article allows for a brief discussion of plausible endoscopic treatment strategies available to the surgeon faced with a similar situation.

Design of a Compliant Endoscopic Suturing Instrument

This paper describes the initial design and optimization of a compliant endoscopic suturing instrument. The emerging field of Natural Orifice Transluminal Endoscopic Surgery (NOTES) requires innovative instruments to meet the size limitations inherent in this type of minimally invasive surgery; using compliant mechanisms is proposed as one method of meeting this requirement. The compliant design was modeled and optimized to maximize the distal opening and provide a puncture force of at least 4.6N, while being small enough to fit within a 3.3mm working channel. The design utilizes contact for stress relief and intertwining parts for added deflection. ANSYS® was used for finite element analysis including contact and nonlinear deformations. A prototype was fabricated from the optimized geometry and experimentally tested. The best geometry is predicted to have a distal opening of 14.6mm at the tips and supply a puncturing force of 4.83N. The force supplied at the tip was measured and was found to exceed the required 4.6N. The prototype successfully passed two complete sutures and qualitative results are provided. The results of the study will lead to further refinements and improvements in future designs.

NOTES transvaginal cholecystectomy: preliminary clinical application

BACKGROUND

Natural orifice translumenal endoscopic surgery (NOTES) is an emerging concept in the recent literature that could lead to potential benefits in clinical applications. Restricted to animal experiments, however, human procedures have not yet been published. Because of the technical and ethical challenges involved in perforation and closure of a healthy organ-as is also seen in operating via the transgastric route-and because of the lack of understanding of the physiopathology and infection risk with these approaches, they have not been applied in the clinical setting. Thus the present study, based on previous animal experiments, describes preliminary clinical application in four cases of transvaginal NOTES cholecystectomy, and discusses safety, feasibility, and potential benefits of the method.

METHODS

Preliminary acute and survival animal experiments developed by the NOTES Research Group at our institution solved such technical problems for transvaginal NOTES as spatial orientation, insufflation, and instrumentation, making possible the introduction of NOTES as a clinical application. The trials were approved by ethics committee of our institution, and informed consent was obtained from all patients. Since 13 March 2007, four female patients with elective surgical indication for cholecystectomy have undergone transvaginal NOTES cholecystectomy. All intraoperative and postoperative parameters were documented. Vaginal access was achieved under direct vision with conventional instruments, and a 2-channel colonoscope was inserted into the abdominal cavity. After endoscopic insufflation to achieve pneumoperitoneum with CO(2), instruments were inserted through and alongside a colonoscope, allowing successful NOTES cholecystectomy in all patients, with vaginal extraction of the gallbladder. The vaginal wound was closed by direct vision using conventional instruments.

RESULTS

The procedure was successful in all patients, with operative time of 45-115 min. Patients experienced low need for postoperative analgesia. Free oral intake was permitted 2 h after the procedure. There were no postoperative complications, and patients were discharged, according to the study protocol, 48 h after the procedure.

CONCLUSIONS

Preliminary results showed the feasibility and safety of the transvaginal NOTES method in this small initial study population. The technique, developed in our institution, and not transgastric NOTES, may be the preferred approach to serve as the basis for clinical studies.

Developing essential tools to enable transgastric surgery

Natural orifice transluminal endoscopic surgery (NOTES) is a largely theoretical but potentially exciting evolution of minimally invasive surgical care. Using technology borrowed from current diagnostic and therapeutic flexible endoscopy, the idea is to replicate current laparoscopic procedures in an "incisionless" manner. It is widely recognized that for NOTES to become a practical reality, many issues need to be resolved, both methodologic and political. One critical element of development will be the design of appropriate instrumentation for NOTES. This is currently happening and involves a complex collaboration between industry and clinicians both to adapt current equipment and to design and create new tools to enable the performance of transluminal procedures. This article describes the current process of such technology development as well as the resulting instrumentation that enables the performance of NOTES. The issues of access and platform stability, laparoscopic-like instruments, and secure tissue approximation are described, and the devices to solve these issues are detailed.

The role of the surgeon in the evolution of flexible endoscopy

Several cultures, including the Egyptians, Greeks, Romans, and Arabs, made attempts to view accessible human body cavities using a variety of instruments such as spatulas and specula. The first endoscope was created in 1806 when Phillip Bozzini, a German-born urologist, constructed the lichtleiter, which used concave mirrors to reflect candlelight through an open tube into the esophagus, bladder, or rectum. Maximilian Carl-Friedrich Nitze, another German urologist, produced the first usable cystoscope in 1877 by using series of lenses to increase magnification. He was also the first to place light inside the organ of interest to aid visualization. In 1880 Mikulicz made the first gastroscope using a system similar to Nitze's cystoscope. Modern endoscopy was born with the introduction of the fiberoptic endoscope in the late 1950s. Over the ensuing 50 years endoscopy revolutionized many aspects of the surgeon's practice. Endoscopy can now be used to diagnose and often treat gastrointestinal cancer, hemorrhage, obstruction, and inflammatory conditions. This review was initiated by the SAGES Flexible Endoscopy Committee to chronicle the role of the surgeon in the development and introduction of flexible endoscopy into clinical practice, historically and in contemporary surgery. Flexible endoscopy evolved out of surgeons' need to overcome diagnostic and therapeutic challenges. There have been many recent technological advances that facilitate endoluminal therapies, and flexible endoscopy is now traversing new ground. Surgeons have been major contributors in the development of all aspects of endoscopy. There is a continually expanding list of therapeutic options available to patients. The difficult questions of which procedure, on which patient, and when can be answered best by the surgeon versed in endoscopic, laparoscopic, and open surgical techniques.

Desarrollo tecnológico actual de la cirugía endoscópica transluminal a través de orificios naturales

Natural orifice transluminal endoscopic surgery (NOTES) is a novel concept which combines aspects of flexible endoscopy with laparoscopic surgery with the aim of creating a new field of patient friendly "incisionless" surgery. This will require novel advanced technologies to be developed specifically for NOTES. We discuss the technical requirements and the process of creating NOTES instrumentation and illustrate the process with some current enabling devices. The development process is outlined, including the requirements for NOTES, the current technology that can be used, and some prototype devices for access, retraction, and tissue approximation. Endoscopes for NOTES must have high resolution, large instrument channels, some degree of triangulation, and the ability to lock into position inside the abdominal cavity. Instrumentation should echo the capabilities of current laparoscopic tools. They should be large and sturdy, torque-able, and offer the full spectrum of end-effectors. Finally, NOTES technology must permit secure, tailorable tissue approximation. The "R" scope from Olympus and the Transport scope from USGI Medical are possible solutions to the design requirements for access and visualization. Eagle Claw (Olympus), The Swain system (Ethicon), and the G-prox (USGI) are current tissue approximation systems under development and investigation in clinical trials. NOTES is a potential advance in surgical care. This new approach requires the development of new platform devices, tailored to allow the safe and effective practice of this advanced endoscopic approach.

Endoluminal methods for gastrotomy closure in natural orifice transenteric surgery (NOTES)

Natural orifice transenteric surgery (NOTES) is a new and rapidly evolving concept for intra-abdominal operations that offers the potential for a revolutionary advance in patient care. Conceptually, operations that currently require an open or laparoscopic approach could be performed without incisions in the abdomen, with their concomitant pain and scarring. A recent consensus statement by a joint group of gastrointestinal surgeons and gastroenterologists has identified several technical and technologic hurdles that would need to be overcome before NOTES becomes a clinical reality. One of the most significant requirements identified is the need for a very secure closure of the gastrotomy site that is required for scope passage and specimen removal. Although a rapidly expanding variety of transgastric procedures has been reported, only a few reports address the basic problem of gastrotomy closure. Availability of a safe and simple gastrotomy closure device, however, will be essential for the widespread adoption of the new field of NOTES. Unless new safe and simple devices for endoscopic gastrotomy closure are available and have proven efficacy, NOTES will remain in the hands of a few specialists at centers of excellence because the risk of complications due to insufficient gastrotomy closure will not be acceptable for the surgeon and gastroenterologist in general practice. In this article, we describe three new devices in development or newly on the market that are targeted to advance the safe endoscopic closure of gastrotomy from NOTES.

Transvesical endoscopic peritoneoscopy: a novel 5 mm port for intra-abdominal scarless surgery

PURPOSE

Recently various groups reported successful attempts to perform intra-abdominal surgery through a transgastric pathway. We assessed the feasibility and safety of a novel transvesical endoscopic approach to the peritoneal cavity through a 5 mm port in a porcine model.

MATERIALS AND METHODS

Transvesical endoscopic peritoneoscopy was performed in 8 anesthetized female pigs, including 3 nonsurvival and 5 survival animals. Under cystoscopic guidance a vesical hole was created on the ventral bladder wall with an open-ended ureteral catheter. An over tube with a luminal diameter of 5.5 mm was placed in the peritoneal cavity, guided by a 0.035-inch guidewire. In all animals we performed peritoneoscopy of the entire abdomen as well as liver biopsy and falciform ligament section. A vesical catheter was placed for 4 days in all survival animals, which were sacrificed by day 15 postoperatively.

RESULTS

After a learning curve in the first 3 nonsurvival animals the creation of a vesical hole and placement of the over tube were performed without complication in all survival animals. In these animals we easily introduced an EndoEYEtrade mark into the peritoneal cavity, which provided a view of all intra-abdominal viscera, as well as a 9.8Fr ureteroscope, which allowed simple surgical procedures without complications. In survival experiments all pigs recovered. Necropsy examination revealed complete healing of the vesical hole and no signs of infection or adhesions into the peritoneal cavity.

CONCLUSIONS

Transvesical endoscopic peritoneoscopy was technically feasible and it could be safely performed in a porcine model. This study provides encouragement for additional preclinical studies of transvesical surgery with or without combinations with other natural orifices approaches to design new intra-abdominal scarless procedures in what seems to be third generation surgery.

Future trends in minimally invasive surgery

Health care costs in the United States are climbing annually at a staggering rate. Technology often is blamed for rising health care costs; however, some medical advances, such as minimally invasive surgery (MIS), are critical to improving health care efficiency, enhancing the quality of care provided, and decreasing overall expenses. Savings or profits relating to technology may be difficult to measure quantitatively, but when surgeons and perioperative personnel have reached the peak of the learning curve for performing MIS procedures, complication rates drop significantly. Patients are experiencing the benefits of MIS (eg, decreased postoperative pain, shorter hospital stays and often no need for an overnight stay, ability to return to work sooner), all of which encourage technologically savvy consumers to seek MIS options.