Immediate endoscopic closure of colon perforation by using a prototype endoscopic suturing device: feasibility and outcome in a porcine model (with video)

Outcomes of Deep Mural Injury After Endoscopic Resection: An International Cohort of 3717 Large Non-Pedunculated Colorectal Polyps

BACKGROUND & AIMS

Although perforation is the most feared adverse event associated with endoscopic mucosal resection (EMR), limited data exists concerning its management. Therefore, we sought to evaluate the short- and long-term outcomes of intra-procedural deep mural injury (DMI) in an international multi-center observational cohort of large (≥20 mm) non-pedunculated colorectal polyps (LNPCPs).

METHODS

Consecutive patients who underwent EMR for a LNPCP ≥20 mm were evaluated. Significant DMI (S-DMI) was defined as Sydney DMI Classification type III (muscularis propria injury, target sign) or type IV/V (perforation without or with contamination, respectively). The primary outcome was successful S-DMI defect closure. Secondary outcomes included technical success (removal of all visible polypoid tissue during index EMR), surgical referral and recurrence at first surveillance colonscopy (SC1).

RESULTS

Between July 2008 to May 2020, 3717 LNPCPs underwent EMR. Median lesion size was 35mm (interquartile range (IQR) 25 to 45mm). Significant DMI was identified in 101 cases (2.7%), with successful defect closure in 98 (97.0%) using a median of 4 through-the-scope clips (TTSCs; IQR 3 to 6 TTSCs). Three (3.0%) patients underwent S-DMI-related urgent surgery. Technical success was achieved in 94 (93.1%) patients, with 46 (45.5%) admitted to hospital (median duration 1 day; IQR 1 to 2 days). Comparing LNPCPs with and without S-DMI, no differences in technical success (94 (93.1%) vs 3316 (91.7%); P = .62) or SC1 recurrence (12 (20.0%) vs 363 (13.6%); P = .15) were identified.

CONCLUSIONS

Significant DMI is readily managed endoscopically and does not appear to affect technical success or recurrence.

OverStitch Sx Endoscopic suturing system in minimally invasive endoscopic procedures: overview of its safety and efficacy and comparison to oversticthTM

INTRODUCTION

OverStitch endoscopic suturing enables advanced closure by tissue approximation via endoscopically placed sutures with the ability to customize suture patterns. Newer OverStitch generation also known as OverStitch Sx overcame the limitation of the previous generation and is compatible with 20 single channel scopes over four platforms with greater maneuverability and visibility.

AREAS COVERED

In this article we will focus on the differences between three generations of OverStitch. In addition, we will review existing literature on the efficacy of OverStitch in the management of full thickness defect closure, fistula and leaks repair, stent fixation, and bariatric surgeries along with its complications and limitations.

EXPERT OPINION

Assembling overstitch takes less than five minutes and the correct sequence of system assembly is the key for a successful procedure. Transition from the second-generation OverStitch to OverStitch Sx may require three to five cases for learning curve.

Life on a knife edge: the optimal approach to the management of perforations during endoscopic submucosal dissection (ESD)

INTRODUCTION

Endoscopic submucosal dissection (ESD) is a well-established procedure that can provide curative resection of malignant and premalignant lesions endoscopically, thereby offering patients an effective non-operative option. Though ESD is safe and highly effective when performed in appropriately selected patients by an experienced ESD expert, it carries risks including intraprocedural and delayed perforation.

AREAS COVERED

This review provides a practical approach to the initial management of perforation to minimize subsequent complications. The importance of prompt recognition of perforation and early intervention cannot be overstated. This review summarizes indications for closure, anatomic considerations impacting closure, and closure techniques. This article also highlights the do's and don'ts of various closure devices, focusing particularly on advanced closure methods, the-over-the-scope clips (OTSCs) and endoscopic suturing.

EXPERT OPINION

As ESD offers surgery-sparing alternatives to patients, advanced closure techniques allow endoscopists to effectively and promptly manage associated complications, improving the possibility of the widespread implementation of ESD in the US. With continued improvements in OTSCs and endoscopic suturing, ESD will become a stalwart of endoscopic management of malignant and premalignant gastrointestinal lesions.

The Use of the Overstitch to Close Perforations and Fistulas

Endoscopic suturing allows for select patients with perforations, leaks, and fistulas to be managed endoscopically. Experience with the Overstitch endoscopic suturing device suggests it may be superior to endoclips in the management of perforations, because of its ability to achieve full-thickness suturing and create an airtight closure. Although successful closure of leaks and fistulas using the Overstitch device has been described, additional therapy with a multimodality approach is often required because of inherent challenges with fistula recurrence. This article reviews the existing literature on the Overstitch endoscopic suturing system specifically in the management of gastrointestinal perforations, leaks, and fistulas.

Closure of Defects and Management of Complications

Large and complex colon polyps are frequently referred to surgery for fear of perforation that may need emergency surgery. During the last 15 years, advances in clip and suturing devices allowed us to close perforations and avoid surgery. In addition, we have made substantial progress in our understanding of the lesions at risk for either immediate or delayed perforation. This article focuses on the colonoscopic closure of resection defects and perforations and the prevention and treatment of colon perforations after endoscopic resection.

Clips for managing perforation and bleeding after colorectal endoscopic mucosal resection

INTRODUCTION

The most commonly used treatment for advanced colorectal adenomas is endoscopic mucosal resection (EMR). The increased number of EMRs since the introduction of the screening program for colorectal cancer has resulted in an increase in EMR-related complications. This review summarizes the current knowledge for the use of clips for the treatment and prevention of complications after EMR.

AREAS COVERED

The historical development of clips is summarized and their properties are evaluated. An overview is presented of the evidence for therapeutic and prophylactic clipping for bleeding or perforation after EMR in the colon. Several clipping techniques are discussed in relation to the efficacy of wound closure. Furthermore, new techniques that will likely influence the use of clips in the future endoscopic practice, such as endoscopic full-thickness resection (eFTR) are also highlighted.

EXPERT COMMENTARY

Most research focuses on prophylactic clipping for delayed bleeding after EMR of large adenomas. We advocate a distance of 0.5-1.0 cm between aligning clips. This focus may likely shift from bleeding to perforation. Here, endoscopic treatment with through-the-scope clips and large-diameter clips may well replace surgery. The future role of clips will also depend on the further development of new endoscopic technologies, such as eFTR.

Endoscopic Band Ligation Is Able to Close Perforations Caused by Colonoscopy: A Porcine Model Study

Objective

Diagnostic colonoscopy is important for diagnosing colorectal diseases, including inflammatory bowel disease and colorectal tumours. Perforation during diagnostic colonoscopy, a rare but serious complication, is a considerable factor before performing the procedure. Immediate endoluminal closure of a perforation could prevent the adverse consequences associated with general anaesthesia and surgery. This study is aimed at assessing the potential effectiveness and safety of endoscopic band ligation (EBL) in closing a colon perforation during endoscopy in a porcine model.

Methods

Colon perforations were created and then subsequently closed with EBL in six porcine models. After 28 days of careful follow-up, pigs were euthanized for clinical and pathologic evaluations.

Results

All colon perforations were successfully closed using EBL in pigs. The mean time of perforation closure with EBL was 244.3 seconds with one to two bands, and there were no immediate complications or clinical manifestations of peritonitis or sepsis in any animals. No pericolonic abscess or peritonitis was found during necropsy. Histopathology demonstrated reepithelialization of the mucosa at the perforation site.

Conclusions

Immediate closure of perforations caused during colonoscopy with EBL is feasible and safe in a porcine model.

Endoscopic string clip suturing method: a prospective pilot study (with video)

BACKGROUND AND AIMS

We developed a suturing method with string and clips for a single-channel endoscope. The feasibility of the string clip suturing method is evaluated in this prospective pilot study.

METHODS

This study involved 10 consecutive patients who underwent endoscopic submucosal dissection (ESD) for a duodenal tumor. Polyester string was tied to the arm of a partially out thrust clip. The clip and string can be passed through the instrument channel (3.2 mm) of a single-channel endoscope. The clip with string was placed at the distal edge of the large mucosal defect. A second clip was hooked on the string and placed on the opposite side. Both clips were gathered by pulling the free end of the string, and additional clips were placed to achieve complete closure. This method was compared with that for the previous 10 patients without mucosal closure after duodenal ESD.

RESULTS

Mean size of resected specimens was 39.1 ± 12.4 mm. The success rate of the string clip suturing method was 100% (10/10). The mean procedure time was 23.4 ± 13.8 minutes. Perforation during ESD occurred in 1 patient and was successfully closed by this method. None of the treated patients developed serious adverse events after the procedure. Compared with the no-suture group, the length of stay was significantly shorter (P = .038).

CONCLUSION

The string clip suturing method appears to be a safe and effective method for closure of large mucosal defects. (Clinical trial registration number: UMIN000023698.).

Endoscopic slip-knot clip suturing method: prospective pilot study (with video)

BACKGROUND AND AIMS

We developed a suturing method with a slip-knot string and clips for a single-channel endoscope. The feasibility of the slip-knot clip suturing method was evaluated in this clinical pilot study.

METHODS

Ten patients underwent endoscopic submucosal dissection for colorectal and duodenal tumors 5 cm or less. A slip-knot loop can be tightened when tension is applied to the free end of the string. A clip and string can be passed through an instrument channel (3.2 mm) of a single-channel endoscope. The slip-knot loop is anchored onto the mucosal defect's proximal margin with the clip. Additional clips anchoring the slip-knot loop are placed at the opposite side of the margin. The slip-knot loop is tightened by pulling the string. Additional clips are placed to achieve complete closure.

RESULTS

The mean size of resected specimen was 34.4 ± 10.0 mm. The success rate of the slip-knot clip suturing method was 90% (9/10). In the first patient, the string was cut because of friction, and the patient dropped out of the study. After the failure of the first patient, we used wet string to reduce friction, and slip-knot string worked effectively. The mean procedure time was 18.2 ± 3.3 minutes.

CONCLUSION

The slip-knot clip suturing method could close large mucosal defects completely using a single-channel endoscope. (Clinical trial registration number: UMIN000017583.).

Utility of endoscopic therapy in the management of Boerhaave syndrome

Background/aims: The optimal intervention for Boerhaave perforation has not been determined. Options include surgical repair with/without a pedicled muscle flap, T tube placement, esophageal resection or diversion, or an endoscopic approach. All management strategies require adequate drainage and nutritional support. Our aim was to evaluate outcomes following Boerhaave perforation treated with surgery, endoscopic therapy, or both. Patients and methods: We performed a 10-year review of our prospectively maintained databases of adult patients with Boerhaave perforations. We documented clinical presentation, extent of injury, primary intervention, "salvage" treatment (any treatment for persistent leak), and outcome. Results were analyzed using the Fisher's exact and Kruskal - Wallis tests. Results: Between October 2004 and October 2014, 235 patients presented with esophageal leak/fistula with 17 Boerhaave perforations. Median age was 68 years. Median length of perforation was 1.25 cm (range 0.8 - 5 cm). Four patients presented with systemic sepsis (two treated with palliative stent and two surgically). Primary endotherapy was performed for eight (50 %) and primary surgery for eight (50 %) patients. Two endotherapy patients required multiple stents. Median stent duration was 61 days (range 56 - 76). "Salvage" intervention was required in 2/8 (25 %) endotherapy patients and 1/8 (13 %) surgery patient (stent). All patients healed without resection/reconstruction. There were no deaths in the surgically treated group and two in the endotherapy group (stented with palliative intent due to poor systemic condition). Readmission within 30 days occurred in 3/6 of alive endotherapy patients (50 %) and 0/8 surgery patients. Re-intervention within 30 days was required for one endotherapy patient. Conclusion: Endoscopic repair of Boerhaave perforations can be useful in carefully selected patients without evidence of systemic sepsis. Endoscopic therapy such as stenting is particularly valuable as a "salvage" intervention. The benefits of endoscopic therapy and esophageal preservation are offset against an increased risk of readmission in patients primarily treated endoscopically.

Endoscopic "rescue" treatment for gastrointestinal perforations, anastomotic dehiscence and fistula

Luminal perforations and anastomotic leaks of the gastrointestinal tract are life-threatening events with high morbidity and mortality. Early recognition and prompt therapy is essential for a favourable outcome. Surgery has long been considered the "gold standard" approach for these conditions; however it is associated with high re-intervention morbidity and mortality. The recent development of endoscopic techniques and devices to manage perforations, leaks and fistulae has made non-surgical treatment an attractive and reasonable alternative approach. Although endoscopic therapy is widely accepted, comparative data of the different techniques are still lacking. In this review we describe, benefits and limitations of the current options in the management of patients with perforations and leaks, in order to improve outcomes.

Endoscopic Treatment of Gastrointestinal Perforations, Leaks, and Fistulae

Gastrointestinal leaks and fistulae are common postoperative complications, whereas intestinal perforation more commonly complicates advanced endoscopic procedures. Although these complications have classically been managed surgically, there exists an ever-expanding role for endoscopic therapy and the involvement of advanced endoscopists as part of a multidisciplinary team including surgeons and interventional radiologists. This review will serve to highlight the innovative endoscopic interventions that provide an expanding range of viable endoscopic approaches to the management and therapy of gastrointestinal perforation, leaks, and fistulae.

Management of polypectomy complications

The 2 most significant complications of colonoscopy with polypectomy are bleeding and perforation. Incidence rates for bleeding (0.1%-0.6%) and perforation (0.7%-0.9%) are generally low. Recognition of pertinent risk factors helps to prevent these complications, which can be grouped into patient-related, polyp-related, and technique/device-related factors. Endoscopists should be equipped to manage bleeding and perforation. Currently available devices and techniques are reviewed to achieve hemostasis and close colon perforations.

Prospective randomized comparison of gastrotomy closure associating tunnel access and over-the-scope clip (OTSC) with two other methods in an experimental ex vivo setting

BACKGROUND

Safe transgastric natural orifice transluminal endoscopic surgery (NOTES) procedures require a reliable closure of the gastrotomy. Recently a novel peritoneal access method via a submucosal tunnel has been described with encouraging preliminary results.

AIM

The aim is to compare a submucosal tunnel access plus over-the-scope clip (OTSC) system for closure with two other closure modalities.

PATIENTS AND METHODS

This is a prospective ex vivo study conducted on 42 porcine stomach models equally randomized into three groups in an academic medical center. The procedures performed in each group included: (1) Tunnel (6 cm) + endoclips; (2) Knife + balloon dilation access + OTSC; and (3) Tunnel + OTSC. A pressurized air-leak test was performed to evaluate the strength of the closure. Stomach volumes, procedure times, number of clips, and incision sizes were also registered.

RESULTS

The mean air-leak pressure was statistically higher in Group 3 than in Groups 1 and 2-95.2 ± 19.3 mmHg versus 72.5 ± 35.2 and 79.0 ± 24.5 mmHg (P < 0.05). The gastrotomy creation times for Groups 1, 2, and 3 were 28.0 ± 10.1, 4.3 ± 1.4, and 20.1 ± 10.6 minutes, respectively, with significantly lower time in Group 2 (P < 0.001). The closure times were 16.1 ± 6.1, 6.5 ± 1.2, and 5.3 ± 3.0 minutes, respectively, and significantly longer in the endoclip group (P < 0.001). There were no differences in the volumes and the incision sizes among the three groups.

CONCLUSION

The combination of a submucosal tunnel access and OTSC offers a stronger closure than the other methods studied.

Endoscopic stitching: techniques and indications

PURPOSE OF REVIEW

Endoscopic suturing has evolved dramatically over the past decade. Early suturing devices had significant limitations preventing widespread use. Newer devices, though not perfect, have overcome many of these limitations. The purpose of this review is to discuss the techniques and current indications for endoscopic suturing.

RECENT FINDINGS

In addition to technological advances, the indications for endoscopic suturing continue to increase in number. Recent literature has demonstrated successful use of endoscopic suturing for the treatment of procedural adverse events such as leaks, perforations, and fistulas, but newer indications such as anchoring of self-expandable metal stents and bariatric therapy, both primary and secondary, have also been proven to be successful.

SUMMARY

The availability of endoscopic suturing will likely increase in the coming years and will not be limited to expert centers. Currently available devices require technical expertise but are improved over previous devices.

A novel method for endoscopic perforation management by using abdominal exploration and full-thickness sutured closure

BACKGROUND

Perforation of the GI tract during endoscopy can result in significant morbidity and mortality. Early recognition and immediate management of endoscopic perforation are essential to optimize outcome. Larger perforations, defects with complex geometry, and those complicated by leakage of luminal contents have traditionally required surgical management.

OBJECTIVE

To assess the feasibility of a new method for managing complex perforations that incorporates abdominal exploration and endoscopic sutured closure.

DESIGN

Case series.

SETTING

Tertiary care center.

PATIENTS

Two patients with large, complicated perforations and peritoneal contamination.

INTERVENTIONS

Endoscopic exploration of abdomen with angiocatheter placement under direct visualization, management of leaked luminal contents, and full-thickness sutured defect closure.

RESULTS

Endoscopic abdominal exploration through the perforation site allowed safe placement of an angiocatheter for management of pneumoperitoneum, inspection for injury that may warrant surgical management, and removal of leaked luminal contents. Endoscopic sutured closure allowed safe and robust perforation management. Repair of gastrojejunal anastomotic perforation required 2 sutures and 63 minutes. Repair of gastric perforation required 4 sutures and 48 minutes. Patients had successful endoscopic defect closure confirmed by an upper GI series and were discharged 1 day later.

LIMITATIONS

Report of a new method in 2 patients performed at tertiary care center.

CONCLUSIONS

We demonstrate successful management of complex perforations with peritoneal contamination by incorporating endoscopic exploration and sutured closure with standard treatment measures. Traditional practice would have directed these patients to surgical management, which introduces additional morbidity and cost. A means for safe and broad implementation of these techniques should be evaluated.

A new endoscopic closure method for gastric mucosal defects: feasibility of endoscopic hand suturing in an ex vivo porcine model (with video)

BACKGROUND AND STUDY AIMS

More secure endoscopic closure techniques for iatrogenic gastric defects are required for safe endoscopic surgery. We developed a novel endoscopic suturing method, endoscopic hand suturing (EHS), of gastric mucosal defects and determined its feasibility and efficacy ex vivo.

MATERIALS AND METHODS

We created 24 mucosal defects (each 2 cm in diameter) by endoscopic submucosal dissection. The following three techniques were tested: EHS with a 3 - 0 barbed suture that was grasped with biopsy forceps (n = 6) or a prototype through-the-scope needle holder (n = 6) by endoscopy, looping with endoloops (n = 6) by endoscopy, and clipping with hemoclips (n = 6) by hand. The mucosal edges were attached to each other at three points. The closure strength was compared among the three groups, and the procedural duration was compared between the EHS and looping groups.

RESULTS

All 12 lesions were completely closed by EHS. The median strength of the closure, measured with a spring scale, was significantly greater in the EHS group (0.74 kg) than in the looping group (0.33 kg, P = 0.0012) or clipping group (0.07 kg, P = 0.0009). The median procedural duration did not significantly differ between the EHS and looping groups (19.7 vs. 19.8 minutes, P = 1.0000). The use of the needle holder significantly reduced the procedural duration compared with the biopsy forceps.

CONCLUSION

Mucosal defects can be firmly closed with EHS, which may be helpful for establishing a safer and more secure endoscopic surgery.

Endoscopic clip closure of gastrointestinal perforations, fistulae, and leaks

Development of endoscopic devices to close perforations has certainly revolutionized endoscopy. Immediate closure of perforations eliminates the need for surgery, which allows us to push the limits of endoscopic surgery from the mucosal plane to deep submucosal layers and eventually transmurally. The present article focuses on endoscopic closure devices, closure techniques, followed by a review of animal and clinical studies on endoscopic closure of perforations.

Safety and effectiveness of an endoscopic suturing device in a human colonic treat-and-resect model

BACKGROUND

Despite advances in many areas of therapeutic endoscopy, the development of an effective endoscopic suturing device has been elusive. The purpose of this trial was to evaluate the safety and effectiveness of a suturing device to place and secure sutures within normal, in vivo human colonic tissue prior to surgical resection.

METHODS

Patients undergoing elective colectomy were enrolled in this treat-and-resect model. The Overstitch endoscopic suturing device (Apollo Endosurgery, Austin, TX) was used to place sutures in healthy colonic tissue during a 15-minute, time-limited period. Following colectomy, the explanted tissue was evaluated to determine the depth of suture penetration and the effectiveness of the suture/cinch element. Clinical and operative data were recorded.

RESULTS

Four patients (50% female) were enrolled. Seven sutures were successfully placed, incorporating a total of 10 tissue bites in a mean of 13.5 minutes. On inspection of the explanted tissue, all sutures were found to be located subserosal (no full thickness bites were taken). The suture and cinch elements were judged to be effective in the majority of cases. One device-related issue did not inhibit the ability to oppose tissue or place the cinch. There were no intraoperative or postoperative complications.

CONCLUSIONS

The Overstitch permitted safe and effective suturing in an in vivo human colon model. The sutures were placed at a consistent subserosal depth and at no point risked iatrogenic injury to adjacent structures. Technical issues with the device were infrequent and did not inhibit the ability to place sutures effectively.

Endoscopic knot tying: In vitro assessment in a porcine stomach model

AIM: To determine if surgical knotting performed via endoscopy is an effective closure method for natural orifice translumenal endoscopic surgery.

METHODS: The proposed method was tested on an in vitro pig stomach model using standard endoscopy suite materials. A single use laparoscopy trocar (Versaport Plus manufactured by Tyco Healthcare) was fixed onto a plastic rectangular box in a horizontal position. A fresh pig stomach was tightly attached via its esophageal end to the trocar opening on the inner side of the box. The stomach cavity was closed at the duodenal end with Kocher forceps. A standard upper gastrointestinal endoscope fitted at its tip with a transparent plastic cap was introduced into the stomach through the outer trocar opening, so that the passage of the surgical trocar would mimic the passage of an esophagus. The stomach was subsequently inflated, followed by irrigation and washing. A neutral electrode of an electrocautery unit was placed inside the plastic box, underneath the pig stomach. The stomach’s outer surface was kept moist using normal saline in order to maintain the natural elasticity and to ensure good contact with the electrode.

RESULTS: The submucosal space on the anterior face of the stomach was accessed using the technique of endoscopic submucosal dissection. First, a site on the anterior face of the stomach was chosen, near the angle. Then, saline was injected into the submucosa with a standard endoscopic needle, so as to create a 20 mm diameter elevation. A linear 15 mm vertical incision was created at its center using a Dual Knife (KD650U manufactured by Olympus). This incision was used to access the submucosal space, and about 10 mm was dissected on both sides of the incision. The endoscope was then pushed through to the outside of the stomach after dilating a small puncture made by the Dual Knife in the muscularis propria, which simulated the peritoneoscopy procedure. Then, a 0.025” guidewire (Jagwire/450 cm manufactured by Boston Scientific) was inserted into the puncture, followed by a dilating balloon (Quantum TT manufactured by Cook Medical) that was used to enlarge the aperture orifice. After withdrawing the scope back into the stomach, the procedure continued with guidewires being passed from the submucosal space into the gastric lumen through small orifices on the left and right sides of the mucosal opening. These orifices were made with the Dual Knife, and the guidewires were inserted via a guiding catheter (HGC-6 manufactured by Cook Medical). As the guidewires were pulled outside of the stomach, they were replaced with a single surgical suture that had been initially attached to their tip and was now untied. Finally, one loop of this surgical suture was formed on the exterior. One loop end was fixed while the opposite suture end was pulled by biopsy forceps through the endoscope channel as the scope was inserted into the stomach. The loop was advanced until it approached and fixed the two mucosal incision margins. Three alternating loops were made in this manner to create a genuine tight surgical knot.

CONCLUSION: Endoscopic knotting of the gastric wall is feasible, but an in vitro survival study is necessary to validate clinical significance.

Outcome of surgery for colonoscopic perforation

AIM

The aetiology of colonoscopic perforation and factors related to poor outcome of surgical treatment were studied.

METHOD

A single-centre review was conducted of all patients who underwent surgical treatment of a colonoscopic perforation, identified from a prospective registry of 21,981 consecutive colonoscopies carried out between 1993 and 2009.

RESULTS

There were 29 (eight women) patients of mean age 73 years including 10 who had a nonelective colonoscopy. The perforation was not immediately recognized in 12 patients and in the remaining 17, seven were initially managed conservatively. The causes of perforation were barotrauma (11), mechanical force (14) and polypectomy-related (3). Barotrauma was more frequent in emergency colonoscopy and mechanical force in elective colonoscopy. The outcome of surgery was as follows: mortality 10%, complications 34.5%, reoperation 14%, secondary surgery 23% and permanent colostomy 3%. The only factor related to in-hospital mortality was an increased American Society of Anesthesiologists (ASA) score.

CONCLUSION

Colonoscopic perforation requiring surgery is a catastrophic event with high mortality, morbidity and reoperation rates.

Endoscopic treatment for gastric perforation using T-tag and a plastic protection chamber: a short-term survival study

CONTEXT: The endoscopic gastric perforation is a consequence of some endoscopic procedures and now a way to manage abdominal organs. This is the reason why endoscopists are studying a safe endoscopic repair. OBJECTIVE: To evaluate an endoscopic closure method for the gastric opening in natural orifice transenteric surgery DESIGN: Short-term survival animal study. METHODS: Ten White Landrace pigs underwent a gastric perforation of 1.8 cm in diameter under general anesthesia. The opening was repaired with stitch assembled in a T-tag anchor placed through the gastric wall with a needle. A plastic transparent chamber, adapted to the endoscope tip protected the abdominal organs from the needle puncture outside the stomach. Six T-tags were placed in most cases and the stitches were tied with a metallic tie-knot, forming three sutures. The animals received liquids in the same operative day. One shoot antibiotic was used. The leakage test was performed with a forceps and by air distention. RESULTS: No complication was detected in the postoperative course. One month later the endoscopy revealed a scar and some suture material was observed in all animals. The antral anterior gastric wall was clear with few adhesions in the laparotomy performed in the same time. The adhesions were intense in an animal in which a cholecystectomy was performed before the repair. CONCLUSION: The endoscopic repair using T-tag and a protector chamber is feasible, easy to perform and safe. Further studies are needed to show the real value of this kind of procedure.

Assessment of a simple, novel endoluminal method for gastrotomy closure in NOTES

BACKGROUND

A reliable method for gastrotomy closure in NOTES will be essential for NOTES to become viable clinically. However, methods using existing and widely available endoscopic accessories have been ineffective. The objective of this study was to evaluate the feasibility and safety of a new simple method for gastric closure (retracted clip-assisted loop closure) that uses existing endoscopic accessories with minor modifications.

METHODS

The retracted clip-assisted loop closure technique involves deploying 3-4 Resolution(®) clips (modified by attaching a 90-cm length of suture to the end of each clip) along the margin of the gastrotomy with one jaw on the serosal surface and the other jaw on the mucosal surface. The suture strings are threaded through an endoloop. Traction is then applied to the strings causing the gastric wall to tent. The endoloop is secured below the tip of the clips, completing a full-thickness gastrotomy closure. The main outcome measures were feasibility, efficacy, and safety of the new retracted clip-assisted loop closure technique for NOTES gastrotomy closure.

RESULTS

An air-tight seal was achieved in 100% (n = 9) of stomachs. The mean leak pressure was 116.3 (±19.4) mmHg.

CONCLUSIONS

The retracted clip-assisted loop closure technique can be used to perform NOTES gastrotomy closure by using existing endoscopic accessories with minor modifications.

Feasibility of endoscopic closure of an iatrogenic colon perforation occurring during colonoscopy

BACKGROUND

Colon perforation is one of the most dreaded complications of colonoscopy. Traditionally, patients with a colon perforation have been treated surgically. Although there are several case reports documenting the usefulness of endoscopic closure of colon perforations, there are few current data evaluating the feasibility of endoscopic closure for an iatrogenic perforation on consecutive patients undergoing colonoscopy.

OBJECTIVE

To assess the incidence of colon perforations and the utility of immediate endoscopic closure during colonoscopy.

DESIGN

Retrospective, observational study.

SETTING

Tertiary-care academic medical center.

PATIENTS

All patients who underwent colonoscopy at 1 institution from June 2002 to December 2008 were identified.

INTERVENTION

An attempt at immediate colon perforation closure by endoscopic means.

MAIN OUTCOME MEASUREMENTS

Successful endoscopic closure of colon perforation.

RESULTS

During the study period, a total of 8601 colonoscopies were performed (2472 therapeutic interventions, 28.7%). A total of 12 iatrogenic colon perforations occurred, yielding a rate of 1.4/1000. Five (41.7%) occurred during a diagnostic colonoscopy (0.8/1000), and 7 perforations (58.3%) occurred as the result of a therapeutic intervention (2.8/1000). Endoscopic closure of the perforation site was possible in 5 patients (42%). Seven patients were treated surgically (large defects [n = 3], including 1 failed endoscopic closure, difficult endoscope position [n = 2], stool contamination [n = 1], and endoscopist's inexperience with closure of mucosal defects [n = 1]).

LIMITATION

Retrospective design.

CONCLUSIONS

In this study, the incidence of colon perforations was 1.4/1000. Endoscopic closure of iatrogenic colon perforations was attempted in 50% of patients and was successful in 83%. All patients with successful endoscopic closure had lesions smaller than 10 mm.

Yes, we can: reliable colonic closure with the Padlock-G clip in a survival porcine study (with video)

BACKGROUND

Secure closure of the colonic access site is one of the most important issues for the development of natural orifice transluminal endoscopic surgery.

OBJECTIVE

To evaluate the feasibility, reproducibility, and efficacy of a new over-the-scope clip.

DESIGN

Descriptive study, in vivo porcine colon.

INTERVENTION

In 10 female Yorkshire pigs weighing 30 to 35 kg, a 10-mm colotomy was performed by using a needle-knife and advancing the endoscope to the peritoneal cavity. Colonic closure was performed by using the Padlock-G clip (Aponos Medical, Kingston, NH) delivered with the Lock-It system (Aponos).

MAIN OUTCOME MEASUREMENTS

Animals were monitored daily for signs of peritonitis and sepsis over a period of 14 days. During necropsy, the peritoneal cavity was examined, and the colon segment containing the incision was excised for pathological study.

RESULTS

Closure was achieved in all cases. Nine of 10 pigs survived 14 days without complications, but 1 pig was killed immediately after the procedure because of severe bleeding during the colonic incision. The median closure time was 8 minutes (range 1-30 minutes). At necropsy, adhesions were observed in 5 cases. The incision was hardly visible at the serosa side in 3 cases and was not identified in 6 cases. In 6 cases, the clip was still slightly attached to the mucosa, and it was not found in 3 cases. The pathological study revealed a complete remodeling of the colonic wall in all cases.

LIMITATIONS

Animal model, noncomparative study.

CONCLUSION

The Padlock-G clip procedure is feasible, reproducible, effective, and easy to perform, and it provides a reliable colonic closure.

Hybrid NOTES transgastric cholecystectomy with reliable gastric closure: an animal survival study

Background

Secure transluminal closure remains the most fundamental barrier to safe translation of transgastric natural orifice transluminal endoscopic surgery (NOTES) procedures to humans. Obtaining optimal critical view of safety (CVS) is a prerequisite to performing cholecystectomy avoiding common bile duct injury.

Objectives

(1) To evaluate feasibility and safety of hybrid transgastric NOTES cholecystectomy. (2) To evaluate feasibility and reliability of gastrotomy closure using a novel Over-The-Scope-Clip (OTSC; Ovesco) in survival porcine experiments.

Methods

Laparoscopic access to the abdominal cavity was obtained by two 2-mm and one umbilical optical trocar(s). Gastric access was created by balloon dilatation of a needle knife puncture up to 18 mm. Exposure of CVS was obtained and evaluated by aid of a 2-mm device. Subsequently the cystic duct and artery were clipped endoscopically. After laparoscopic dissection the specimen was extracted via the stomach. The gastrotomy was closed endoscopically using the OTSC. Necropsy was performed after 10 days with inspection of gastrotomy and peritoneal cavity for complications. Experiments were planned in 3 acute and 16 survival pigs. Main outcome parameters were documented exposure of CVS, successful cholecystectomy and closure, uncomplicated survival and histology-confirmed full-thickness closure.

Results

In all 16 survival experiments CVS was obtained satisfactorily and hybrid cholecystectomy was successfully performed [100%; 95% confidence interval (CI): 81–100%]. Transgastric closure was endoscopically successful in all experiments in mean time of 7 min [standard deviation (SD) 3 min]. At necropsy 10 days after surgery there were no signs of (infectious) complications. Histology confirmed full-thickness healing with 100% success (95% CI: 81–100%).

Conclusion

Hybrid transgastric NOTES cholecystectomy is feasible, safe and results in optimal CVS. Use of OTSC for gastrotomy closure is feasible, reliable and results in histology-proven full-thickness closure in survival porcine experiments.

Electronic supplementary material

The online version of this article (doi:10.1007/s00464-010-1242-4) contains supplementary material, which is available to authorized users.

Endoscopic mucosal resection with full-thickness closure for difficult polyps: a prospective clinical trial

BACKGROUND

Large flat polyps may be more amenable to endoscopic resection if an endoluminal method for full-thickness closure were available.

OBJECTIVE

Assessment of feasibility of endoluminal full-thickness closure.

DESIGN

Prospective, open-label, interventional study.

SETTING

Tertiary referral center.

PATIENTS

Patients referred to surgery for endoscopically unresectable polyps.

INTERVENTIONS

Endoscopic resection of colon polyps with full-thickness closure of the resection site under laparoscopic observation by using a novel needle and T-tag tissue apposition system.

MAIN OUTCOME MEASUREMENTS

Feasibility and efficacy of tissue apposition with the TAS during procedure and safety at 3-month follow-up.

RESULTS

Nineteen patients referred with unresectable polyps at initial colonoscopy were enrolled. Five patients had successful endoscopic polypectomy and did not require closure of the resulting defect. In 6 patients, the polyp could not be resected endoscopically and surgical resection was performed. Use of the TAS was attempted in 8 and successfully deployed in 7 patients; there was 1 device malfunction. Deployment of the tags through the needle could be performed more safely under laparoscopic guidance when the resection site was visible from the peritoneal cavity. The location of the tags could not be safely determined when the needle was directed toward the retroperitoneal or mesenteric site. There were no long-term complications. Colonoscopy at a 3-month follow-up showed normal healed mucosa with the sutures and anchoring devices in place.

LIMITATIONS

Small number of patients, single-center feasibility study without control arm.

CONCLUSIONS

Full-thickness endoluminal closure of large polypectomy sites in humans is feasible for selected difficult polyps. Closure should be performed with concurrent laparoscopic guidance to maximize safety. (

CLINICAL TRIAL REGISTRATION NUMBER

NCT00553436.).

Early healing of transcolonic and transgastric natural orifice transluminal endoscopic surgery access sites

BACKGROUND

Natural Orifice Transluminal Endoscopic Surgery (NOTES) is a developing, minimally invasive surgical approach whose potential benefits are being investigated. Little is known about secure access site closure and early healing kinetics of transvisceral access.

STUDY DESIGN

Transvisceral access incisions were created in the colon (C-NOTES, n = 8) and stomach (G-NOTES, n = 8) for peritoneal exploration. Incisions were closed primarily with endoloops, endoclips, or t-tags. Macroscopic and histologic analyses performed on postoperative day 7 assessed gross appearance, granulation tissue, inflammation, ulceration, and complications.

RESULTS

Macroscopically, incisions appeared closed without intraperitoneal spillage. Incisions closed by endoloop and t-tags showed intense granulation tissue fill of defect despite partial (G-NOTES, n = 3) and transmural ulceration (C-NOTES, n = 8; G-NOTES, n = 3). Of the 30 t-tags applied, 40% broke or deployed into the peritoneal cavity. Endoclip closures (C-NOTES, n = 1; G-NOTES, n = 1) did not show histologic mucosal continuity. Healing complications included transmural necrosis (C-NOTES, n = 1; G-NOTES, n = 1), foreign body material (C-NOTES, n = 3; G-NOTES, n = 2), and microabscesses (G-NOTES, n = 1).

CONCLUSIONS

This study provides a reproducible model to assess noninvasive repair of planned visceral perforations. Of investigated technologies, endoloop closure was favored for transcolonic incisions, and t-tags with omental patch for transgastric incisions, although these have significant limitations. Endoclips were inadequate for primary closure, but may be useful as an adjunctive closure modality. Additional studies are needed to examine visceral repair at later time points, as they will help determine the quality and kinetics of repair of a variety of incision closure strategies. This study demonstrates the need for improved technologies to more reliably close visceral transluminal defects.

[Diagnostic and interventional endoscopy in gastroenterology : from high-resolution chips and procedures for endoscopic resection to NOTES]

In the past 10 years endoscopic diagnostics has benefited from technologies such as big chips, high-definition television (HDTV) and narrow band imaging (NBI). Video capsule endoscopy and double balloon enteroscopy have facilitated visualization of the entire small bowel. A number of studies on mucosal Barrett's and gastric cancers could prove that endoscopic mucosal resection (EMR) is oncologically equivalent to surgical resection when certain criteria are respected. However, EMR is less invasive and carries a substantially lower complication risk and mortality compared to surgery. Endoscopic submucosal dissection (ESD) facilitates en bloc resection with thorough histopathologic evaluation of the specimen, e.g. for mucosal lesions in the stomach and rectum. Endosonography (EUS) guided transgastric necrosectomy using a flexible gastroscope has set a milestone in the treatment of infected pancreatic necroses and has replaced open surgery in many centers. Natural orifice transluminal endoscopic surgery (NOTES) uses natural body openings as minimally invasive access to the abdomen and mediastinum. Interventional GI endoscopists and minimally invasive surgeons have profited from these innovations in micromechanics and microelectronics.

NOTES transvaginal nephrectomy: first human experience

OBJECTIVES

To present the operative outcomes of the first natural orifice translumenal endoscopic surgery (NOTES) transvaginal nephrectomy.

METHODS

A 57-year-old woman with hypertension, right-sided flank pain, and radiographic evidence of an atrophic right kidney consented for NOTES transvaginal nephrectomy. Pneumoperitoneum was achieved with a Veress needle inserted deep in the umbilicus. Under direct vision, a colpotomy was made and a transvaginal port positioned. Using standard and articulating operating instruments inserted transvaginally, the kidney was mobilized and the renal hilum was controlled with an endovascular stapler. The kidney was placed in a laparoscopic retrieval bag and extracted through the vaginal incision. Salient demographic and operative data were obtained.

RESULTS

NOTES transvaginal nephrectomy was successfully completed, with all the operative steps performed transvaginally. Dense pelvic adhesions from a prior hysterectomy necessitated the use of a 5-mm umbilical port during vaginal port placement and for retraction of the ascending colon during division of the renal hilum. No intraoperative complications occurred. Operative time was 307 minutes, with 124 minutes dedicated to vaginal port placement and 183 minutes dedicated to adhesiolysis and nephrectomy. The duration of hospitalization was 23 hours. The visual analog pain scale score was 1 of 10 on postoperative day 2.

CONCLUSIONS

Our experience shows that NOTES transvaginal nephrectomy is technically feasible. Access to the peritoneal cavity should be performed under visual guidance and after insufflation through the umbilicus. Additional experience is needed to better define patient selection criteria and indications for NOTES transvaginal urologic surgery.

Colonoscopic full-thickness resection of the colon in a porcine model as a prelude to endoscopic surgery of difficult colon polyps: a novel technique (with videos)

BACKGROUND

Colonoscopic full-thickness resection (CFTR) of the colon may obviate the need for surgical resection of benign lesions.

OBJECTIVE

To develop an animal model for CFTR of the colon followed by endoscopic suture closure with through-the-endoscope devices.

DESIGN

Pilot study.

SETTING

University medical center.

ANIMALS

Twenty pigs.

INTERVENTIONS

A 2-cm circular area was resected on the antimesenteric side of the colon (phase 1, n = 10) and on the mesenteric side (phase 2, n = 10) by using an insulated tip knife cut followed by the use of a grasping forceps and a snare to resect and retrieve the specimen. The tissue apposition system was used to close the defect.

MAIN OUTCOME MEASUREMENTS

Resection and closure times were recorded. The animals were euthanized at 2 weeks and examined for peritonitis, adhesions, wound healing, and T-tag injury to adjacent viscera.

RESULTS

The CFTR was successful in all 20 attempts. The median resection time was 6 minutes (range 2.5-35 minutes). Suture closure was successful in 19 animals. It took a median time of 41 minutes (range 21-125 minutes) and 4 sutures to close the defect. Eighteen animals survived without clinical signs of distress; there was a well-healed scar without peritonitis or distant adhesions on necropsy at 2 weeks. One animal failed to thrive, and necropsy revealed mild peritonitis, small abscesses, distant adhesions, and a 2-mm hole at the suture site. Two of the 132 T-tags were inserted in the adjacent viscera.

LIMITATIONS

Colon resection in the proximal colon was not studied.

CONCLUSIONS

In this animal model, CFTR of the colon followed by suture closure can be accomplished successfully by using through-the-endoscope devices.

Feasibility of transgastric and transcolonic natural orifice transluminal endoscopic surgery peritoneoscopy combined with intraperitoneal EUS

BACKGROUND

If natural orifice transluminal endoscopic surgery (NOTES) peritoneoscopy is to become an alternative to diagnostic laparoscopy, NOTES peritoneoscopy must be comparable to laparoscopy in its diagnostic accuracy.

OBJECTIVE

To assess the feasibility of transgastric (TG) and transcolonic (TC) NOTES peritoneoscopy combined with intraperitoneal EUS.

DESIGN

Twelve nonsurvival experiments on 6 female pigs.

SETTING

Animal laboratory.

PATIENTS

Six 35- to 40-kg female pigs.

INTERVENTIONS

Randomization was performed to determine the order of approach (TG or TC as first procedure). After peritoneal access, systematic peritoneoscopy was performed according to a preassessed list of 12 locations considered clinically important. For each visualized location, 1 point was scored and 1 point added if it was touched as well, leading to a maximum score of 24 points. Subsequently, the endoscope was exchanged for a linear EUS-scope. The percentage of visualization of the 4 sections of the liver was recorded (0, not visible; 1, 33%; 2, 66%; 3, 100%; maximum score, 12 points). After withdrawal, the protocol was repeated by using the second natural orifice (TG or TC).

MAIN OUTCOME MEASUREMENTS

Extent of adequate visualization of diagnostic peritoneoscopy and intraperitoneal EUS measured by a preassessed record form.

RESULTS

Access was achieved without difficulties at all 12 sites. TG peritoneoscopy resulted in a median of 23 points (range 20-24) via the TC approach. A maximum of 24 points was recorded in all pigs (P = .102). TG-EUS resulted in a median of 11 points (range 6-12) and TC-EUS in a median of 12 points (range 8-12) (P = .317).

LIMITATION

Lack of objective landmarks for EUS.

CONCLUSIONS

TG and TC NOTES peritoneoscopy combined with intraperitoneal EUS is technically feasible. Furthermore, NOTES peritoneoscopy and intraperitoneal EUS seem to result in adequate visualization of the peritoneal cavity and liver, respectively.

Transluminal endosurgery: novel use of endoscopic tacks for the closure of access sites in natural orifice transluminal endoscopic surgery (with videos)

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) is a novel and potentially less-invasive alternative to laparoscopic surgery. Successful reproducible secure closure of the transluminal access site represents one of the largest obstacles in the evolution of this discipline.

AIM

To study the feasibility and efficacy of a novel transluminal closure device in a live porcine model.

DESIGN

Experimental endoscopic study of transgastric incision and closure with a novel device in a porcine survival model. Six survival experiments were conducted on Yorkshire pigs that weighed 22 to 25 kg.

INTERVENTIONS

After general anesthesia was administered, a therapeutic endoscope was inserted into the stomach. Two gastrotomies were made in each pig by using a needle-knife with blended current, a guidewire, and an 18-mm through-the-scope dilating balloon. The peritoneum was easily accessed in all pigs without complications. One gastrotomy was closed with T-tag fasteners and the other one with endoscopic tacks. Two different closure methods were used with the tacks: the anchor-and-loop technique (ALT) and the serosa-to-serosa closure (SSC). All closures were immediately completely sealed, with no carbon dioxide (CO(2)) leak detected at 25 cm of water pressure. After recovery from anesthesia, all the animals resumed feeding and returned to preprocedure activities on the same day as the procedure. The animals were monitored daily for signs of peritonitis and sepsis. Preplanned euthanasia of the animals was performed after 7 to 14 days. The peritoneal cavity was studied at necropsy for evidence of wound dehiscence, abscess formation, and gross adhesions.

MAIN OUTCOME MEASUREMENTS

Full-thickness healing of the gastric-wall incisions without intraperitoneal complications on postmortem examination.

RESULTS

All animals survived without complications. Transgastric closure was successful in all the animals by using both study techniques (ALT and SSC) and the T-tag closure. The deployment device performed well, and accurate closure was rapid and reproducible.

CONCLUSIONS

This prototype closure device holds promise in solving some of the problems of closure for transluminal access for NOTES. Both the ALT and the SSC technique hold promise for threadless closure and for simplifying endoscopic techniques. The SSC technique holds promise to maintain surgical principles of serosa-to-serosa apposition. Further studies are recommended before in vivo human use.

Gastrotomy creation and closure for NOTES using a gastropexy technique (with video)

BACKGROUND

Safe and efficient gastrotomy creation and closure is pivotal for natural orifice transluminal endoscopic surgery (NOTES).

OBJECTIVE

To test a method of transgastric access and closure with commercially available devices.

DESIGN

An animal survival study.

SETTING

University hospital.

PATIENTS

Fifteen pigs.

INTERVENTIONS

By using a surgical suture passer, under endoscopic guidance, 3 percutaneous stay sutures were placed, in a triangular fashion, through the gastric wall. A gastrotomy was created with a dilation balloon, which was introduced over a guidewire through the gastric wall in the center of the 3 sutures. After performing a NOTES procedure, the gastrotomy was closed by tying the sutures. Necropsies were performed after 2 to 4 weeks.

MAIN OUTCOME MEASUREMENTS

Success and time of gastrotomy creation and closure, and intraoperative and postoperative complications.

RESULTS

Gastrotomies were successfully created and closed in all the animals. The median time to create a gastrotomy was 19 minutes (range 11-85 minutes), and the median closure time was 1 minute (range 1-45 minutes). One pig died on postoperative day 1 because of peritonitis caused by a leaking gastrotomy site that extended beyond the stay sutures. There were no other gastrotomy-related complications. All gastrotomies were well healed at the necropsy.

LIMITATION

No control group.

CONCLUSIONS

We evaluated a simple method by using the principles of the PEG technique combined with a gastropexy, which is familiar to the majority of endoscopists. Strict attention to the gastrotomy site is needed, because one leak was from the gastrotomy site that extended beyond the stay sutures.

Endoscopic colotomy closure for natural orifice transluminal endoscopic surgery using a T-fastener prototype in comparison to conventional laparoscopic suture closure

BACKGROUND

Safe and efficient endoscopic closure of a colotomy is essential for transcolonic peritoneal access or endoscopic full-thickness resection of the colon, if open or laparoscopic surgery is to be avoided.

OBJECTIVE

To compare the feasibility and safety of colotomy closure with the newly developed Tissue Approximation System (TAS, Ethicon Endo-Surgery, Inc.) to conventional laparoscopic suture closure.

DESIGN

Prospective randomized survival animal study involving 16 pigs.

SETTING

University hospital.

INTERVENTIONS

Pigs were randomized for closure of a 2- to 3-cm full-thickness colotomy with the TAS or with a conventional laparoscopic running suture.

MAIN OUTCOME MEASUREMENTS

Success of colotomy closure, time of colotomy closure, postoperative infection, and complication rates.

RESULTS

Colotomies were successfully closed in all animals. Median closure time (range) was 39.5 minutes (25-95 min) in the TAS group and 23 minutes (16-40 min) in the laparoscopic group (P = .0134). There were no postoperative infections or complications.

LIMITATIONS

Closure with the TAS was performed under laparoscopic vision. There was no control group without closure of the colotomy site.

CONCLUSIONS

Colotomies are safely closed with the TAS with comparable results to laparoscopic closure. The TAS may serve as a useful tool to close full-thickness colon defects or colotomy sites made for transluminal endoscopic procedures.

Natural orifice translumenal endoscopic surgery (NOTES) applied totally to sigmoidectomy: an original technique with survival in a porcine model

BACKGROUND

Natural orifice translumenal endoscopic surgery (NOTES) continues to evolve. This study investigated the feasibility and outcome of performing localized sigmoidectomy in its entirety via NOTES.

METHODS

A survival study of five male minipigs (mean weight, 30 kg) was conducted. After anesthesia, a gastrotomy was created by a per os double-channel endoscope, and full peritoneoscopy was performed. A Berci needle then was inserted transparietally to allow maintenance and monitoring of the pneumoperitoneum. Using a transanal probe to facilitate intestinal retraction, the mesentery was dissected with instruments worked through the channels of the transgastric endoscope. The anvil of a circular stapler then was passed per anum into the colon above the point of intended transection. A penetrating transrectal trocar was placed to allow entry of a linear stapler into the peritoneum through a colotomy, and the sigmoid was cross-stapled proximally. The strut of the anvil then was snugged into a colotomy made at this staple line. The specimen was delivered via the anus by a "pull-through" technique. The distal sigmoidal margin was cross-stapled extracorporeally, ensuring that the colotomy was included within the specimen. Retrograde passage of the circular stapler head per anus allowed colocolonic reanastomosis by its mating with the anvil already in situ. The gastrotomy was closed with a previously validated prosthesis. Postoperatively, all the animals were recovered and monitored for well-being during convalescence. Endoscopy (gastroscopy and sigmoidoscopy), laparoscopy, and laparotomy were performed on postoperative day 14 as follow-up measures.

RESULTS

Each operation was satisfactorily completed. The mean operative time was 76 min (range, 44-95 min). All the animals prospered postoperatively. Follow-up examination showed full healing of all anastomoses and gastrotomy sites. There was no evidence of luminal stricturing, peritonitis, or intraabdominal sepsis in any animal.

CONCLUSIONS

Using this experimental model, colonic resection and reanastomosis can be performed safely within the NOTES format.

Endoscopic closure of colon perforation compared to surgery in a porcine model: a randomized controlled trial (with videos)

BACKGROUND

Endoscopic closure of inadvertent or intentional colon perforations might be valuable if comparable to surgical closure.

OBJECTIVE

The aim of this study was to compare endoscopic closure of a 4-cm colon perforation in a porcine model with surgical closure in a multicenter study.

SETTING

University hospitals in the United States and Europe.

DESIGN AND INTERVENTIONS

After creating a 4-cm linear colon perforation, the animals were randomized to either endoscopic or surgical closure. The total procedure time from the beginning of perforation to the completion of procedure was measured. The animals were euthanized after 2 weeks to evaluate healing, unless there was a complication.

RESULTS

Fifty-four animals were randomized to either surgical or endoscopic closure of colon perforation. Eight animals developed complications, and 7 of these were euthanized before 2 weeks. Twenty-three animals in each group survived for 2 weeks. Surgical closure of the perforation was successful in all animals in that group, and endoscopic closure was successful in 25 of the 27 animals. The median procedure time was shorter in the surgery group compared to the endoscopy group (35 vs 44 minutes, P = .016). Peritonitis, local adhesions, and leak test results were comparable in both groups. Distant adhesions were less frequent in the endoscopic closure group (26.1% vs 56.5%, P = .03). Five of the 186 T-tags (2.7%) were noted in the adjacent viscera.

LIMITATION

This porcine study does not mimic clean colon perforation in humans; it mimics dirty colon perforation in humans.

CONCLUSIONS

Endoscopic closure of a 4-cm colon perforation was comparable to surgery, and this technique can be potentially used for closure of intentional or inadvertent colon perforations.