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Mat E, Kale A, Yıldız G, Başol G, Gündogdu EC. Alternative method for the diagnosis of acid cases of unknown cause: Transvaginal natural orifice transluminal endoscopic surgery. J Obstet Gynaecol Res 2020; 47:645-652. [PMID: 33197989 DOI: 10.1111/jog.14575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 10/20/2020] [Accepted: 11/03/2020] [Indexed: 12/21/2022]
Abstract
AIM To evaluate the efficacy and reliability of transvaginal natural orifice transluminal endoscopic surgery (vNOTES) technique in making the diagnosis of ascites with unknown cause. METHODS Seven patients with ascites with unknown cause and diagnosed with vNOTES between November 2018 and May 2019 were analyzed retrospectively. The following data were collected retrospectively: body mass index, age, parity, previous abdominal or pelvic surgery, total operating time, perioperative complications and visual analog scale scores for evaluation of postoperative pain. After general anesthesia and disinfection, a 2-3 cm incision was made in the posterior fornix of the vagina. In all of the vNOTES procedures, a handmade glove port system comprised of a glove-wound retractor NOTES port was used. RESULTS Transvaginal natural orifice transluminal endoscopic surgery for diagnostic peritoneoscopy was successfully performed in seven patients. Following postoperative pathological examination; three patients were established to have peritoneal carcinomatosis, one patient abdominal tuberculous, one patient ovarian fibroma, one patient ovarian mature cystic teratoma and one patient stomach cancer. In 1-year follow-up period after vNOTES procedure, no adverse events occurred in patients. CONCLUSION In making histological diagnosis of ascites with unknown cause, vNOTES is a feasible, safe and efficient technique. Due to its high performance in diagnosis, this technique helps to initiate treatment early in some diseases in addition to preventing unnecessary treatment and examination in benign diseases. Besides, via obtaining a detailed and enlarged image of abdominal cavity, this procedure also guides the clinician in the evaluation of the suitability of patient for operation.
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Affiliation(s)
- Emre Mat
- Department of Obstetrics and Gynecology, University of Health Sciences, Kartal Dr. Lutfi Kirdar Research and Training Hospital, Istanbul, Turkey
| | - Ahmet Kale
- Department of Obstetrics and Gynecology, University of Health Sciences, Kartal Dr. Lutfi Kirdar Research and Training Hospital, Istanbul, Turkey
| | - Gazi Yıldız
- Department of Obstetrics and Gynecology, University of Health Sciences, Kartal Dr. Lutfi Kirdar Research and Training Hospital, Istanbul, Turkey
| | - Gülfem Başol
- Department of Obstetrics and Gynecology, University of Health Sciences, Kartal Dr. Lutfi Kirdar Research and Training Hospital, Istanbul, Turkey
| | - Elif C Gündogdu
- Department of Obstetrics and Gynecology, University of Health Sciences, Kartal Dr. Lutfi Kirdar Research and Training Hospital, Istanbul, Turkey
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Bai Y, Qiao WG, Zhu HM, He Q, Wang N, Cai JQ, Jiang B, Zhi FC. Role of transgastric natural orifice transluminal endoscopic surgery in the diagnosis of ascites of unknown origin (with videos). Gastrointest Endosc 2014; 80:807-16. [PMID: 24818547 DOI: 10.1016/j.gie.2014.03.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2013] [Accepted: 03/14/2014] [Indexed: 12/25/2022]
Abstract
BACKGROUND Natural orifice transluminal endoscopic surgery (NOTES) has been established in animal models and human studies. OBJECTIVE The aim of this study was to assess the feasibility and efficacy of applying transgastric NOTES to diagnose patients with ascites of unknown origin. DESIGN Prospective study. SETTING Two university and teaching hospitals. PATIENTS Patients with ascites of unknown origin. INTERVENTIONS Diagnostic transgastric NOTES. MAIN OUTCOME MEASUREMENTS Characteristic of ascites cases, conditions of the abdominal cavity, diagnostic accuracy, adverse events, and follow-up time. RESULTS Transgastric NOTES was performed successfully in 78 patients with ascites of unknown origin, and 72 cases (92.3%) were clearly diagnosed. They included malignant tumors (39 cases), tuberculous peritonitis (28 cases), chronic hepatic inflammation (3 cases), necrotizing lymphadenitis (1 case), and eosinophilic serositis of the small intestine (1 case). In addition, there were 6 nondiagnostic cases, and no severe adverse events were found. LIMITATIONS Nonrandomized control analysis. CONCLUSION Transgastric NOTES in combination with biopsy can elucidate the causes of ascites of unknown origin in the majority of cases. Therefore, it is a feasible and effective approach to access the peritoneal cavity and also a valuable modality to detect the cause of diseases with ascites of unknown origin.
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Affiliation(s)
- Yang Bai
- Guangdong Provincial Key Laboratory of Gastroenterology, Guangdong, China; Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Wei-guang Qiao
- Guangdong Provincial Key Laboratory of Gastroenterology, Guangdong, China; Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Hui-ming Zhu
- Department of Gastroenterology, The Second Affiliated Clinical Medical College, Shenzhen People's Hospital, Shenzhen, China
| | - Qiong He
- Department of Gastroenterology, The Third Affiliated Hospital of Southern Medical University, Guangzhou, China
| | - Na Wang
- Department of Gastroenterology, The Second Affiliated Clinical Medical College, Shenzhen People's Hospital, Shenzhen, China
| | - Jian-qun Cai
- Guangdong Provincial Key Laboratory of Gastroenterology, Guangdong, China; Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Bo Jiang
- Guangdong Provincial Key Laboratory of Gastroenterology, Guangdong, China; Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
| | - Fa-chao Zhi
- Guangdong Provincial Key Laboratory of Gastroenterology, Guangdong, China; Department of Gastroenterology, Nanfang Hospital, Southern Medical University, Guangzhou, China
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Banerjee S, Barth BA, Bhat YM, Desilets DJ, Gottlieb KT, Maple JT, Pfau PR, Pleskow DK, Siddiqui UD, Tokar JL, Wang A, Song LMWK, Rodriguez SA. Endoscopic closure devices. Gastrointest Endosc 2012; 76:244-51. [PMID: 22658920 DOI: 10.1016/j.gie.2012.02.028] [Citation(s) in RCA: 90] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 02/17/2012] [Indexed: 02/08/2023]
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Nakajima K, Takahashi T, Souma Y, Miyazaki Y, Mori M, Doki Y. A novel percutaneous insufflating guidewire system for transgastric natural orifice translumenal endoscopic surgery (NOTES) (with video). Surg Endosc 2012; 27:1016-20. [PMID: 22717795 DOI: 10.1007/s00464-012-2298-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2011] [Accepted: 04/02/2012] [Indexed: 11/25/2022]
Abstract
BACKGROUND A modified percutaneous endoscopic gastrostomy (PEG) technique has been widely used as a safe alternative for gaining peritoneal access in transgastric (TG) natural orifice translumenal endoscopic surgery (NOTES). The authors developed a novel insufflating guidewire (IGW) system, which further maximizes the safety of the modified PEG technique by preparation of a preliminary pneumoperitoneum (PP) before TG route creation. This study aimed to assess the feasibility and safety of the modified PEG technique under PP using the IGW system. METHODS The IGW system was evaluated in porcine models (n = 5). The process of PP creation was monitored with either laparoscopy or real-time magnetic resonance imaging. The times required to create PP and to establish the TG route were prospectively registered. The animals were killed at the end of each experiment for evaluation of any injuries to adjacent organs. RESULTS Preliminary pneumoperitoneum was successfully created in all the animals (median procedural time, 240 s) in rapid and highly reproducible fashion. The creation of the TG route also was quick and straightforward (median procedural time, 100 s). No injuries to the adjacent organs were noted at necropsy. CONCLUSIONS The establishment of the TG route under PP is feasible and safe with the authors' newly developed IGW system. The device seems to be advantageous because the entire session is endoscopically controlled. The device may become one of the useful alternatives for adopting TG NOTES in daily practice. Further assessment with human subjects is necessary to make this system practical and universal.
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Affiliation(s)
- Kiyokazu Nakajima
- Department of Surgery, Osaka University Graduate School of Medicine, 2-2, E-2, Yamadaoka, Suita, Osaka 565-0871, Japan.
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Schomisch SJ, Furlan JP, Andrews JM, Trunzo JA, Ponsky JL, Marks JM. Comparison of anterior transgastric access techniques for natural orifice translumenal endoscopic surgery. Surg Endosc 2011; 25:3906-11. [PMID: 21789648 DOI: 10.1007/s00464-011-1818-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2010] [Accepted: 06/04/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND The advancement of natural orifice translumenal endoscopic surgery (NOTES) into clinical practice is dependent on its safety, efficacy, and efficiency. Access is the obligatory first step in NOTES and serves as a surrogate to technical difficulties associated with this novel surgical approach. This study aimed to compare endoscopic transgastric access techniques in terms of safety, reproducibility, and efficiency. METHODS Seven variations for anterior transgastric NOTES access were evaluated with female domestic swine. After marking of an anterior site, electrocautery was used to create a small gastrotomy, followed by balloon dilation and entry into the peritoneal cavity. Methodologic variations incorporated the use of guidewires, electrocautery and dilation combined within a single device, support tubes, and dilation without electrocautery. Access times were recorded, and tissue injury was evaluated. RESULTS In 70 access attempts, the most serious complication was bleeding from the gastroepiploic vessel, controlled with electrocautery. High variability in access times was prevalent with almost all the access techniques. CONCLUSIONS This study supports the presumption that an anterior transgastric access technique for NOTES procedures is safe. The use of a wire to mark the site and another wire to retain the gastrotomy provided safe, efficient, and reproducible transgastric access. Comparison with laparoscopy exposed the disparity in technical challenges facing NOTES, suggesting that new technology and further refinement in methodology are required for NOTES to be clinically relevant.
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Affiliation(s)
- Steve J Schomisch
- Department of Surgery, University Hospitals Case Medical Center, 11100 Euclid Avenue, Cleveland, OH 44106, USA.
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Reliability of gastric access closure with the self-approximating transluminal access technique (STAT) for NOTES. Surg Endosc 2011; 25:2718-24. [PMID: 21487879 DOI: 10.1007/s00464-011-1659-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Accepted: 02/20/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND STAT, or the self-approximating transluminal access technique, has been previously described and involves the dissection of a submucosal tunnel for peritoneal or mediastinal access from the esophagus and stomach. The objective of this study was to assess the safety and reliability of gastric access and closure in a porcine experience using STAT for natural orifice transluminal endoscopic surgery (NOTES). METHODS A review of the experience using STAT access tunnels for intraperitoneal access was performed in 39 female pigs at a university animal lab. All animals underwent a predetermined NOTES surgical procedure using a STAT transgastric access tunnel based on a specific protocol. Details of the procedure, complications, and clinical course were documented. Necropsy was performed at 2 weeks. The main outcome measurements were clinical or necropsy evidence of gastrostomy site leak or inadequate access site closure. RESULTS STAT was successful in providing safe peritoneal access in all animals. The width of the tunnel ranged from 1.5 to 5.5 cm and the length was up to 27 cm. There was no evidence of gastrostomy site leak in any animals. One animal required a single laparoscopic suture to help with tunnel closure. CONCLUSION STAT provides safe transgastric access and allows secure closure of the gastrotomy site.
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Sodergren MH, Coomber R, Clark J, Karimyan V, Athanasiou T, Teare J, Yang GZ, Darzi A. What are the elements of safe gastrotomy closure in NOTES? A systematic review. Surg Innov 2010; 17:318-31. [PMID: 20829216 DOI: 10.1177/1553350610381089] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
INTRODUCTION The safe closure of the gastrotomy needs to be established before natural orifice translumenal endoscopic surgery (NOTES) can be extended to routine clinical practice. As yet no optimum closure method has been identified. METHODS A systematic review of the literature on gastrotomy closure modalities for NOTES up until December 2009 was undertaken. An assessment of each closure modality was determined using specified quantitative and qualitative parameters. RESULTS There were 46 studies included in this review describing 20 closure techniques. Some robustly designed experimental studies have now been published particularly in relation to the over-the-scope clip system. CONCLUSION Current evidence is experimental and therefore limited, but there appears to be some clarification in the direction of the innovative process in this area outlining favorable characteristics of an ideal system. Based on the studies examined in this review, a standardized assessment method is summarized for future in vivo studies, necessary prior to phase 1 trials.
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Affiliation(s)
- Mikael H Sodergren
- Department of Biosurgery and Surgical Technology, Imperial College London, London, UK.
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Gastric wall healing after NOTES procedures: closure with endoscopic clips provides superior histological outcome compared with threaded tags closure. Gastrointest Endosc 2010; 72:343-50. [PMID: 20674622 DOI: 10.1016/j.gie.2010.02.023] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/21/2009] [Accepted: 02/08/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Closure of the transgastric access to the peritoneal cavity is a critical step in natural orifice transluminal endoscopic surgery (NOTES). OBJECTIVE To perform a direct comparison of the histological healing post clips and threaded tags (T-tags) closure after transgastric NOTES procedures. DESIGN AND INTERVENTION Twelve survival porcine experiments. After standardized endoscopic gastric wall puncture, balloon-dilation, and transgastric peritoneoscopy, closure of the gastric wall was performed with either clips or T-tags. Necropsy at 14 days was performed for histological evaluation of 2-mm interval transversal cross sections of the gastrotomy site. MAIN OUTCOME MEASUREMENTS Histological healing of the gastric wall opening. RESULTS Endoscopic closure of the gastrotomy was successfully achieved in all 12 animals, followed by an uneventful 2-week clinical follow-up. Transmural healing was seen in 3 (75%) animals after clip closure compared with only 1 (12.5%) in the group with T-tag closure (P = .06). Gastric wall muscular bridging was observed in 4 (100%) animals with clip closure compared with only 1 (12.5%) in the group with T-tag closure (P = .01). LIMITATIONS Animal model with short-term follow-up. CONCLUSIONS Endoscopic clip closure results in a layer-to-layer transmural healing of the gastric wall. In contrast, T-tag gastric wall plication impairs gastric layer bridging. These findings might guide the future design of new endoscopic devices and techniques for gastrotomy closure after NOTES procedures.
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Asakuma M, Cahill RA, Lee SW, Nomura E, Tanigawa N. NOTES: The question for minimal resection and sentinel node in early gastric cancer. World J Gastrointest Surg 2010; 2:203-6. [PMID: 21160875 PMCID: PMC2999236 DOI: 10.4240/wjgs.v2.i6.203] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2009] [Revised: 02/28/2010] [Accepted: 03/07/2010] [Indexed: 02/06/2023] Open
Abstract
Surgical therapy for gastric cancer involves both removal of the cancer lesion and complete lymph node dissection. Natural orifice transluminal endoscopic surgery (NOTES) is considered to represent the next revolution in surgery. Many surgeons and endoscopists believe that NOTES may be a superior alternative for early gastric cancer treatment. Sentinel node (SN) navigation surgery for gastric cancer: Single institution results of SN mapping for early gastric cancer are increasingly being considered acceptable. Furthermore, a major large-scale clinical trial of SN mapping for gastric cancer has recently been completed by The Japan Society of SN Navigation Surgery study group. They reported false negative rate of 7.0% while the sensitivity of metastasis detection based on SN status was 93%. Combination of SN biopsy and NOTES: This concept was first described by Cahill et al who proved the feasibility of lymphatic mapping and SN biopsy by NOTES. Lymphatic channel filling was immediately observable via the intraperitoneal optics. Partial resection of the stomach by hybrid NOTES: Several centers have already reported gastrectomy assisted by NOTES using the transvaginal route. However, the main problem of full-thickness resection of gastric wall remains endoscopic gastric closure. Establishing an endoscopic suturing method would be an important step toward expanding potential indications. NOTES is met with both enthusiasm and skepticism but will gain its own place as human creativity eventually provides solutions to its technical limitations. In the near future, NOTES can evolve the capacity to complement the existing armamentarium for gastric cancer surgery.
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Affiliation(s)
- Mitsuhiro Asakuma
- Mitsuhiro Asakuma, Ronan A Cahill, Sang-Woong Lee, Eiji Nomura, Nobuhiko Tanigawa, Department of General and Gastroenterological Surgery, Osaka Medical College, Osaka 569-8686, Japan
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Fortelny RH, Petter-Puchner AH, Gruber-Blum S, Mika K, Brand J, Keibl C, Glaser KS, Redl H. The feasibility of FS mesh fixation by a transgastric approach--an important benefit in future NOTES procedures? J Surg Res 2010; 171:80-6. [PMID: 20451922 DOI: 10.1016/j.jss.2010.01.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2009] [Revised: 12/07/2009] [Accepted: 01/07/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND Preserving the integrity of the abdominal wall is a major benefit in NOTES procedures. It may result in a decrease of postoperative (postOP) pain, infection, and port site hernia. This experimental study on intra-peritoneal onlay mesh (IPOM) repair was designed to apply meshes by a transgastric access (TGA) and to use a combination of transfascial sutures and fibrin sealant as fixation. MATERIALS AND METHODS Four abdominal wall defects were created by TGA under laparoscopic control in five nonsurvival and three survival pigs (4, 11, and 22 d observation period). Titanized polypropylene meshes were fixed transfascially by four polypropylene sutures using a "suture passer" device. Meshes were additionally fixed with 0.2 mL of fibrin sealant (FS) by an endoscopic application. TGA was closed with endoclips in the nonsurvival model and with laparoscopic suturing in survival pigs. RESULTS The three survival pigs were euthanized on the d 4, 11, and 22 postOP. The macroscopic evaluation revealed excellent integration of the meshes without signs of shrinkage, dislocation, or inflammation. Histology confirmed macroscopic findings. CONCLUSIONS Our findings confirm that IPOM repair of ventral hernia in an experimental NOTES hybrid procedure is feasible. This study also demonstrates the technical feasibility and the potential advantages of FS mesh fixation to further reduce trauma to the abdominal wall following the key principles of the NOTES approach.
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Affiliation(s)
- René H Fortelny
- II Department of General Surgery, Wilhelminenspital, Vienna, Austria
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Rolanda C, Lima E, Silva D, Moreira I, Pêgo JM, Macedo G, Correia-Pinto J. In vivo assessment of gastrotomy closure with over-the-scope clips in an experimental model for varicocelectomy (with video). Gastrointest Endosc 2009; 70:1137-45. [PMID: 19647246 DOI: 10.1016/j.gie.2009.04.054] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2009] [Accepted: 04/24/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastrotomy closure remains the major limiting factor for human translation of transgastric surgery; the over-the-scope clip (OTSC) system was proposed as a possibility for this purpose. Transgastric access is good for a pelvic approach, making varicocelectomy a possible indication for natural orifice transluminal endoscopic surgery (NOTES). OBJECTIVE To evaluate the reliability of the OTSC system in vivo after transgastric testicular vessel ligation (varicocelectomy model). DESIGN There were 3 experimental groups (5 animals in each): groups 1 and 3, gastrotomy dilation up to 18 mm, surgery was performed with a double-channel endoscope; group 2, gastrotomy dilation up to 13 mm, surgery was performed with a single-channel endoscope. SETTING Surgical Sciences Research Domain, Life and Health Sciences Research Institute (ICVS), School of Health Sciences, University of Minho, Braga, Portugal. INTERVENTIONS Bilateral testicular vessel ligation by transgastric access. Gastrotomy closed with the largest version of OTSC system (12 mm): a single clip in groups 1 and 2, and 2 clips in group 3. Animals were monitored for 2 weeks, killed, and submitted for necropsy. MAIN OUTCOME MEASUREMENTS Adequacy of closure and healing after the use of the OTSC system. Statistical analysis. RESULTS Vessel ligation was easily achieved in all groups. Although differences in the complication rate did not reach statistical significance (P = .099), there was a clear tendency for a better prognosis in groups 2 and 3 than group 1. In fact, only 2 animals from group 1 had complications related to incomplete gastrotomy closure. LIMITATIONS Small number of animals per group; nonrandomized study. CONCLUSIONS The OTSC system was shown to be easy and efficient for gastrotomy closure in a survival experimental model of varicocelectomy, when correctly matching the gastrotomy size with the clip size and/or number.
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Affiliation(s)
- Carla Rolanda
- Life and Health Sciences Research Institute, School of Health Sciences, University of Minho, Braga, Portugal
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Loop-anchor purse-string versus endoscopic clips for gastric closure: a natural orifice transluminal endoscopic surgery comparison study using burst pressures. Gastrointest Endosc 2009; 70:1225-30. [PMID: 19846078 DOI: 10.1016/j.gie.2009.05.019] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2008] [Accepted: 05/06/2009] [Indexed: 12/10/2022]
Abstract
BACKGROUND The success of natural orifice surgery depends on a reliable, secure closure of the opening in the gut. Few tests of the integrity of these closures have been published. OBJECTIVE To determine whether a gastrotomy can be closed safely and effectively from within the stomach by using looped T-anchors-a novel, endoscopically placed device. DESIGN Head-to-head comparison trial of 2 closure methods in 9 explanted porcine stomachs. SETTING Animal laboratory. INTERVENTION Paired gastrotomies were made in porcine explants. One was closed by using endoscopic clips, and the other was closed by using modified T-anchors in a purse-string fashion. MAIN OUTCOME MEASUREMENTS Gastric transmural pressure gradients at bursting of these closures were measured while the explanted stomachs were inflated with a high-pressure insufflator. RESULTS The mean burst pressure of the looped T-anchors was 27.3 mm Hg, whereas that of the clip closures was 14 mm Hg. By using 10 mm Hg as a threshold for a "secure" closure, 7 of 9 clip closures failed to meet the threshold value, whereas all 9 of the T-anchor closures met or exceeded the threshold value (P = .0023, 2-tailed Fisher exact test). LIMITATION Nonsurvival study. CONCLUSION Looped T-anchors provide a secure gastric closure for natural orifice surgery and are superior to endoscopic clips for this purpose.
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Rendezvous gastrotomy technique using direct percutaneous endoscopic gastrostomy for transgastric cholecystectomy in hybrid natural orifice translumenal endoscopic surgery. ACTA ACUST UNITED AC 2009; 16:758-62. [DOI: 10.1007/s00534-009-0143-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2009] [Accepted: 03/31/2009] [Indexed: 02/03/2023]
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Supplementation of endoscopic submucosal dissection with sentinel node biopsy performed by natural orifice transluminal endoscopic surgery (NOTES) (with video). Gastrointest Endosc 2009; 69:1152-60. [PMID: 19328485 DOI: 10.1016/j.gie.2008.11.036] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/24/2008] [Accepted: 11/12/2008] [Indexed: 12/12/2022]
Abstract
BACKGROUND Endoscopic submucosal dissection (ESD) is proving to be effective for the resection of selected early gastric and colon cancers. Its application and appropriateness could be extended if a means of determining lymphatic dissemination without recourse to a conventional operation could be provided. OBJECTIVE To demonstrate the feasibility of companion sentinel node biopsy (SNB) by natural orifice transluminal endoscopic surgery (NOTES) concurrent with intraluminal ESD in both the sigmoid colon and stomach. DESIGN Acute porcine model. INTERVENTION Arbitrarily selected mucosal foci were targeted for combined NOTES-SNB and ESD in the sigmoid and stomach of 2 separate anesthetized animals. NOTES peritoneal access was obtained either transgastrically or transvaginally. A second intraluminal endoscope was passed either orally or rectally, as appropriate, to perform submucosal injection for lymphatic mapping under direct vision of the NOTES endoscope. This endoscope then identified the first-order draining (sentinel) nodes and allowed their excisional biopsy. The sigmoid was retracted by magnetic assistance as required, while torque of an intraluminal gastroscope manipulated the stomach. After retrieval of the nodes, 1-cm and 1.5-cm specimens were resected from the sigmoid and stomach, respectively, by conventional ESD. At procedure end, necropsy was performed. RESULTS All sentinel nodes were identified, underwent biopsy, and were retrieved intact. ESD was subsequently readily performed without complication. SNB completeness and ESD quality were confirmed postprocedure. LIMITATIONS Experimental model with limited sample size. CONCLUSIONS Although not yet appropriate for human use, this proposal merits serious consideration as a potential means of augmenting the effectiveness and appropriateness of ESD techniques for GI neoplasia.
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Sánchez-Margallo FM, Asencio Pascual JM, Del Carmen Tejonero Alvarez M, Sánchez Hurtado MA, Pérez Duarte FJ, Usón Gargallo J, Sánchez-Gijón SP. [Training design and improvement of technical skills in the transvaginal cholecystectomy (NOTES)]. Cir Esp 2009; 85:307-13. [PMID: 19376505 DOI: 10.1016/j.ciresp.2009.02.004] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2008] [Accepted: 02/17/2009] [Indexed: 01/15/2023]
Abstract
INTRODUCTION The current surgical scenario of the surgery through natural orifices or <<no-scar surgery>> requires acquiring new technical skills by the surgeon. We introduce the initial experience of the Minimally Invasive Surgery Centre Jesús Usón (MISCJU) in the design and setting-up of a surgical training programme using the the natural orifices approach for the acquisition of surgical skills and abilities, based on the preliminary trials in simulators and a pig model. MATERIAL AND METHODS After initial training, using a laparoscopic pelvic-trainer, 7 female pigs, with weights between 35-40 kg, were operated on. The transvaginal approach was completed using a one-channel gastroscope in all the animals. After accessing the abdomen, the abdominal cavity was explored, and the surgery was concluded with the endoscopic cholecystectomy. RESULTS Endoscopic cholecystectomy was successfully completed in 6 cases. In one of the animals, the procedure was stopped because of technical problems regarding the endoscope leaning to one end. The average surgical time was 107.14 min (range, 80-150 min). The transvaginal approach enabled the abdominal to be explored and the dissection, ligature and section of the cystic duct and the cystic artery. After cholecystectomy, the gallbladder was extracted through the vagina. After the procedure necropsy did not reveal intra-abdominal lesions or intraoperative complications. CONCLUSIONS The pure transvaginal cholecystectomy is a feasible and reproducible procedure in the animal model. A systematized training model, which includes physiopathology knowledge as well as technical knowledge, in order to translate these procedures to the clinical practice in a safe way, is needed.
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Transgastric placement of biologic mesh to the anterior abdominal wall. Surg Endosc 2009; 23:1212-8. [PMID: 19263146 DOI: 10.1007/s00464-009-0352-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2008] [Revised: 12/22/2008] [Accepted: 01/12/2009] [Indexed: 12/30/2022]
Abstract
BACKGROUND Incisional hernia repairs have a risk of wound complications that may be decreased using a natural orifice transluminal endoscopic surgery (NOTES) approach. The aim of this study was to determine the feasibility and safety of transgastric mesh placement to the anterior abdominal wall in a porcine model as a precursor to future studies of NOTES ventral hernia repair. METHODS The procedure was done under sterile conditions with a double lumen endoscope using a plastic overtube. The endoscope was placed in the stomach preloaded with an overtube. Entrance of the endoscope and overtube into the peritoneal cavity was performed with the percutaneous endoscopic gastrostomy (PEG) technique. A 13 x 15 cm Surgisis Gold mesh with four corner sutures was delivered through the overtube. Transfascial suture passer and endoscopic grasper were used to externalize the sutures and attach the mesh to the anterior abdominal wall. The gastrotomy was closed with a transabdominal gastropexy. The pigs were sacrificed at 2 weeks. RESULTS Mesh placement was performed in five pigs. Operative time was 215 min (standard deviation, SD 99 min). The most difficult portion of the procedure involved manipulating the gastric overtube, likely exposing the mesh to bacteria in the stomach. Culture-positive abscesses were present at the mesh in 3/5 animals. The mesh appeared intact in 4/5 animals; one of the infected meshes had delamination of 50% of the mesh. Adhesions to the mesh surface varied from 2% to 100%. At 2 weeks, median mesh size was 116 cm2 (range 96-166 cm2) and median contraction was 41% (range 15-51%). Histologic evaluations demonstrated marked inflammation and fibrosis progressing into the mesh material. CONCLUSIONS Totally endoscopic transgastric delivery and fixation of a biologic mesh to the anterior abdominal wall is feasible. Challenges remain in designing systems for mesh delivery that exclude gastric content. Once these problems can be surmounted NOTES ventral hernia repair may become an option in man.
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Astudillo JA, Sporn E, Bachman S, Miedema B, Thaler K. Transgastric cholecystectomy using a prototype endoscope with 2 deflecting working channels (with video). Gastrointest Endosc 2009; 69:297-302. [PMID: 19013569 DOI: 10.1016/j.gie.2008.05.035] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2008] [Accepted: 05/12/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Transgastric cholecystectomy has been shown to be feasible in animal models and human case reports but cumbersome with current available instrumentation. OBJECTIVE To evaluate a prototype endoscope with 2 working channels with deflectors at the distal tip for performance of transgastric cholecystectomy. DESIGN Animal study, nonsurvival and survival. ANIMALS Sixteen male pigs. SETTING University hospital. INTERVENTION Transgastric cholecystectomy in 6 nonsurvival pigs by using several different dual-channel endoscopes and 10 survival pigs by using the Olympus dual-channel endoscope with an up-down deflecting channel to the left of the objective lens and a left-right deflecting channel located below the lens. Gallbladder fundic retraction was performed with the aid of one laparoscopic grasper. RESULTS Cholecystectomy was successful in all survival animals. Median procedure time was 81 minutes (range 31-163 minutes), with a decrease over time. Visualization of all structures was achieved, and clipping of the cystic duct and artery was successful in all cases. Dissection of the gallbladder via the left-right channel was enhanced with retraction via the up-down deflecting channel. Nine of 10 animals survived without complications. One animal died, on postoperative day 2, secondary to peritonitis due to a leak from the gastrotomy site. CONCLUSIONS This endoscope, with deflecting working channels, allows transgastric cholecystectomy in pigs. The endoscope was stable enough to be used without an overtube and facilitated retraction and dissection. This endoscope is promising for use in transgastric cholecystectomy in human beings.
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Affiliation(s)
- J Andres Astudillo
- Department of Surgery, University of Missouri-Columbia, Columbia, Missouri 65212, USA.
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