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Liu S, Luan Z, Wang T, Xu K, Luo Q, Ye S, Wang W, Dan R, Shu Z, Huang Y, Mequanint K, Fan C, Xing M, Yang S. Endoscopy Deliverable and Mushroom-Cap-Inspired Hyperboloid-Shaped Drug-Laden Bioadhesive Hydrogel for Stomach Perforation Repair. ACS NANO 2023; 17:111-126. [PMID: 36343209 DOI: 10.1021/acsnano.2c05247] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/16/2023]
Abstract
Gastrointestinal tract perforation is a full-thickness injury that causes bleeding and fatal infection of the peritoneum. This condition worsens in an acidic gastric environment which interferes with the normal coagulation cascade. Current endoscopic clips to repair gastric perforations are ineffective, and metal or plastic occluders need secondary surgery to remove them. Herein, we report a self-expandable, endoscopy deliverable, adhesive hydrogel to block gastric perforation. We found the nanosilica coating significantly enhanced the adhesive strength even under a simulated strong acidic stomach environment. The developed device was disulfide cross-linked for the reducible degraded gel. By loading with vonoprazan fumarate (VF) and acidic fibroblast growth factor (AFGF), the hyperboloid-shaped device can have a sustained drug release to regulate intragastric pH and promote wound healing. The gel device can be compressed and then expanded like a mushroom when applied in an acute gastric perforation model in both rabbits and minipigs. By utilizing a stomach capsule robot for remotely monitoring the pH and by immunohistochemical analysis, we demonstrated that the compressible hyperboloid-shaped gel could stably block the perforation and promoted wound healing during the 28 days of observation. The real-time pH meter demonstrated that the gel could control intragastric pH above 4 for nearly 60 h to prevent bleeding.
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Affiliation(s)
- Shuang Liu
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, No.183, Xinqiao Street, Shapingba District, Chongqing400037, China
| | - Zhaohui Luan
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, No.183, Xinqiao Street, Shapingba District, Chongqing400037, China
| | - Tongchuan Wang
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, No.183, Xinqiao Street, Shapingba District, Chongqing400037, China
| | - Kaige Xu
- Departments of Mechanical Engineering, University of Manitoba, Winnipeg, ManitobaR3T 2N2, Canada
| | - Qiang Luo
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, No.183, Xinqiao Street, Shapingba District, Chongqing400037, China
| | - Shaosong Ye
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, No.183, Xinqiao Street, Shapingba District, Chongqing400037, China
| | - Wei Wang
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, No.183, Xinqiao Street, Shapingba District, Chongqing400037, China
| | - Ruijue Dan
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, No.183, Xinqiao Street, Shapingba District, Chongqing400037, China
| | - Zhenzhen Shu
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, No.183, Xinqiao Street, Shapingba District, Chongqing400037, China
| | - Yu Huang
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, No.183, Xinqiao Street, Shapingba District, Chongqing400037, China
| | - Kibret Mequanint
- Department of Chemical and Biochemical Engineering, and School of Biomedical Engineering, The University of Western Ontario, London, OntarioN6A 5B9, Canada
| | - Chaoqiang Fan
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, No.183, Xinqiao Street, Shapingba District, Chongqing400037, China
- Chongqing Municipality Clinical Research Center for Gastroenterology, Chongqing400037, China
| | - Malcolm Xing
- Departments of Mechanical Engineering, University of Manitoba, Winnipeg, ManitobaR3T 2N2, Canada
| | - Shiming Yang
- Department of Gastroenterology, Xinqiao Hospital, Army Medical University, No.183, Xinqiao Street, Shapingba District, Chongqing400037, China
- Chongqing Municipality Clinical Research Center for Gastroenterology, Chongqing400037, China
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Wang ZJ, Li SY, Zhang YH, Chen Y, Zhang PP, Li ZS, Bai Y, Wang D. Endoscopic closure of large colonic perforations with a novel endoscopic clip device: An animal study (with videos). J Gastroenterol Hepatol 2019; 34:2152-2157. [PMID: 31318990 DOI: 10.1111/jgh.14787] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2019] [Revised: 05/31/2019] [Accepted: 07/10/2019] [Indexed: 01/15/2023]
Abstract
BACKGROUND AND AIM An endoscopic clip device was newly designed to accomplish the closure of large gastrointestinal defects. The aim of this study was to determine the feasibility and efficacy of this device in an ex vivo experimental setting. METHODS This prospective study was conducted in porcine colons (n = 5). A large (3-4 cm) linear full-thickness incision was created using a scalpel externally. The device was used for endoscopic closure. The procedure time, number of clips, and success rate of closure were determined. RESULTS Ten defects were created in five porcine colons (two incisions in each specimen). Successful closure was achieved in all defects. The mean procedure time was 24.30 ± 4.42 min, the mean leak pressure is 28.30 ± 9.49 mmHg, and the mean number of additional conventional hemostatic clips used was 5.10 ± 0.99. CONCLUSIONS The results indicated that this clip achieved the convenient and reliable closure of large defects in the colon wall in an ex vivo porcine model and seems to be a promising option for closing large gastrointestinal perforations.
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Affiliation(s)
- Zhi-Jie Wang
- Department of Gastroenterology, Gongli Hospital, Second Military Medical University, Shanghai, China.,Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Shi-Yu Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yan-Hui Zhang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yan Chen
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Ping-Ping Zhang
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Zhao-Shen Li
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Yu Bai
- Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
| | - Dong Wang
- Department of Gastroenterology, Gongli Hospital, Second Military Medical University, Shanghai, China.,Department of Gastroenterology, Changhai Hospital, Second Military Medical University, Shanghai, China
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Donatelli G, Cereatti F, Dhumane P, Vergeau BM, Tuszynski T, Marie C, Dumont JL, Meduri B. Closure of gastrointestinal defects with Ovesco clip: long-term results and clinical implications. Therap Adv Gastroenterol 2016; 9:713-21. [PMID: 27582884 PMCID: PMC4984331 DOI: 10.1177/1756283x16652325] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The Over-The-Scope Clip (OTSC®, Ovesco Endoscopy GmbH, Tübingen, Germany) is an innovative clipping device that provides a strong tissue grasp and compression without provoking ischemia or laceration. In this retrospective study we evaluated immediate and long-term success rates of OTSC deployment in various pathologies of the gastrointestinal (GI) tract. METHODS A total of 45 patients (35 female, 10 male) with an average age of 56 years old (range, 24-90 years) were treated with an OTSC for GI defects resulting from a diagnostic or interventional endoscopic procedure (acute setting group) or for fistula following abdominal surgery (chronic setting group). All procedures were performed with CO2 insufflation. RESULTS From January 2012 to December 2015 a total of 51 OTSCs were delivered in 45 patients for different kinds of GI defects. Technical success was always achieved in the acute setting group with an excellent clip adherence and a clinical long-term success rate of 100% (15/15). Meanwhile, considering the chronic setting group, technical success was achieved in 50% of patients with a long-term clinical success of 37% (11/30); two minor complications occurred. A total of three patients died due to causes not directly related to clip deployment. Overall clinical success rate was achieved in 58% cases (26/45 patients). A mean follow-up period of 17 months was accomplished (range, 1-36 months). CONCLUSION OTSC deployment is an effective and minimally-invasive procedure for GI defects in acute settings. It avoids emergency surgical repair and it allows, in most cases, completion of the primary endoscopic procedure. OTSC should be incorporated as an essential technique of today's modern endoscopic armamentarium in the management of GI defects in acute settings. OTSCs were less effective in cases of chronic defects.
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Affiliation(s)
| | - Fabrizio Cereatti
- Digestive Endoscopy and Gastroenterology Unit, A.O. Istituti Ospitalieri di Cremona, Cremona, Italy
| | - Parag Dhumane
- Department of General and Laparoscopic Surgery, Lilavati Hospital and Research Center, Bandra (w), Mumbai, India
| | - Bertrand Marie Vergeau
- Unité d’Endoscopie Interventionnelle, Ramsay Générale de Santé, Hôpital Privé des Peupliers, Paris, France
| | - Thierry Tuszynski
- Unité d’Endoscopie Interventionnelle, Ramsay Générale de Santé, Hôpital Privé des Peupliers, Paris, France
| | - Christian Marie
- Unité d’Endoscopie Interventionnelle, Ramsay Générale de Santé, Hôpital Privé des Peupliers, Paris, France
| | - Jean-Loup Dumont
- Unité d’Endoscopie Interventionnelle, Ramsay Générale de Santé, Hôpital Privé des Peupliers, Paris, France
| | - Bruno Meduri
- Unité d’Endoscopie Interventionnelle, Ramsay Générale de Santé, Hôpital Privé des Peupliers, Paris, France
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Endoscopic Suturing, an Essential Enabling Technology for New NOTES Interventions. Gastrointest Endosc Clin N Am 2016; 26:375-384. [PMID: 27036903 DOI: 10.1016/j.giec.2015.12.005] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Natural orifice transluminal endoscopic surgery (NOTES) was developed as a new, minimally invasive approach for various interventions inside the peritoneal cavity. Since the first reports of NOTES animal interventions, various devices have been used for closure of the transluminal entrance site. This article reviews the most commonly used endoscopic closure devices and advantages of the latest generation of endoscopic suturing devices enabling reliable, surgical-quality closure of the full-thickness gastrointestinal wall defects.
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Schmidt A, Fuchs KH, Caca K, Küllmer A, Meining A. The Endoscopic Treatment of Iatrogenic Gastrointestinal Perforation. DEUTSCHES ARZTEBLATT INTERNATIONAL 2016; 113:121-8. [PMID: 26976712 DOI: 10.3238/arztebl.2016.0121] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2015] [Revised: 10/05/2015] [Accepted: 10/05/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Iatrogenic gastrointestinal perforation is a life-threatening complication that arises very rarely in routine endoscopic procedures, with an incidence of 0.03-0.8%. It is more likely in highly complex and invasive therapeutic interventions. In certain situations, endoscopic closure of the perforation and treatment with antibiotics can obviate the need for emergency surgical repair. METHODS This review is based on pertinent articles retrieved by a selective literature search in PubMed and on a relevant position paper. RESULTS Existing clinical studies of treatment for iatrogenic gastrointestinal perforation are mainly retrospective and uncontrolled. No randomized and controlled trials have been performed to date. If the perforation is discovered soon after it arises, endoscopic treatment can be considered. Gastrointestinal perforations that are less than 30 mm in size can be closed with a clip. In the esophagus, expanding metal stents can be used as well. Clip application is successful in 80-100% of cases of gastrointestinal perforation, and the perforation remains permanently closed in 60-100% of cases. Reports on the endoscopic treatment of esophageal perforation show mixed results, with closure rates of roughly 90% and clinical success rates of roughly 80%. If endoscopic treatment is not possible, timely laparoscopic or open surgical repair is needed. CONCLUSION The endoscopic treatment of iatrogenic perforations is safe and reliable. Success depends on early detection, adequate endoscopic closure with properly mastered technique, and the early initiation of concomitant antibiotic treatment, which must be continued for a full course. Most patients who are treated in this way do not need emergency surgery.
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Affiliation(s)
- Arthur Schmidt
- Department of Internal Medicine, Gastroenterology and Oncology, Klinikum Ludwigsburg, Department of General, Visceral and Thoracic Surgery,, AGAPLESION Markus Krankenhaus Frankfurt am Main, Ulm University Hospital Medical Center, Department of Internal Medicine I
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Lu J, Jiao T, Li Y, Zheng M, Lu X. Facilitating retroflexed endoscopic full-thickness resection through loop-mediated or rope-mediated countertraction (with videos). Gastrointest Endosc 2016; 83:223-8. [PMID: 26364964 DOI: 10.1016/j.gie.2015.08.063] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/18/2015] [Accepted: 08/07/2015] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Endoscopic full-thickness resection (EFTR) is difficult to perform in a retroflexed fashion in the gastric fundus and lesser curvature. Here we describe two simple methods to provide countertraction and thereby facilitate dissection. METHODS In this retrospective cohort study, 62 patients diagnosed as having gastric submucosal tumors in the fundus or in the lesser curvature received EFTR with or without countertraction methods. For the clip-with-thread method, a clip tied with surgical suture was anchored on the distal edge of the tumor to provide countertraction; for the loop-assisted method, a snare placed on the transparent cap beforehand was adopted to grasp the tumor to provide countertraction. RESULTS Mean operative time was significantly reduced in the thread-with-clip group and loop-assisted group (45 minutes, 40 minutes, respectively) compared with the time needed in the traditional EFTR group (85 minutes). Intraoperative pneumoperitoneum occurred regularly among the 3 groups because of iatrogenic perforation, but fewer patients in the thread-with-clip group and loop-assisted group (23%, 18%, respectively) needed abdominal puncture to relieve free air and stabilize life signs compared with patients in the traditional EFTR group (63%). A reduced occurrence of high fever after surgery may contribute as another advantage from accelerated dissection. Both techniques did not jeopardize oncologic safety during short-term follow-up. CONCLUSIONS Both the thread-with-clip method and loop-assisted method provide effective countertraction and offer faster and safer gastric EFTR in difficult anatomic locations.
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Affiliation(s)
- Jiaoyang Lu
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China; Department of Gastroenterology, Qilu Hospital, Shandong University School of Medicine, Jinan, Shandong, China
| | - Taotao Jiao
- Department of Statistics, Shandong Provincial Hospital, Jinan, Shandong, China
| | - Yanmei Li
- Department of Gastroenterology, Qilu Hospital, Shandong University School of Medicine, Jinan, Shandong, China; Department of Gastroenterology, Renji Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Minhua Zheng
- Department of General Surgery, Ruijin Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Xuefeng Lu
- Department of Gastroenterology, Qilu Hospital, Shandong University School of Medicine, Jinan, Shandong, China
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Verlaan T, Voermans RP, van Berge Henegouwen MI, Bemelman WA, Fockens P. Endoscopic closure of acute perforations of the GI tract: a systematic review of the literature. Gastrointest Endosc 2015; 82:618-28.e5. [PMID: 26005015 DOI: 10.1016/j.gie.2015.03.1977] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2014] [Accepted: 03/25/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND Surgical repair of endoscopic perforations of the GI tract used to be the standard, but immediate, secure endoscopic closure has become an attractive alternative treatment with the potential to reduce morbidity and mortality. OBJECTIVE We aimed to perform a systematic review of the medical literature on endoscopic closure of acute iatrogenic perforations of the GI tract. DESIGN A systematic review was conducted according to the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-analyses) guidelines. SETTING Available medical literature from 1966 through November 2013. PATIENTS Patients with an acute perforation after an endoscopic procedure that was closed endoscopically. INTERVENTIONS Endoscopic closure of an acute perforation of the GI tract. MAIN OUTCOME MEASUREMENTS Clinically successful endoscopic closure. RESULTS In our search, we identified 726 studies, 702 of which had to be excluded. Twenty-four cohort studies (21 retrospective, 3 prospective) were included in the analysis. No randomized trials were identified. Overall, the methodological quality was low. The 24 studies included described 466 acute perforations in which endoscopic closure was attempted. Successful endoscopic closure was achieved in 419 cases (89.9%; 95% CI, 87%-93%). Successful closure was achieved in 90.2% (n = 359; 95% CI, 87%-93%) of cases by using endoclips, in 87.8% (n = 58; 95% CI, 78%-95%) by using the over-the-scope-clip, and in 100% (n = 2) by using a metal stent. LIMITATIONS Low methodological quality of included studies. CONCLUSION This systematic review suggests that endoscopic perforation closure is a safe and effective alternative for surgical intervention in selected cases; however, the overall methodological quality was low. Prospective, true consecutive studies are needed to define the definitive role of endoscopic closure of perforations.
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Affiliation(s)
- Tessa Verlaan
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Rogier P Voermans
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands; Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | | | - Willem A Bemelman
- Department of Surgery, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
| | - Paul Fockens
- Department of Gastroenterology and Hepatology, Academic Medical Center, University of Amsterdam, Amsterdam, the Netherlands
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Kantsevoy SV. Endoscopic suturing for closure of transmural defects. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2015. [DOI: 10.1016/j.tgie.2015.06.008] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
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Endoluminal flexible endoscopic suturing for minimally invasive therapies. Gastrointest Endosc 2015; 81:262-9.e19. [PMID: 25440675 DOI: 10.1016/j.gie.2014.09.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 09/03/2014] [Indexed: 12/12/2022]
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Abstract
Small (<2 cm) or incidentally found gastrointestinal submucosal tumors pose challenges to gastroenterologists due to the potential malignancy of tumors and current suboptimal diagnostic methods. On the basis of the development of endoscopic submucosal dissection, recent technical advances, including endoscopic submucosal excavation, submucosal tunneling and endoscopic resection, and endoscopic full-thickness resection, have been able to resect submucosal tumors in the muscularis propria. These techniques provide definitive histologic diagnosis as well as a minimally invasive therapeutic approach to such tumors. Current studies, despite with promising results, are limited to small, retrospective studies, focusing on introducing new methods and varied in technical details. This review provides a thorough discussion of technical details of each endoscopic method, and compares different methods in terms of tumor sites, to ensure safety and optimize treatment outcomes.
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Raju GS. Endoscopic clip closure of gastrointestinal perforations, fistulae, and leaks. Dig Endosc 2014; 26 Suppl 1:95-104. [PMID: 24373001 DOI: 10.1111/den.12191] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2013] [Accepted: 09/17/2013] [Indexed: 02/06/2023]
Abstract
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.
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Affiliation(s)
- Gottumukkala S Raju
- Department of Gastroenterology, Hepatology, and Nutrition, University of Texas MD Anderson Cancer Center, Houston, USA
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Gonzalez JM, Bonin EA, Vanbiervliet G, Garnier E, Berdah S, Matthes K, Barthet M. Evaluation of feasibility, efficiency and safety of a pure NOTES gastrojejunal bypass with gastric outlet obstruction, in an in vivo porcine model. Endosc Int Open 2013; 1:31-8. [PMID: 26135510 PMCID: PMC4440371 DOI: 10.1055/s-0033-1353686] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2013] [Accepted: 12/05/2013] [Indexed: 12/20/2022] Open
Abstract
INTRODUCTION Natural orifice transluminal endoscopic surgery (NOTES) gastrojejunal anastomosis (GJA) is a less invasive surgery for bariatric procedures and gastric outlet obstruction. The aim of this study was to evaluate the feasibility, efficacy, and safety of a pure NOTES gastrojejunal bypass using an in vivo porcine model. MATERIAL AND METHODS A prospective study was performed on nine swine. A double-channel scope was used. The intervention steps were: (i) gastric incision; (ii) peritoneal access; (iii) jejunal loop selection and mobilization into the stomach; (iv) stoma creation within the gastric wall and incision; (v) anastomosis suture and pylorus closure using a T-tag prototype. The animals were assessed clinically for 3 weeks including the weight gain. The patency of the GJA was assessed at necropsy and a histological analysis was performed. RESULTS We successfully performed all the procedures with a mean (standard deviation [SD]) operative time of 108 (26) minutes. We used a mean of 5.55 (1.30) stitches. There were no intraprocedural adverse events. Five animals survived up till euthanasia at 3 weeks (65 %). These showed a significant difference in weight curves of a loss of 3.2 kg compared with gain of 5.2 kg in a control group. Four pigs died from anastomotic dehiscence complicated by peritonitis. CONCLUSION Gastrojejunal bypass with a pure NOTES approach is feasible. This procedure is effective, resulting in a patent anastomosis and a significant weight loss. However, the anastomotic dehiscence is a major concern because of its mortality rate, and further studies including improvement of the suturing device and the technique are needed.
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Affiliation(s)
- J.-M. Gonzalez
- Department of Gastroenterology, Public Assistance Hospitals of Marseille, North Hospital, Marseille, France,Department of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States,Corresponding author Dr. Jean-Michel Gonzalez, MD Laboratory Dana 506Department of GastroenterologyBeth Israel Deaconess Medical CenterHarvard Medical SchoolBoston, MAUnited States
| | - E. A. Bonin
- Department of Gastroenterology, Public Assistance Hospitals of Marseille, North Hospital, Marseille, France
| | - G. Vanbiervliet
- Department of Endoscopy, University Hospital of Nice, Nice, France
| | - E. Garnier
- Aix-Marseille University, CERC, Faculty of Medicine, Marseille, France
| | - S. Berdah
- Department of Digestive Surgery, Public Assistance Hospitals of Marseille, Marseille, France
| | - K. Matthes
- Department of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States
| | - M. Barthet
- Department of Gastroenterology, Public Assistance Hospitals of Marseille, North Hospital, Marseille, France
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Vanbiervliet G, Gonzalez JM, Bonin EA, Garnier E, Giusiano S, Saint Paul MC, Berdah S, Barthet M. Gastrojejunal Anastomosis Exclusively Using the "NOTES" Technique in Live Pigs: A Feasibility and Reliability Study. Surg Innov 2013; 21:409-18. [PMID: 24253256 DOI: 10.1177/1553350613508016] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Natural orifice transluminal endoscopic surgery (NOTES) could reduce procedure-associated morbidity and mortality. The aim of this study was to determine the feasibility of performing a simple model of gastrojejunal anastomosis in a living porcine model exclusively using NOTES. METHODS It was a prospective experimental animal study concerning pigs weighing between 25 and 30 kg. Endoscopies were performed using a double-channel gastroscope. A preliminary phase allowed for the development of the technique on 3 animals that were immediately euthanized. The experimental phase included the implementation of a gastrojejunal anastomosis in 9 animals. Antibiotic therapy was continued for 7 days with gradual feeding. Surviving animals were euthanized after 3 weeks. Anastomosis permeability in each animal was confirmed by opacification, endoscopy, and histopathological analysis. The main outcome measurements were the feasibility and animal survival at 3 weeks postsurgery. RESULTS The entire procedure was performed on 9 animals (4 males and 5 females). Anastomosis required 4.7 ± 1.2 stitches (range 4-7). The average total length of the procedure was 143 ± 50.8 minutes (range 87-225 minutes). One bleeding, 2 suture dehiscences, and a poor stomach incision were the immediate complications endoscopically resolved. At 3 weeks, 5 animals had survived. Three animals died as a result of anastomotic leakage confirmed at necropsy and histopathology. In the surviving animals, histology confirmed permeable anastomoses with collagen scar tissue and continuity of the mucosa and mucosa muscle layers. CONCLUSION Successful gastrojejunal anastomosis by NOTES is technically feasible but is subject to a learning curve.
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Affiliation(s)
- Geoffroy Vanbiervliet
- University of Nice Sophia-Antipolis, Nice, France University Hospital of Nice, Nice, France Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR/Aix-Marseille University, France
| | - Jean-Michel Gonzalez
- Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR/Aix-Marseille University, France Public Assistance Hospitals of Marseille, Marseille, France
| | - Eduardo Aimore Bonin
- Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR/Aix-Marseille University, France Public Assistance Hospitals of Marseille, Marseille, France
| | - Emmanuelle Garnier
- Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR/Aix-Marseille University, France
| | - Sophie Giusiano
- Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR/Aix-Marseille University, France Public Assistance Hospitals of Marseille, Marseille, France
| | | | - Stéphane Berdah
- Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR/Aix-Marseille University, France Public Assistance Hospitals of Marseille, Marseille, France
| | - Marc Barthet
- Laboratoire de Biomécanique Appliquée, UMRT24 IFSTTAR/Aix-Marseille University, France Public Assistance Hospitals of Marseille, Marseille, France
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Sun G, Yang Y, Zhang X, Li W, Wang Y, Zhang L, Tang P, Kong J, Zhang R, Meng J, Wang X. Comparison of gastrotomy closure modalities for natural orifice transluminal surgery: a canine study. Gastrointest Endosc 2013; 77:774-83. [PMID: 23453129 DOI: 10.1016/j.gie.2012.12.017] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2012] [Accepted: 12/17/2012] [Indexed: 02/08/2023]
Abstract
BACKGROUND Reliable closure of the gastrotomy after transgastric natural orifice transluminal endoscopic surgery (NOTES) remains unresolved. OBJECTIVE To compare the technical aspects and clinical and histologic outcomes of NOTES gastrotomy closure techniques. DESIGN Experimental study. SETTING Animal laboratory. PATIENTS Thirty-four dogs, 14 for nonsurvival study and 20 for survival study. INTERVENTIONS The animals randomly received different gastrotomy closures after NOTES: endoclip, omentoplasty, over-the-scope-clip (OTSC), and hand-suturing. MAIN OUTCOME MEASUREMENTS Procedure time, closure strength, survival, postoperative adverse events, and histologic evaluation of wound healing. RESULTS Omentoplasty and OTSC groups needed shorter procedure times and fewer clips than the endoclip group. The endoclip and omentoplasty groups generated similar leakage pressures (34.5 ± 2.6 vs 42.2 ± 4.1 mm Hg, P > .05), both lower than OTSC and hand-suturing groups (81.5 ± 2.1 and 87.0 ± 3.0 mm Hg, respectively, P < .001). Of the 20 animals in the survival study (all 4 groups), only 2 of 6 in the endoclip group were killed prematurely due to sepsis. Necropsy revealed the OTSC group reached a 100% clip retention rate, higher than the endoclip (47.9%) and omentoplasty groups (44.4%, P < .05) rates. Complete healing, defined as intact and continuous gastric layers microscopically, was seen in 83.3% of animals (5 of 6) in the omentoplasty group, comparable with OTSC (4 of 6, 66.7%, P = .500) but higher than the endoclip group (1 of 6, 16.7%, P = .04). LIMITATIONS Animal study. CONCLUSIONS Omentoplasty is easier and safer for NOTES gastrotomy closure than endoclips and offers safety profile and efficacy similar to OTSC and hand-suturing.
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Affiliation(s)
- Gang Sun
- Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China
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Martínek J, Ryska O, Tuckova I, Filípková T, Doležel R, Juhas S, Motlík J, Zavoral M, Ryska M. Comparing over-the-scope clip versus endoloop and clips (KING closure) for access site closure: a randomized experimental study. Surg Endosc 2012; 27:1203-10. [PMID: 23073683 DOI: 10.1007/s00464-012-2576-x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2012] [Accepted: 08/31/2012] [Indexed: 01/04/2023]
Abstract
BACKGROUND A safe technique is essential for successful access site closure in Natural Orifice Translumenal Endoscopic Surgery (NOTES) and for closures of iatrogenic perforations. AIM To compare an over-the-scope clip (OTSC) versus an endoloop + endoclips closure technique (KING closure). METHODS 40 minipigs underwent NOTES peritoneoscopy with liver biopsy. Gastrotomies and rectotomies were closed with OTSC (n = 20; 10× stomach, 10× rectum) or KING closure (n = 20; 10× stomach, 10× rectum). The animals were euthanized 28 days after the procedure. The main outcome variables were technical feasibility, effectiveness, and healing. RESULTS Stomach: All but one closure (KING) was successfully completed. The times of closure were similar between the techniques. At necropsy, all access sites were healed. In two animals (1× KING, 1× OTSC), an abscess, probably related to the closure technique, was found. Histologically, transmural healing with muscular bridging was observable in nine pigs for KING versus two pigs for OTSC closure (p = 0.003). Inflammation was present in three pigs for KING versus seven pigs for OTSC closure (p = 0.08). Rectum: All closures were successfully completed. The times of closure were similar between the techniques. At necropsy, all closure sites had healed. Transmural healing with muscular bridging was present in nine pigs for KING versus two pigs for OTSC closure (p = 0.003). Inflammation was present in two pigs for KING versus seven pigs for OTSC closure (p = 0.03). In one animal (OTSC), an enterocolic fistula developed in the proximity of the closure site. CONCLUSIONS OTSC and KING closure are comparable closure techniques in terms of technical feasibility and effectiveness. KING closure provides a superior histological outcome compared with OTSC closure.
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Affiliation(s)
- J Martínek
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Videnska 1958, 140 21, Prague 4, Czech Republic.
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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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NOTES transvaginal hybrid cholecystectomy: the United States human experience. Surg Endosc 2012; 27:514-7. [PMID: 22806528 DOI: 10.1007/s00464-012-2470-6] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 06/18/2012] [Indexed: 12/11/2022]
Abstract
BACKGROUND "Pure" NOTES and "hybrid" NOTES procedures have gained popularity during the past few years. However, most of these published series have been documented outside the United States. METHODS This is a prospective, nonrandomized series of patients. Female subjects who presented to the University of California at San Diego surgery clinic for elective cholecystectomy were offered participation in this study. Patients met the following criteria: aged 18-75 years; diagnosis of gallbladder disease that required cholecystectomy and American Society of Anesthesiology (ASA) class 1. Hybrid NOTES transvaginal technique was used for cholecystectomy. RESULTS A total of 27 women underwent hybrid transvaginal NOTES cholecystectomy during a 43-month period. The median age was 40.1 (range 23-63) years. The mean body mass index was 25.2 (range 16.4-34.1). All patients had an ASA I-II classification. The mean operative time was 92 (range 38-165) min. There was no conversion to an open operation. The mean hospital stay was 1.07 (range 1-2) days. Patients were followed for a mean of 3.32 (range 0.06-12.2) months. There were no postoperative complications. No scars were visible on the abdominal wall. CONCLUSIONS This study is the largest series of hybrid transvaginal cholecystectomy published in the United States. With our experience, we demonstrate that this technique is safe and clinically viable.
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Antoniou SA, Bartsch DK. NOTES: Current Status and Recent Developments. VISZERALMEDIZIN 2012. [DOI: 10.1159/000346150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Abstract
PURPOSE OF REVIEW Understanding the role of endoscopic closure techniques helps in expanding the endoscopist's role in the management of gastrointestinal neoplasia and explore new frontiers of minimally invasive endoluminal surgery. RECENT FINDINGS This article covers recent advances in endoscopic closure of various gastrointestinal perforations, with a special focus on devices, experimental evidence and clinical outcomes of endoscopic closure of gastrointestinal perforations. SUMMARY Endoscopic closure techniques help the endoscopist to walk on thin ice and save himself and the patient in the case of mishap.
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