Pure NOTES sigmoid resection in an animal survival model

Transvaginal cholecystectomy vs conventional laparoscopic cholecystectomy for gallbladder disease: A meta-analysis

AIM: To compare the results of transvaginal cholecystectomy (TVC) and conventional laparoscopic cholecystectomy (CLC) for gallbladder disease.

METHODS: We performed a literature search of PubMed, EMBASE, Ovid, Web of Science, Cochrane Library, Google Scholar, MetaRegister of Controlled Trials, Chinese Medical Journal database and Wanfang Data for trials comparing outcomes between TVC and CLC. Data were extracted by two authors. Mean difference (MD), standardized mean difference (SMD), odds ratios and risk rate with 95%CIs were calculated using fixed- or random-effects models. Statistical heterogeneity was evaluated with the χ² test. The fixed-effects model was used in the absence of statistically significant heterogeneity. The random-effects model was chosen when heterogeneity was found.

RESULTS: There were 730 patients in nine controlled clinical trials. No significant difference was found regarding demographic characteristics (P > 0.5), including anesthetic risk score, age, body mass index, and abdominal surgical history between the TVC and CLC groups. Both groups had similar mortality, morbidity, and return to work after surgery. Patients in the TVC group had a lower pain score on postoperative day 1 (SMD: -0.957, 95%CI: -1.488 to -0.426, P < 0.001), needed less postoperative analgesic medication (SMD: -0.574, 95%CI: -0.807 to -0.341, P < 0.001) and stayed for a shorter time in hospital (MD: -1.004 d, 95%CI: -1.779 to 0.228, P = 0.011), but had longer operative time (MD: 17.307 min, 95%CI: 6.789 to 27.826, P = 0.001). TVC had no significant influence on postoperative sexual function and quality of life. Better cosmetic results and satisfaction were achieved in the TVC group.

CONCLUSION: TVC is safe and effective for gallbladder disease. However, vaginal injury might occur, and further trials are needed to compare TVC with CLC.

Natural Orifice Transluminal Endoscopic Surgery (NOTES) for colon resections--analysis of the first 139 patients of the German NOTES Registry (GNR)

BACKGROUND

The German NOTES registry (GNR) is the largest published database for natural orifice transluminal endoscopic surgery (NOTES) worldwide. Although transvaginal cholecystectomy is the most frequent procedure in the GNR, the number of colorectal resections is increasing. The objective of this study was to analyze the first 139 colonic procedures of the GNR.

METHODS

All colonic procedures from the GNR were analyzed regarding patient- and therapy-related parameters. A multivariate analysis was conducted for transvaginal sigmoid resections regarding procedural time, hospital stay, conversion rate, and rate of complications.

RESULTS

From October 2008 to January 2013, 139 colon NOTES procedures (12 male, 127 female) were registered. Main diagnoses were sigmoid diverticulitis (85.6 %), colon carcinoma (9.4 %), and ulcerative colitis (3.6 %). Sigmoid resections (87.1 %), proctocolectomies (3.6 %), right-sided resections (2.9 %), left-sided resections (3.6 %), segmental resections (2.2 %), and 1 ileocecal resection (0.7 %) were performed. All procedures were conducted in transvaginal (87.8 %) or transrectal (12.2 %) hybrid technique, with a median of 3 percutaneous trocars. Conversions to laparoscopic technique were necessary in 3.6 % (none to conventional technique). Intraoperative complications were recorded in 2.9 % and postoperative complications in 12.2 %. The institutional case number in transvaginal sigmoid resections correlated negatively with procedural time (p = 0.041) and the number of percutaneous trocars (p = 0.002).

CONCLUSION

The analysis of the first 139 colon NOTES operations of the GNR shows the feasibility of co on operations in hybrid technique, especially for transvaginal sigmoid resection as the most frequent procedure.

[Further technical and digital development in minimally invasive and conventional surgery]

Technological innovations have initiated a fundamental change in invasive therapeutic approaches which has led to a welcome reduction of surgical trauma but was also associated with a declining role of conventional surgery. Active utilization of future technological developments is decisive to promote new therapeutic strategies and to avoid a further loss of importance of surgery. This includes individualized preoperative therapy planning as well as intraoperative diagnostic work-up and navigation and the use of new functional intelligent implants. The working environment "surgical operating room" has to be refurbished into an integrated cooperating functional system. The impact of new technological developments is particularly obvious in minimally invasive surgery. There is a clear tendency towards further reduction in trauma in the surgical access. The incision will become smaller and the number of ports will be further reduced, with the aim of ultimately having just one port (monoport surgery) or even via natural access routes (scarless surgery). Among others, improved visualization including, e.g. autostereoscopy, digital image processing and intelligent support systems, which are able to assist in a cooperative way, will enable these goals to be achieved.

Comparison of gastrotomy closure modalities for natural orifice transluminal surgery: a canine study

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.

Innovative noninsufflation EFTR: sufficient endoscopic operative field by mechanical counter traction device

BACKGROUND

No reliable pure natural orifice transluminal endoscopic surgery (NOTES) mechanical counter traction (MCT) device for the flexible endoscope to obtain a sufficient surgical endoscopic field has yet been developed. Our experience with 10 cases of hybrid NOTES prompted the realization of the importance of an MCT device for the flexible endoscope and inspired us to establish innovative noninsufflation endoscopic full-thickness resection (EFTR) with an MCT device.

METHODS

We performed 40 EFTR 40 mm in diameter on excised whole porcine stomachs. Twenty were resected by an MCT device to obtain a surgical field (MCT group), and another 20 were resected with a conventional endoscopic attachment (control group). We evaluated the successful resection rates of EFTR and procedure times between two groups. Next, we implemented EFTR with a custom prototype MCT device in three cases of stomach pseudotumors in female dogs. Gastric pseudotumors ~40 mm in diameter were marked within the open surgical field created by the MCT device. After resecting the pseudotumors, we conducted full-thickness suturing using over-the-scope clips.

RESULTS

In the MCT group, all 20 cases were completely resected. On the other hand, in the control group, only 8 cases were performed via EFTR (P < 0.01). The mean ± standard deviation EFTR procedure times for the MCT and control groups were 4.13 ± 0.824 and 36.26 ± 8.67 min, respectively (P = 0.001). In three dogs, sufficient surgical working spaces were obtained up to 78 mm (range, 65-78 mm), and full-thickness resections were performed safely and sutured with over-the-scope clips.

CONCLUSIONS

Our new prototype MCT device effectively obtains a sufficient surgical endoscopic field during EFTR. We are developing a new MCT with a bending function to perform EFTR in any location in the stomach.

Performance of the OTSC System in the endoscopic closure of iatrogenic gastrointestinal perforations: a systematic review

BACKGROUND

Reliable closure is a prerequisite for conventional and innovative endoscopic procedures, such as NOTES. The purpose of this study is the systematic evaluation of the procedural and clinical success rates in closure of iatrogenic gastrointestinal perforations and acute anastomotic leaks by means of the over-the-scope-clip system (OTSC(®)).

DESIGN

PubMed and other sources were searched systematically for clinical and preclinical research on the evaluation of the OTSC System for closure of gastrointestinal perforations and leaks. Appraisal of studies for inclusion and data extraction was performed independently by two reviewers using an a priori determined data extraction grid. Major endpoints to be extracted were data on procedural success (successful clip application) and clinical access (durable closure of defect without secondary adjunct therapy).

RESULTS

A total of 17 clinical research articles/abstracts and 22 preclinical research articles/abstracts were identified. The examined clinical studies comprised case series and clinical single-arm studies. The reviewed studies revealed a consistently high mean rate of procedural success of 80-100 % and durable clinical success of 57-100 %. An identified major drawback preventing successful clip application was occurrence of fibrotic or inflamed lesion edges. Usage of the OTSC System was accompanied by neither major clip-related nor application-related complication. In experimental settings, closure of larger perforations and gastric access sites of NOTES or endoscopic full-thickness resection were achieved with high rates of success.

CONCLUSIONS

Because randomized, clinical trials are not available in this field of indication, the evaluation is based on small case series. Nevertheless, by pooling all experience gained, we conclude that endoscopic closure of iatrogenic gastrointestinal perforations and acute anastomotic leaks by means of the OTSC System is a safe and effective method.