The Performance of Multiple Transgastric Procedures Using the Natural Orifice Transluminal Endoscopic Surgery Technique: Is Pure NOTES Satisfactory?

Enteric neuropathies: Yesterday, Today and Tomorrow

Enteric neuropathy is a term indicating an impairment of the innervation supplying the gastrointestinal tract. The clinical phenotypes of the enteric neuropathies are the 'tip of the iceberg' of severe functional digestive diseases, such as intestinal pseudo-obstruction syndromes (e.g., chronic intestinal pseudo-obstruction). Despite progress acquired over the years, the pathogenetic mechanisms leading to enteric neuropathies are still far from being elucidated and the therapeutic approaches to these patients are mainly supportive, rather than curative.The purpose of this chapter is to review the advancements that have been done in the knowledge of enteric neuropathies identified in adult patients ('tomorrow'), going through where we currently are ('today') following a brief history of the major milestones on the pioneering discoveries in the field ('yesterday').

Transumbilical endoscopic cholecystectomy in a porcine model

PURPOSE

Natural orifice transluminal endoscopic surgery (NOTES) is a new technique. This study describes our initial experience of NOTES and investigates the feasibility of transumbilical endoscopic cholecystectomy (TUEC).

METHODS

Eight domestic pigs were submitted to TUEC. After establishment of pneumoperitoneum, a bi-channel endoscope was placed through an infra-umbilical trocar. The gallbladder fundus was lifted by a grasper. The cystic duct and artery was dissected with a flexible hook and clipped by a clip fixing device. The specimen was extracted through the infra-umbilical trocar.

RESULTS

The mean operation time was 114 minutes, ranging from 75 to 155 minutes. All the gallbladders were removed successfully. There was one case of subtotal resection, two cases of bleeding and three cases of bile leakage.

CONCLUSION

Transumbilical endoscopic cholecystectomy is feasible although it needs more support of experiments and techniques before being applied on human subjects.

Endoscopic gastrojejunostomy with a natural orifice transluminal endoscopic surgery technique

AIM: To determine the technical feasibility and safety of an endoscopic gastrojejunostomy with a pure natural orifice transluminal endoscopic surgery (NOTES) technique using a T-anchoring device in a porcine survival model.

METHODS: An endoscopic gastrojejunostomy with a pure NOTES technique using a T-anchoring device was performed on 10 healthy female minipigs weighing approximately 40 kg each under general anesthesia. All procedures were performed with a transgastric approach using a 2-channel therapeutic endoscope.

RESULTS: The transgastric gastrojejunostomy was technically successful in all cases. A total of four to six stitched pairs of a T-anchoring device were used to secure the anastomosis. The median time required to enter the peritoneal cavity and pull the small bowel into the stomach was 34 min (range: 19-41 min); the median time required to suture the anastomosis was 67 min (range: 44-78 min). An obstruction of the efferent limb occurred in one case, and a rupture of the anastomosis site occurred in another case. As a result, the functional success rate was 80% (8/10). Small bowel adhesion to the stomach and liver occurred in one case, but the anastomosis was intact without leakage or obstruction.

CONCLUSION: A transgastric gastrojejunostomy with a T-anchoring device may be safe and technically feasible. A T-anchoring device may provide a simple and effective endoscopic suturing method.