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Directed submucosal tunneling permits in-line endoscope positioning for transgastric natural orifice translumenal endoscopic surgery (NOTES)

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Abstract

Background

Submucosal dissection is demonstrated to be a technically feasible, safe means of obtaining peroral transgastric peritoneal access for natural orifice translumenal endoscopic surgery (NOTES). The authors hypothesized that their previously described self-approximating translumenal access technique (STAT) could be used to create directed gastric submucosal tunnels permitting in-line endoscope positioning with predetermined abdominal locations that might otherwise be difficult to access.

Methods

In this study, 14 domestic farm swine underwent peroral transgastric peritoneoscopy. Under direct endoscopic visualization, a submucosal tunnel was created by dissecting between the mucosal and muscular layers of the stomach. Each tunnel was created with one of four intraabdominal locations (right upper quadrant, left upper quadrant, lesser sac, and pelvis) as the final target for in-line endoscope positioning. Once peritoneal access had been achieved, in-line positioning was assessed and peritoneoscopy was performed. The submucosal tunnels were closed with endoscopically placed clips. The animals were killed 2 weeks after the procedure, and necropsy was performed.

Results

Submucosal tunnels were successfully directed at predetermined intraabdominal targets in 12 of the 14 animals. The mean dissection time required to create the tunnel was 51 ± 32 min. All the transgastric tunnels were successfully closed with endoscopically placed clips (mean, 3.2 ± 1.1), and at necropsy showed no evidence of gastrotomy leak in any of the animals. One animal experienced a duodenal perforation unrelated to the transgastric tunneling and was killed on postoperative day 2. The remaining animals recovered and gained weight (mean, 5.5 ± 1.2 kg) in the 2-week survival period.

Conclusions

Directed submucosal dissection is technically feasible in a porcine model and permits in-line endoscope positioning with predetermined abdominal target locations. The STAT approach provides safe peritoneal access, allows for a simple reliable endoclip closure, and has an excellent short-term survival rate. This method of achieving transgastric access may be an enabling technique for future NOTES procedures.

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References

  1. 1.

    Rattner D, Kalloo A, ASGE/SAGES Working Group (2006) ASGE/SAGES Working Group on natural orifice translumenal endoscopic surgery, October 2005. Surg Endosc 20:329–333

  2. 2.

    Lamade W, Hochberger J (2006) Transgastric surgery: avoiding pitfalls in the development of a new technique. Gastrointestinal Endosc 63:698–700

  3. 3.

    Pearl JP, Ponsky JL (2008) Natural orifice translumenal endoscopic surgery: a critical review. J Gastrointest Surg 12(7):1293–1300

  4. 4.

    Swanstrom LL, Kozarek R, Pasricha PJ, Gross S, Birkett D, Park PO, Saadat V, Ewers R, Swain P (2005) Development of a new access device for transgastric surgery. J Gastrointest Surg 9:1129–1136 discussion 1136–1137

  5. 5.

    Sclabas GM, Swain P, Swanstrom LL (2006) Endoluminal methods for gastrotomy closure in natural orifice transenteric surgery (NOTES). Surg Innov 13:23–30

  6. 6.

    Seaman DL, Gostout CJ, de la Mora Levy JG, Knipschield MA (2006) Tissue anchors for transmural gut-wall apposition. Gastrointest Endosc 64:577–581

  7. 7.

    Sumiyama K, Gostout CJ, Rajan E, Bakken TA, Deters JL, Knipschield MA (2007) Endoscopic full-thickness closure of large gastric perforations by use of tissue anchors. Gastrointest Endosc 65:134–139

  8. 8.

    Ryou M, Pai RD, Sauer JS, Rattner DW, Thompson CC (2007) Evaluating an optimal gastric closure method for transgastric surgery. Surg Endosc 21:677–680

  9. 9.

    Katsarelias D, Polydorou A, Tsaroucha A, Pavlakis E, Dedemadi G, Pistiolis L, Karakostas N, Kondi-Paphiti A, Mallas E (2007) Endoloop application as an alternative method for gastrotomy closure in experimental transgastric surgery. Surg Endosc 21:1862–1865

  10. 10.

    Perretta S, Sereno S, Forgione A, Dallemagne B, Coumaros D, Boosfeld C, Moll C, Marescaux J (2007) A new method to close the gastrotomy by using a cardiac septal occluder: long-term survival study in a porcine model. Gastrointest Endosc 66:809–813

  11. 11.

    McGee MF, Marks JM, Onders RP, Chak A, Jin J, Williams CP, Schomisch SJ, Ponsky JL (2008) Complete endoscopic closure of gastrotomy after natural orifice translumenal endoscopic surgery using the NDO Plicator. Surg Endosc 22:214–220

  12. 12.

    Mintz Y, Horgan S, Cullen J, Falor E, Talamini MA (2008) Dual-lumen natural orifice translumenal endoscopic surgery (NOTES): a new method for performing a safe anastomosis. Surg Endosc 22:348–351

  13. 13.

    Cios TJ, Reavis KM, Renton DR, Hazey JW, Mikami DJ, Narula VK, Allemang MT, Davis SS, Melvin WS (2008) Gastrotomy closure using bioabsorbable plugs in a canine model. Surg Endosc 22:961–966

  14. 14.

    McGee MF, Rosen MJ, Marks J, Onders RP, Chak A, Faulx A, Chen VK, Ponsky J (2006) A primer on natural orifice transluminal endoscopic surgery: building a new paradigm. Surg Innov 13:86–93

  15. 15.

    Sumiyama K, Gostout CJ, Rajan E, Bakken TA, Knipschield MA, Marler RJ (2007) Submucosal endoscopy with mucosal flap safety valve. Gastrointest Endosc 65:688–694

  16. 16.

    Sumiyama K, Gostout CJ, Rajan E, Bakken TA, Knipschield MA (2007) Transesophageal mediastinoscopy by submucosal endoscopy with mucosal flap safety valve technique. Gastrointest Endosc 65:679–683

  17. 17.

    Sumiyama K, Gostout CJ, Rajan E, Bakken TA, Knipschield MA, Chung S, Cotton PB, Hawes RH, Kalloo AN, Kantsevoy SV, Pasricha PJ (2007) Transgastric cholecystectomy: transgastric accessibility to the gallbladder improved with the SEMF method and a novel multibending therapeutic endoscope. Gastrointest Endosc 65:1028–1034

  18. 18.

    Moyer MT, Pauli EM, Haluck RS, Mathew A (2007) A self-approximating transluminal access technique for potential use in NOTES: an ex vivo porcine model (with video). Gastrointest Endosc 66:974–978

  19. 19.

    Kalloo AN (2007) Is STAT (self-approximating translumenal access technique) the first step for NOTES? Gastrointest Endosc 66:979–980

  20. 20.

    Pauli EM, Moyer MT, Haluck RS, Mathew A (2008) Self-approximating transluminal access technique for natural orifice transluminal endoscopic surgery: a porcine survival study (with video). Gastrointest Endosc 67:690–697

  21. 21.

    Pai RD, Fong DG, Bundga ME, Odze RD, Rattner DW, Thompson CC (2006) Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model (with video). Gastrointest Endosc 64:428–434

  22. 22.

    Vosburgh KG, San Jose Estepar R (2007) Natural orifice transluminal endoscopic surgery (NOTES): an opportunity for augmented reality guidance. In: Westwood JD et al (eds) Medicine meets virtual reality. IOS Press, Amsterdam, pp 485–490

  23. 23.

    Patil PV, Hanna GB, Cuschieri A (2004) Effect of the angle between the optical axis of the endoscope and the instruments’ plane on monitor image and surgical performance. Surg Endosc 18:111–114

  24. 24.

    Kantsevoy SV, Jagannath SB, Niiyama H, Isakovich NV, Chung SS, Cotton PB, Gostout CJ, Hawes RH, Pasricha PJ, Kalloo AN (2007) A novel safe approach to the peritoneal cavity for per-oral transgastric endoscopic procedures. Gastrointest Endosc 65:497–500

  25. 25.

    Feretis C, Kalantzopoulos D, Koulouris P, Kolettas C, Archontovasilis F, Chandakas S, Patsea H, Pantazopoulou A, Sideris M, Papalois A, Simopoulos K, Leandros E (2007) Endoscopic transgastric procedures in anesthetized pigs: technical challenges, complications, and survival. Endoscopy 39:394–400

  26. 26.

    Fernandez-Esparrach G, Matthes E, Maurice D, Enderle M, Thompson CC, Carr-Locke D (2008) A novel device for endoscopic submucosal dissection that combines water-jet submucosal hydrodissection and elevation with electrocautery. Gastrointest Endosc 67:AB141

  27. 27.

    Ionescu AM, Pauli EM, Haluck RS, Shope TR, Rogers AM, Mathew A, Moyer MT (2008) Intestinal occlusion catheter for natural orifice translumenal endoscopic surgery (NOTES). Surg Endosc 22:S238

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Acknowledgments

This project was funded through a 2007 Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) Research Grant Award (EMP). Olympus Medical, Inc, and Pentax Medical, Inc provided endoscopes. Boston Scientific, Inc and Olympus Medical, Inc provided some endoscopic equipment.

Disclosures

Eric M. Pauli, Randy S. Haluck, Adrian M. Ionescu, Ann M. Rogers, Timothy R. Shope, Matthew T. Moyer, Arnab Biswas, and Abraham Mathew have no conflicts of interest or financial ties to disclose.

Author information

Correspondence to Eric Mark Pauli.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Video 1. Brief overview of the self-approximating translumenal access technique (STAT). (MPG 8911 kb)

Video 2. Demonstration of endoscopic access toward each of the four intraabdominal target locations. (MPG 39953 kb)

Video 3. Methods for endoscopic clip closure of the self-approximating translumenal access technique (STAT) tunnel at the conclusion of the natural orifice translumenal endoscopic surgery (NOTES) procedure. (MPG 28429 kb)

Video 1. Brief overview of the self-approximating translumenal access technique (STAT). (MPG 8911 kb)

Video 2. Demonstration of endoscopic access toward each of the four intraabdominal target locations. (MPG 39953 kb)

Video 3. Methods for endoscopic clip closure of the self-approximating translumenal access technique (STAT) tunnel at the conclusion of the natural orifice translumenal endoscopic surgery (NOTES) procedure. (MPG 28429 kb)

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Pauli, E.M., Haluck, R.S., Ionescu, A.M. et al. Directed submucosal tunneling permits in-line endoscope positioning for transgastric natural orifice translumenal endoscopic surgery (NOTES). Surg Endosc 24, 1474–1481 (2010). https://doi.org/10.1007/s00464-009-0760-4

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Keywords

  • Gastrotomy
  • NOTES
  • Submucosal endoscopy
  • Transgastric surgery