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Endoscopy 2009; 41(2): 154-159
DOI: 10.1055/s-0028-1119465
Original article

© Georg Thieme Verlag KG Stuttgart · New York

Endoscopic closure of the natural orifice transluminal endoscopic surgery (NOTES) access site to the peritoneal cavity by means of transmural resorbable sutures: an animal survival study

D. von  Renteln1 , A.  Eickhoff2 , G.  Kaehler3 , B.  Riecken1 , K.  Caca1
  • 1Department of Gastroenterology, Medizinische Klinik I, Klinikum Ludwigsburg, Ludwigsburg, Germany
  • 2Department of Gastroenterology, Medizinische Klinik C, Klinikum Ludwigshafen, Ludwigshafen, Germany
  • 3Section Endoscopy, University hospital Mannheim, University of Heidelberg, Germany
Further Information

Publication History

submitted 2 September 2008

accepted after revision 20 November 2008

Publication Date:
12 February 2009 (online)

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Commentaire de travail de D. von Renteln et al., pp. 154Endoscopy 2009; 41(02): 252-252
DOI: 10.1055/s-0032-1306734

Background and study aims: Endoscopic closure of the transgastric access site is still a critical area of active research and development into natural orifice transluminal surgery (NOTES). To date, no endoscopic technique has utilized resorbable transmural sutures for closure of the NOTES gastrostomy.

Material and methods: Endoscopic gastrostomy closure by means of resorbable sutures was performed in ten female domestic pigs in an animal survival study. Peritoneal cavity access was gained through the anterior gastric wall using the percutaneous endoscopic gastrostomy (PEG) technique and an 18-mm balloon dilator. NOTES exploration of the gallbladder and tubal ligation were performed prior to endoscopic gastrostomy closure. Necropsy was performed 3 weeks post procedure.

Results: Mean suturing time was 26 minutes (range 14 – 35 minutes). In total 90 % (9/10) of gastrostomy closures were performed by means of two transmural resorbable sutures. One gastrostomy was closed using a single resorbable suture. One case of gallbladder perforation occurred during peritoneoscopy and the pig was sacrificed due to subsequent peritonitis 2 days after the procedure. All other pigs (9/10) were found to be healthy 3 weeks after the NOTES procedure and were sacrificed as planned per protocol. Of all the 17 sutures that were applied in the remaining nine pigs, 16 (94 %) had been absorbed, releasing the pledgets intraluminally. During laparotomy no signs of injury to adjacent organs were found in any of these nine animals. In 8/10 pigs (80 %) the gastrostomy site did not burst with pressures exceeding 100 mmHg. Two suturing sites did burst at pressures of 57 and 62 mmHg, respectively.

Conclusions: Endoscopic transmural suturing enables rapid and easy placement of leak-proof resorbable sutures and is suitable for closure of the NOTES transgastric access.

References

  • 1 Kalloo A N, Singh V K, Jagannath S B. et al . Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions.  Gastrointest Endosc. 2004;  60 114-117
    CrossrefPubMedGoogle Scholar
  • 2 Voermans R P, Van Berge Henegouwen M I, Fockens P. Natural orifice transluminal endoscopic surgery (NOTES).  Endoscopy. 2007;  39 1013-1017
    Article in Thieme ConnectPubMedGoogle Scholar
  • 3 Meining A, Wilhelm D, Burian M. et al . Development, standardization, and evaluation of NOTES cholecystectomy using a transsigmoid approach in the porcine model: an acute feasibility study.  Endoscopy. 2007;  39 860-864
    Article in Thieme ConnectPubMedGoogle Scholar
  • 4 ASGE/SAGES Working Group on natural orifice transluminal endoscopic surgery . White Paper October 2005.  Gastrointest Endosc. 2006;  63 199-203
    CrossrefPubMedGoogle Scholar
  • 5 Rattner D, Kalloo A,. ASGE/SAGES Working Group . ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery white paper. October 2005.  Surg Endosc. 2006;  20 329-333
    CrossrefPubMedGoogle Scholar
  • 6 Hawes R H, Rattner D W, Fleischer D. et al . NOTES: where have we been and where are we going?.  Gastrointest Endosc. 2008;  67 779-780
    CrossrefPubMedGoogle Scholar
  • 7 Varadarajulu S, Tamhane A, Drelichman E R. Patient perception of natural orifice transluminal endoscopic surgery as a technique for cholecystectomy.  Gastrointest Endosc. 2008;  67 854-860
    CrossrefPubMedGoogle Scholar
  • 8 Cardoso Ramos A, Murakami A, Galvao Neto M. et al . NOTES transvaginal video-assisted cholecystectomy: first series.  Endoscopy. 2008;  40 572-575
    Article in Thieme ConnectPubMedGoogle Scholar
  • 9 Ko C W, Shin E J, Buscaglia J M. et al . Preliminary pneumoperitoneum facilitates transgastric access into the peritoneal cavity for natural orifice transluminal endoscopic surgery: a pilot study in a live porcine model.  Endoscopy. 2007;  39 849-853
    Article in Thieme ConnectPubMedGoogle Scholar
  • 10 Ryou M, Fong D G, Pai R D. et al . Dual-port distal pancreatectomy using a prototype endoscope and endoscopic stapler: a natural orifice transluminal endoscopic surgery (NOTES) survival study in a porcine model.  Endoscopy. 2007;  39 881-887
    Article in Thieme ConnectPubMedGoogle Scholar
  • 11 Swain P. A justification for NOTES – natural orifice translumenal endosurgery.  Gastrointest Endosc. 2007;  65 514-516
    CrossrefPubMedGoogle Scholar
  • 12 Dray X, Gabrielson K L, Buscaglia J M. et al . Air and fluid leak tests after NOTES procedures: a pilot study in a live porcine model.  Gastrointest Endosc. 2008;  68 513-519
    CrossrefPubMedGoogle Scholar
  • 13 Moyer M T, Pauli E M, Haluck R S. et al . A self-approximating transluminal access technique for potential use in NOTES: an ex vivo porcine model (with video).  Gastrointest Endosc. 2007;  66 974-978
    CrossrefPubMedGoogle Scholar
  • 14 Ryou M, Fong D G, Pai R D. et al . Evaluation of a novel access and closure device for NOTES applications: a transcolonic survival study in the porcine model.  Gastrointest Endosc. 2008;  67 964-969
    CrossrefPubMedGoogle Scholar
  • 15 Magno P, Giday S A, Dray X. et al . A new stapler-based full-thickness transgastric access closure: results from an animal pilot trial.  Endoscopy. 2007;  39 876-880
    Article in Thieme ConnectPubMedGoogle Scholar
  • 16 Chiu P W, Lau J Y, Lam C C. et al . Closure of gastrotomy after transgastric tubal ligation using the Eagle Claw VII: a survival experiment in a porcine model.  Gastrointest Endosc. 2007;  65 AB294
    PubMedGoogle Scholar
  • 17 Fritscher-Ravens A. Transgastric endoscopy – a new fashion, a new excitement!.  Endoscopy. 2007;  39 161-167
    Article in Thieme ConnectPubMedGoogle Scholar
  • 18 Zorron R, Fang H L, Costa M. et al . Alternative techniques for gastric closure for NOTES.  Gastrointest Endosc. 2007;  65 AB294
    PubMedGoogle Scholar
  • 19 Pauli E M, Moyer M T, Haluck R S. et al . Self-approximating transluminal access technique for natural orifice transluminal endoscopic surgery: a porcine survival study.  Gastrointest Endosc. 2008;  67 690-697
    CrossrefPubMedGoogle Scholar
  • 20 Bergstrom M, Swain P, Park P O. Measurements of intraperitoneal pressure and the development of a feedback control valve for regulating pressure during flexible transgastric surgery (NOTES).  Gastrointest Endosc. 2007;  66 174-178
    CrossrefPubMedGoogle Scholar
  • 21 Ryou M, Fong D G, Pai R D. et al . Transluminal closure for NOTES: an ex vivo study comparing leak pressures of various gastrotomy and colotomy closure modalities.  Endoscopy. 2008;  40 432-436
    Article in Thieme ConnectPubMedGoogle Scholar
  • 22 Fritscher-Ravens A, Ghanbari A, Thompson S. et al . Which parameters might predict complications after natural orifice endoluminal surgery (NOTES)? Results from a randomized comparison with open surgical access in pigs.  Endoscopy. 2007;  39 888-892
    Article in Thieme ConnectPubMedGoogle Scholar
  • 23 Voermans R P, Worm A M, Van Berge Henegouwen M I. et al . In vitro comparison and evaluation of seven gastric closure modalities for natural orifice transluminal endoscopic surgery (NOTES).  Endoscopy. 2008;  40 595-601
    Article in Thieme ConnectPubMedGoogle Scholar
  • 24 Chuttani R, Sud R, Sachdev G. et al . A novel endoscopic full-thickness plicator for the treatment of GERD: a pilot study.  Gastrointest Endosc. 2003;  58 770-776
    CrossrefPubMedGoogle Scholar
  • 25 Pleskow D, Rothstein R, Lo S. et al . Endoscopic full-thickness plication for the treatment of GERD: 12-month follow-up for the North American open-label trial.  Gastrointest Endosc. 2005;  61 643-649
    CrossrefPubMedGoogle Scholar
  • 26 Rothstein R, Filipi C, Caca K. et al . Endoscopic full-thickness plication for the treatment of gastroesophageal reflux disease: a randomized, sham-controlled trial.  Gastroenterology. 2006;  131 704-712
    CrossrefPubMedGoogle Scholar
  • 27 Pleskow D, Rothstein R, Kozarek R. et al . Endoscopic full-thickness plication for the treatment of GERD: five-year long-term multicenter results.  Surg Endosc. 2008;  22 326-332
    CrossrefPubMedGoogle Scholar
  • 28 von Renteln D, Brey U, Riecken B, Caca K. Endoscopic full-thickness plication (Plicator) with two serially placed implants improves esophagitis, GERD symptoms and reduces PPI use and esophageal acid exposure.  Endoscopy. 2008;  40 173-178
    Article in Thieme ConnectPubMedGoogle Scholar
  • 29 Renteln D von, Schiefke I, Fuchs K H. et al . Endoscopic full-thickness plication for the treatment of gastroesophageal reflux disease by application of multiple plicator implants: a multi-center study.  Gastrointest Endosc. 2008;  68 833-844
    CrossrefPubMedGoogle Scholar
  • 30 Renteln D von, Kaehler G, Eickhoff A. et al . Gastric full-thickness suturing following NOTES procedures for closure of the access site to the peritoneal cavity.  Endoscopy. 2008;  40 E99-E100
    Article in Thieme ConnectPubMedGoogle Scholar
  • 31 Renteln D von, Riecken B, Walz B. et al . Endoscopic GIST resection using FlushKnife ESD and subsequent perforation closure by means of endoscopic full-thickness suturing.  Endoscopy. 2008;  40 E224-E225
    Article in Thieme ConnectPubMedGoogle Scholar
  • 32 Renteln D von, Schmidt A, Riecken B, Caca K. Gastric full-thickness suturing during endoscopic mucosal resection and for treatment of gastric wall defects.  Gastrointest. Endosc ;  67 738-744
    PubMedGoogle Scholar
  • 33 McGee M F, Marks J M, Jin J. et al . Complete endoscopic closure of gastric defects using a full-thickness tissue plicating device.  J Gastrointest Surg. 2008;  12 38-45
    CrossrefPubMedGoogle Scholar
  • 34 McGee M F, Marks J M, Onders R P. et al . Complete endoscopic closure of gastrotomy after natural orifice translumenal endoscopic surgery using the NDO Plicator.  Surg Endosc. 2008;  22 214-220
    CrossrefPubMedGoogle Scholar
  • 35 Kantsevoy S V, Jagannath S B, Niiyama H. et al . A novel safe approach to the peritoneal cavity for per-oral transgastric endoscopic procedures.  Gastrointest Endosc. 2007;  65 497-500
    CrossrefPubMedGoogle Scholar
  • 36 Assumpcao L, Dray X, Donatelli G. et al . Direct comparison of different techniques of transgastric access for NOTES procedures.  Endoscopy. 2008;  40 (Suppl. 1) A71
    PubMedGoogle Scholar

D. von RentelnMD 

Department of Gastroenterology, Hepatology, and Oncology
Klinikum Ludwigsburg

71640 Ludwigsburg
Germany

Fax: 49-7141-9967219

Email: renteln@gmx.net

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