Transcolonic endoscopic cholecystectomy: A NOTES survival study in a porcine model (with video)

Harvard University, Cambridge, Massachusetts, United States
Gastrointestinal Endoscopy (Impact Factor: 4.9). 10/2006; 64(3):428-34. DOI: 10.1016/j.gie.2006.06.079
Source: PubMed

ABSTRACT Transgastric cholecystectomy is a natural orifice transluminal endoscopic surgery (NOTES) procedure that has been reported in 2 nonsurvival studies. Both studies detail substantial technical limitations, with only a 33% success rate when limited to 1 gastric incision site, despite the use of a multichannel locking endoscope.
The aim of this study was to evaluate the feasibility and technical limitations of transcolonic cholecystectomy in a survival model.
Animal feasibility study.
Five pigs, under general anesthesia, were prepared with tap-water enemas, a peranal antibiotic lavage, and a Betadine rinse. A dual-channel endoscope was advanced into the peritoneum through an anterior, transcolonic incision 15 to 20 cm from the anus. After cystic duct and artery ligation, dissection of the gallbladder was achieved by using grasping and cutting instruments. After removing the gallbladder, the colonic incision was closed by using Endoloops and/or endoclips. The animals lived for 2 weeks after the procedure, then they were euthanized, and a necropsy was performed.
All 5 gallbladders were successfully resected. Four of the 5 animals flourished in the postoperative period, with appropriate weight gain. In 1 animal, complete closure of the colonic incision was not possible, and it was euthanized at 48 hours for suspected peritonitis.
This study reports the first transcolonic organ resection and demonstrates the first successful NOTES cholecystectomy in a survival model. The transcolonic approach provided improved endoscope stability and biliary exposure compared with the transgastric route, and complete incision closure appeared critical for procedural success.

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Available from: Christopher Thompson, Apr 28, 2015
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    • "Soon, other natural orifices were presented as good access points for NOTES. Pai et al. published transcolonic peritoneoscopy followed by a series of transcolonic procedures [5]. The access from below gives a good, direct view of the upper abdominal cavity. "
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    ABSTRACT: The main goal of Natural Orifice Transluminal Endoscopic Surgery (NOTES) is performing surgery avoiding skin incisions. Theoretical advantages of NOTES include decreased postoperative pain, reduction/elimination of general anesthesia, improved cosmetic outcomes, elimination of skin incision-related complications such as wound infections and hernias, and increased overall patient satisfaction. Although various forms of port creation to accomplish thoracic NOTES procedures have been proposed, transesophageal NOTES has been shown to be the most reliable one. The evolution of endoscopic submucosal transesophageal access resulted in the development of per-oral endoscopic myotomy (POEM), which had a fast transition to clinical practice. The authors present a review of the current state of the art concerning transesophageal NOTES, looking at its potential for diagnostic and therapeutic interventions as well as the hurdles yet to be overcome.
    04/2012; 2012:896952. DOI:10.1155/2012/896952
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    • "The fear of fecal contamination of the peritoneal cavity during clean procedures such as diagnostic peritoneoscopy, cholecystectomy and appendectomy, has been deemed an unacceptably high risk, and the main rate limiting step for this type of access. The early cumulative published experience from survival studies in swine on transanal NOTES was critical in demonstrating that procedures were associated with low infectious complications provided adequate colotomy closure was achieved [8]. Subsequently , the number of published studies describing translumenal access to the peritoneal cavity through the colon and rectum has been increasing steadily (Fig. 1). "
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    ABSTRACT: BACKGROUND: With a rapidly expanding international registry of cases, Natural Orifice Translumenal Endoscopic Surgery (NOTES) continues to be held as the next phase in minimally invasive surgery. While pure and hybrid transvaginal procedures predominate clinically, there is growing interest in transanal NOTES as it may potentially minimize the morbidity of colorectal resections. METHODS: Extensive experimental and clinical evidence support the fact that septic complications from intentional colotomy during colorectal procedures are minimized with adequate closure. Other advantages of transanal NOTES include the favorable ergonomics of transanal endoscopy and availability of Transanal Endoscopic Microsurgery (TEM) as a particularly well-suited endoscopic platform. RESULTS: Since the description of transanal endoscopic rectosigmoid resection using TEM in 2007, extensive evaluation in swine acute and survival studies has demonstrated that this technique is feasible, safe, and easily reproducible using conventional instrumentation. Validation of this approach in human cadavers has confirmed the feasibility of transanal total mesorectal excision using a standardized technique. In the first clinical report published to date, transanal endoscopic rectosigmoid resection with TME was performed using laparoscopic assistance in a female patient with a stage III mid-rectal cancer treated with neoadjuvant therapy. CONCLUSIONS: Although preliminary, these results highlight the potential impact of this approach in minimizing the morbidity associated with rectal cancer resection, and warrant further investigation with respect to safety and long-term oncologic outcomes. Improvements in the design of currently available endoscopic platforms and instrumentation will be important for widespread clinical application in the future, and if pure NOTES transanal resection remains the ultimate goal. KeywordsNOTES–Transanal–Rectal cancer–TME–TEM
    European Surgery 06/2011; 43(3):146-152. DOI:10.1007/s10353-011-0012-4 · 0.26 Impact Factor
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    • "A hagyományos, elsôdlegesen vérzéscsillapításra használható endoklipek nem alkalmasak a gyomor vagy a colon sebszéleinek egyeztetésére, korrekt zárására . Vizsgálatok történtek speciálisan erre a célra kifejlesztett varrógépek alkalmazhatósága tekintetében is [16] [17] [18], illetve túlélô állatkísérletben sikerrel alkalmaztak a gastrotomiás nyílás zárására polietilén alapanyagú, a szív kamrai szeptumdefektusainak zárására használt occludert [12]. Napjainkig több mint 10-féle módszert, illetve eszközt fejlesztettek ki, de eddig egyik sem felelt meg maradéktanul a követelményeknek: legyen könnyen kivitelezhetô, gyors, egyszerû, és zárja biztonságosan a nyílást [19] [20] [21]. "
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    ABSTRACT: Minimal invasive surgical techniques, namely laparoscopic procedures to the abdominal surgery have been introduced more than 20 years ago. In view of clinical results, the majority of these are considered as routinely performed procedure today. Natural Orifice Transluminal Endoscopic Surgery can be considered as a new generation of abdominal surgery. It means a method directed through natural orifices, and abdominal surgery operated by transluminal endoscopic techniques (transgastric, transcolonic, transvaginal) to reach diagnostic and therapeutic goals. Theoretically, this method allows the possibility to decrease invasiveness and postoperative pain, to prevent postoperative hernias and to improve cosmetic results. At present numerous researchers work worldwide to receive scientifically based answers to arising questions (surgical technique, indication, contraindication, complications, monitoring) and concerns in this area. The present paper gives an overview of the national and international literature on experimental results and clinical approaches in the field of this new surgical technique.
    Orvosi Hetilap 07/2008; 149(22):1029-33. DOI:10.1556/OH.2008.28369
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