Colonic sterilization for natural orifice translumenal endoscopic surgery (NOTES) procedures: A comparison of two decontamination protocols

Surgical Endoscopy (Impact Factor: 3.26). 08/2009; 23(8):1854-1859. DOI: 10.1007/s00464-008-0295-0


This study aimed to evaluate the effect of two different sterilization protocols on the bacterial counts in the swine colon as preparation for natural orifice translumenal endoscopic surgery (NOTES) surgery.
In this study, 16 swine were randomized to two different colonic sterilization protocols: low colonic irrigation using 300 ml of a 1:1 dilution of 10% povidone–iodine (Betadine) with sterile saline, followed by 1 g of cefoxitin dissolved in 300 ml of saline or two consecutive 300-ml irrigations using a quaternary ammonium antimicrobial agent (Onamer M). Colonic cultures were taken before colonic cleansing after a decontamination protocol and after completion of the NOTES procedure. The Invitrogen live/dead bacterial viability kit was used to assess for change in the bacterial load. A qualitative culture of peritoneal fluid was obtained at the end of the NOTES procedure. Colon mucosal biopsies obtained immediately after the sterilization procedure and at the 2-week necropsy point were evaluated for mucosal changes.
Protocol 1 resulted in an average 93% decrease in live colonic bacteria versus 90% with protocol 2 (nonsignificant difference). After a NOTES procedure, group 1 had a 62% increase in live bacteria and group 2 had a 31% increase (nonsignificant difference). Peritoneal cultures also were obtained. Bacteria were isolated from the peritoneal fluid of all the animals, and two or more species were isolated from 75% of the animals. There was no evidence of peritoneal infection at necropsy. Reactive epithelial changes and mild inflammation were the only pathologic abnormalities. No changes were noted at histologic evaluation of colonic mucosa after 2 weeks, demonstrating that these were temporary changes.
Colonic irrigation with Betadine and antibiotics are as effective for bacterial decontamination of the swine colon as a quaternary ammonium compound. The results of this study support the use of either protocol. Despite thorough decontamination, peritoneal contamination occurs. The significance of this for humans is unknown.

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    • "Whereas most investigators have chosen to gain peritoneal access via a transvaginal or transgastric route, few have investigated the transcolonic route.[34567] This approach has several theoretic advantages over the transgastric route. "
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    ABSTRACT: BACKGROUND: Applications for natural orifice translumenal endoscopic surgery (NOTES) to access the abdominal cavity have increased in recent years. Despite potential advantages of transanal and transcolonic NOTES for colorectal pathology, it has not been widely applied in the clinical setting. This study describes a series of nine patients for whom we performed transanal retrograde (“Down-to-Up”) total mesorectal excision for rectal cancer. MATERIALS AND METHODS: Under IRB approval, informed consent was obtained from each patient with rectal adenocarcinoma. Rectosigmoidectomy with total mesorectal excision was performed using low rectal translumenal access to the mesorectal fascia and subsequent dissection in a retrograde fashion. This was achieved using either a single port device or flexible colonoscope with endoscopic instrumentation and laparoscopic assistance. This was followed by transanal extraction of the specimen and hand-sewn anastomosis. RESULTS: Mean operative time was 311 min. Mean hospital stay was 7.56 days. Complications occurred in two patients, and consisted of one anastomotic leakage with reoperation and one intraoperative conversion to open surgery because of impossibility to dissect the specimen. TME specimen integrity was adequate in six patients. CONCLUSION: This series suggests that a retrograde mesorectal dissection via a NOTES technique is feasible in patients with rectal adenocarcinoma. This technique may act as a complimentary part of operative treatment for rectal cancer alongside other minimally invasive strategies. Long-term follow up will be needed to assess oncological results.
    Full-text · Article · Jul 2014 · Journal of Minimal Access Surgery
    • "Therefore, an evaluation of the frequency of bacteremia and methods to potentially reduce bacterial infection after EUS-guided FNA are needed. One study showed that washing of the gastrointestinal mucosa with povidone-iodine solution was an effective method for reducing the frequency of bacteremia following natural orifice transluminal endoscopic surgery (NOTES).18 This raises the possibility that washing of the gastrointestinal mucosa with povidone-iodine solution can also reduce the frequency of bacteremia after EUS-FNA. "
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    ABSTRACT: Objective: Few studies have evaluated the risk of bacteremia and infectious complications after endoscopic ultrasonography-guided fine needle aspiration (EUS-FNA). Therefore, we aimed to study the frequency of bacteremia and search for a method to potentially reduce bacterial infection after EUS-FNA. We also investigated the effect of taking proton pump inhibitors (PPIs) before examination on the occurrence of bacteremia. Methods: A total of 28 healthy adult dogs were randomly assigned into three groups: control group, povidone-iodine group and omeprazole group. The dogs in the povidone-iodine group were administered with 0.5% povidone-iodine solution (10 mL) to wash gastrointestinal mucosa, while the dogs in the omeprazole group were fed with 20 mg omeprazole orally twice a day for 3 days before the EUS-FNA procedure. Blood samples were collected for cultures before EUS examination, between EUS and FNA, and 5 min, 15 min and 30 min after FNA. Results: There were 3 true-positive cases of bacteremia in the control group while there was 1 true-positive case of bacteremia in each of the two experiment groups. The differences in the occurrences of bacteremia between the control group and both experiment groups were not statistically significant. Conclusion: There are no statistically significant differences in the frequencies of bacteremia between the two experiment groups and the control group. Therefore, washing of the gastrointestinal mucosa with 0.5% povidone-iodine solution may not reduce the risk of bacterial infection and taking the PPIs does not increase the risk of bacteremia after EUS-FNA.
    No preview · Article · Jul 2012
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    • "The colon as a route of access for NOTES presents with a greater and more diverse bacterial flora than the stomach, vagina, or bladder and as a result a theoretically greater risk of peritonitis following a transcolonic procedure. Several case series have demonstrated the feasibility of this approach for procedures including laparoscopic cholecystectomy [20] and peritoneoscopy [21, 22] in porcine models. Bachman et al. [21] compared colonic irrigation with povidone-iodine and antibiotic solution with irrigation using a quaternary ammonium solution and report that both solutions were effective at significantly reducing colonic flora (by 93% and 90%, resp.), with no clinical evidence of infection at necropsy in 16 swine following transcolonic NOTES peritoneoscopy and T-tag closure. "
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    ABSTRACT: Introduction. Appropriate prevention of infection is a key area of research in natural orifice translumenal endoscopic surgery (NOTES), as identified by the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR). Methods. A review of the literature was conducted evaluating the evidence base for access orifice preparation/treatment in NOTES procedures in the context of infectious complications. Recommendations based on the Oxford Centre for Evidence-Based Medicine guidelines were made. Results. The most robust evidence includes several experimental randomised controlled trials assessing infectious complications in the transgastric approach to NOTES. Transvaginal procedures are long established for accessing the peritoneal cavity following disinfection with antiseptic. Only experimental case series for transcolonic and transvesical approaches are described. Conclusion. Grade C recommendation requiring no preoperative preparation can be made for the transgastric approach. Antiseptic irrigation is recommended for transvaginal (grade C) NOTES access, as is current practice. Further human trials need to be conducted to corroborate the current evidence base for transgastric closure. It is important that future trials are conducted in a methodologically robust fashion, with emphasis on clinical outcomes and standardisation of enterotomy closure and postoperative therapy.
    Full-text · Article · Jul 2011 · Diagnostic and Therapeutic Endoscopy
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