A reliable and safe gastrotomy closure technique assessed in a porcine survival model pilot study: success of the Queen’s closure

Background and study aims: The evolution of NOTES to clinical implementation has been hampered by lack of a reliable, safe, and easy-to-implement technique for closure of the opening created in accessing the peritoneum. The Queen’s closure uses a combination of endoscopic clips and loop devices to seal such defects in the stomach wall. This study aimed to assess the Queen’s closure in a porcine survival model.

Methods: Five 30-kg pigs underwent endoscopic transgastric surgery with exploration of the peritoneum. The endoscope was then withdrawn back into the stomach and the closure performed. The animals were recovered, monitored closely, and underwent endoscopy 1 week after surgery. They were then euthanized at 2 (n = 2) and 3 (n = 3) weeks after surgery with subsequent necropsy.

Results: The mean procedure time (from intubation of the esophagus to withdrawal of the endoscope) was 79 minutes (range 45 – 105 minutes) with a mean time of exploration of the peritoneum of 14 minutes (range 8 – 25 minutes). All animals recovered well with no apparent pain, distress, or signs of infection. Endoscopic examination 1 week after surgery revealed all the closures to be intact and only identifiable by a small ulcer. At necropsy, the gastrotomy site was identifiable only by minor serosal adhesions. Histological study demonstrated full-thickness closure with minimal inflammation.

Conclusions: The Queen’s closure is a reliable and safe technique that provides full-thickness gastrotomy closure without any observed complications. The technique has proven to be transferable knowledge that holds promise for clinical implementation.

References

• 1 ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery White Paper October 2005 . .  Gastrointest Endosc. 2006;  63 199-203
• 2 Inui K. Natural orifice transluminal endoscopic surgery: a step toward clinical implementation?.  Gastrointest Endosc. 2007;  65 694-695
• 3 Swain P. A justification for NOTES – natural orifice translumenal endosurgery.  Gastrointest Endosc. 2007;  65 514-516
• 4 Isariyawongse J P, McGee M F, Rosen M J. et al . Pure natural orifice transluminal endoscopic surgery (NOTES) nephrectomy using standard laparoscopic instruments in the porcine model.  J Endourol. 2008;  22 1087-1091
• 5 Nakajima K, Takahashi T, Souma Y. et al . Transvaginal endoscopic partial gastrectomy in porcine models: the role of an extra endoscope for gastric control.  Surg Endosc. 2008;  22 2733-2736
• 6 Ramos A C, Murakami A, Galvao N M. et al . NOTES transvaginal video-assisted cholecystectomy: first series.  Endoscopy. 2008;  40 572-575
• 7 Swain P. Nephrectomy and natural orifice translumenal endoscopy (NOTES): transvaginal, transgastric, transrectal, and transvesical approaches.  J Endourol. 2008;  22 811-818
• 8 Zorron R, Maggioni L C, Pombo L. et al . NOTES transvaginal cholecystectomy: preliminary clinical application.  Surg Endosc. 2008;  22 542-547
• 9 Zorron R, Soldan M, Filgueiras M. et al . NOTES: transvaginal for cancer diagnostic staging: preliminary clinical application.  Surg Innov. 2008;  15 161-165
• 10 Mintz Y, Horgan S, Savu M K. et al . Hybrid natural orifice translumenal surgery (NOTES) sleeve gastrectomy: a feasibility study using an animal model.  Surg Endosc. 2008;  22 1798-1802
• 11 Thele F, Zygmunt M, Glitsch A. et al . How do gynecologists feel about transvaginal NOTES surgery?.  Endoscopy. 2008;  40 576-580
• 12 Dubcenco E, Grantcharov T, Streutker C J. et al . The development of a novel intracolonic occlusion balloon for transcolonic natural orifice transluminal endoscopic surgery: description of the technique and early experience in a porcine model (with videos).  Gastrointest Endosc. 2008;  68 760-766
• 13 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 (with video).  Gastrointest Endosc. 2008;  67 964-969
• 14 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
• 15 Meireles O R, Kantsevoy S V, Assumpcao L R. et al . Reliable gastric closure after natural orifice translumenal endoscopic surgery (NOTES) using a novel automated flexible stapling device.  Surg Endosc. 2008;  22 1609-1613
• 16 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
• 17 Seaman D L, Gostout C J, de la Mora L evy, Knipschield M A. Tissue anchors for transmural gut-wall apposition.  Gastrointest Endosc. 2006;  64 577-581
• 18 Sporn E, Miedema B W, Astudillo J A. et al . Gastrotomy creation and closure for NOTES using a gastropexy technique (with video).  Gastrointest Endosc. 2008;  68 948-953
• 19 Voermans R P, Worm A M, van Berge H enegouwen. et al . In vitro comparison and evaluation of seven gastric closure modalities for natural orifice transluminal endoscopic surgery (NOTES).  Endoscopy. 2008;  40 595-601
• 20 Chiu P W, Lau J Y, Ng E K. et al . Closure of a gastrotomy after transgastric tubal ligation by using the Eagle Claw VII: a survival experiment in a porcine model (with video).  Gastrointest Endosc. 2008;  68 554-559
• 21 Hookey L C, Khokhotva V, Bielawska B. et al . The Queen’s closure: a novel technique for closure of endoscopic gastrotomy for natural-orifice transluminal endoscopic surgery.  Endoscopy. 2009;  41 149-153
• 22 Desilets D J, Mader T J, Romanelli J R, Earle D. Gastric transmural pressure measurements in vivo: implications for natural orifice transluminal endoscopic surgery (NOTES^®).  Gastrointest Endosc. 2009;  69 AB305