Submucosal tunneling using endoscopic submucosal dissection for peritoneal access and closure in natural orifice transluminal endoscopic surgery: a porcine survival study

Background and study aims: Safe peritoneal access and gastric closure are the most important concerns in the clinical application of natural orifice transluminal endoscopic surgery (NOTES). We aimed to clarify the feasibility of a submucosal tunnel technique using endoscopic submucosal dissection (ESD) for transgastric peritoneal access and subsequent closure for NOTES.

Methods: Seven female pigs, each weighing about 40 kg were included in the study. The following procedures were performed: (i) after injection of normal saline into the submucosa, the mucosa was cut with a flex knife; (ii) the submucosal layer was dissected using an insulation-tipped electrosurgical knife to make a narrow longitudinal 50-mm submucosal tunnel; (iii) a small incision was made at the end of the tunnel and enlarged with a dilation balloon. After transgastric peritoneoscopy, the mucosal incision site was closed with clips. The following outcome measures were used: (a) evaluation of the technical feasibility of making a submucosal tunnel; (b) clinical monitoring for 7 days; (c) follow-up endoscopy and necropsy; and (d) peritoneal fluid culture.

Results: Natural orifice transluminal endoscopic peritoneoscopy with a submucosal tunnel was successfully carried out in all pigs. The pigs recovered well, without signs of peritonitis. Follow-up endoscopy showed healing of mucosal incision sites without open defects. Necropsy revealed no findings of peritonitis, confirming completeness of gastric closure; there was a thin scar in one pig and adhesion of the omentum in six pigs. Peritoneal fluid culture demonstrated no bacterial growth.

Conclusions: The submucosal tunnel technique is feasible and effective for transgastric peritoneal access and closure.

References

• 1 Baron T H. Natural orifice transluminal endoscopic surgery.  Br J Surg. 2007;  94 1-2
• 2 Pearl J P, Ponsky J L. Natural orifice translumenal endoscopic surgery: a critical review.  J Gastrointest Surg. 2008;  12 1293-1300
• 3 Swain C P. A justification for NOTES – natural orifice translumenal endoscopic surgery [editorial].  Gastrointest Endosc. 2007;  65 514
• 4 Hawes R H. ASGE/SAGES Working Group on natural orifice translumenal endoscopic surgery.  Gastrointest Endosc. 2006;  63 199-203
• 5 Rattner D, Kalloo A N. ASGE/SAGES Working Group on natural orifice translumenal endoscopic surgery.  Surg Endosc. 2006;  20 329-333
• 6 Voermans R P, Van Berge Henegouwen M I, Fockens P. Natural orifice transluminal endoscopic surgery (NOTES).  Endoscopy. 2007;  39 1013-1017
• 7 Kalloo A N, Singh V K, Jagannath S B. et al . Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic intervention in the peritoneal cavity.  Gastrointest Endosc. 2004;  60 114-117
• 8 Park P O, Bergstrome M, Ikeda K. et al . Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis.  Gastrointest Endosc. 2005;  61 601-606
• 9 Jagannath S B, Kantsevoy S V, Vaughn C A. et al . Peroral transgastric endoscopic ligation of fallopian tubes with long term survival in a porcine model.  Gastrointest Endosc. 2005;  61 449-453
• 10 Feretis C, Kalantzopoulos D, Koulouris P. et al . Endoscopic transgastric procedures in anesthetized pigs: technical challenges, complications, and survival.  Endoscopy. 2007;  39 394-400
• 11 Kantsevoy S V, Jagannath S B, Niiyama H. et al . Endoscopic gastrojejunostomy with survival in a porcine model.  Gastrointest Endosc. 2005;  62 287-292
• 12 Marescaux J, Dallemagne B, Perretta S. et al . Surgery without scars.  Arch Surg. 2007;  142 823-826
• 13 Bessler M, Stevens P D, Milone L. et al . Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid approach to natural orifice surgery.  Gastrointest Endosc. 2007;  66 1243-1245
• 14 Ono H, Kondo H, Gotoda T. et al . Endoscopic mucosal resection for treatment of early gastric cancer.  Gut. 2001;  48 225-229
• 15 Gotoda T, Yamamoto H, Soetikno R M. Endoscopic submucosal dissection of early gastric cancer.  J Gastroenterol. 2006;  41 929-942
• 16 Ikeda K, Fritscher-Ravens A, Mosse C A. et al . Endoscopic full-thickness resection with sutured closure in a porcine model.  Gastrointest Endosc. 2005;  62 122-129
• 17 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
• 18 Hu B, Chung S C, Sun L C. et al . Eagle Claw II: A novel endosuture device that uses a curved needle for major arterial bleeding: a bench study.  Gastrointest Endosc. 2005;  62 266-270
• 19 Merrifield B F, Wagh M S, Thompson C C. Peroral transgastric organ resection: a feasibility study in pigs.  Gastrointest Endosc. 2006;  63 693-697
• 20 Sumiyama K, Gostout C J, Rajan E. et al . Submucosal endoscopy with mucosal flap safety valve.  Gastrointest Endosc. 2007;  65 688-694
• 21 Sumiyama K, Gostout C J, Rajan E. et al . Transgastric cholecystectomy: transgastric accessibility to the gallbladder improved with the SEMF method and a novel multibending therapeutic endoscope.  Gastrointest Endosc. 2007;  65 1028-1034
• 22 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.  Gastrointest Endosc. 2007;  66 974-978
• 23 Delius S V, Gillen S, Doundoulakis E. et al . Comparison of transgastric access techniques for natural orifice transluminal endoscopic surgery.  Gastrointest Endosc. 2008;  68 940-947
• 24 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