Endoskopie heute 2010; 23 - FV12
DOI: 10.1055/s-0030-1251632

Continuous monitoring of hemodynamics during complex NOTES® procedures

MA Gromski 1, SH Lee 2, SJ Thakkar 3, RB Lim 4, J Janschek 5, SB Jones 6, DB Jones 7, R Chuttani 2, K Matthes 2
  • 1Harvard Medical School, Boston, United States
  • 2Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Medicine, Division of Gastroenterology, Boston, United States
  • 3West Penn Allegheny Health System, Department of Medicine, Division of Gastroenterology, Pittsburgh, United States
  • 4Department of Surgery, Tripler Army Medical Center, TAMC, Hawaii, United States
  • 5University Hospital Carl Gustav Carus, Technical University of Dresden, Dresden, Germany
  • 6Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Anesthesia, Critical Care and Pain Medicine, Boston, United States
  • 7Harvard Medical School, Beth Israel Deaconess Medical Center, Department of Surgery, Boston, United States

Aims: Natural orifice transluminal endoscopic surgery (NOTES®) is being investigated in animal models and a limited number of procedures performed in humans. There is, however, still insufficient evidence of the impact of intraoperative cardiopulmonary effects during NOTES®. Our primary aim is to characterize the continuous hemodynamic profile of a complex NOTES® procedure.

Methods: Ten swine underwent distal pancreatic tumor enucleation under general anesthesia. This procedure involves a distinct endoscopic ultrasound phase and a distinct NOTES enucleation phase. We performed continuous hemodynamic monitoring of all study animals using PiCCO technology (Pulsion Medical, Inc.). The animals underwent percutaneous cannulation of the internal jugular vein to place a double-lumen central line and percutaneous cannulation of the femoral artery to place a proprietary catheter of Pulsion Medical. Using a thermodilution method, continuous measurement of multiple measures of hemodynamics may be measured.

Results: Continuous hemodynamic data were recorded for all experiments (average 198±51 minutes). Data from two distinct intervals of the procedure, representing the beginning of the endoscopic ultrasound (EUS) examination and the NOTES tumor enucleation are compared and presented in Table 1. When comparing the entire endoscopy-only portion versus the entire NOTES portion of the procedure, the cardiac output was greater for the NOTES portion (2.8 L/min vs. 3.1 L/min, respectively; p=0.05).

Conclusions: It is feasible to record continuous hemodynamic markers during complicated NOTES® procedures. The cardiac output was greater during the NOTES portion of the procedure compared to the endoscopy-only portion, which likely represents the increased stress of the procedure. When comparing two distinct time points in the procedure, NOTES tumor enucleation resulted in lower systemic vascular resistance and stroke volume variation, compared to the EUS-only time point. Further knowledge regarding hemodynamic variation during NOTES® is necessary before advancing the technique to large human trials, as there may be important surgical and anesthetic implications.

Tab.1: Hemodynamic Data at Distinct Endoscopy and NOTES Time Points

HR=Heart Rate; SBP=Systolic Blood Pressure (mmHg); DBP=Diastolic Blood Pressure (mmHg); SVRI=Systemic Vascular Resistance Index (dyn · m2· s–1· cm–5); SVV=stroke volume variation (%); CI=Cardiac Index (L/min/m2).

Start of EUS Examination

NOTES Tumor Enucleation

P Value

HR

94.5±13.9

86.2±10.3

0.18

SBP

84.6±8.3

80.1±10.9

0.34

DBP

55.9±9.4

52.1±9.5

0.39

SVRI

1901±373

1520±236

0.02

SVV

20.4±8.8

12.4±4.9

0.03

CI

2.7±0.9

3.2±0.6

0.17