Transgastric endoscopic gastroenterostomy using a partially covered occluder: a canine feasibility study^[1]

Background and study aims: The use of natural orifice transluminal endoscopic surgery (NOTES) for gastroenterostomy has been previously reported, but it remains technically challenging and additional assistance is often needed. The aim of this study was to develop and evaluate a novel method for the creation of a gastroenterostomy using NOTES with an occluder.

Methods: Transgastric endoscopic gastroenterostomy was performed in 12 healthy female dogs using a therapeutic upper gastrointestinal endoscope and a partially covered occluder. The occluder was removed with a snare 1 week later. The patency of the gastroenterostomy was confirmed by endoscopy, contrast radiological study, necropsy, and histological examination after 2 weeks.

Results: NOTES gastroenterostomy with an occluder was successful in all 12 dogs. The mean operative time was 32.3 ± 10.3 min (range 20.3 – 53.5). One dog (the first; 8.3 %) died 4 days after the operation of severe intra-abdominal infection due to incorrect deployment of the occluder and poor bowel preparation. Minor bleeding occurred at the anastomosis after removal of the occluder in two of the remaining dogs (18.2 %). Necropsy revealed postoperative adhesions that had developed at the anastomotic site in one dog (9.1 %). No anastomotic leakage or intestinal obstruction was observed. Complete healing of the anastomosis was confirmed on histological evaluation.

Conclusion: Gastroenterostomy performed entirely by NOTES using an occluder was technically feasible in this survival animal model.

• References

• 1 Ly J, O’Grady G, Mittal A et al. A systematic review of methods to palliate malignant gastric outlet obstruction. Surg Endosc 2010; 24: 290-297
• 2 Hamad MA, Mentges B, Buess G. Laparoscopic sutured anastomosis of the bowel. Surg Endosc 2003; 17: 1840-1844
• 3 Shang E, Hasenberg T, Magdeburg R et al. First experiences with a circular stapled gastro-jejunostomy by a new transorally introducible stapler system in laparoscopic Roux-en-Y gastric bypass. Obes Surg 2009; 19: 230-236
• 4 Higa KD, Boone KB, Ho T. Complications of the laparoscopic Roux-en-Y gastric bypass: 1,040 patients – what have we learned?. Obes Surg 2000; 10: 509-513
• 5 Scott JD, Cobb WS, Carbonell AM et al. Reduction in anastomotic strictures using bioabsorbable circular staple line reinforcement in laparoscopic gastric bypass. Surg Obes Relat Dis 2011; 7: 637-642
• 6 Schiesser M, Guber J, Wildi S et al. Utility of routine versus selective upper gastrointestinal series to detect anastomotic leaks after laparoscopic gastric bypass. Obes Surg 2010; 21: 1238-1242
• 7 Edwards MA, Jones DB, Ellsmere J et al. Anastomotic leak following antecolic versus retrocolic laparoscopic Roux-en-Y gastric bypass for morbid obesity. Obes Surg 2007; 17: 292-297
• 8 Pearl JP, Ponsky JL. Natural orifice translumenal endoscopic surgery: a critical review. J Gastrointest Surg 2008; 12: 1293-1300
• 9 Freeman LJ, Rahmani EY, Al-Haddad M et al. Comparison of pain and postoperative stress in dogs undergoing natural orifice transluminal endoscopic surgery, laparoscopic, and open oophorectomy. Gastrointest Endosc 2010; 72: 373-380
• 10 Kantsevoy SV, Jagannath SB, Niiyama H et al. Endoscopic gastrojejunostomy with survival in a porcine model. Gastrointest Endosc 2005; 62: 287-292
• 11 Bergstrom M, Ikeda K, Swain P et al. Transgastric anastomosis by using flexible endoscopy in a porcine model (with video). Gastrointest Endosc 2006; 63: 307-312
• 12 Chiu PW, Wai Ng EK, Teoh AY et al. Transgastric endoluminal gastrojejunostomy: technical development from bench to animal study (with video). Gastrointest Endosc 2010; 71: 390-393
• 13 Ryou M, Cantillon-Murphy P, Azagury D et al. Smart Self-Assembling MagnetS for ENdoscopy (SAMSEN) for transoral endoscopic creation of immediate gastrojejunostomy (with video). Gastrointest Endosc 2011; 73: 353-359
• 14 Alam TA, Baines M, Parker MC. The management of gastric outlet obstruction secondary to inoperable cancer. Surg Endosc 2003; 17: 320-323
• 15 Jeurnink SM, Steyerberg EW, Hof G et al. Gastrojejunostomy versus stent placement in patients with malignant gastric outlet obstruction: a comparison in 95 patients. J Surg Oncol 2007; 96: 389-396
• 16 Jeurnink SM, van Eijck CH, Steyerberg EW et al. Stent versus gastrojejunostomy for the palliation of gastric outlet obstruction: a systematic review. BMC Gastroenterol 2007; 7: 18
• 17 Bessoud B, de Baere T, Denys A et al. Malignant gastroduodenal obstruction: palliation with self-expanding metallic stents. J Vasc Interv Radiol 2005; 16: 247-253
• 18 Gutzeit A, Binkert CA, Schoch E et al. Malignant gastroduodenal obstruction: treatment with self-expanding uncovered wallstent. Cardiovasc Intervent Radiol 2009; 32: 97-105
• 19 Lock JE, Block PC, McKay RG et al. Transcatheter closure of ventricular septal defects. Circulation 1988; 78: 361-368
• 20 Mills NL, King TD. Nonoperative closure of left-to-right shunts. J Thorac Cardiovasc Surg 1976; 72: 371-378
• 21 Rabenstein T, Boosfeld C, Henrich R et al. First use of ventricular septal defect occlusion device for endoscopic closure of an esophagorespiratory fistula using bronchoscopy and esophagoscopy. Chest 2006; 130: 906-909
• 22 Kouklakis G, Zezos P, Liratzopoulos N et al. Billroth II gastrectomy complicated by gastrojejunocolonic fistulas, treated endoscopically with a cardiac septal defect closure device. Endoscopy 2010; 42 (Suppl. 2): E134-E135
• 23 Zhang J, Hu S, Gao B et al. Interventional closure of postpneumonectomy bronchial pleural fistula with a self-expandable double umbrella-shaped occluder knitted with nitinol shape memory alloy. J Thorac Cardiovasc Surg 2007; 134: 531-533
• 24 Perretta S, Sereno S, Forgione A et al. A new method to close the gastrotomy by using a cardiac septal occluder: long-term survival study in a porcine model. Gastrointest Endosc 2007; 66: 809-813
• 25 Cope C, Ginsberg GG. Long-term patency of experimental magnetic compression gastroenteric anastomoses achieved with covered stents. Gastrointest Endosc 2001; 53: 780-784
• 26 van Hooft JE, Vleggaar FP, Le Moine O et al. Endoscopic magnetic gastroenteric anastomosis for palliation of malignant gastric outlet obstruction: a prospective multicenter study. Gastrointest Endosc 2010; 72: 530-535
• 27 Kantsevoy SV, Niiyama H, Jagannath SB et al. The endoscopic transilluminator: an endoscopic device for identification of the proximal jejunum for transgastric endoscopic gastrojejunostomy. Gastrointest Endosc 2006; 63: 1055-1058
• 28 Elmunzer BJ, Schomisch SJ, Trunzo JA et al. EUS in localizing safe alternate access sites for natural orifice transluminal endoscopic surgery: initial experience in a porcine model. Gastrointest Endosc 2009; 69: 108-114
• 29 Sohn DK, Turner BG, Gee DW et al. Reducing the unexpectedly high rate of injuries caused by NOTES gastrotomy creation. Surg Endosc 2010; 24: 277-282