Transgastric instrumentation and bacterial contamination of the peritoneal cavity

Introduction Natural orifice transluminal endoscopic surgery (NOTES) is a rapidly evolving technique providing access to the peritoneum utilizing an endoscope via a natural orifice. One of the most significant requirements of this technique is the need to minimize the risk of clinically significant peritoneal contamination. We report the bacterial load and contamination of the peritoneal cavity in patients requiring a gastrotomy Roux-en-Y gastric bypass (LSRYGB). Methods We prospectively studied 50 patients undergoing a gastrotomy with creation of a gastrojejunostomy during LSRYGB. We recorded the patient’s proton-pump inhibitor (PPI) utilization preoperatively and sampled gastric contents without lavage. We also sampled peritoneal fluid prior to and after gastrotomy, noting the length of time the gastrotomy was open to the peritoneum. Each of the three samples was sent for bacterial colony counts, and culture with identification of species. Results Fifty patients underwent LSRYGB with a mean operative time of 93 min. The gastrotomy was open to the peritoneal cavity for an average of 18 min. Seventeen of 50 patients were on PPIs preoperatively, resulting in a significant difference in postgastrostomy peritoneal bacterial counts. The average number of colony-forming units (CFU) of the gastric aspirate was 22,303 CFU/ml. Peritoneal aspirates obtained for examination prior to creation of a gastrotomy showed no CFUs in 44 of 50 patients. Peritoneal sampling after gastrotomy showed contamination of the abdomen with an average of 1102 CFU/ml. There was no correlation between the bacterial load in the stomach and peritoneal load after gastrotomy. No infectious complications or leaks developed. One complication of rhabdomyolysis in a patient with no peritoneal bacterial contamination developed. Conclusions Transgastric instrumentation does contaminate the abdominal cavity but pathogens are clinically insignificant due to species or bacterial load. Patients on PPIs do have an increased bacterial load in the gastric aspirate, with no clinical significant infection.     

Transgastric endoscopic peritoneoscopy does not require decontamination of the stomach in humans

Introduction  Natural orifice translumenal endoscopic surgery (NOTES) is a rapidly evolving field that provides endoscopic access to the peritoneum via a natural orifice. One important requirement of this technique is the need to minimize the risk of clinically significant peritoneal contamination. We report the bacterial load and contamination of the peritoneal cavity in ten patients who underwent diagnostic transgastric endoscopic peritoneoscopy. Methods  Patients participating in this trial were scheduled to undergo diagnostic laparoscopy for evaluation of presumed pancreatic cancer. Findings at diagnostic laparoscopy were compared with those of diagnostic transgastric endoscopic peritoneoscopy, using an orally placed gastroscope, blinding the endoscopist to the laparoscopic findings. We performed no gastric decontamination. Diagnostic findings, operative times, and clinical course were recorded. Gastroscope and peritoneal fluid aspirates were obtained prior to and after the gastrotomy. Each sample was sent for bacterial colony counts, culture, and identification of species. Results  Ten patients, with an average age of 63.7 years, have completed the protocol. All patients underwent diagnostic laparoscopy followed by successful transgastric access and diagnostic peritoneoscopy. The average time for laparoscopy was 7.2 min, compared with 18 min for transgastric instrumentation. Bacterial sampling was obtained in all ten patients. The average number of colony-forming units (CFU) in the gastroscope aspirate was 132.1 CFU/ml, peritoneal aspirates prior to creation of a gastrotomy showed 160.4 CFU/ml, and peritoneal sampling after gastrotomy had an average of 642.1 CFU/ml. There was no contamination of the peritoneal cavity with species isolated from the gastroscope aspirate. No infectious complications or leaks were noted at 30-day follow-up. Conclusions  There was no clinically significant contamination of the peritoneal cavity from the gastroscope after transgastric endoscopic instrumentation in humans. Transgastric instrumentation does contaminate the abdominal cavity but, the pathogens do not mount a clinically significant response in terms of either the species or the bacterial load.     

Development of a new access device for transgastric surgery

Flexible endoscope-based endoluminal and transgastric surgery for cholecystectomy, appendectomy, bariatric, and antireflux procedures show promise as a less invasive form of surgery. Current endoscopes and instruments are inadequate to perform such complex surgeries for a variety of reasons: they are too flexible and are insufficient to provide robust grasping and anatomic retraction. The lack of support for a retroflexed endoscope in the peritoneal cavity makes it hard to reach remote structures and makes vigorous retraction of tissues and organs difficult. There is also a need for multiple channels in scopes to allow use of several instruments and to provide traction/countertraction. Finally, secure means of tissue approximation are critical. The aim was to develop and test a new articulating flexible endoscopic system for endoluminal and transgastric endosurgery. A multidisciplinary group of gastrointestinal physicians and surgeons worked with medical device engineers to develop new devices and instruments. Needs assessments and design parameters were developed by consensus. Prototype devices were tested using inanimate models until usable devices were arrived at. The devices were tested in nonsurvival pigs and dogs. The devices were accessed through an incision in the wall of the stomach and manipulated in the peritoneal cavity to accomplish four different tasks: right upper quadrant wedge liver biopsy, right lower quadrant cecal retraction, left lower quadrant running small bowel, and left lower quadrant exposure of esophageal hiatus. In another three pigs, transgastric cholecystectomy was attempted. The positions of the device, camera, and endosurgical instruments, with and without ShapeLock technology, were recorded using laparoscopy and endoscopy and procedure times and success rates were measured. Instrument design parameters and their engineering solutions are described. Flexible multilumen guides which could be locked in position, including a prototype which allowed triangulation, were constructed. Features of the 18-mm devices include multidirectional mid body and/or tip angulation, two 5.5-mm accessory channels allowing the use of large (5-mm) flexible endosurgical instruments, as well as a 4-mm channel for an ultraslim prototype video endoscope (Pentax 4 mm). Using the resulting devices, the four designated transgastric procedures were performed in anesthetized animals. One hundred percent of the transgastric endosurgical procedures were accomplished with the exception of a 50% success for hiatal exposure, a 90% success rate for wedge liver biopsy, and a 33.3% success rate for cholecystectomy. A new endosurgical multilumen device and advanced instrumentation allowed effective transgastric exploration and procedures in the abdominal cavity including retraction of the liver and stomach to allow exposure of the gallbladder, retraction of the cecum, manipulation of the small bowel, and exposure of the esophageal hiatus. This technology may serve as the needed platform for transgastric cholecystectomy, gastric reduction, fundoplication, hiatus hernia repair, or other advanced endosurgical procedures. Presented at the Forty-Sixth Annual Meeting of The Society for Surgery of the Alimentary Tract, Chicago, Illinois, May 14–18, 2005 (oral presentation). Partially funded and supported by USGI Medical, San Clemente, California.     

Endoloop application as an alternative method for gastrotomy closure in experimental transgastric surgery

Background Experimental studies investigating transgastric endoscopic surgery report closure of the gastric wall incision with clips. The author of this report describes endoloop placement as an alternative, equally efficient, faster method for gastrotomy closure. Methods Eight female pigs with a mean weight of 30 kg were used. Abdominal endoscopic exploration and transgastric operations including hepatic biopsies, bilateral tubal ligation, cholecystectomy, and closure of the gastrotomy were performed. The experiment was divided into two parts. The first part included five animals, which were killed immediately after the procedure. The second part included five animals, which were kept alive and killed 15 to 20 days later. Results The first part of the experiment, performed for technical skills acquisition, involved transgastric abdominal exploration, liver biopsies, and bilateral tubal ligation, which were successful for all five animals. The gastric wall incision was closed by applying clips in four animals and endoloops in one animal. During the autopsy at the end of the experiment, the sites of intervention were examined macroscopically. In the second part of the experiment, gastrotomy closure with endoloop application was performed in two animals and with clip application in one animal. All three animals survived, gained weight, and demonstrated no signs of infection. They were killed 15 to 20 days after the procedure, and no signs of intraabdominal infection were found. Cultures from the peritoneal cavity were negative. At necropsy, macroscopic and microscopic examination confirmed complete healing of the gastrotomy. Conclusions Transgastric endoscopic surgery is technically feasible and effective. The application of endoloops for closure of the gastric opening is a fast, easy, and equally safe alternative to clip placement. An erratum to this article can be found at     

Evaluating an optimal gastric closure method for transgastric surgery

Background The transgastric approach is currently being studied as a potentially less invasive alternative to conventional laparoscopy for intra-abdominal surgery. A major obstacle to overcome is the closure of the transgastric incision in a rapid, reproducible, and safe manner. The effectiveness of various techniques for gastrotomy closure were compared by assessing leak pressures in an ex vivo porcine stomach model. Methods Whole stomachs from adult white pigs were suspended in a Plexiglas box to facilitate endoscopic technique. Standard gastrotomies were made by needle knife incision and dilation with a controlled radial expansion (CRE) balloon. The first arm used standard QuickClips™; the second, a prototype device developed by LSI Solutions; the third, hand-sewn by a senior surgeon; the final, a control with open gastrotomy. Five stomachs were tested per study arm. After closure, each stomach was inflated by an automated pressure gauge. The pressures to achieve air leakage and liquid leakage were recorded. Results The unclosed controls demonstrated air leakage at a median pressure of 15 mmHg, representing baseline system resistance. The QuickClip closures leaked air at a median pressure of 33 mmHg. The prototype gastrotomy device yielded the highest median air leak pressure of 85 mmHg while dramatically diminishing time for incision and gastrotomy closure to approximately 5 min. The hand-sewn closures leaked air at a median pressure of 47 mmHg. Using Kruskal-Wallis statistical analysis, the comparisons were significant (p = 0.0019). Post hoc paired comparisons using MULTTEST procedure with both Bonferroni and bootstrap adjustments revealed that the difference between prototype and clips was significant; prototype versus hand-sewn was not. Liquid-leak pressures produced similar results. Conclusions The prototype device decreases procedure time and yields leak-resistant gastrotomy closures that are superior to clips and rival hand-sewn interrupted stitches. An erratum to this article can be found at     

Endoluminal and transluminal surgery: current status and future possibilities

The field of minimally invasive surgery has seen tremendous growth since the first laparoscopic cholecystectomy was performed in 1987. The key question is not how successful these techniques are currently, but rather where may they lead in the future? New technologies promise to usher in an era of even less invasive procedures. The terms being coined in the literature include “incisionless,” “endoluminal,” “transluminal,” and “natural orifice” transluminal endoscopic surgery. These techniques certainly have the potential to become the next wave of minimally invasive procedures. A recent editorial in Surgical Endoscopy by Macfadyen and Cuschieri highlighted the ongoing developments in endoscopic surgery and stressed the critical importance of surgeons being involved in future applications and permutations of these techniques [1]. There are early signs of such involvement. The work of numerous investigators in the field was presented recently at the 2005 Digestive Disease Week. The American Society for Gastrointestinal Endoscopy and the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), in collaboration with the American College of Surgeons, recently organized a postgraduate course in endoluminal therapy at the spring 2005 meeting held in Hollywood, Florida. The course is being offered again at the 2006 SAGES annual meeting. Similar courses are being offered at other regional and national meetings. This review attempts to highlight some of the available and evolving endoluminal therapies reviewed at that forum, including techniques for the management of gastroesophageal reflux disease, endoscopic mucosal resection, endoluminal bariatric surgery, transanal endoscopic microsurgery, and transgastric endoscopic surgery, as well as new technologies and possible future directions in luminal access surgery.     

胃肠肿瘤腹腔镜手术中内镜检查的应用价值

目的评价胃肠肿瘤腹腔镜手术中内镜检查的应用价值。方法回顾分析2004年1月～2008年11月我院505例胃肠肿瘤腹腔镜手术中39例(7.7%)术中内镜检查的临床资料。结果 32例以定位病变为指征,其中30例找到病变,检出率达93.8%(30/32);5例以评价吻合口为指征,术后均未出现吻合口狭窄,其中3例同时内镜定位病变切除了合并存在的结肠腺瘤;1例术中出血,行术中内镜明确了出血部位;1例拟在腹腔镜辅助下行内镜下胃脂肪瘤切除,因内镜下注射后抬举征阴性,提示病变深度超过黏膜下层,故改为腹腔镜下切除。结论术中内镜检查对腹腔镜胃肠肿瘤手术病变定位及吻合口评估有重要价值。     

Reliable gastric closure after natural orifice translumenal endoscopic surgery (NOTES) using a novel automated flexible stapling device

Background  Reliable closure of the translumenal incision is one of the main challenges facing natural orifice translumenal endoscopic surgery (NOTES). This study aimed to evaluate the use of an automated flexible stapling device (SurgASSIST) for closure of the gastrotomy incision in a porcine model. Methods  A double-channel gastroscope was advanced into the stomach. A gastric wall incision was made, and the endoscope was advanced into the peritoneal cavity. After peritoneoscopy, the endoscope was withdrawn into the stomach. The SurgASSIST stapler was advanced orally into the stomach. The gastrotomy edges were positioned between the opened stapler arms using two endoscopic grasping forceps. Stapler loads with and without a cutting blade were used for gastric closure. After firing of the stapler to close the gastric wall incision, x-ray with contrast was performed to assess for gastric leakage. At the end of the procedure, the animals were killed for a study of closure adequacy. Results  Four acute animal experiments were performed. The delivery and positioning of the stapler were achieved, with technical difficulties mostly due to a short working length (60 cm) of the device. Firing of the staple delivered four rows of staples. Postmortem examination of pig 1 (when a cutting blade was used) demonstrated full-thickness closure of the gastric wall incision, but the cutting blade caused a transmural hole right at the end of the staple line. For this reason, we stopped using stapler loads with a cutting blade. In the three remaining animals (pigs 2–4), we were able to achieve a full-thickness closure of the gastric wall incision without any complications. Conclusions  The flexible stapling device may provide a simple and reliable technique for lumenal closure after NOTES procedures. Further survival studies are currently under way to evaluate the long-term efficacy of gastric closure with the stapler after intraperitoneal interventions. Presented in part at the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) Annual Meeting, Las Vegas, Nevada, April 2007.     

快速康复外科在胃肠手术中的新理念及展望

快速康复外科是一种广泛应用于外科手术中的理念,贯穿患者手术前后的整个治疗过程,通过采取一系列积极措施,极大地改善了患者术后康复速度及预后,提高了治疗效果及患者生活质量.本文综述了快速康复外科在胃肠外科围手术期的新理念及应用展望.     

胃肠手术中吻合器的选择及合理使用

消化道重建是胃肠手术的重要组成部分。随着吻合器技术的快速发展和广泛应用，越来越多的外科医生选择机械吻合来完成消化道重建。机械吻合相比于手工缝合．能明显缩短手术时间，减少住院天数。但在种类繁多的手术器械中选择适合的吻合器械并进行规范的操作并非易事。现就胃肠手术中吻合器的选择及其合理应用进行总结和评价。     

论＂损伤控制性外科＂理念在胃肠外科中的应用

近年来,应用＂损伤控制性外科＂来救治一些危重的创伤患者取得了较大的成功.我们认为,损伤控制性外科这一理念也同样适用于胃肠外科危重患者的救治,因为这些危重患者与创伤患者有类似的病理生理改变--即低温、酸中毒和凝血功能障碍,这＂致命三联＂形成一个恶性循环,使得患者不能承受传统的常规大手术打击.对于胃肠外科危重患者,实施损伤控制性外科的理念,总体原则应该是先用最小的方式解决出血、梗阻和感染等危及生命的病况,待患者病情稳定后,再择期行确定性手术,从而提高患者的存活率.具体可分为3阶段,第一阶段：急诊手术用最小的创伤解决出血、梗阻和（或）感染等问题,改善患者状况 第二阶段：在监护病房恢复措施包括稳定血流动力学、纠正凝血功能障碍及酸中毒、复温和机械通气等 第三阶段：择期行确定性手术.     

Management of obliterated urinary segments using a laser fiber for access

PURPOSE: We describe a modification of the cut to the light and core-through procedures using a laser fiber to gain through and through access for treatment of complete occlusion of the ureter or urethra. MATERIALS AND METHODS: Three patients presented with complete obliteration of the ureter (2) and vesicourethral anastomosis (1). In each case the laser fiber was advanced through the obliterated segment under direct vision and then exchanged for a standard guide wire using an open ended catheter. RESULTS: Through and through access was obtained in all 3 cases and allowed subsequent incision for repair. In all 3 patients the area of incision was stented and urinary continuity was restored. CONCLUSIONS: Loss of access can lead to complications and termination of any endoscopic procedure. Use of the laser fiber to incise through the obliterated segment and subsequently act as a guide wire in our experience minimized the possibility for loss of access. The disadvantage is the cost of the laser fiber, which cannot be reused. Use of a laser fiber as a guide wire can be a viable and effective option for gaining access across strictures when alternative methods fail.     

Principles of renal access surgery

The treatment of end stage renal failure is renal replacement therapy. This may be by dialysis (blood or peritoneal) or by kidney transplantation. The outlook for those who have a successful renal transplant has improved massively over the past 20 years with graft survival of a mean of 14 years from non-heart beating donation and 18 years for live donated transplant.     

Optimizing contraceptive access for women undergoing bariatric surgery

With the dramatic increase in the prevalence of obesity, there is a corresponding increase in surgical procedures to treat obesity. Reproductive aged women (18–45 years old) undergo half of the bariatric surgical procedures performed in the United States each year. These women experience profound physiologic changes in response to bariatric surgery, including dramatic changes in reproductive function. Current guidelines recommend delaying attempts at conception for 12–24 months after bariatric surgery during the time of most profound weight loss. Despite these recommendations, many women report unprotected intercourse during this time, and many use less efficacious contraceptive options. Herein, we address contraceptive considerations in women of reproductive age who undergo bariatric surgery and opportunities to maximize a multidisciplinary surgical approach to optimize their overall health.     

The results of direct access day surgery for minor operations

Direct access surgery (DAS) is a method of patient management which eliminates many of the common delays in providing treatment. It relies on accurate correspondence from general practitioners and a degree of confidence in these referrals so that preoperative assessment is made on the day of surgery and postoperative wound management performed in the community. This is a retrospective study of 5776 patients treated over 5 yr for minor surgical procedures under the care of one consultant at Kingston NHS Hospital Trust. Half of these patients, mostly with skin lesions, were dealt with using the direct access approach. No clinical problems were experienced in those patients treated by DAS and a very significant reduction in waiting time for more serious conditions was achieved in the outpatient department. It is concluded that DAS is the method of choice for minor skin lesions and that the technique should be used in the future for more complex procedures.     

胸腔镜辅助下小切口在胸椎前路手术的临床应用

目的探讨胸腔镜辅助下小切口行胸椎前路手术的可行性. 方法 2001年10月～2002年10月,我院在胸腔镜辅助下小切口行胸椎前路手术14例.其中6例胸椎转移瘤行病变椎体切除、钢板骨水泥椎体重建及前路针棒内固定;4例胸椎结核行病灶清除、植骨及前路钉棒内固定;2例胸椎间盘突出症行髓核摘除、椎间植骨融合;2例胸椎椎体骨折合并脱位行脱位椎体复位、椎管减压、椎体间植骨及前路钉棒内固定. 结果术后影像学显示病灶清除彻底,内固定效果确切.14例术后随访 4～12个月,14例胸背痛完全消失,13例脊髓压迫症中除1例转移瘤无改善外,其余12例肌力术前A～D级,术后恢复至C～E级. 结论胸腔镜辅助下小切口行胸椎前路手术方法可行,近期疗效满意.     

腹腔镜诊治胃肠道急腹症146例

目的 探讨腹腔镜在胃肠外科急腹症诊治中的应用价值.方法 回顾分析我院2008年10月至2011年12月问接受腹腔镜探查治疗的146例胃肠外科急腹症患者的临床资料,并将其中的阑尾炎及上消化道穿孔手术与同期开腹手术比较.结果 本组146例患者全部在腹腔镜下明确诊断,其中129例运用腹腔镜治疗成功,17例中转开腹手术,无术中并发症发生,术后未发生腹腔残余感染、肠梗阻、胃肠瘘等,2例发生穿刺孔感染.将其中腹腔镜下阑尾切除及上消化道穿孔修补病例与同期开腹手术比较,结果 表明在术中出血、术后止痛药用量、胃肠道功能恢复时问、切口感染及住院天数等方面具有明显优势.结论 腹腔镜技术在胃肠外科急腹症诊治中安全有效,具有显著的优势.     

单孔腹腔镜技术在胃肠外科手术中应用的问题与决策

经脐单孔腹腔镜外科技术足现阶段最为町行的“无瘢痕”手术．国内外均已将该技术应用于胃肠外科于术一本文结合作者的经验,就经脐单孔腹腔镜外科技术任胃肠外科领域的应用现状、所而临问题和相应对策进行探讨．直线视野、器械难以彤成三角关系及Trocar与器械手柄仡腹腔外部分的拥挤等是单孔腹腔镜外科技术的操作难点,单孔条件下进行胃或结直肠手术时上述难点更为凸硅提高手术技能、选择合适的单孔腔镜器械、相对同定单孔腹腔镜手术同队以及灵活的暴露方法等可以保证单孔胃或结区肠手术的安全进行为了保证单孔腹腔镜技术被大家所接受并坚持开展,胃肠道恶性肿瘤手术的安全性和彳丁效性峨需评价,单孔腹腔镜技术作为一种新兴的外科技术．住初涉胃肠道肿瘤治疗领域后的进一步发展离不开理念的认同、技术瓶颈的突破及器械的更新,