Per‐oral transgastric abdominal surgery

Laparoscopic surgery has several advantages over traditional surgery because it has been shown to be less invasive. The next logical step in the evolution of minimally invasive surgery may be to eliminate all abdominal incisions. The natural orifices provide a port of entry via the gastrointestinal tract to the peritoneal cavity. This approach would require the creation of a perforation, which is considered to be a major complication of endoscopy with significant morbidity and mortality. However, there are several recent studies that have described the technical feasibility and safety of a per‐oral transgastric approach to the peritoneal cavity using conventional endoscopes. Theoretically, this approach could reduce postoperative abdominal wall pain, wound infection, hernia formation, and adhesions. This article aims to summarize the current status of transgastric surgery, currently referred to as natural orifice transluminal endoscopic surgery (NOTES), and to address some of its future challenges.     

NATURAL ORIFICE TRANSLUMENAL ENDOSCOPIC SURGERY FOR PREOPERATIVE STAGING IN A PANCREATIC CANCER PATIENT

Background: Many experimental studies have shown the technical feasibility of natural orifice translumenal endoscopic surgery (NOTES). We report the first clinical application of natural orifice transgastric endoscopic peritoneoscopy in Japan for preoperative staging in a patient with pancreatic cancer. Methods: A submucosal tunnel was created for safe peritoneal access and secure closure of the gastric‐incision site. Results: Transgastric peritoneoscopy provided an excellent view and allowed approach to various areas of the abdominal cavity. After confirmation of operative curability, the patient underwent an open standard operation without complication. Conclusions: Natural orifice transgastric endoscopic peritoneoscopy for cancer staging using the submucosal tunnel technique appears to be feasible and safe.     

Initial experience from the transgastric endoscopic peritoneoscopy and biopsy: a stepwise approach from the laboratory to clinical application

Background and Aim: Natural‐orifice translumenal endoscopic surgery (NOTES) is a newly minimally invasive technique that gives access to the abdominal cavity via transgastric, transcolonic, transvaginal or transvesical routes. The aim of the present study was to evaluate the safety and feasibility of transgastric endoscopic peritoneoscopy and biopsy from laboratory to clinical application. Methods: With the animals under general anesthesia, a sterile esophageal overtube was placed and a gastric antibiotic lavage was performed. Subsequently, a needle‐knife and through‐the‐scope dilating balloon were used to make an anterior gastric wall incision through which a therapeutic gastroscope was advanced into the peritoneal cavity. After 2 weeks, another transgastric endoscopic exploration was performed in a different location of the stomach. The peritoneal cavity was examined before the gastric incision was closed. After 4 weeks of observation, necropsy was performed. In the clinical application, after gastric lavage, the first step was the creation of the gastrotomy under general anesthesia, sometime under direct vision of the laparoscopic scope. Then the endoscope can be maneuvered in the peritoneal cavity. And peritoneoscopy and biopsy were performed. Biopsies can be obtained from any suspicious areas using punch biopsy forceps. The gastrotomy was then closed with clips. The gastroscopy was examined after one week. Results: Twenty‐eight transgastric endoscopic peritoneoscopies and biopsies in pigs and a total of five transgastric human endoscopic peritoneoscopies and biopsies have been performed. All procedures were completed satisfactorily in the pig model and all patients. There were no intraoperative or postoperative complications. Conclusions: The advantages of peritoneoscopy and biopsy appeared to be enhanced by this approach. Patients had minor postoperative pain and minimal scarring. It is safe and feasible for us to use transgastric endoscopic peritoneoscopy and biopsy in humans.     

Apical transgastric echocardiography: new imaging projections

New transgastric echocardiographic projections, obtained bymonoplane transoesophageal echocardiography are presented. Startingfrom the transgastric short-axis view, the probe is first advanced3–5 cm and slightly rotated clockwise. From this projectioneither a tricuspid valve long-axis or a subcostal-like 4-chamberview is obtained. Advancing the probe 48–55 cm from theincisor teeth and rotating it counter clockwise with maximalanterior flexion, an apical long-axis view is obtained. Theleft ventricle, including the apex, the left ventricular outflowtract, the aortic valve, the proximal ascending aorta and theleft atrium are imaged. In this projection the Doppler beamis parallel to the left ventricular outflow tract, resultingin more accurate flow velocity measurements than from the oesophagus.Additional morphological and Doppler information on right ventricularoutflow tract obstruction are obtained by slight changes intransducer position. The feasibility of these new transgastric imaging projectionswas assessed in 196 consecutive patients undergoing diagnosticTEE (104 conscious patients) or peroperative TEE monitoring(92 anaesthetized patients). Eighty-nine patients had coronaryheart disease, 55 had valvular heart disease, nine had congenitalheart disease, 22 had aortic aneurysm or dissection and 21 werestudied for detection of cardiac sources of embolism. The morphology of the right ventricular outflow tract was visualizedin detail in all patients, and high quality Doppler tracingsparallel to tile direction of flow were obtained. The subcostal-likeview was successful in 86 out of 196 subjects (44%). The apical4 andlor 5-chamber view was obtained in 139 subjects (71%). These new transgastric projections are particularly useful inthe intra-operative setting and in the early postoperative period,when other imaging modalities are not feasible and when conventionaltransoesophageal echocardiography does not yield conclusiveresults. Technical improvement in probe flexibility and changesin transducer frequency may increase the success rate of transgastricimaging. Biplanar and multiplanar transgastric scanning mayfurther extend the potential of this approach.     

Feasibility of endoscopic transgastric distal pancreatectomy in a porcine animal model

BACKGROUND: In contrast to laparoscopic tubal ligation, oophorectomy, and appendectomy, laparoscopic distal pancreatectomy is associated with a morbidity rate of more than 50% and a mortality rate of more than 3%. OBJECTIVE: To develop a minimally invasive, transgastric endoscopic technique for distal pancreatectomy in a nonsurvival series in swine. DESIGN: Experimental study. SETTING: Animal trial at a tertiary-care academic hospital. SUBJECTS: Six healthy Yorkshire swine under general anesthesia. INTERVENTIONS: A double-channel gastroscope was introduced into the stomach, and a gastric incision was created by using a triple-lumen, 4-mm, cutting-wire needle knife. The peritoneal cavity was accessed. An Endoloop was placed endoscopically around the distal aspect of the pancreas, and the tail of the pancreas was transected by using a diathermic snare. One to 3 hemoclips were placed across the pancreatic duct. The pancreatic specimen was retrieved, and the gastrotomy was closed endoscopically with metal clips. The animals were euthanized after the procedure. The abdominal cavity was examined grossly, and the resected pancreas was examined histologically. MAIN OUTCOME AND MEASUREMENTS: Feasibility of endoscopic transgastric distal pancreatectomy and rate of complications. RESULTS: The pancreatic tail was successfully resected via a transgastric endoscopic approach in all animals. The procedure took an average (standard deviation) of 77.3 +/- 18.9 minutes. There was 1 complication, an episode of bleeding from a splenic laceration, which resulted in the loss of 250 mL of blood. LIMITATIONS: Nonsurvival series, animal study. CONCLUSIONS: Transgastric endoscopic distal pancreatectomy is technically feasible and can be performed in the porcine animal model.     

Cholecystectomy by a combined transgastric and transparietal approach using two flexible endoscopes

Objective

This experimental study was designed to assess the technical feasibility and benefits of our novel approach for transgastric NOTES (natural orifice translumenal endoscopic surgery) cholecystectomy.

Methods

Four pigs were subjected to NOTES cholecystectomy by the combined transgastric and transparietal approach using two flexible endoscopes. Under the guidance of a transparietal endoscope inserted through a trocar placed in the right upper abdomen, a gastrotomy was constructed, and a peroral endoscope was advanced into the peritoneal cavity through the gastrotomy and moved on retroflexion toward the gallbladder. Gallbladder excision with ligation of the cystic artery and duct using endoclips was performed using the peroral endoscope. After gastrotomy closure with endoclips inside the stomach, intraperitoneal lavage were carried out using the transparietal endoscope.

Results

A complete gallbladder excision was carried out without major adverse events in all cases. The gastrotomies were successfully closed using endoclips (n = 3) or by the omentum-plug method (n = 1).

Conclusion

This approach is technically feasible and makes transgastric NOTES cholecystectomy easier and safer.     

经胃腹腔内镜手术的研究进展

自从人类首次行腹腔镜胆囊手术以来,微创手术已有了巨大发展.近2a来人们又开始了由天然管腔(natural orifice)进入腹腔进行一系列内镜下的手术操作,特别是由胃腔进入腹腔.人们已先后在动物完成了经胃内镜胃空肠吻合术和胆囊切除术;经胃腹腔内组织活检;经胃胆道系统内镜手术;经胃输卵管接扎;经胃内镜脾切除;经胃阑尾切除;经胃内镜腹膜后胰腺清创术等手术.其中一些手术已在人类完成,这为腹部手术进入真正微创提供了一个新平台.但此项技术仍处于早期发展阶段,他涉及多专科的合作,仍需要克服许多不足,不断使之完善,最终服务于临床.     

Ultrasonography performed by primary care residents for abdominal aortic aneurysm screening

A prospective pilot study was undertaken to assess a protocol to educate primary care residents in how to personally perform ultrasonography for abdominal aortic aneurysm screening. Resident exams were proctored by a primary care physician trained in ultrasonography and were scored on the level of competence in doing the examination. Patients had ultrasound performed by a resident, followed by repeat examination by the vascular lab. Primary care resident abdominal aortic imaging was achieved in 79 of 80 attempts. Four abdominal aortic aneurysms were identified. There were 75 normal examinations; resident ultrasonography results were consistent with the results of the vascular lab. Ten residents achieved an abdominal aortic ultrasound-independent competence level after an average of 3.4 proctored exams. The main outcome of this study is that a primary care resident, with minimal training in ultrasonography imaging, is able to rapidly learn the technique of ultrasonography imaging of the abdominal aorta.     

Endoscopic approach to gastric remnant outlet obstruction after gastric bypass: A case report

BACKGROUND Acute gastric remnant bleeding is a rare complication of bariatric surgery. Furthermore, acute bleeding from the gastric remnant resulting in gastric remnant outlet obstruction has not been described previously. Endoscopic management of gastric remnant bleed has been challenging due to difficulty accessing the excluded stomach. Traditionally, this necessitates surgical intervention. Recently, however, the adoption of endoscopic ultrasound-directed transgastric intervention provides an alternative approach to management.CASE SUMMARY A 65-year-old male with a prior gastric bypass presented with the sudden onset of progressive abdominal distension, nausea, and melena of two days duration. His imaging illustrated a massively distended stomach. A nasogastric tube did not result in drainage of fluid or decompression of his abdomen. His endoscopy revealed a normal-appearing gastro-jejunal anastomosis and confirmed the distended "fluid"-filled gastric remnant. An endoscopic ultrasound-directed gastrogastrostomy was created to decompress the gastric remnant. Two liters of blood was suctioned before a large adherent clot was visualized in the gastric antrum. The patient underwent emergent angiography with embolization of the gastroduodenal artery. He was discharged with a stable hemoglobin level and resolution of symptoms. Healing superficial gastric ulcers were visualized on a follow-up endoscopy. Gastric biopsies were consistent with Helicobacter pylori infection for which the patient was treated, and successful eradication was achieved.CONCLUSION This patient benefited from a timely diagnosis and effective therapy of an acute gastric remnant obstruction from a bleeding ulcer with endoscopic ultrasound-directed transgastric intervention.     

Self-approximating transluminal access technique for natural orifice transluminal endoscopic surgery: a porcine survival study (with video)

BACKGROUND: The ability to access the abdominal cavity though a direct (modified-PEG type) gastric incision to perform natural orifice transluminal endoscopic surgery (NOTES) has been demonstrated in the literature. However, the optimal technique to access the abdomen remains unknown. OBJECTIVE: The aim of this study was to evaluate the safety and feasibility of a transgastric approach to the abdominal cavity through an extended submucosal tunnel. DESIGN: Animal feasibility study. INTERVENTIONS: Transgastric endoscopic peritoneoscopy was performed in 7 anesthetized swine, including 2 acute and 5 survival animals. After the creation of a 10-cm to 12-cm tunnel in the gastric submucosal plane, the peritoneal cavity was accessed by needle-knife puncture through the gastric wall near the greater curvature. The peritoneal cavity was examined before the gastric mucosal incision was closed with endoclips. Survival animals were euthanized two weeks after the procedure, and a necropsy was performed. RESULTS: The abdominal cavity was successfully entered without complication in all 7 animals. The mucosal incisions were able to be closed by endoscopy. In the survival experiments, all animals recovered and gained weight. Two animals experienced clinically unapparent infectious complications. LIMITATIONS: Small sample size. CONCLUSIONS: A peroral transgastric approach to the abdominal cavity through an extended submucosal tunnel is technically feasible and allows safe abdominal access and reliable closure with currently available technology. It has potential benefits as an alternative to direct transgastric access for NOTES procedures.     

Laparoscopic endogastric and transgastric cystgastrostomy and pancreatic necrosectomy

BACKGROUND/AIMS: Pancreatic pseudocysts (PP) that complicate acute necrotizing pancreatitis (ANP) and require internal drainage may be managed laparoscopically. We present our experience with the laparoscopic endogastric and transgastric approaches to pseudocyst-gastrostomy (PCG). METHODOLOGY: Seven patients (4 female) aged 25-75 (median, 60) years with large (median, 12cm), symptomatic and persistent (median, 5 months) retrogastric PP underwent PCG. All procedures were attempted laparoscopically. The endogastric approach was applied in the initial three patients and was replaced with the transgastric approach in the subsequent four patients. All patients underwent concomitant necrosectomy for sterile pancreatic necrosis. Patients were followed up with regular abdominal ultrasonography. Results shown represent median (range). RESULTS: There were no conversions to open surgery. The operating time was 135 (60-200) minutes and was longer with the endogastric approach (165 vs. 112 minutes). There were no postoperative complications and the postoperative hospital stay was 2 (1-4) days. There were no recurrences at a follow-up of 12 (2-21) months. CONCLUSIONS: Laparoscopic PCG with concomitant necrosectomy for PP that complicate ANP is feasible and safe and is associated with smooth and rapid recovery. The transgastric approach provides better access and is simpler to apply than that of the endogastric approach.     

Per-oral transgastric abdominal surgery

Laparoscopic surgery has several advantages over traditional surgery because it has been shown to be less invasive. The next logical step in the evolution of minimally invasive surgery may be to eliminate all abdominal incisions. The natural orifices provide a port of entry via the gastrointestinal tract to the peritoneal cavity. This approach would require the creation of a perforation, which is considered to be a major complication of endoscopy with significant morbidity and mortality. However, there are several recent studies that have described the technical feasibility and safety of a per-oral transgastric approach to the peritoneal cavity using conventional endoscopes. Theoretically, this approach could reduce postoperative abdominal wall pain, wound infection, hernia formation, and adhesions. This article aims to summarize the current status of transgastric surgery, currently referred to as natural orifice transluminal endoscopic surgery (NOTES), and to address some of its future challenges.     

Challenges and lessons learned from NOTES cholecystectomy initial experience: a stepwise approach from the laboratory to clinical application

Background/Purpose

The initial idea behind natural orifice transluminal endoscopic surgery (NOTES) was that of an incisionless surgery. NOTES cholecystectomy is a good model of human ingenuity and technological advance. NOTES cholecystectomy in a human being was performed at our institution after extensive laboratory work in live pig models. In this process we gained helpful information related to NOTES cholecystectomy.

Methods

More than 250 cholecystectomies in pigs have been performed. From May 2007 to November 2008 a total of 10 and 6 transvaginal and transgastric human cholecystectomies, respectively, have been performed.

Results

The procedure was successful in all patients, with a mean operative time of 120 min. There were no intraoperative or postoperative complications. Patients recovered promptly after surgery and had minor postoperative pain. They were discharged on the second postoperative day.

Conclusions

The advantages of laparoscopy appeared to be enhanced by this approach: patients had minor postoperative pain and minimal scarring. This stepwise experience in the cholecystectomy procedure is an important first step in the development of methods and devices to enable the evaluation of potential incisionless NOTES surgery. Additional research and comparison studies are needed for further improvement in order to provide NOTES procedures to a wider range of patients.     

Transcolonic endoscopic abdominal exploration: a NOTES survival study in a porcine model

BACKGROUND: Published reports on NOTES (natural orifice transluminal endoscopic surgery) have thus far been limited to the transgastric method. OBJECTIVE: The aim of this study was to assess the transcolonic approach as a means of accessing and systematically exploring the abdominal cavity in a survival study design. DESIGN: Six pigs were placed under general anesthesia and were prepped with multiple tap-water enemas, followed by instillation of a cefazolin suspension and a povidone-iodine lavage. Equipment was prepared with a high-level chemical disinfection, and an aseptic technique was used. An incision was made in the anterior colonic wall, and abdominal exploration was performed by using a double-channel endoscope. The incision was subsequently closed with endoscopic clips, endoloops, or a prototype closure device. PATIENTS: Six female Yorkshire pigs that weighed 25 to 30 kg. RESULTS: Stomach, liver, gallbladder, spleen, small bowel, colon, and peritoneal surfaces were identified in all animals in less than 3 minutes. The lower pelvic organs were not consistently visualized. All animals were alive for 14 days without apparent complications. At necropsy, the colonic incision sites were completely closed and appeared well healed. Microscopic inflammatory changes were seen at the closure site in all animals, including microabscesses. Incision-related adhesions were identified in 4 of 6 animals. CONCLUSIONS: This study demonstrated the use of a novel transcolonic approach to successfully access and explore the abdominal cavity. In contrast to the transgastric method, a transcolonic approach provides more consistent identification of structures in the upper abdomen and provides better en face orientation and scope stability. Therapeutic interventions in the upper abdomen, including organ resection, may be more tenable by using a transcolonic method; however, further studies are needed to address issues of sterility and colonic closure.     

坏死性胰腺炎的微创治疗进展

急性胰腺炎(acute pancreatitis,AP)是临床常见的急腹症,由各种病因导致胰酶的激活,以胰腺的局部炎症反应为特征,伴或不伴有其他器官功能改变的疾病。其中,约20%的AP可发展为坏死性胰腺炎(necrotizing pancreatitis,NP),病死率高,预后差。近年来,随着科学研究的深入,治疗NP的手术方式,也得到了快速的发展。其手术方式由传统的开腹手术,逐步发展为微创介入治疗,包括CT引导下经皮导管引流术、经胃内镜下清创引流术、微创外科清创术等,有效降低了NP患者的病死率,提高了患者的生存质量。本文就NP的最新微创治疗进展做一综述。     

ENDOSCOPIC ULTRASOUND‐GUIDED CHOLEDOCHODUODENOSTOMY

Endoscopic biliary drainage (EBD) may be unsuccessful in some patients, because of failed biliary cannulation or tumor infiltration, limiting endoscopic access to major papilla. The alternative method of percutaneous transhepatic biliary drainage carries a risk of complications, such as bleeding, portal vein thrombus, portal vein occlusion and intra‐ or extra‐abdominal bile leakage. Recently, endoscopic ultrasonography (EUS)‐guided biliary stent placement has been described in patients with malignant biliary obstruction. Technically, EUS‐guided biliary drainage is possible via transgastric or transduodenal routes or through the small intestine using a direct access or rendezvous technique. We describe herein a technique for direct stent insertion from the duodenal bulb for the management of patients with jaundice caused by malignant obstruction of the lower extrahepatic bile duct. We think transduodenal direct access is the best treatment in patients with jaundice caused by inoperable malignant obstruction of the lower extrahepatic bile duct when EBD fails.     

Endoscopic ultrasonography‐guided cholecystogastrostomy in patients with unresectable pancreatic cancer using anti‐migratory metal stents: A new approach

Cholecystectomy is contraindicated in patients with comorbidities or unresectable cancer. Percutaneous transhepatic gallbladder drainage (PTGBD) is typically offered with response rates ranging from 56% to 100%, but has several risks such as bleeding, pneumothorax, pneumoperitoneum, bile leak, and/or catheter migration. Endoscopic transpapillary gallbladder drainage (ETGD) and endoscopic ultrasound‐guided transmural gallbladder drainage (EUS‐GBD) are alternative endoscopic modalities that have a technical feasibility, efficacy and safety profile comparable with PTGBD. In this report, we present the first case series of transgastric EUS‐GBD with placement of a fully covered self‐expandable metal stent with anti‐migratory fins. In three pancreatic cancercases with acute cholecystitis when ETGD was unsuccessful, there were no bile leaks or procedurally related complications. There were no acute cholecystitis recurrences. In conclusion, EUS‐GBD is a promising, minimally invasive treatment for acute cholecystitis. Additional comparative studies are needed to validate the benefit of this technique.     

Intravenous leiomyomatosis involving the right heart: Comprehensive evaluation using echocardiography combined with abdominal ultrasonography

Intravenous leiomyomatosis (IVL) is a rare condition characterized by a tumor that originates within a pelvic vein wall or the uterine smooth muscle, with extension into the right heart (referred to as intracardiac leiomyomatosis) in approximately 10% of all IVL cases. Usually, computed tomography (CT) or magnetic resonance imaging (MRI) is performed for diagnostic imaging of IVL. Notably, this neoplasm presents with characteristic ultrasonographic findings. In this report, we present the case of a 49-year-old woman with IVL, which extended into the right heart. Echocardiography combined with abdominal ultrasonography was useful to outline the course of the tumor from the right heart to the uterus. Our findings suggest that in addition to CT or MRI, ultrasonography shows high diagnostic value in cases of IVL, and ultrasonography combined with CT or MRI can further improve the preoperative diagnosis rate of IVL.     

Percutaneous transgastric irrigation drainage in combination with endoscopic necrosectomy in necrotizing pancreatitis (with videos)

BACKGROUND: Endoscopic drainage of pancreatic acute and chronic pseudocysts and pancreatic necrosectomy have been shown to be beneficial for critically ill patients, with complete endoscopic resolution rates of around 80%. OBJECTIVE: Our purpose was to describe an improved endoscopic technique used to treat pancreatic necrosis. DESIGN: Case report. SETTING: University hospital. PATIENTS AND INTERVENTIONS: Two patients with large retroperitoneal necroses were treated with percutaneous transgastric retroperitoneal flushing tubes and a percutaneous transgastric jejunal feeding tube by standard percutaneous endoscopic gastrostomy access in addition to endoscopic necrosectomy. RESULTS: Intensive percutaneous transgastric flushing in combination with percutaneous normocaloric enteral nutrition and repeated endoscopic necrosectomy led to excellent outcomes in both patients. LIMITATIONS: Small number of patients. CONCLUSIONS: The "double percutaneous endoscopic gastrostomy" approach for simultaneous transgastric drainage and normocaloric enteral nutrition in severe cases of pancreatic necroses is safe and effective. It could be a promising improvement to endoscopic transgastric treatment options in necrotizing pancreatitis.     

Clinical significance of ultrasonographically detected coincidental gallstones

The clinical profiles of 139 patients with gallstones found coincidentally during ultrasonography were reviewed and the patients followed prospectively for five years. Indications for ultrasonography included follow-up of abdominal malignancy (33%), evaluation of abdominal aortic aneurysm or other arteriosclerotic vascular disease (22%), renal insufficiency (12%), and lower abdominal pain (7%). At the time of gallstone detection, 14 patients (10%) had symptoms attributable to cholelithiasis. Over the next five years, only 15 patients (11%) developed episodes resembling biliary pain. Nine patients underwent cholecystectomy during this period. Three of the cholecystectomies were incidental to other abdominal procedures. Two cholecystectomies were performed as emergencies for gallstone complications with no perioperative mortality. Interestingly, 54 patients (40%) with coincidental gallstones died during the follow-up period. All the deaths were unrelated to gallstones. These data indicate that Ultrasonographically detected coincidental gallstones rarely have clinical significance, lending strong support to the expectant management of most patients with purely coincidental gallstones.