Abstract

Background: NOTES (natural orifice translumenal endoscopic surgery) is an area of active research in experimental endoscopy and has the potential to significantly advance the field of minimally invasive surgery. Several transgastric access techniques have been described to date. The aim of the current ex-vivo, experimental study was to evaluate different methods of transluminal access with regard to safe closure and leakage after the procedure. Methods: By using ex vivo porcine stomachs mounted on a custom-made board, the following endoscopic techniques for transgastric access were evaluated. The first arm used standard gastrotomy by needle knife incision; the second, a small gastrotomy and dilation with a controlled radial expansion (CRE) balloon. In the third arm a short (4 cm) submucosal tunnel was created by physically separating the mucosa from the muscularis. After the tract was initiated, the scope was advanced within its lumen and a needle knife was used to incise the seromuscular layer at the distal end of the submucosal tunnel. The fourth arm also used a submucosal tunnel, but with an extended tract (8 cm). In the interventional arms each mucosal incision was closed with endoscopic clips. Finally, hand-sewn gastric closure by a senior surgeon after needle knife incision served as positive control. Negative controls were stomachs in which the needle knife gastrotomy was not closed. Five stomachs were tested per study arm. After closure, each stomach was inflated with methylen blue stained water by an automated pressure gauge. The pressures to liquid leakage were recorded. Results: The unclosed controls demonstrated liquid leakage at 2.4 ± 1.8 mmHg (mean ± standard deviation), representing baseline system resistance. The hand-sewn gastric closure after linear incision leaked at 50.4 ± 7.0 mmHg. The needle knife gastrotomy, the balloon dilation, the short submucosal tunnel and the extended submucosal tunnel leaked at 37.4 ± 15.1 mmHg, 48.2 ± 25.0 mmHg, 43.7 ± 12.5 mmHg, and 88.6 ± 22.3 mmHg, respectively. There were significant differences in leak pressures between the group with the extended submucosal tunnel and all other transgastric access techniques. The techniques with submucosal tunneling required longer time than transgastric access by linear incision or balloon dilation (20.8 ± 7.8 min vs. 4.9 ± 3.0 min) and were technically more demanding. Conclusions: The extended submucosal tunnel yielded the best leak-resistance that is superior to standard transgastric access methods and rival hand-sewn interrupted stitches.

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