New Peritoneal Access for NOTES: Esophago-Cardial-Gastric-Tunneling Access

Abstract

Introduction: Safe and easy peritoneal access is a key point for the clinical application of NOTES. This study aims to develop a novel peritoneal access (Esophago-Cardial-Gastric-Tunneling Access) and evaluate its feasibility and safety. Methods: The study comprised 10 Beagle dogs. A longitudinal mucosal incision was made on esophageal wall and a submucosal tunnel was created through cardia into stomach. An incision was made on the muscular layer of the stomach and then the endoscope was advanced into the peritoneal cavity. After intraperitoneal exploration, the esophageal mucosal entry was closed with endoclips. All dogs resumed food 12 hours after the procedures. Diets, behavior and body temperature of all dogs were observed. Endoscopic examinations were performed 4 weeks after the procedure, and then necropsy were executed.Figure 1: The diagram of ECGT access. A Creation of the submucosal tunnel at right esophageal wall approximately 5 cm proximal to the EGJ. B Submucosal tunneling 3-5 cm distal to the EGJ and seromuscular incision at the end of the tunnel for advancing the scope to peritoneal cavity. C Gastric mucosal integrity was maintained after the procedure and esophageal mucosal incision was closed by clips. D Radiographic view of the ECGT access trace: esophageal mucosal entrance (white arrow); marked gastric exit (yellow arrow); marked greater curvature (red arrow); ECGT peritoneal access (green line).Results: The ECGT access was successfully created in all dogs. Diets, behavior and body temperature were normal in all dogs. The entry of esophagus was healed well in 9 dogs. The mucosa of the entry was torn in one dog, but the submucosal tunnel was healed well at cardia. Necropsy showed complete closure of gastric serosal exit, and no intraperitoneal abscess was found. Histopathological examinations showed submucosal tunnels healed well. Conclusion: The ECGT access is feasible and safe for NOTES peritoneal access. It should be a good choice for the clinical application of NOTES procedures.