New Techniques for Transgastric Anastomosis Using Flexible Endoscopes

Abstract

Background: Transgastric flexible endoscopic surgical anastomosis might offer advantages over open and laparoscopic surgery especially for baryatric patients or those with obstructive pancreatic malignancy. The limitations and opportunities of this new minimally invasive surgical approach require further study. Aim: To develop and improve methods for performing transgastric anastomosis. Methods/Results: 12 gastro-jejunal anastomoses were formed in anaesthetized 27-38 Kg pigs via a transgastric route using a single double-channel gastroscope (Olympus 2T160). Both non-survival and survival experiments were carried out. The stomach was penetrated using a needle-knife guide-wire combination followed by bow-sphincterotome incision. Rapid methods for forming a gastrojejunal anstomosis were developed. For simple transgastric jejuno-gastrostomy a snare in one channel was looped over forceps in the other. The small intestine (SI) was grasped on the ante-mesenteric border and the snare closed and SI pulled into the stomach for suturing. This method was safe if the SI was inadvertently dropped since the bowel was not penetrated until securely attached. The endoscope and the desired loop of small intestine were then pulled into the stomach. The endoscope was pulled up through the mouth leaving the snare holding the SI in the stomach, and then passed down the esophagus again beside the snare. This manoeuvre made the scope independent of the small intestine for suturing. Several stitches were then placed using a hollow needle based flexible endoscopic sewing kit, into the stomach wall and the small intestine and locked together in pairs. The small intestine was then incised with an endoscopic hook knife to open the anastomosis. Anastomoses were placed close to the cardio-esophageal junction for baryatric purposes or in the antrum for pancreatic bypass. Despite limitations in measuring SI distance using flexible endoscopy, anastomoses could be placed using proximal or mid jejunum as well as ileum. Survival studies showed healing and anastomosis patency at 10 days. Limitations: Difficulties in controlling differential lateral movement, limitations in measuring SI lengths require innovative solutions. Conclusion: Gastro-jejunal anastomosis was accomplished via the transgastric route using a double channel endoscope with new tools and methods. This might offer advantages for baryatric surgery or obstructive malignancy. Background: Transgastric flexible endoscopic surgical anastomosis might offer advantages over open and laparoscopic surgery especially for baryatric patients or those with obstructive pancreatic malignancy. The limitations and opportunities of this new minimally invasive surgical approach require further study. Aim: To develop and improve methods for performing transgastric anastomosis. Methods/Results: 12 gastro-jejunal anastomoses were formed in anaesthetized 27-38 Kg pigs via a transgastric route using a single double-channel gastroscope (Olympus 2T160). Both non-survival and survival experiments were carried out. The stomach was penetrated using a needle-knife guide-wire combination followed by bow-sphincterotome incision. Rapid methods for forming a gastrojejunal anstomosis were developed. For simple transgastric jejuno-gastrostomy a snare in one channel was looped over forceps in the other. The small intestine (SI) was grasped on the ante-mesenteric border and the snare closed and SI pulled into the stomach for suturing. This method was safe if the SI was inadvertently dropped since the bowel was not penetrated until securely attached. The endoscope and the desired loop of small intestine were then pulled into the stomach. The endoscope was pulled up through the mouth leaving the snare holding the SI in the stomach, and then passed down the esophagus again beside the snare. This manoeuvre made the scope independent of the small intestine for suturing. Several stitches were then placed using a hollow needle based flexible endoscopic sewing kit, into the stomach wall and the small intestine and locked together in pairs. The small intestine was then incised with an endoscopic hook knife to open the anastomosis. Anastomoses were placed close to the cardio-esophageal junction for baryatric purposes or in the antrum for pancreatic bypass. Despite limitations in measuring SI distance using flexible endoscopy, anastomoses could be placed using proximal or mid jejunum as well as ileum. Survival studies showed healing and anastomosis patency at 10 days. Limitations: Difficulties in controlling differential lateral movement, limitations in measuring SI lengths require innovative solutions. Conclusion: Gastro-jejunal anastomosis was accomplished via the transgastric route using a double channel endoscope with new tools and methods. This might offer advantages for baryatric surgery or obstructive malignancy.