Endoscopy 2010; 42(5): 405-412
DOI: 10.1055/s-0029-1243948
Original article

© Georg Thieme Verlag KG Stuttgart · New York

Natural orifice transluminal endoscopic surgery: cardiopulmonary safety of transesophageal mediastinoscopy

S. von  Delius1 , 3 , D.  Wilhelm2 , 3 , H.  Feussner2 , 3 , J.  Sager1 , 3 , V.  Becker1 , T.  Schuster4 , A.  Schneider3 , R.  M.  Schmid1 , A.  Meining1 , 3
  • 1Medizinische Klinik II, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
  • 2Chirurgische Klinik, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
  • 3Arbeitsgruppe für minimalinvasive Therapie und Intervention, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
  • 4Institut für medizinische Statistik und Epidemiologie, Technische Universität München, Klinikum rechts der Isar, Munich, Germany
Further Information

Publication History

submitted 13 August 2009

accepted after revision 23 December 2009

Publication Date:
04 March 2010 (online)

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Commentaire de travail de S. von Delius et al., pp. 405Endoscopy 2010; 42(05): 434-434
DOI: 10.1055/s-0031-1291859

Background and study aims: Physiological reactions during natural orifice transluminal endoscopic surgery (NOTES) mediastinoscopy may lead to cardiorespiratory depression. The aim of the current study was to assess cardiopulmonary changes during transesophageal mediastinoscopy in an acute porcine model.

Methods: Transesophageal mediastinoscopy was performed under general anesthesia in eight female pigs with a bodyweight of 39 ± 6 kg. Mediastinal access was achieved via a submucosal tunnel. The cardiac index and global end-diastolic volume index (reflecting preload) were measured every 3 minutes by transpulmonary thermodilution. The following parameters were also recorded: mediastinal pressure, heart rate, mean arterial pressure, systemic vascular resistance index (SVRI; reflecting afterload), peak inspiratory pressure, pH, pCO2, and pO2.

Results: In three animals, small tears in the parietal pleura resulted in tension pneumothoraces. The associated cardioplumonary deterioration was fatal in one pig. The other two pigs recovered after decompression with a chest tube. In the remaining five animals there were only mild hemodynamic and respiratory changes during mediastinoscopy. There was a significant (P = 0.005) but minor transient fall in cardiac index, which correlated with a small rise in SVRI (r =  – 0.857, P < 0.001). In the pigs with uncomplicated mediastinoscopy, on-demand insufflation via the endoscope resulted in median mediastinal pressures of 4.5 mm Hg (range 2.3 – 10.2 mm Hg). Overall, mediastinal and thoracic structures could be identified without difficulty via the transesophageal approach.

Conclusions: NOTES mediastinoscopy carries a substantial risk of inadvertent development of a pneumothorax. Otherwise, it leads to negligible hemodynamic and pulmonary changes. In conclusion, close monitoring for the presence of a pneumothorax during NOTES mediastinoscopy appears to be mandatory.

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S. von DeliusMD 

Technische Universität München
Klinikum rechts der Isar
Medizinische Klinik II

Ismaninger Str. 22
81675 Munich
Germany

Fax: ++49-89-41404905

Email: stefan_ruckert@yahoo.de

    The following figure is available online:
    Fig. e1  Pressure calibration curve for the single-channel gastroscope (13801 PKS, Karl Storz GmbH, Tuttlingen, Germany). Least-squares linear regression of the endoscopically measured pressures compared with the pressures obtained from the Veress needle.