Background and aim: Natural-orifice transluminal endoscopic surgery (NOTES) is an emerging transluminal technique in which interventions are carried out by entering the abdominal cavity via a natural orifice such as the stomach. Infection is a potential risk of the procedure, and the potential pathogens are different from those encountered with skin incisions. Currently, available data regarding prophylactic anti-infective treatment are limited. We compared the effectiveness of topical antimicrobial lavage of mouth and stomach and proton pump inhibitor therapy with gastric cleansing with sterile saline solution in preventing NOTES-related contamination and infection.
Methods: A randomized survival swine study was performed. Eight pigs underwent preparation with intravenously administered proton pump inhibitors, mouth and gastric lavage (chlorhexidine), and gastric irrigation (diluted neomycin), plus single-shot intravenous antibiotics. Control group (n = 8) underwent gastric cleansing with sterile saline solution. Peritoneal biopsy, multiple smears, and dilutions for cultures were taken and incubated. The swine were sacrificed after 14 days. Bacterial load was expressed in colony-forming units (CFU).
Results: One pig died due to gallbladder perforation after 3 days, 2/15 swine presented minor clinical signs of infection in the 14-day follow-up (all 3 pigs were in the control group). Mean C-reactive protein levels were 5.7 ± 2.4 g/dL (therapy group) and 12.2 ± 3.8 g/dL (control) (P = 0.17). Bacterial growth was seen in 1/8 swine (therapy group) and 6/8 swine (control group) (P = 0.002). Bacterial load was 282 CFU/mL (therapy) vs. 3.2 × 105 CFU/mL (control) (P = 0.023) in the follow-up.
Conclusion: The use of intravenous antibiotics in addition to topical antimicrobial lavage of mouth and stomach and treatment with proton pump inhibitors decreased the peritoneal bacterial load to almost zero and this was associated with a significantly lower peritoneal infection rate compared with saline-only lavage.
References
1
Swain P.
A justification for NOTES – natural orifice transluminal endosurgery.
Gastrointest Endosc.
2007;
65
514-516
2
Flora E D, Wilson T G, Martin I J. et al .
A review of natural orifice transluminal endoscopic surgery (NOTES) for intra-abdominal surgery: experimental models, techniques, and applicability to the clinical setting.
Ann Surg.
2008;
247
583-602
3
Abbas Fehmi S M, Kochman M L.
Natural orifice transluminal endoscopic surgery 2009: what is the future for the gastroenterologist?.
Curr Opin Gastroenterol.
2009;
25
399-404
4
Kalloo A N, Singh V K, Jagannath S B. et al .
Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions.
Gastrointest Endosc.
2004;
60
114-117
6
Hazey J W, Narula V K, Renton D B. et al .
Natural-orifice transgastric endoscopic peritoneoscopy in humans: initial clinical trial.
Surg Endosc.
2008;
22
16-20
7
Narula V K, Happel L C, Volt K. et al .
Transgastric endoscopic peritoneoscopy does not require decontamination of the stomach in humans.
Surg Endosc.
2009;
23
1331-1336
8
Steele K, Schweitzer M A, Lyn-Sue J, Kantsevoy S V.
Flexible transgastric peritoneoscopy and liver biopsy: a feasibility study in human beings.
Gastrointest Endosc.
2008;
68
61-66
10
McGee S M, Routh J C, Pereira C W, Gettman M T.
Minimal contamination of the human peritoneum after transvesical incision.
J Endourol.
2009;
23
659-663
11
Buck L, Michalek J, Van Sickle K. et al .
Can gastric irrigation prevent infection during NOTES mesh placement?.
J Gastrointest Surg.
2008;
12
2010-2014
12
Narula V K, Hazey J W, Renton D B. et al .
Transgastric instrumentation and bacterial contamination of the peritoneal cavity.
Surg Endosc.
2008;
22
605-611
13
Lomanto D, Chua H C, Myat M M. et al .
Microbiological contamination during transgastric and transvaginal endoscopic techniques.
J Laparoendosc Adv Surg Tech A.
2009;
19
465-469
14
McGee M F, Marks J M, Onders R P. et al. Case Advanced Surgical Endoscopy Team [CASE-T] .
Infectious implications in the porcine model of natural orifice transluminal endoscopic surgery (NOTES) with PEG-tube closure: a quantitative bacteriologic study.
Gastrointest Endosc.
2008;
68
310-318
15
Mintz Y, Cullen J, Horgan S. et al .
Pre-op antibiotic gastric lavage reduces post-operative peritoneal infection in a murine natural orifice surgery model.
Gastrointest Endosc.
2008;
67(5)
T1920
16
Ryou M, Hazan R, Rahme L, Thompson C C.
The effectiveness of current sterility techniques in natural orifice transluminal endoscopic surgery (NOTES).
Gastrointest Endosc.
2008;
67(5)
T1553
17
Kantsevoy S V, Jagannath S B, Niiyama H. et al .
A novel safe approach to the peritoneal cavity for per-oral transgastric endoscopic procedures.
Gastrointest Endosc.
2007;
65
497-500
18
von Renteln D, Eickhoff A, Kaehler G. et al .
Endoscopic closure of the natural orifice transluminal endoscopic surgery (NOTES) access site to the peritoneal cavity by means of transmural resorbable sutures: an animal survival study.
Endoscopy.
2009;
41
154-159
20
Ramamoorthy S L, Lee J K, Luo L. et al .
The inflammatory response in transgastric surgery: gastric content leak leads to localized inflammatory response and higher adhesive disease.
Surg Endosc.
2010;
24
531-535
22
Grant S W, Hopkins J, Wilson S E.
Operative site bacteriology as an indicator of postoperative infectious complications in elective colorectal surgery.
Am Surg.
1995;
61
856-861
24
Törnqvist A, Forsgren A, Leandoer L, Ursing J.
Identification and antibiotic prophylaxis of high-risk patients in elective colorectal surgery.
World J Surg.
1987;
11
115-119
25
Ramamoorthy S L, Lee J K, Mintz Y. et al .
The impact of proton-pump inhibitors on intraperitoneal sepsis: a word of caution for transgastric NOTES procedures.
Surg Endosc.
2010;
24
16-20
26
Dubcenco E, Assumpcao L, Dray X. et al .
Adhesion formation after peritoneoscopy with liver biopsy in a survival porcine model: comparison of laparotomy, laparoscopy, and transgastric natural orifice transluminal endoscopic surgery (NOTES).
Endoscopy.
2009;
41
971-978
27
Bachman S L, Sporn E, Furrer J L. et al .
Colonic sterilization for natural orifice transluminal endoscopic surgery (NOTES) procedures: a comparison of two decontamination protocols.
Surg Endosc.
2009;
23
1854-1859
28
Romagnuolo J, Morgan K A, Morris J. et al .
Differences in peritoneal bacterial contamination of natural orifice transluminal endoscopic surgery (NOTES) vs. laparoscopy in a colon perforation and repair model.
Gastrointest Endosc.
2008;
67(5)
S1342