Peroral esophageal segmentectomy and anastomosis with single transthoracic trocar: a step forward in thoracic NOTES

Background and study aims: A transesophageal natural orifice transluminal endoscopic surgery (NOTES) approach has been proposed for thoracic and mediastinal access. Similarly to transgastric surgery, serious limitations remain related to creating an esophagotomy and its safe closure. A hybrid approach in thoracic NOTES could work as an intermediate step before pure transesophageal NOTES. We assessed the benefit of hybrid thoracic NOTES for peroral segmental esophagectomy and subsequent complete esophageal anastomosis with a single transthoracic port.

Methods: Two protocols were used to attempt esophago-esophageal anastomosis: ex vivo using a phantom model (n = 5), and in vivo after esophageal mobilization, and segmental esophagectomy achieved using either a gastroscope (flexible) (n = 5) or thoracoscope (rigid) instruments (n = 5). A forward-viewing double-channel endoscope and a transthoracic operative thoracoscope with a working channel were coordinated in order to create a complete single-layer, end-to-end esophageal anastomosis ex vivo as well as in vivo. Feasibility and anastomosis quality were evaluated by inside and outside assessment of: patency, the incorporation of mucosa in all stitches, and a leak test.

Results: Anastomosis was achieved in all ex vivo experiments and thoracoscopically-led in vivo procedures. All anastomoses were patent, allowing distal passage of the endoscope, with mucosa incorporation. In in vivo experiments, a leak was detected in three animals and corrected with additional stitching.

Conclusions: Peroral esophageal anastomosis with a single transthoracic trocar is feasible, which may represent a step forward in thoracic NOTES.

References

• 1 Fabian T, Martin J, Katigbak M et al. Thoracoscopic esophageal mobilization during minimally invasive esophagectomy: a head-to-head comparison of prone versus decubitus positions.  Surg Endosc. 2008;  22 2485-2491
• 2 Cuschieri A, Shimi S, Banting S. Endoscopic oesophagectomy through a right thoracoscopic approach.  J R Coll Surg Edinb. 1992;  37 7-11
• 3 Shichinohe T, Hirano S, Kondo S. Video-assisted esophagectomy for esophageal cancer.  Surg Today. 2008;  38 206-213
• 4 Perretta S, Allemann P, Dallemagne B et al. Natural orifice transluminal orifice surgery (NOTES) for neoplasia of the chest and mediastinum.  Surg Oncol. 2009;  18 177-180
• 5 Kalloo A N, Singh V K, Jagannath S B et al. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity.  Gastrointest Endosc. 2004;  60 114-117
• 6 Lima E, Rolanda C, Pego J M et al. Transvesical endoscopic peritoneoscopy: a novel 5 mm port for intra-abdominal scarless surgery.  J Urol. 2006;  176 802-805
• 7 Decker A. Culdoscopy a method for visual diagnosis of gynecologic disease.  Clin Symp. 1952;  4 201-210
• 8 Fong D G, Pai R D, Thompson C C. Transcolonic endoscopic abdominal exploration: a NOTES survival study in a porcine model.  Gastrointest Endosc. 2007;  65 312-318
• 9 Sumiyama K, Gostout C J, Rajan E et al. Transesophageal mediastinoscopy by submucosal endoscopy with mucosal flap safety valve technique.  Gastrointest Endosc. 2007;  65 679-683
• 10 Lima E, Henriques-Coelho T, Rolanda C et al. Transvesical thoracoscopy: A natural orifice translumenal endoscopic approach for thoracic surgery.  Surg Endosc. 2007;  21 854-858
• 11 Willingham F F, Gee D W, Lauwers G Y et al. Natural orifice transesophageal mediastinoscopy and thoracoscopy.  Surg Endosc. 2008;  22 1042-1047
• 12 Fritscher-Ravens A, Patel K, Ghanbarri A et al. Natural orifice transluminal endoscopic surgery (NOTES) in the mediastinum: long-term survival animal experiments in transesophageal access, including minor surgical procedures.  Endoscopy. 2007;  39 870-875
• 13 Gee D W, Willingham F F, Lauwers G Y et al. Natural orifice transesophageal mediastinoscopy and thoracoscopy: a survival series in swine.  Surg Endosc. 2008;  22 2117-2122
• 14 Woodward T, McCluskey D, Wallace M B et al. Pilot study of tranesophageal endoscopic surgery: NOTES esophagomyotomy, vagotomy, lymphadenectomy.  J Laparoendosc Adv Surg Tech. 2008;  18 743-745
• 15 Pauli E M, Mathew A, Haluck R S et al. Technique for transesophageal endoscopic cardiomyotomy (Heller myotomy): video presentation at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES).  Surg Endosc. 2008;  22 2279-2280
• 16 Fritscher-Ravens A, Cuming T, Jacobsen B et al. Feasibility and safety of endoscopic full-thickness esophageal wall resection and defect closure: a prospective long-term survival animal study.  Gastrointest Endosc. 2009;  69 1314-1320
• 17 ASGE, SAGES . ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery White Paper.  Gastrointest Endosc. 2005;  63 199-203
• 18 Asakuma M, Perretta S, Alleman P et al. Challenges and lessons learned from NOTES cholecystectomy initial experience: a stepwise approach from the laboratory to clinical application.  J Hepatobiliary Pancreat Surg. 2009;  16 249-254
• 19 Sodergren M H, Clark J, Athanasiou T et al. Natural orifice transluminal endoscopic surgery: critical appraisal of applications in clinical practice.  Surg Endosc. 2009;  23 680-687
• 20 Rolanda C, Lima E, Pego J M et al. Third-generation cholecystectomy by natural orifices: transgastric and transvesical combined approach.  Gastrointest Endosc. 2007;  65 111-117
• 21 Rolanda C, Lima E, Silva D et al. In vivo assessment of gastrotomy closure by over-the-scope-clips in an experimental model for varicocelectomy.  Gastrointest Endosc. 2009;  70 1137-1145
• 22 Song S Y, Na K J, Oh S G et al. Learning curves of minimally invasive esophageal cancer surgery.  Eur J Cardiothorac Surg. 2009;  35 689-693
• 23 Luketich J D, Alvelo-Rivera M, Buenaventura P O et al. Minimally invasive esophagectomy: outcomes in 222 patients.  Ann Surg. 2003;  238 486-495
• 24 Malek M M, Shah S R, Katz A L et al. Endoscopically guided thoracoscopic esophagectomy for stricture in a child.  Surg Endosc. 2009;  [Epub ahead of print]
• 25 Reavis M K. The esophageal anastomosis: how improving blood supply affects leak rate.  J Gastrointest Surg. 2009;  13 1558-1560
• 26 Law S. Minimally invasive techniques for esophageal cancer surgery.  Best Pract Res Clin Gastroenterol. 2006;  20 925-940
• 27 Cense H A, Van Eijck C H, Tilanus H W. New insights in lymphatic spread of esophageal cancer and its implications for the extent of surgical resection.  Best Pract Res Clin Gastroenterol. 2006;  20 893-906