Endoscopy 2007; 39(10): 888-892
DOI: 10.1055/s-2007-966918
Original article

© Georg Thieme Verlag KG Stuttgart · New York

Which parameters might predict complications after natural orifice endoluminal surgery (NOTES)? Results from a randomized comparison with open surgical access in pigs

A.  Fritscher-Ravens1 , A.  Ghanbari2 , S.  Thompson3 , K.  Patel4 , E.  Kahle5 , T.  Fritscher6 , H.  Niemann4 , P.  Koehler4 , P.  Milla7
  • 1Department of Gastroenterology, Homerton University Hospital, London, UK
  • 2Department of Surgery, Homerton University Hospital, London, UK
  • 3Ethicon Endosurgery, Cincinnati, OH, USA
  • 4Department of Radiology, Homerton University Hospital, London, UK
  • 5Institute for Animal Breeding, Mariensee, Germany
  • 6Department for Nuclear Medicine, Erlangen, Germany
  • 7UCL Institute of Child Health, London, UK
Further Information

Publication History

submitted 21 August 2007

accepted after revision 4 September 2007

Publication Date:
29 October 2007 (online)

Background and study aims: Natural orifice transluminal endoscopic surgery (NOTES) is currently developed and assessed mainly in pig experiments. The vast majority of studies show a good outcome in short-term follow-up. The current study aims at comparing various parameters of postinterventional assessment and surveillance in relation to clinical behavior and autopsy results to find suitable control parameters and also to assess the pig as suitable model for NOTES compared with open surgery.

Methods: Within the framework of a randomized prospective study of 20 pigs with iatrogenic colonic perforation comparing endoscopic with open surgical closure, clinical examination, including observation of behavior, food intake, and body temperature, was carried out daily. Laboratory parameters (white blood cells [WBC], granulocytes) were measured in 14 animals. Weight was measured preoperatively and on days 2 and 7 postoperatively. Results were matched with complications found during/after 2 weeks’ survival. Pre-autopsy sterile cultures were taken from the peritoneal cavities to determine possible bacterial contamination.

Results: Three animals from the surgical group were sacrificed on days 4, 8, and 12 because they became severely ill, with autopsy revealing intussusception from adhesions, peritoneal abscess, and peritonitis, in one pig each; another animal had culture positive for Escherichia coli. Three minor complications (2 cough, 1 continuing fever with adhesions to the bladder found on autopsy) occurred in the endoscopic group without compromised recovery. WBC were measured in 14 animals, and found to be elevated (8 - 36 × 109/l) in six on day 2 including the two animals with severe complications. Between pre- and post-procedure, WBC increased about twofold in the uneventful cases but fourfold in the two animals with severe complications. Cultures from the abdominal cavity before autopsy were negative in all but one animal.

Conclusion: Animal behavior was a reliable indicator of severe complications. Fever, body weight, and the results of in vitro cultures of the peritoneal fluid did not indicate complications. WBC proved not to be specific but showed a larger increase in pigs with severe complications.

References

  • 1 Kelly D M, Demetris A J, Fung J J. et al . Porcine partial liver transplantation: a novel model of the ”small-for-size” liver graft.  Liver Transpl. 2004;  10 253-263
  • 2 Li D, Ren B H, Shen Y. et al . A Swine model for long-term evaluation of prosthetic heart valves.  ANZ J Surg. 2007;  77 654-658
  • 3 Jahan R, Solberg T D, Lee D. et al . An arteriovenous malformation model for stereotactic radiosurgery research.  Neurosurgery. 2007;  61 152-159
  • 4 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
  • 5 Fritscher-Ravens A, Mosse C A, Mukherjee D. et al . Transluminal endosurgery: single lumen access anastomotic device for flexible endoscopy.  Gastrointest Endosc. 2003;  58 585-591
  • 6 Jagannath S B, Kantsevoy S V, Vaughn C A. et al . Peroral transgastric endoscopic ligation of fallopian tubes with long-term survival in a porcine model.  Gastrointest Endosc. 2005;  61 449-453
  • 7 Park P O, Bergstrom M, Ikeda K. et al . Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis.  Gastrointest Endosc. 2005;  61 601-606
  • 8 Kantsevoy S V, Hu B, Jagannath S B. et al . Transgastric endoscopic splenectomy: is it possible?.  Surg Endosc. 2006;  20 522-525
  • 9 Ure B M, Niewold T A, Bax N M. et al . Peritoneal, systemic, and distant organ inflammatory responses are reduced by a laparoscopic approach and carbon dioxide versus air.  Surg Endosc. 2002;  16 836-842
  • 10 Clary E M, Bruch S M, Lau C L. et al . Effects of pneumoperitoneum on hemodynamic and systemic immunologic responses to peritonitis in pigs.  J Surg Res. 2002;  108 32-38
  • 11 Tam C S, Wong M, Tam K. et al . The effect of acute intermittent hypercapnic hypoxia treatment on IL-6, TNF-alpha, and CRP levels in piglets.  Sleep. 2007;  30 723-727
  • 12 Raju G S, Bergstroem M, Swain P. et al . Randomized multicenter controlled study of endoscopic and surgical closure of a 4 cm gaping wide colon perforation in a porcine model [abstract].  Gastrointest Endosc. 2007;  65 AB128
  • 13 Lu L, Zhang Q, Pu L J. et al . Elevation of tumor necrosis factor-alpha, interleukin-1beta and interleukin-6 levels in aortic intima of Chinese Guizhou minipigs with streptozotocin-induced diabetes.  Chin Med J. 2007;  120 479-484
  • 14 Ait-Ali T, Wilson A D, Westcott D G. et al . Innate immune responses to replication of porcine reproductive and respiratory syndrome virus in isolated Swine alveolar macrophages.  Viral Immunol. 2007;  20 105-118
  • 15 McGee M F, Schomisch S J, Marks J M. et al . Systemic inflammation and physiologic burden of transgastric natural orifice translumenal (NOTES) peritoneoscopy. A controlled, prospective comparison between NOTES and laparoscopy [abstract].  Gastrointest Endosc. 2007;  65 AB 127
  • 16 Jonasson R, Johannisson A, Jacobson M. et al . Differences in lymphocyte subpopulations and cell counts before and after experimentally induced swine dysentery.  J Med Microbiol. 2004;  53 267-272

A. Fritscher-Ravens, MD 

Department of Gastroenterology

Homerton University Hospital

Homerton Row

London E9 6SR

UK

Fax: +44-776-4412920

Email: fri.rav@btopenworld.com