Endoscopy 2009; 41(6): 487-492
DOI: 10.1055/s-0029-1214721
Original article

© Georg Thieme Verlag KG Stuttgart · New York

Facilitating gastrotomy closure during natural-orifice transluminal endoscopic surgery using tissue anchors

J.  A.  Trunzo1 , L.  T.  Cavazzola1 , B.  J.  Elmunzer1 , 2 , B.  K.  Poulose1 , M.  F.  McGee1 , S.  Schomish1 , J.  L.  Ponsky1 , J.  M.  Marks1
  • 1Department of Surgery, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
  • 2Division of Gastroenterology, Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, Michigan, USA
Further Information

Publication History

submitted 11 August 2008

accepted after revision 17 March 2009

Publication Date:
13 May 2009 (online)

Background and study aims: Reliable and secure closure of the gastrotomy after natural-orifice transluminal endoscopic surgery (NOTES) remains a critical step for widespread acceptance and use of this mode of surgery. We describe a novel method for gastrotomy closure using endoscopic tissue anchors.

Methods: A standard upper endoscopy and wire placement as used for percutaneous endoscopic gastrostomy placement was performed in five pigs. Prior to gastrotomy, four tissue anchors were placed in four quadrants (1 cm away from the wire). A 12-mm gastrotomy was created endoscopically using a combination of needle-knife and balloon dilation. After transgastric peritoneoscopy, the sutures were approximated using a device knotting element. One additional pair of sutures was placed after evaluation of the gastric closure. The animals underwent in vivo contrast fluoroscopy, methylene blue instillation, and bursting pressure studies for assessment of the closure site.

Results: All animals studied showed complete sealing of the gastrotomy site without evidence of leak on fluoroscopic imaging or at final postmortem intragastric methylene blue instillation. Improved insufflation ability following gastrotomy was also noted using this technique, which enhanced overall visualization during the closure.

Conclusion: Positioning tissue anchors prior to creating a NOTES gastrotomy was a feasible and reliable method to perform gastric closure. Follow-up survival studies will be warranted to support these preliminary findings.

References

  • 1 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
  • 2 Hu B, Chung S C, Sun L C. et al . Endoscopic suturing without extracorporeal knots: a laboratory study.  Gastrointest Endosc. 2005;  62 230-233
  • 3 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
  • 4 Ikeda K, Fritscher-Ravens A, Mosse C A. et al . Endoscopic full-thickness resection with sutured closure in a porcine model.  Gastrointest Endosc. 2005;  62 122-129
  • 5 Raju G S, Ahmed I, Brining D, Xiao S Y. Endoluminal closure of large perforations of colon with clips in a porcine model (with video).  Gastrointest Endosc. 2006;  64 640-646
  • 6 Hausmann U, Feussner H, Ahrens P, Heinzl J. Endoluminal endosurgery: rivet application in flexible endoscopy.  Gastrointest Endosc. 2006;  64 101-103
  • 7 Pai R D, Fong D G, Bundga M E. et al . Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model (with video).  Gastrointest Endosc. 2006;  64 428-434
  • 8 Marks J M, Ponsky J L, Pearl J P, McGee M F. PEG ”rescue“: a practical NOTES technique.  Surg Endosc. 2007;  21 816-819
  • 9 Sumiyama K, Gostout C J, Rajan E. et al . Endoscopic full-thickness closure of large gastric perforations by use of tissue anchors.  Gastrointest Endosc. 2007;  65 134-139
  • 10 Sumiyama K, Gostout C J, Rajan E. et al . Submucosal endoscopy with mucosal flap safety valve.  Gastrointest Endosc. 2007;  65 688-694
  • 11 Mellinger J D, MacFadyen B V, Kozarek R A. et al . Initial experience with a novel endoscopic device allowing intragastric manipulation and plication.  Surg Endosc. 2007;  21 1002-1005
  • 12 Perretta S, Sereno S, Forgione A. et al . A new method to close the gastrotomy by using a cardiac septal occluder: long-term survival study in a porcine model.  Gastrointest Endosc. 2007;  66 809-813
  • 13 Magno P, Giday S A, Dray X. et al . A new stapler-based full-thickness transgastric access closure: results from an animal pilot trial.  Endoscopy. 2007;  39 876-880
  • 14 McGee M F, Marks J M, Onders R P. et al . Complete endoscopic closure of gastrotomy after natural orifice translumenal endoscopic surgery using the NDO plicator.  Surg Endosc. 2008;  22 214-220
  • 15 Pauli E M, Moyer M T, Haluck R S, Mathew A. Self-approximating transluminal access technique for natural orifice transluminal endoscopic surgery: a porcine survival study (with video).  Gastrointest Endosc. 2008;  67 690-697
  • 16 Chiu P W, Lau J Y, Ng E K. et al . Closure of a gastrotomy after transgastric tubal ligation by using the Eagle Claw VII: a survival experiment in a porcine model (with video).  Gastrointest Endosc. 2008;  68 554-559
  • 17 Sporn E, Miedema B W, Astudillo J A. et al . Gastrotomy creation and closure for NOTES using a gastropexy technique (with video).  Gastrointest Endosc. 2008;  68 948-953
  • 18 Raju G S, Shibukawa G, Ahmed I. et al . Endoluminal suturing may overcome the limitations of clip closure of a gaping wide colon perforation (with videos).  Gastrointest Endosc. 2007;  65 906-911
  • 19 Sporn E, Miedema B W, Bachman S L. et al . Endoscopic colotomy closure after full thickness excision: comparison of T fastener with multiclip applier.  Endoscopy. 2008;  40 589-594
  • 20 Sporn E, Bachman S L, Miedema B W. Endoscopic colotomy closure for natural orifice transluminal endoscopic surgery using a T-fastener prototype in comparison to conventional laparoscopic suture closure.  Gastrointest Endosc. 2008;  68 724-730
  • 21 McGee M F, Rosen M J, Marks J. et al . A reliable method for monitoring intraabdominal pressure during natural orifice translumenal endoscopic surgery.  Surg Endosc. 2007;  21 672-676
  • 22 Rosen M J, McGee M F, Marks J. et al . Optimizing peritoneal access for natural orifice transvisceral endoscopic surgery (NOTES) [abstract].  Surg Endosc. 2006;  20 (Suppl. 1) S365
  • 23 Carter J T, Tafreshian S, Campos G M. et al . Routine upper GI series after gastric bypass does not reliably identify anastomotic leaks or predict stricture formation.  Surg Endosc. 2007;  21 2172-2177
  • 24 Tirnaksiz M B, Deschamps C, Allen M S. et al . Effectiveness of screening aqueous contrast swallow in detecting clinically significant anastomotic leaks after esophagectomy.  Eur Surg Res. 2005;  37 123-128
  • 25 Ryou M, Pai R D, Sauer J S. et al . Evaluating an optimal gastric closure method for transgastric surgery.  Surg Endosc. 2007;  21 677-680
  • 26 Voermans R P, Worm A M, van Berge Henegouwen M I. et al . In vitro comparison and evaluation of seven gastric closure modalities for natural orifice transluminal endoscopic surgery (NOTES).  Endoscopy. 2008;  40 595-601

J. A. TrunzoMD 

University Hospitals Case Medical Center

11100 Euclid Ave.
Lakeside Building 7th Floor
Cleveland
OH 44106
USA

Fax: +1-216-8448201

Email: joseph.trunzo@uhhospitals.org