Gastroenteroanastomosis using NOTES-technologies — results of an experimental study

Abstract

Introduction. Transluminal endoscopic surgery performed through natural orifices can reduce the incidence of complications associated with the surgical procedure and the incidence of postoperative complications. The purpose of this study was to determine the feasibility of performing an experimental gastroenteroanastomosis in a live pig model using NOTES.

Materials and methods. The experimental study was performed on living laboratory models — pigs weighing from 25 to 30 kg. The study’s preliminary phase allowed working out the technique using two animals removed from the experiment after its successful completion. The final phase included the implementation of gastrojejunoanastomosis in six animals with subsequent observation. In three animals, the procedure was performed with laparoscopic assistance using a single-channel video gastroscope. In the other three animals, it was performed without laparoscopy using a two-channel video gastroscope. Antibiotic therapy continued for seven days after surgery. The surviving animals were removed from the experiment after four weeks. Patency of the anastomosis was confirmed by repeated endoscopy and histological analysis of tissues.

Results. All procedures were completed successfully in six animals (three males and three females). The formation of anastomosis required an average of 133.3 ± 43.8 minutes (range, 80–200 minutes). In one animal, bleeding during gastric wall incision was recorded and was stopped by electrocoagulation. One animal died because of an anastomotic leak and peritonitis, confirmed by autopsy. In the five surviving animals, repeated endoscopy demonstrated fully passable anastomoses covered by the mucosa.

Conclusion. Gastrojejunal anastomosis using NOTES technology is technically possible but requires additional study.

Keywords

NOTES / gastroenteroanastomosis / experiment / children

References

[1] Podnos YD, Jimenez JC, Wilson SE, et al. Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg. 2003;138(9):957–961. DOI: https://doi.org/10.1001/archsurg.138.9.957

[2] Buchwald H, Avidor Y, Braunwald E, et al. Bariatric surgery: a systematic review and meta-analysis. JAMA. 2004;292(14):1724–1737. DOI: https://doi.org/10.1001/jama.292.14.1724.

[3] Jeurnink SM, Steyerberg EW, van Hooft JE, et al. Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT study): a multicenter randomized trial. Gastrointest Endosc. 2010;71(3):490–499. DOI: https://doi.org/10.1016/j.gie.2009.09.042

[4] Ly J, O’Grady G, Mittal A, et al. A systematic review of methods to palliate malignant gastric outlet obstruction. Surg Endosc. 2010;24(2):290–297. DOI: https://doi.org/10.1007/s00464-009-0577-1

[5] Barthet M, Binmoeller KF, Vanbiervliet G, et al. Natural orifice transluminal endoscopic surgery gastroenterostomy with a biflanged lumen-apposing stent: first clinical experience (with videos). Gastrointest Endosc. 2015;81(1):215–218. DOI DOI: https://doi.org/10.1016/j.gie.2014.09.039

[6] Tyberg A, Perez-Miranda M, Sanchez-Ocana R, et al. Endoscopic ultrasound guided gastrojejunostomy with a lumen-apposing metal stent: a multicenter, international experience. Endosc Int Open. 2016;4(3):E276–E281. DOI: https://doi.org/10.1055/s-0042-101789

[7] Liu B, Liu D, Zhao L, et al. Pure natural orifice transluminal endoscopic surgery (NOTES) nonstenting endoscopic gastroenterostomy: first human clinical experience. VideoGIE. 2019;4(5):206-208. DOI: https://doi.org/10.1016/j.vgie.2019.01.004

[8] Ramos AC, Zundel N, Neto MG, Maalouf M. Human hybrid NOTES transvaginal sleeve gastrectomy: initial experience. Surg Obes Relat Dis. 2008;4(5):660–663. DOI: https://doi.org/10.1016/j.soard.2008.06.009

[9] von Renteln D, Schmidt A, Vassiliou MC, et al. Natural orifice transluminal endoscopic surgery gastrotomy closure with an over-the-endoscope clip: a randomized, controlled porcine study (with videos). Gastrointest Endosc. 2009;70(4):732–739. DOI: https://doi.org/10.1016/j.gie.2009.03.010

[10] Park PO, Bergstrom M, Rothstein R, et al. Endoscopic sutured closure of a gastric natural orifice transluminal endoscopic surgery access gastrotomy compared with open surgical closure in a porcine model. A randomized, multicenter controlled trial. Endoscopy. 2010;42(4):311-317. DOI: https://doi.org/10.1055/s-0029-1243938

[11] Romanelli JR, Desilets DJ, Chapman CN, et al. Loop-anchor purse-string closure of gastrotomy in NOTES(R) procedures: survival studies in a porcine model. Surg Innov. 2010;17(4):312-317. DOI: https://doi.org/10.1177/1553350610378515

[12] Romanelli JR, Desilets DJ, Earle DB. Natural orifice transluminal endoscopic surgery gastrotomy closure in porcine explants with the Padlock-G clip using the Lock-It system. Endoscopy. 2010;42(4):306-310. DOI: https://doi.org/10.1055/s-0029-1243950

[13] Kalloo AN, Singh VK, Jagannath SB, et al. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc. 2004;60(1):114–117. DOI: https://doi.org/10.1016/s0016-5107(04)01309-4

[14] Song TJ, Seo DW, Kim SH, et al. Endoscopic gastrojejunostomy with a natural orifice transluminal endoscopic surgery technique. World J Gastroenterol. 2013;19(22):3447–3452. DOI: https://doi.org/10.3748/wjg.v19.i22.3447

[15] Yi SW, Chung MJ, Jo JH, et al. Gastrojejunostomy by pure natural orifice transluminal endoscopic surgery using a newly designed anastomosing metal stent in a porcine model. Surg Endosc. 2014;28(5):1439–1446. DOI: https://doi.org/10.1007/s00464-013-3371-z

[16] Vanbiervliet G, Bonin EA, Garces R, et al. Gastrojejunal anastomosis using a tissue-apposing stent: a safety and feasibility study in live pigs. Endoscopy. 2014;46(10):871–877. DOI: https://doi.org/10.1055/s-0034-1377347

[17] Vanbiervliet G, Gonzalez JM, Bonin EA, et al. Gastrojejunal anastomosis exclusively using the ‘‘NOTES’’ technique in live pigs: a feasibility and reliability study. Surg Innov. 2014;21(4):409–418. DOI: https://doi.org/10.1177/1553350613508016

[18] Chiu PW, Wai Ng EK, Teoh AY, et al. Transgastric endoluminal gastrojejunostomy: technical development from bench to animal study (with video). Gastrointest Endosc. 2010;71(2):390–393. DOI: https://doi.org/10.1016/j.gie.2009.09.019

RIGHTS & PERMISSIONS

Smirnov A.А., Chernov A.V., Kargabaeva A.B., Konkina N.V., Baranova N.A., Rasputin A.A., Ochirov C.B., Cheremnov V.S., Kozlov Y.A.