Directed submucosal tunneling permits in-line endoscope positioning for transgastric natural orifice translumenal endoscopic surgery (NOTES)

Eric Pauli, Randy Haluck, Adrian M. Ionescu, Ann Rogers, Timothy R. Shope, Matthew Moyer, Arnab Biswas, Abraham Mathew

Research output: Contribution to journalArticle

17 Citations (Scopus)

Abstract

Background Submucosal dissection is demonstrated to be a technically feasible, safe means of obtaining peroral transgastric peritoneal access for natural orifice translumenal endoscopic surgery (NOTES). The authors hypothesized that their previously described self-approximating translumenal access technique (STAT) could be used to create directed gastric submucosal tunnels permitting inline endoscope positioning with predetermined abdominal locations that might otherwise be difficult to access. Methods In this study, 14 domestic farm swine underwent peroral transgastric peritoneoscopy. Under direct endoscopic visualization, a submucosal tunnel was created by dissecting between the mucosal and muscular layers of the stomach. Each tunnel was created with one of four intraabdominal locations (right upper quadrant, left upper quadrant, lesser sac, and pelvis) as the final target for inline endoscope positioning. Once peritoneal access had been achieved, in-line positioning was assessed and peritoneoscopy was performed. The submucosal tunnels were closed with endoscopically placed clips. The animals were killed 2 weeks after the procedure, and necropsy was performed. Results Submucosal tunnels were successfully directed at predetermined intraabdominal targets in 12 of the 14 animals. The mean dissection time required to create the tunnel was 51 ± 32 min. All the transgastric tunnels were successfully closed with endoscopically placed clips (mean, 3.2 ± 1.1), and at necropsy showed no evidence of gastrotomy leak in any of the animals. One animal experienced a duodenal perforation unrelated to the transgastric tunneling and was killed on postoperative day 2. The remaining animals recovered and gained weight (mean, 5.5 ± 1.2 kg) in the 2-week survival period. Conclusions Directed submucosal dissection is technically feasible in a porcine model and permits in-line endoscope positioning with predetermined abdominal target locations. The STAT approach provides safe peritoneal access, allows for a simple reliable endoclip closure, and has an excellent short-term survival rate. This method of achieving transgastric access may be an enabling technique for future NOTES procedures.

Original languageEnglish (US)
Pages (from-to)1474-1481
Number of pages8
JournalSurgical endoscopy
Volume24
Issue number6
DOIs
StatePublished - Jan 1 2010

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Natural Orifice Endoscopic Surgery
Endoscopes
Dissection
Surgical Instruments
Laparoscopy
Stomach
Swine
Lesser Pelvis
Peritoneal Cavity
Weights and Measures

All Science Journal Classification (ASJC) codes

  • Surgery

Cite this

@article{474f43ca3c8340d4af24b5d0b8e9e5c4,
title = "Directed submucosal tunneling permits in-line endoscope positioning for transgastric natural orifice translumenal endoscopic surgery (NOTES)",
abstract = "Background Submucosal dissection is demonstrated to be a technically feasible, safe means of obtaining peroral transgastric peritoneal access for natural orifice translumenal endoscopic surgery (NOTES). The authors hypothesized that their previously described self-approximating translumenal access technique (STAT) could be used to create directed gastric submucosal tunnels permitting inline endoscope positioning with predetermined abdominal locations that might otherwise be difficult to access. Methods In this study, 14 domestic farm swine underwent peroral transgastric peritoneoscopy. Under direct endoscopic visualization, a submucosal tunnel was created by dissecting between the mucosal and muscular layers of the stomach. Each tunnel was created with one of four intraabdominal locations (right upper quadrant, left upper quadrant, lesser sac, and pelvis) as the final target for inline endoscope positioning. Once peritoneal access had been achieved, in-line positioning was assessed and peritoneoscopy was performed. The submucosal tunnels were closed with endoscopically placed clips. The animals were killed 2 weeks after the procedure, and necropsy was performed. Results Submucosal tunnels were successfully directed at predetermined intraabdominal targets in 12 of the 14 animals. The mean dissection time required to create the tunnel was 51 ± 32 min. All the transgastric tunnels were successfully closed with endoscopically placed clips (mean, 3.2 ± 1.1), and at necropsy showed no evidence of gastrotomy leak in any of the animals. One animal experienced a duodenal perforation unrelated to the transgastric tunneling and was killed on postoperative day 2. The remaining animals recovered and gained weight (mean, 5.5 ± 1.2 kg) in the 2-week survival period. Conclusions Directed submucosal dissection is technically feasible in a porcine model and permits in-line endoscope positioning with predetermined abdominal target locations. The STAT approach provides safe peritoneal access, allows for a simple reliable endoclip closure, and has an excellent short-term survival rate. This method of achieving transgastric access may be an enabling technique for future NOTES procedures.",
author = "Eric Pauli and Randy Haluck and Ionescu, {Adrian M.} and Ann Rogers and Shope, {Timothy R.} and Matthew Moyer and Arnab Biswas and Abraham Mathew",
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Directed submucosal tunneling permits in-line endoscope positioning for transgastric natural orifice translumenal endoscopic surgery (NOTES). / Pauli, Eric; Haluck, Randy; Ionescu, Adrian M.; Rogers, Ann; Shope, Timothy R.; Moyer, Matthew; Biswas, Arnab; Mathew, Abraham.

In: Surgical endoscopy, Vol. 24, No. 6, 01.01.2010, p. 1474-1481.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Directed submucosal tunneling permits in-line endoscope positioning for transgastric natural orifice translumenal endoscopic surgery (NOTES)

AU - Pauli, Eric

AU - Haluck, Randy

AU - Ionescu, Adrian M.

AU - Rogers, Ann

AU - Shope, Timothy R.

AU - Moyer, Matthew

AU - Biswas, Arnab

AU - Mathew, Abraham

PY - 2010/1/1

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N2 - Background Submucosal dissection is demonstrated to be a technically feasible, safe means of obtaining peroral transgastric peritoneal access for natural orifice translumenal endoscopic surgery (NOTES). The authors hypothesized that their previously described self-approximating translumenal access technique (STAT) could be used to create directed gastric submucosal tunnels permitting inline endoscope positioning with predetermined abdominal locations that might otherwise be difficult to access. Methods In this study, 14 domestic farm swine underwent peroral transgastric peritoneoscopy. Under direct endoscopic visualization, a submucosal tunnel was created by dissecting between the mucosal and muscular layers of the stomach. Each tunnel was created with one of four intraabdominal locations (right upper quadrant, left upper quadrant, lesser sac, and pelvis) as the final target for inline endoscope positioning. Once peritoneal access had been achieved, in-line positioning was assessed and peritoneoscopy was performed. The submucosal tunnels were closed with endoscopically placed clips. The animals were killed 2 weeks after the procedure, and necropsy was performed. Results Submucosal tunnels were successfully directed at predetermined intraabdominal targets in 12 of the 14 animals. The mean dissection time required to create the tunnel was 51 ± 32 min. All the transgastric tunnels were successfully closed with endoscopically placed clips (mean, 3.2 ± 1.1), and at necropsy showed no evidence of gastrotomy leak in any of the animals. One animal experienced a duodenal perforation unrelated to the transgastric tunneling and was killed on postoperative day 2. The remaining animals recovered and gained weight (mean, 5.5 ± 1.2 kg) in the 2-week survival period. Conclusions Directed submucosal dissection is technically feasible in a porcine model and permits in-line endoscope positioning with predetermined abdominal target locations. The STAT approach provides safe peritoneal access, allows for a simple reliable endoclip closure, and has an excellent short-term survival rate. This method of achieving transgastric access may be an enabling technique for future NOTES procedures.

AB - Background Submucosal dissection is demonstrated to be a technically feasible, safe means of obtaining peroral transgastric peritoneal access for natural orifice translumenal endoscopic surgery (NOTES). The authors hypothesized that their previously described self-approximating translumenal access technique (STAT) could be used to create directed gastric submucosal tunnels permitting inline endoscope positioning with predetermined abdominal locations that might otherwise be difficult to access. Methods In this study, 14 domestic farm swine underwent peroral transgastric peritoneoscopy. Under direct endoscopic visualization, a submucosal tunnel was created by dissecting between the mucosal and muscular layers of the stomach. Each tunnel was created with one of four intraabdominal locations (right upper quadrant, left upper quadrant, lesser sac, and pelvis) as the final target for inline endoscope positioning. Once peritoneal access had been achieved, in-line positioning was assessed and peritoneoscopy was performed. The submucosal tunnels were closed with endoscopically placed clips. The animals were killed 2 weeks after the procedure, and necropsy was performed. Results Submucosal tunnels were successfully directed at predetermined intraabdominal targets in 12 of the 14 animals. The mean dissection time required to create the tunnel was 51 ± 32 min. All the transgastric tunnels were successfully closed with endoscopically placed clips (mean, 3.2 ± 1.1), and at necropsy showed no evidence of gastrotomy leak in any of the animals. One animal experienced a duodenal perforation unrelated to the transgastric tunneling and was killed on postoperative day 2. The remaining animals recovered and gained weight (mean, 5.5 ± 1.2 kg) in the 2-week survival period. Conclusions Directed submucosal dissection is technically feasible in a porcine model and permits in-line endoscope positioning with predetermined abdominal target locations. The STAT approach provides safe peritoneal access, allows for a simple reliable endoclip closure, and has an excellent short-term survival rate. This method of achieving transgastric access may be an enabling technique for future NOTES procedures.

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