|
1
|
The application of rigid and flexible mediastinoscopy in esophagectomy: our experience and a new technology. World J Surg Oncol 2021; 19:234. [PMID: 34364369 PMCID: PMC8349502 DOI: 10.1186/s12957-021-02352-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 07/27/2021] [Indexed: 01/08/2023] Open
Abstract
Background To avoid the inconvenience of triangulation among various rigid operating instruments in mediastinoscopy-assisted esophagectomy, we invented a new technique: used a flexible endoscope to mobilize thoracic esophagus and dissected mediastinal lymph nodes through the left cervical incision. This technology has not been reported so far. In this study, we introduce our long-term experience and demonstrate this new technique. Methods Twenty-nine patients with early esophageal cancer underwent mediastinoscopy-assisted esophagectomy in our hospital from June 2018 to September 2020. Among them, 12 patients used flexible mediastinoscopy, and 17 patients used conventional rigid mediastinoscopy and instruments to observe their therapeutic effect. Results There were no significant differences between the two groups in gender, average age, body mass index, incidence of adverse reactions, bleeding volume, and postoperative hospital stay. The operation time of flexible mediastinoscopy group was significantly shorter than that of rigid mediastinoscopy group (192.9 ± 13.0 vs 246.8 ± 6.9 min, p < 0.01). The number of lymph nodes removed by flexible endoscopy was significantly more than that of rigid endoscopy (8.5 ± 0.6 vs 6.0 ± 0.3, P < 0.01). Postoperative follow-up was completed for all patients, and the average follow-up time was 11.6 ± 7.2 months. During the follow-up period, no recurrence or death was observed. Conclusions Mediastinoscopy-assisted esophagectomy is an effective way to treat early esophageal cancer. The application of flexible mediastinoscopy provides more convenience and better stability. It can facilitate the operation of the surgeon and lymph node dissection, which proved to be a feasible technology.
Collapse
|
|
2
|
2007-2019: a "Third"-Space Odyssey in the Endoscopic Management of Gastrointestinal Tract Diseases. ACTA ACUST UNITED AC 2019; 17:202-220. [PMID: 31037613 DOI: 10.1007/s11938-019-00233-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW The main scope of this review article is to introduce readers to the innovative field of third-space endoscopy and offer a closer look at its history, milestones, and procedure spectrum while discussing ongoing and future challenges arising from its increasing adoption worldwide. RECENT FINDINGS Over the past few years, third-space endoscopy has been utilized in various diagnostic and interventional procedures performed throughout the gastrointestinal tract: obliteration of Zenker's diverticulum, myotomy for achalasia, gastroparesis or Hirschsprung's disease, biopsy or removal of subepithelial tumors, stricture management, post-per-oral endoscopic myotomy endoscopic fundoplication, and mediastino-, thoraco-, and peritoneoscopy. Third-space endoscopic interventions have revolutionized the management of esophageal motility disorders, gastroparesis, and gastrointestinal tract subepithelial tumors. Despite the high efficacy and safety of such interventions, some common (e.g., the high level of necessary endoscopic skill) and unique for each procedure (e.g., post-procedure gastroesophageal reflux or poor outcomes in patient subgroups) challenges still remain. Through a dedicated endoscopic training, a rigorous pre-procedure patient evaluation and selection, and the application of modified or new techniques, challenges can be overcome thus establishing existing procedures and paving the way for additional breakthroughs in the field of third-space endoscopy.
Collapse
|
|
3
|
Córdova H, Cubas G, Boada M, Rodríguez de Miguel C, Martínez-Pallí G, Gimferrer JM, Fernández-Esparrach G. Adverse events of NOTES mediastinoscopy compared to conventional video-assisted mediastinoscopy: a randomized survival study in a porcine model. Endosc Int Open 2015; 3:E571-6. [PMID: 26716115 PMCID: PMC4683132 DOI: 10.1055/s-0034-1392599] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2015] [Accepted: 06/16/2015] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Safety is a concern in natural orifice transluminal endoscopic surgery (NOTES) mediastinoscopy. The objective of this study was to compare the safety of NOTES mediastinoscopy with video-assisted mediastinoscopy (VAM). METHODS Twenty-four pigs were randomly assigned to NOTES or VAM. Thirty-minute mediastinoscopies were performed with the identification of seven predetermined structures. The animals were euthanized after 7 days and necropsy was performed. RESULTS Mediastinoscopy was not possible in one animal in each group. There were more intraoperative adverse events with NOTES than VAM (7 vs. 2, P = 0.04); hemorrhage was the most frequent adverse event (4 and 1, respectively). At necropsy, pathological findings were observed in 13 animals (9 NOTES and 4 VAM; P = 0.03). Inflammatory parameters were not different between groups and were not related to adverse events. CONCLUSION Systematic NOTES mediastinoscopy is possible and comparable to VAM in terms of number of organs identified and inflammatory impact. However, the safety profile of NOTES mediastinoscopy has to be improved before it can be adopted in a clinical setting.
Collapse
Affiliation(s)
- Henry Córdova
- Department of Gastroenterology, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Georgina Cubas
- Anesthesiology Department, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Marc Boada
- Department of Thoracic Surgery, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | | | | | - Josep M. Gimferrer
- Department of Thoracic Surgery, Hospital Clínic, University of Barcelona, Barcelona, Spain
| | - Gloria Fernández-Esparrach
- Department of Gastroenterology, Hospital Clínic, University of Barcelona, Barcelona, Spain,Corresponding author G. Fernández-Esparrach, MD PhD Department of GastroenterologyICMDiMHospital ClínicVillarroel 17008036 BarcelonaSpain+34-93-2279387
| |
Collapse
|
|
4
|
Khereba M, Thiffault V, Goudie E, Tahiri M, Hadjeres R, Razmpoosh M, Ferraro P, Liberman M. Transtracheal thoracic natural orifice transluminal endoscopic surgery (NOTES) in a swine model. Surg Endosc 2015; 30:783-788. [PMID: 26017909 DOI: 10.1007/s00464-015-4228-4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Accepted: 05/01/2015] [Indexed: 12/29/2022]
Abstract
BACKGROUND Natural orifice transluminal endoscopic surgery (NOTES) has the potential to be the final frontier in minimally invasive procedures in thoracic surgery. In order for thoracic pleural NOTES to 1 day be ready for clinical trials, each step of the procedure must be independently evaluated for both safety and efficacy. The aim of this study was to evaluate the trachea as a portal of entry for thoracic NOTES. METHODS Eight 40-kg swine underwent right thoracic pleuroscopy in a survival model. In order to avoid inadvertent injury to the superior vena cava, endobronchial ultrasound was employed to select the location of airway incision. A 7-mm linear incision was then performed at the chosen location using an endoscopic electrocautery needle knife through a therapeutic flexible videobronchoscope. The mediastinal fat and parietal pleura were then dissected with electrocautery, and complete right pleuroscopy was performed. The tracheal and mediastinal portal of entry were then sealed with 1-2 cc of fibrin sealant. The pigs were kept alive for 21 days postoperatively. Postmortem diagnostic bronchoscopy was performed to assess tracheal healing. All tracheal specimens underwent histologic examination for healing and signs of mediastinal infection. RESULTS Thoracic NOTES procedures on all eight pigs were successful. There were no intraoperative complications except for one minor bleeding episode within the mediastinal dissection site which stopped spontaneously. Two pigs died from severe laryngospasm in the early postoperative period. Six pigs survived for 21 days post-procedure and experienced uneventful postoperative courses. Postmortem examination demonstrated complete tracheal healing with appropriate scarring in all pigs. CONCLUSIONS The trachea appears to be a safe port of entry for thoracic NOTES procedures in a swine model. Smaller tracheal incisions followed by balloon dilatation are associated with less postoperative morbidity and mortality. Tracheal incisions sealed with fibrin sealant healed rapidly and without signs of mediastinal infection. This procedure represents a work in progress and is not yet ready for human trials.
Collapse
Affiliation(s)
- Mohamed Khereba
- Division of Thoracic Surgery, Department of Surgery, CHUM Endoscopic Tracheobronchial and Oesophageal Center (CETOC), University of Montréal, Montreal, QC, Canada
| | - Vicky Thiffault
- Division of Thoracic Surgery, Department of Surgery, CHUM Endoscopic Tracheobronchial and Oesophageal Center (CETOC), University of Montréal, Montreal, QC, Canada
| | - Eric Goudie
- Division of Thoracic Surgery, Department of Surgery, CHUM Endoscopic Tracheobronchial and Oesophageal Center (CETOC), University of Montréal, Montreal, QC, Canada
| | - Mehdi Tahiri
- Division of Thoracic Surgery, Department of Surgery, CHUM Endoscopic Tracheobronchial and Oesophageal Center (CETOC), University of Montréal, Montreal, QC, Canada
| | - Rachid Hadjeres
- Department of Pathology, Centre Hospitalier de l'Université de Montréal, University of Montréal, Montreal, QC, Canada
| | - Maryam Razmpoosh
- Department of Pathology, Centre Hospitalier de l'Université de Montréal, University of Montréal, Montreal, QC, Canada
| | - Pasquale Ferraro
- Division of Thoracic Surgery, Department of Surgery, CHUM Endoscopic Tracheobronchial and Oesophageal Center (CETOC), University of Montréal, Montreal, QC, Canada
| | - Moishe Liberman
- Division of Thoracic Surgery, Department of Surgery, CHUM Endoscopic Tracheobronchial and Oesophageal Center (CETOC), University of Montréal, Montreal, QC, Canada. .,Division of Thoracic Surgery, Centre Hospitalier de l'Université de Montréal, 1560 rue Sherbrooke Est, 8e CD - Pavillon Lachapelle, bureau D-8051, Montreal, QC, H2L 4M1, Canada.
| |
Collapse
|
|
5
|
Clinical impact of submucosal tunneling endoscopic resection for the treatment of gastric submucosal tumors originating from the muscularis propria layer (with video). Surg Endosc 2015; 29:3640-6. [PMID: 25740640 DOI: 10.1007/s00464-015-4120-2] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Accepted: 02/02/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND Submucosal tunneling endoscopic resection (STER) can be adequately adopted as an effective treatment for submucosal tumors (SMTs) originating from the muscularis propria (MP) layer at the esophagus and cardia. However, it has been seldom used for gastric SMTs. Our purpose was to evaluate the clinical impact of STER for gastric SMTs arising from the MP layer. METHODS Thirty-two patients with gastric SMTs from the MP layer were retrospectively included. The main outcome measurements were complete resection rate, adverse events, local recurrence, and distant metastases during follow-up. RESULTS Of the 32 lesions, 12 were located in the gastric corpus close to the cardia, 3 in the gastric fundus close to the cardia, 6 in the lesser curvature of the gastric corpus, and 11 in the greater curvature of the gastric antrum. STER was successfully performed in all patients with en bloc resection of tumors. The mean tumor size was 2.3 cm (range 1.0-5.0 cm). The complete resection rate was 100%. The operation time ranged from 25 to 125 min (mean 51.8 min). All complications related to STER were successfully managed with conservative treatments. Local recurrence or distant metastasis did not occur during a follow-up period of 6-32 months. CONCLUSION STER is a safe and effective therapeutic strategy for eligible gastric SMTs originating from the MP layer. Submucosal tunneling in the stomach may be more challenging than that in the esophagus, but does not increase procedure-related adverse events or prevent successful STER for eligible gastric SMTs.
Collapse
|
|
6
|
Navarro-Ripoll R, Córdova H, Rodríguez-D'Jesús A, Boada M, Rodríguez de Miguel C, Beltrán M, Cubas G, Perdomo J, Llach J, Balust J, Gimferrer JM, Fernández-Esparrach G, Martínez-Pallí G. Cardiorespiratory impact of transesophageal endoscopic mediastinoscopy compared with cervical mediastinoscopy: a randomized experimental study. Surg Innov 2014; 21:487-95. [PMID: 24435021 DOI: 10.1177/1553350613517943] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Transesophageal natural-orifice transluminal endoscopic surgery (NOTES) mediastinoscopy has been described as a feasible, less-invasive alternative to video-assisted mediastinoscopy (VAM). We aimed to investigate hemodynamic and respiratory effects during transesophageal NOTES mediastinoscopy compared with VAM. PATIENTS AND METHODS This was a short-survival experiment in 20 female pigs randomized to NOTES (n = 10) or VAM (n = 10) mediastinoscopy. In the NOTES group, an endoscopist accessed the mediastinum through a 5-cm submucosal tunnel in the esophageal wall, and CO2 was used to create the pneumomediastinum. Conventional VAM was carried out by thoracic surgeons. A 30-minute systematic exploration of the mediastinum was then performed, including invasive monitoring for hemodynamic and respiratory data. Blood samples were drawn for gas analyses. RESULTS All experiments except 2 in the NOTES group (one because of technical difficulties, the other because of thoracic lymphatic duct lesion) were completed as planned, and animals survived 24 hours. Also, 3 animals in the NOTES group presented a tension pneumothorax that was immediately recognized and percutaneously drained. VAM and NOTES animals showed similar pulmonary and systemic hemodynamic behavior during mediastinoscopy. Pulmonary gas exchange pattern was mildly impaired during the NOTES procedure, showing lower partial arterial oxygen pressure associated with higher airway pressures (more important in animals that presented with pneumothorax). CONCLUSIONS NOTES mediastinoscopy induces minimal deleterious respiratory effects and hemodynamic changes similar to conventional cervical VAM and could be feasible when performed under strict hemodynamic and respiratory surveillance. Notably, serious complications caused by the injury of pleura are more frequent in NOTES, which mandates an improvement in technique and suitable equipment.
Collapse
Affiliation(s)
| | - Henry Córdova
- Hospital Clínic Barcelona, University of Barcelona, Spain
| | | | - Marc Boada
- Hospital Clínic Barcelona, University of Barcelona, Spain
| | | | - Mireia Beltrán
- Hospital Clínic Barcelona, University of Barcelona, Spain
| | - Georgina Cubas
- Hospital Clínic Barcelona, University of Barcelona, Spain
| | - Juan Perdomo
- Hospital Clínic Barcelona, University of Barcelona, Spain
| | - Josep Llach
- Hospital Clínic Barcelona, University of Barcelona, Spain Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Barcelona, Spain Centro de Investigación Biomédica en Red en el Área temática de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Jaume Balust
- Hospital Clínic Barcelona, University of Barcelona, Spain
| | | | - Gloria Fernández-Esparrach
- Hospital Clínic Barcelona, University of Barcelona, Spain Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Barcelona, Spain Centro de Investigación Biomédica en Red en el Área temática de Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Graciela Martínez-Pallí
- Hospital Clínic Barcelona, University of Barcelona, Spain Instituto de Investigaciones Biomédicas August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| |
Collapse
|
|
7
|
Li QL, Chen WF, Zhou PH, Yao LQ, Xu MD, Hu JW, Cai MY, Zhang YQ, Qin WZ, Ren Z. Peroral endoscopic myotomy for the treatment of achalasia: a clinical comparative study of endoscopic full-thickness and circular muscle myotomy. J Am Coll Surg 2013; 217:442-51. [PMID: 23891074 DOI: 10.1016/j.jamcollsurg.2013.04.033] [Citation(s) in RCA: 124] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2013] [Revised: 04/01/2013] [Accepted: 04/23/2013] [Indexed: 12/13/2022]
Abstract
BACKGROUND A circular muscle myotomy preserving the longitudinal outer esophageal muscular layer is often recommended during peroral endoscopic myotomy (POEM) for achalasia. However, because the longitudinal muscle fibers of the esophagus are extremely thin and fragile, and completeness of myotomy is the basis for the excellent results of conventional surgical myotomy, this modification needs to be further debated. Here, we retrospectively analyzed our prospectively maintained POEM database to compare the outcomes of endoscopic full-thickness and circular muscle myotomy. STUDY DESIGN According to the myotomy depth, 103 patients with full-thickness myotomy were assigned to group A, while 131 patients with circular muscle myotomy were assigned to group B. Symptom relief, procedure-related parameters and adverse events, manometry outcomes, and reflux complications were compared between groups. RESULTS The mean operation times were significantly shorter in group A compared with group B (p = 0.02). There was no increase in any procedure-related adverse event after full-thickness myotomy (all p < 0.05). During follow-up, treatment success (Eckardt score ≤ 3) persisted for 96.0% (95 of 99) of patients in group A and for 95.0% (115 of 121) of patients in group B (p = 0.75). There were no statistically significant differences in pre- and post-treatment D-value of symptom scores and lower esophageal sphincter pressures between groups (both p > 0.05). The overall clinical reflux complication rates were also similar (21.2% vs 16.5%, p = 0.38). CONCLUSIONS Short-term symptom relief and manometry outcomes of each method were comparable. Full-thickness myotomy significantly reduced the procedure time but did not increase the procedure-related adverse events or clinical reflux complications.
Collapse
Affiliation(s)
- Quan-Lin Li
- Endoscopy Center and Endoscopy Research Institute, Zhongshan Hospital, Fudan University, Shanghai, China
| | | | | | | | | | | | | | | | | | | |
Collapse
|
|
8
|
Wu YC, Yen-Chu, Yeh CJ, Hsieh MJ, Chen TP, Chao YK, Wu CY, Yuan HC, Ko PJ, Liu YH, Liu HP. Feasibility of Transumbilical Surgical Lung Biopsy and Pericardial Window Creation. Surg Innov 2013; 21:15-21. [DOI: 10.1177/1553350613484825] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
Background. To date there are no practical platforms for performing natural orifice transluminal endoscopic surgery in the thoracic cavity. This study evaluates the feasibility of transumbilical thoracosopy for lung biopsy and pericardial window creation. Methods. Eleven dogs (6 in the nonsurvival group and 5 in the survival group) were used for this study. A homemade metallic tube was advanced into the abdominal cavity via a 12-mm umbilical incision. The metallic tube was advanced into the thoracic cavity through a subxyphoid diaphragmatic incision under video guidance. Access to the thoracic cavity was achieved by a flexible bronchoscope via the metallic tube. Surgical lung biopsy and pericardial window creation were performed using an electrocautery loop and needle knife. The animals were euthanized 20 minutes after the surgery was complete (nonsurvival group) or 14 days postsurgery (survival group) for necropsy evaluation. Results. Eight pericardial window creations and 21 of 22 preplanned lung biopsies were completed in a median time of 72.18 minutes (range 50-105 minutes). One dog in the nonsurvival group died after tension pneumothorax due to postprocedure massive air leaks. In the survival group, the postoperative period was uneventful in all 5 dogs. Autopsies revealed no signs of vital organ injury and complete healing of the diaphragmatic incision occurred in all animals. Conclusions. The study demonstrated that transumbilical thoracoscopic surgical lung biopsy and pericardial window creation is feasible. The safety and efficacy of the transumbilical approach need to be verified by a more detailed survival study.
Collapse
Affiliation(s)
- Yi-Cheng Wu
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Yen-Chu
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chi-Ju Yeh
- Department of Pathology, Chang Gung University, Taoyuan, Taiwan
| | - Ming-Ju Hsieh
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Tzu-Ping Chen
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Ying-Kai Chao
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Ching-Yang Wu
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Hsu-Chia Yuan
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Po-Jen Ko
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Yun-Hen Liu
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Hui-Ping Liu
- Department of Surgery, Benq Medical Center, Nanjing, China
| |
Collapse
|
|
9
|
Transoral endoscopic surgery versus conventional thoracoscopic surgery for thoracic intervention: safety and efficacy in a canine survival model. Surg Endosc 2013; 27:2428-35. [PMID: 23355155 DOI: 10.1007/s00464-012-2753-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2012] [Accepted: 12/04/2012] [Indexed: 10/27/2022]
Abstract
PURPOSE Transoral endoscopic surgery has been shown to be feasible and safe in both humans and animal models. The purpose of this study was to evaluate the safety and efficacy of transoral and conventional thoracoscopy for thoracic exploration, surgical lung biopsy, and pericardial window creation. METHODS The animals (n = 20) were randomly assigned to the transoral endoscopic approach group (n = 10) or conventional thoracoscopic approach group (n = 10). Transoral thoracoscopy was performed with a flexible bronchoscope via an incision over the vestibulum oris. In conventional thoracoscopy, access to the thoracic cavity was obtained through a thoracic incision. Surgical outcomes (body weight, operating time, operative complications, and time to resumption of normal diet), physiologic parameters (respiratory rate, body temperature), inflammatory parameters [white blood cell (WBC) counts and C-reactive protein (CRP)], and pulmonary parameters (arterial blood gases) were compared for both procedures. RESULTS The surgical lung biopsy and pericardial window creation were successfully performed in all animals except one animal in the transoral group. There was no significant difference in operating times between the groups. The increase in WBC in the transoral thoracoscopy group was significantly smaller on postoperative day 1 than in the conventional thoracoscopy group (p = 0.0029). The transoral group had an earlier return to preoperative body temperature (p = 0.041) and respiratory rate (p = 0.045) on day 7. With respect to pulmonary parameters, there was no significant difference in blood pH, pCO2, or PaCO2 between the transoral and transthoracic groups. All animals survived without complications 14 days after surgery. CONCLUSIONS This study demonstrated that the transoral approach was comparable to conventional thoracoscopic surgery for lung biopsy and pericardial window creation in terms of safety and efficacy.
Collapse
|
|
10
|
Natural orifice translumenal endoscopic surgery for anterior spinal procedures. Minim Invasive Surg 2012; 2012:365814. [PMID: 22693665 PMCID: PMC3368208 DOI: 10.1155/2012/365814] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2011] [Revised: 12/26/2011] [Accepted: 03/27/2012] [Indexed: 12/21/2022] Open
Abstract
Background. NOTES techniques allow transesophageal access to the mediastinum. The aim of this study was to assess the feasibility of transesophageal biopsy of thoracic vertebrae. Methods. Nonsurvival experiments on four 50-kg porcine animals were performed. Transesophageal access to the mediastinum was attained using submucosal tunneling technique. Results. The posterior mediastinum was successfully accessed and navigated in all animals. Vertebral bodies and intervertebral spaces were easily approached while avoiding damage to adjacent vessels. Bone biopsy was successfully performed without complications, but the hardness of bone tissue resulted in small and fragmented samples. Conclusions. Peroral transesophageal access into the posterior mediastinum and thoracic vertebral bone biopsy was feasible and safe. The proximity of the esophagus to the vertebral column provides close and direct access to the thoracic spine and opens up new ground for the performance of multilevel anterior spine procedures using NOTES techniques.
Collapse
|
|
11
|
Natural orifice translumenal endoscopic surgery in humans: a review. Minim Invasive Surg 2012; 2012:189296. [PMID: 22720153 PMCID: PMC3375094 DOI: 10.1155/2012/189296] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2012] [Accepted: 03/06/2012] [Indexed: 12/21/2022] Open
Abstract
Natural orifice translumenal endoscopic surgery (NOTES) had its origins in numerous small animal studies primarily examining safety and feasibility. In human trials, safety and feasibility remain at the forefront; however, additional logistic, practical, and regulatory requirements must be addressed. The purpose of this paper is to evaluate and summarize published studies to date of NOTES in humans. The literature review was performed using PUBMED and MEDLINE databases. Articles published in human populations between 2007 and 2011 were evaluated. A review of this time period resulted in 48 studies describing procedures in 916 patients. Transcolonic and transvesicular procedures were excluded. The most common procedure was cholecystectomy (682, 75%). The most common approach was transvaginal (721, 79%). 424 procedures (46%) were pure NOTES and 491 (54%) were hybrid NOTES cases. 127 (14%) were performed in the United States of America and 789 (86%) were performed internationally. Since 2007, there has been major development in NOTES in human populations. A preponderance of published NOTES procedures were performed internationally. With further development, NOTES may make less invasive surgery available to a larger human population.
Collapse
|
|
12
|
Ko PJ, Chu Y, Wu YC, Liu CY, Hsieh MJ, Chen TP, Chao YK, Wu CY, Yuan HC, Liu YH, Liu HP. Feasibility of Endoscopic Transoral Thoracic Surgical Lung Biopsy and Pericardial Window Creation. J Surg Res 2012; 175:207-14. [DOI: 10.1016/j.jss.2011.03.016] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2011] [Revised: 02/22/2011] [Accepted: 03/04/2011] [Indexed: 10/18/2022]
|
|
13
|
Yang C, Chu Y, Wu YC, Hsieh MJ, Lu MS, Liu CY, Yuan HC, Liu YH, Ko PJ, Liu HP. The lateral decubitus position improves transoral endoscopic access to the posterior aspects of the thorax. Surg Endosc 2012; 26:2988-92. [PMID: 22549375 DOI: 10.1007/s00464-012-2296-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2011] [Accepted: 04/02/2012] [Indexed: 10/28/2022]
Abstract
BACKGROUND The success of natural orifice transluminal endoscopic surgery (NOTES) depends on an adequate exploration of surgical regions. Currently, limited data are available regarding the optimal position for the NOTES approach for thoracic surgery. This study therefore aimed to evaluate the effectiveness of transoral thoracic exploration in a canine model placed in a lateral decubitus position. METHODS A total of 14 dogs were used in this study. Transoral thoracoscopy was performed using a custom-made metal tube via an incision over the vestibular incision with the animal in a supine position. After thoracic exploration, the animal was placed in a lateral decubitus position. The thoracic intervention (surgical lung biopsy, pericardial window creation, and dorsal sympathectomy) was performed by passing a flexible bronchoscope through the lumen of a metal tube. RESULTS The mean operative time for this procedure was 70 min (range 45-100 min). For 12 dogs, all procedures were completed without major complications. However, for one dog, the exploration of the thoracic cavity was incorrect (the right lower lobe had been misinterpreted as the left lower lobe). Another dog had minor bleeding because of an intercostal artery injury that occurred during sympathectomy. CONCLUSION The posterior aspect of the thoracic cavity can be exposed via a transoral approach with the animal in a lateral decubitus position. This approach may be considered as an adjuvant to the supine approach, in which exploration of the posterior thoracic cavity is restricted.
Collapse
Affiliation(s)
- Chen Yang
- Division of Genetics, Department of Pediatrics, Taipei Medical University Hospital, Taipei, Taiwan, ROC
| | | | | | | | | | | | | | | | | | | |
Collapse
|
|
14
|
Left atrial appendage ligation with single transthoracic port assistance: a study of survival assessment in a porcine model (with videos). Gastrointest Endosc 2012; 75:1055-61. [PMID: 22381533 DOI: 10.1016/j.gie.2011.12.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2011] [Accepted: 12/16/2011] [Indexed: 12/11/2022]
Abstract
BACKGROUND Left atrial appendage (LAA) exclusion is a well-known procedure for the prevention of stroke in high-risk patients with atrial fibrillation and contraindication to long-term oral anticoagulant therapy. OBJECTIVE To evaluate a natural orifice transluminal endoscopic surgery (NOTES) approach for LAA ligation. DESIGN In 4 acute and 6 survival pigs, we performed LAA by using a forward-viewing, single-channel gastroscope and an operative thoracoscope with a 3-mm working channel (introduced through an 8-mm single transthoracic port). SETTING Animal laboratory. INTERVENTIONS The gastroscope was introduced in the thoracic cavity through an esophageal submucosal tunnel. An end loop introduced through the gastroscope was used to legate the LAA. In the survival experiments, the esophageal mucosa was closed using hemoclips. MAIN OUTCOME MEASUREMENTS The time, safety, and feasibility of the procedure were recorded. In the survival experiments, endoscopy and postmortem examination were performed on postoperative day 14. RESULTS Creation of a submucosal tunnel and esophagotomy were safely performed in all animals without incidents. The mean time for esophagotomy was 17.0 ± 6.3 minutes. Pericardial dissection and LAA ligation were performed in all animals but 1. The mean time for LAA ligation was 34.4 ± 19.1 minutes. No adverse events occurred during the survival period. Endoscopy showed complete esophageal closure. Postmortem examination revealed pleural adhesions on the site of pericardial dissection, and the LAA was fibrotic with the endoloop in place. LIMITATIONS Animal study. CONCLUSIONS LAA ligation with single transthoracic trocar assistance is feasible and may be an alternative to anticoagulant therapy or to permanent intracardiac implants in patients with atrial fibrillation.
Collapse
|
|
15
|
Natural orifice transesophageal endoscopic surgery: state of the art. Minim Invasive Surg 2012; 2012:896952. [PMID: 22567228 PMCID: PMC3337494 DOI: 10.1155/2012/896952] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2011] [Accepted: 02/09/2012] [Indexed: 12/21/2022] Open
Abstract
The main goal of Natural Orifice Transluminal Endoscopic Surgery (NOTES) is performing surgery avoiding skin incisions. Theoretical advantages of NOTES include decreased postoperative pain, reduction/elimination of general anesthesia, improved cosmetic outcomes, elimination of skin incision-related complications such as wound infections and hernias, and increased overall patient satisfaction. Although various forms of port creation to accomplish thoracic NOTES procedures have been proposed, transesophageal NOTES has been shown to be the most reliable one. The evolution of endoscopic submucosal transesophageal access resulted in the development of per-oral endoscopic myotomy (POEM), which had a fast transition to clinical practice. The authors present a review of the current state of the art concerning transesophageal NOTES, looking at its potential for diagnostic and therapeutic interventions as well as the hurdles yet to be overcome.
Collapse
|
|
16
|
Abu Gazala M, Khalaila A, Shussman N, Abu Gazala S, Elazary R, Amar D, Kushnir D, Ponomernco O, Zamir G, Rivkind AI, Mintz Y. Transesophageal endoscopic myotomy for achalasia: recognizing potential pitfalls before clinical application. Surg Endosc 2012; 26:681-687. [PMID: 21993936 DOI: 10.1007/s00464-011-1937-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2011] [Accepted: 09/13/2011] [Indexed: 12/20/2022]
Abstract
BACKGROUND Laparoscopic Heller esophagomyotomy is the standard of care for achalasia treatment. This procedure, although effective, must be performed with the patient under general anesthesia and is associated with several serious potential complications. The authors aimed to develop a method of performing transesophageal endoscopic esophagomyotomy (TEEM) that would obviate the need for both general anesthesia and external incisions while offering lower intra- and postoperative complications. METHODS The TEEM procedure was performed on eight pigs. For six of the pigs, the procedure aimed at survival. A mid-esophageal mucosal incision was performed using an endoscope, and a submucosal plane was developed. The lower esophageal sphincter (LES) muscle fibers were clearly visualized and divided. The mucosal incision was closed using fibrin sealant. After 2 weeks of survival, a gastrografin swallow study and necropsy were performed. RESULTS The TEEM procedure was performed successfully in all eight porcine models. The myotomy included the LES fibers and extended 4 to 6 cm proximally to the esophagus. The proximal gastric muscle was divided up to 1 to 2 cm. No injuries to the abdominal or mediastinal structures occurred. One pig died on postoperative day 1 due to an unrecognized pneumothorax. Two pigs had ischemic ulcers at the myotomy site. The last three pigs had an uneventful recovery. The mucosal incision site healed completely in all the survived pigs, and except for the pig with mediastinal sepsis, all ate heartily and gained weight as expected. CONCLUSION The TEEM procedure is technically feasible. Due to the morbidity encountered in the first three pigs, the reported technique was modified to include a slimmer endoscope, a shorter tunnel, and a partial-thickness myotomy. These changes together with an understanding of the pitfalls involved in this procedure led to successful results for the next three pigs. Nevertheless, the authors believe that TEEM is not yet ready for prime time. Perfection of the technique and development of dedicated instruments are mandatory before safe translation of this method to human patients.
Collapse
Affiliation(s)
- Mahmoud Abu Gazala
- Department of General Surgery, Hadassah Hebrew University Medical Center, P.O. Box 12000, 91120, Jerusalem, Israel.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
17
|
Antoniou SA, Bartsch DK. NOTES: Current Status and Recent Developments. VISZERALMEDIZIN 2012. [DOI: 10.1159/000346150] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
|
|
18
|
Chen WH, Chu Y, Wu YC, Liu CY, Yuan HC, Ko PJ, Liu YH. Endoscopic closure of a tracheal access site using bioglue after transtracheal thoracoscopy in a nonsurvival canine model. Eur Surg Res 2011; 48:26-33. [PMID: 22189409 DOI: 10.1159/000334281] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Accepted: 07/20/2011] [Indexed: 11/19/2022]
Abstract
OBJECTIVES An ideal wound closure device would repair the wound with minimal complexity. In this report, we describe a simple wound closure method using BioGlue sealant. METHOD Eleven canines underwent transtracheal pericardial window creation under endoscopic guidance for natural orifice transluminal endoscopic surgery (NOTES). The tracheal wound was closed using BioGlue sealant. The integrity of the wound was assessed by determining the amount of air leaking under mechanical ventilation. RESULTS Transtracheal thoracic exploration and pericardial window creation was successful for all of the canines, and adequate wound closure was achieved in 10 of the canines. There was 1 case of NOTES-related death arising from misplacement of the endotracheal tube in the left lower lobar bronchus. This caused a collapse of the left upper lobe and ventilatory failure. Minor lung injuries occurred in 3 canines and minor mediastinal bleeding was encountered in 1 canine during the creation of the access site. CONCLUSION BioGlue sealant was found to be effective in sealing the tracheal wound in all but 1 of the canines. This study demonstrates that the use of the sealant is a simple and efficient means of endoscopically closing the tracheal access site in NOTES.
Collapse
Affiliation(s)
- W-H Chen
- Laboratory Animal Center, Department of Surgery, Chang Gung Memorial Hospital, Linko, Chang Gung University, Guei-Shan Shiang, Taiwan, ROC
| | | | | | | | | | | | | |
Collapse
|
|
19
|
Abstract
The following on interventional endoscopy and single incision surgery contains commentaries on transluminal endoscopic esophageal surgery, flexible endoscopy, triangulation, advanced flexible operating platforms, experimental transesophageal procedures, and para- and intra-esophageal endoscopic surgery.
Collapse
Affiliation(s)
- Lee L Swanström
- Minimally Invasive Surgery Division, Oregon Health Sciences University, Portland, Oregon, USA
| | | |
Collapse
|
|
20
|
Ishimaru T, Iwanaka T, Kawashima H, Terawaki K, Kodaka T, Suzuki K, Takahashi M. A Pilot Study of Laparoscopic Gastric Pull-Up by Using the Natural Orifice Translumenal Endoscopic Surgery Technique: A Novel Procedure for Treating Long-Gap Esophageal Atresia (Type A). J Laparoendosc Adv Surg Tech A 2011; 21:851-7. [DOI: 10.1089/lap.2011.0096] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Affiliation(s)
- Tetsuya Ishimaru
- Department of Pediatric Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Tadashi Iwanaka
- Department of Pediatric Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Hiroshi Kawashima
- Department of Pediatric Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Kan Terawaki
- Department of Pediatric Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Tetsuro Kodaka
- Department of Pediatric Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Kan Suzuki
- Department of Pediatric Surgery, The University of Tokyo Hospital, Tokyo, Japan
| | - Masataka Takahashi
- Department of Pediatric Surgery, The University of Tokyo Hospital, Tokyo, Japan
| |
Collapse
|
|
21
|
Liu YH, Chu Y, Wu YC, Chen TP, Lu MS, Lu HY, Yuan HC, Ko PJ. Feasibility of Endoscopic Transoral Surgical Lung Biopsy in a Live Canine Model. Surg Innov 2011; 19:162-70. [DOI: 10.1177/1553350611421915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background. The feasibility of using a transoral approach to the thoracic cavity has not yet been measured in humans or animals. The present study aimed to evaluate the feasibility of transoral surgical lung biopsy (TOLB) in 10 canines. Methods. Through an incision over the vestibulum oris, a homemade metal tube was introduced into the thoracic cavity under endoscopic guidance and used as a working channel of surgical lung biopsy. TOLB was performed on the predetermined lung lobe by using an electrocautery loop and endoscopic grasper. Results. Successful surgical lung biopsy was achieved in 8 of 10 animals in a mean time of 132 minutes (range 130-190 minutes). There were no major intraoperative or postoperative complications, and all animals survived for 2 weeks after surgery. Autopsy showed no evidence of vital structure injury, mediastinitis, or empyema. Conclusions. TOLB was demonstrated to be safe and feasible in a canine model.
Collapse
Affiliation(s)
| | - Yen Chu
- Chang Gung University, Taoyuan, Taiwan, ROC
| | | | | | | | - Hung-Yi Lu
- Chang Gung University, Taoyuan, Taiwan, ROC
| | | | - Po-Jen Ko
- Chang Gung University, Taoyuan, Taiwan, ROC
| |
Collapse
|
|
22
|
Moreira-Pinto J, Lima E, Correia-Pinto J, Rolanda C. Natural orifice transluminal endoscopy surgery: A review. World J Gastroenterol 2011; 17:3795-801. [PMID: 21987621 PMCID: PMC3181440 DOI: 10.3748/wjg.v17.i33.3795] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2010] [Revised: 12/01/2010] [Accepted: 12/08/2010] [Indexed: 02/06/2023] Open
Abstract
Minimally invasive surgery started spreading worldwide in 1987, when the first laparoscopic cholecystectomy was performed. Meanwhile, improvement of endoscopic equipment and instruments allowed gastroenterologists to attempt more aggressive endoluminal interventions, even beyond the wall barrier. The first transgastric peritoneoscopy, in 2004, brought to light the concept of natural orifice transluminal endoscopic surgery (NOTES). The idea of incisionless surgery is attractive and has become a new goal for both surgeons and other people interested in this field of investigation. The authors present a review of all developments concerning NOTES, including animal studies and human experience.
Collapse
|
|
23
|
Abstract
Natural orifice transluminal endoscopic surgery (NOTES) has gained a great deal of attention from gastroenterologists and surgeons all over the world since its introduction in 2000. The field of NOTES has advanced tremendously since that time and exciting and well-designed research has been reported. Both randomized controlled trials and results from large national and international registries have been published. Many experimental and clinical studies have discussed transesophageal, transgastric, transvaginal and transrectal access for a variety of NOTES procedures. Transvaginal access has been the most frequently reported NOTES access route in clinical trials. When suitable instruments become available, a true comparison of NOTES with current laparoscopic approaches can be realized.
Collapse
|
|
24
|
Gee DW, Rattner DW. Transmediastinal endoscopic intervention. J Gastrointest Surg 2011; 15:1303-5. [PMID: 21671114 DOI: 10.1007/s11605-011-1578-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2010] [Accepted: 05/25/2011] [Indexed: 01/31/2023]
|
|
25
|
Liu YH, Yen-Chu, Wu YC, Yeh CJ, Liu CY, Hsieh MJ, Chen TP, Yuan HC, Ko PJ. Single-dose antimicrobial prophylaxis in transoral surgical lung biopsy: a preliminary experience. Surg Endosc 2011; 25:3912-7. [DOI: 10.1007/s00464-011-1819-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2010] [Accepted: 06/04/2011] [Indexed: 11/24/2022]
|
|
26
|
von Renteln D, Vassiliou MC, Caca K, Schmidt A, Rothstein RI. Feasibility and safety of endoscopic transesophageal access and closure using a Maryland dissector and a self-expanding metal stent. Surg Endosc 2011; 25:2350-2357. [PMID: 21136086 DOI: 10.1007/s00464-010-1509-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2010] [Accepted: 11/12/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Secure access and reliable closure is paramount in the setting of transesophageal mediastinal endoscopic surgery. The purpose of this study was to develop a secure transesophageal access technique and to evaluate the feasibility, safety, and efficacy of a novel covered, self-expanding, retractable stent for closure of 15-mm esophageal defects. METHODS Fifteen-millimeter esophagotomies were created in 18 domestic pigs using needle knife puncture and balloon dilatation or a blunt dissection technique. Six animals were randomly assigned to open surgical repair and six animals to endoscopic closure using a self-expanding, covered, nitinol stent (Danis SX-ELLA stent, ELLA-CS) in a nonsurvival setting. Pressurized leak tests were performed on all closures. Six animals underwent transesophageal endoscopic mediastinal interventions and survived for 17 days. Stents were extracted at day 10. RESULTS Nonsurvival experiments revealed two bleeding complications associated with the needle-knife access technique, while blunt-dissection mediastinal access was not associated with any complications. Leak test results were not different for stent compared to surgical closures. All survival animals were found to have complete closure and adequate healing of the esophagotomies. No leakage or infectious complication occurred. CONCLUSION Blunt dissection achieves safe access into the mediastinum. Stent closure achieves similar leak test results compared to surgical closure and results in adequate sealing and wound healing of 15-mm esophageal defects.
Collapse
Affiliation(s)
- Daniel von Renteln
- Department of Gastroenterology, Medizinische Klinik I, Klinikum Ludwigsburg, Ludwigsburg, Germany.
| | | | | | | | | |
Collapse
|
|
27
|
Turner BG, Kim MC, Gee DW, Dursun A, Mino-Kenudson M, Huang ES, Sylla P, Rattner DW, Brugge WR. A prospective, randomized trial of esophageal submucosal tunnel closure with a stent versus no closure to secure a transesophageal natural orifice transluminal endoscopic surgery access site. Gastrointest Endosc 2011; 73:785-90. [PMID: 21288511 DOI: 10.1016/j.gie.2010.11.025] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2010] [Accepted: 11/11/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND Secure esophagotomy closure methods are a critical element in the advancement of transesophageal natural orifice transluminal endoscopic surgery (NOTES) procedures. OBJECTIVE To compare the clinical outcomes in swine receiving an esophageal stent or no stent after a submucosal tunnel NOTES access procedure. DESIGN Prospective, randomized, controlled trial in 10 Yorkshire swine. SETTING Academic center. INTERVENTION An endoscopic mucosectomy device was used to create an esophageal mucosal defect. An endoscope was advanced through a submucosal tunnel into the mediastinum and thorax, and diagnostic mediastinoscopy and thoracoscopy were performed. Ten animals were randomized to no stenting (n = 5) or stenting (n = 5) with a prototype small-intestine submucosa-covered stent. MAIN OUTCOME MEASUREMENTS Gross and histologic appearance of the mucosectomy and esophagotomy sites as well as clinical outcomes. RESULTS There was a significant difference in the overall procedure time between the animals that received a stent (35.0 min, range 27-46.0 min) and those with no closure (19.0 min, range 17-32 min) (P value = .018). The unstented group achieved endoscopic and histologic evidence of complete re-epithelialization and healing (100%) at the mucosectomy site compared with the stented group (20%, P = .048). Stent migration into the stomach occurred in two swine. Both groups had complete closure of the submucosal tunnel and well-healed esophagotomy sites. LIMITATIONS Animal study, small number of subjects. CONCLUSION The placement of a covered esophageal stent significantly interferes with mucosectomy site healing.
Collapse
Affiliation(s)
- Brian G Turner
- Gastroenterology Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
|
28
|
Grund KE, Lehmann TG. Transesophageal NOTES--a critical analysis of relevant problems. MINIM INVASIV THER 2011; 19:252-6. [PMID: 20868297 DOI: 10.3109/13645706.2010.510670] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The transesophageal access route has not become a principal topic in the discussion about NOTES up to now. Analyzing the problems in this new field of surgery, however, the transesophageal route shows high relevance. Here, all possibilities, limitations, and problems of NOTES become obvious. This paper contains a critical analysis of the literature published to date (nine full papers, five abstracts). Nearly all publications represent experimental studies in living pigs. In most cases a submucosal tunnel technique is performed as access route to mediastinum, pleural cavity, and heart. Interventions and operations include simple mediastinoscopies as well as epicardial operations after exposition of the heart. For access and manipulation, conventional flexible endoscopes and instruments are used. Clips, T-bars, or a combination of both achieve the closure. Some studies rely on spontaneous closure of the incision without any suturing or approximation. In such experimental settings, the following results are presented: Access is achieved in 90% of cases, the aim of the operation is met in 92%, technical success in closure is achieved in 90%, healing of incision assessed as good in two of five studies, satisfactory in three of five studies. Mortality, ranging from 6 to 25%, and complication rates were (surprisingly) high. It has to be stressed that analyzing these papers published to date, no adequate attention is paid to basic facts and problems of general and thoracic surgery (e.g. different forms, prevention, diagnosis and therapy of pneumothorax or differentiated forms of ventilation). Relevant differences in the anatomy and physiology of the esophagus and mediastinum between humans and pigs should additionally be taken into account to choose optimal experimental parameters when transferring results to human settings. Moreover, requirements regarding sterility and hygiene in a structure like the mediastinum, which is at high risk from the point of view of infection biology, have not yet been respected. These factors should be taken into account in further studies--as well as clinically relevant disease patterns in humans--to be able to realize possible advantages of this NOTES access in a clinical setting.
Collapse
Affiliation(s)
- Karl E Grund
- Department for General, Visceral, and Transplantation Surgery, Surgical Endoscopy, University Hospital Tübingen, Waldhörnlestrasse 22, Tübingen, Germany.
| | | |
Collapse
|
|
29
|
Makris KI, Rieder E, Swanstrom LL. Natural Orifice Trans-Luminal Endoscopic Surgery (NOTES) in Thoracic Surgery. Semin Thorac Cardiovasc Surg 2010; 22:302-9. [DOI: 10.1053/j.semtcvs.2011.01.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/17/2011] [Indexed: 11/11/2022]
|
|
30
|
Transcervical heller myotomy using flexible endoscopy. J Gastrointest Surg 2010; 14:1902-9. [PMID: 20721635 DOI: 10.1007/s11605-010-1290-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2010] [Accepted: 08/05/2010] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Esophageal achalasia is most commonly treated by laparoscopic myotomy. Transesophageal approaches using flexible endoscopy have recently been described. We hypothesized that using techniques and flexible instruments from our NOTES experience through a small cervical incision would be a safer and less traumatic route for esophageal myotomy. The purpose of this study was to evaluate the feasibility, safety, and success rate of using flexible endoscopes to perform anterior or posterior Heller myotomy via a transcervical approach. METHODS This animal (porcine) and human cadaver study was conducted at the Legacy Research and Technology Center. Mediastinal operations on ten live, anesthetized pigs and two human cadavers were performed using standard flexible endoscopes through a small incision at the supra-sternal notch. The esophagus was dissected to the phreno-esophageal junction using balloon dilatation in the peri-esophageal space followed by either anterior or posterior distal esophageal myotomy. Success rate was recorded of esophageal dissection to the diaphragm and proximal stomach, anterior and posterior myotomy, perforation, and complication rates. RESULTS Dissection of the esophagus to the diaphragm and performing esophageal myotomy was achieved in 100% of attempts. Posterior Heller myotomy was always extendable onto the gastric wall, while anterior gastric extension of the myotomy was found to be more difficult (4/4 and 2/8, respectively; P = 0.061). CONCLUSION Heller myotomy through a small cervical incision using flexible endoscopes is feasible. A complete Heller myotomy was performed with a higher success rate posteriorly possibly due to less anatomic interference.
Collapse
|
|
31
|
Wilhelm T, Klemm W, Leschber G, Harlaar JJ, Kerver ALA, Kleinrensink GJ, Nemat A. Development of a new trans-oral endoscopic approach for mediastinal surgery based on 'natural orifice surgery': preclinical studies on surgical technique, feasibility, and safety. Eur J Cardiothorac Surg 2010; 39:1001-8. [PMID: 20971020 DOI: 10.1016/j.ejcts.2010.09.028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2010] [Revised: 09/08/2010] [Accepted: 09/17/2010] [Indexed: 12/29/2022] Open
Abstract
OBJECTIVE In recent years, several surgical disciplines adopted endoscopic techniques. Presently, natural orifice approaches are under exploration to reduce surgical access trauma. We have developed a trans-oral endoscopic approach for endoscopic mediastinal surgery and have tested this new technique in preclinical studies for feasibility and safety. METHODS We conducted an experimental anatomical study in fresh-frozen cadavers. By a midline, sublingual incision, we placed an optical scissor through a 6.0-mm trocar in the pretracheal region and created a working space; two additional trocars were placed by bi-vestibular incisions in the oral cavity. We visualized and followed the trachea down to the main bronchi. Paratracheal and subcarinal lymph nodes were resected bilaterally; the specimen could be removed through the midline channel. In an additional animal study in pigs, we tested the feasibility and safety for this surgical approach. Anatomical dissection allowed an estimate of collateral damage. RESULTS In all cases, we could reach the target region endoscopically, and no conversion was necessary. Landmarks (the brachiocervical trunk, the azygos vein, and the pulmonary artery) were visualized easily and kept intact. A working space in the mediastinum could be established by the insufflation of air at 6-8mmHg. It was possible to harvest the specimen through the midline channel. Anatomical dissection of the cervical access route as well as of the mediastinal region showed no collateral damage. In the animal study, we encountered seroma of the surgical field due to the conditions of the animal model. The other outcomes with respect to pain and food intake were normal until the third postoperative day. No local infections occurred. Intraoperative gas exchange was normal and was not influenced by CO(2) insufflation with respect to blood gas analysis. CONCLUSION These preclinical studies showed that the mediastinum could be reached by a trans-oral endoscopic approach, based on natural orifice surgery. Complete compartment resection of the paratracheal and subcarinal lymph node stations was possible in a well-defined and clearly visible working space. This approach may enhance the extent of mediastinal resections in oncologic surgery.
Collapse
Affiliation(s)
- Thomas Wilhelm
- Department of Otolaryngology, Head/Neck & Facial Plastic Surgery, HELIOS Klinikum Borna, Borna, Germany.
| | | | | | | | | | | | | |
Collapse
|
|
32
|
Turner BG, Gee DW, Cizginer S, Kim MC, Mino-Kenudson M, Sylla P, Brugge WR, Rattner DW. Endoscopic transesophageal mediastinal lymph node dissection and en bloc resection by using mediastinal and thoracic approaches (with video). Gastrointest Endosc 2010; 72:831-5. [PMID: 20573345 PMCID: PMC3863608 DOI: 10.1016/j.gie.2010.04.019] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2010] [Accepted: 04/08/2010] [Indexed: 02/08/2023]
Abstract
BACKGROUND The criterion standard for sampling mediastinal lymph nodes is cervical mediastinoscopy. Current methods that require transthoracic or cervical incisions can result in significant postoperative pain. OBJECTIVE To determine the feasibility of a novel, transesophageal endoscopic technique for mediastinal lymph node dissection and en bloc resection. DESIGN Nonsurvival and survival animal study. SETTING Animal trial at a tertiary-care academic center. SUBJECTS This study involved 12 Yorkshire swine. INTERVENTION An endoscopic cap band mucosectomy device was used to create an esophageal mucosal defect. By using the tip of the endoscope and biopsy forceps, a submucosal tunnel was fashioned, and, within the submucosal space, a hook-knife incised the muscular esophageal wall. The endoscope was then advanced into the mediastinum and chest. Mediastinoscopy and thoracoscopy were performed to identify lymph node stations. Prototype endoscopic devices permitted lymph node dissection prior to removal with an electrocautery snare. A covered prototype stent was placed over the mucosectomy site. MAIN OUTCOME MEASUREMENTS Feasibility of endoscopic transesophageal lymphadenectomy. RESULTS Three lymph nodes (1 para-aortic and 2 right paratracheal) were removed in the 3 nonsurvival swine. Nine swine were survived for 14 days (range 13-14 days) and had a total of 7 lymph nodes (2 para-aortic and 5 paratracheal) removed. Two swine had no endoscopically visible lymph nodes in the mediastinum or chest. Lymph node dissection and resection was successful in all cases where lymph nodes were identified. Lymphadenectomy was completed in a median time of 20.0 minutes (range 8-60 minutes); median total procedure time was 70.0 minutes (range 28-105 minutes). Median lymph node size was 1.1 cm (range 0.6-1.4 cm). LIMITATIONS Animal study. CONCLUSION An endoscopic transesophageal approach can accomplish mediastinal lymph node dissection and en bloc resection and provides architecturally intact lymph node specimens for histologic examination.
Collapse
Affiliation(s)
- Brian G. Turner
- Gastrointestinal Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114
| | - Denise W. Gee
- Department of Surgery, Massachusetts General Hospital, 15 Parkman Street, Boston, MA 02114
| | - Sevdenur Cizginer
- Gastrointestinal Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114
| | - Min-Chan Kim
- Department of Surgery, Massachusetts General Hospital, 15 Parkman Street, Boston, MA 02114,Dong-A University College of Medicine, Department of Surgery, Minimally Invasive and Robot Center, 3-1 dongdaeshin-dong, seo-gu, Busan, 602-715, Korea
| | - Mari Mino-Kenudson
- Department of Pathology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114
| | - Patricia Sylla
- Department of Surgery, Massachusetts General Hospital, 15 Parkman Street, Boston, MA 02114
| | - William R. Brugge
- Gastrointestinal Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114
| | - David W. Rattner
- Department of Surgery, Massachusetts General Hospital, 15 Parkman Street, Boston, MA 02114
| |
Collapse
|
|
33
|
Zorron R, Palanivelu C, Galvão Neto MP, Ramos A, Salinas G, Burghardt J, DeCarli L, Henrique Sousa L, Forgione A, Pugliese R, Branco AJ, Balashanmugan TS, Boza C, Corcione F, D'Avila Avila F, Arturo Gómez N, Galvão Ribeiro PA, Martins S, Filgueiras M, Gellert K, Wood Branco A, Kondo W, Inacio Sanseverino J, de Sousa JAG, Saavedra L, Ramírez E, Campos J, Sivakumar K, Rajan PS, Jategaonkar PA, Ranagrajan M, Parthasarathi R, Senthilnathan P, Prasad M, Cuccurullo D, Müller V. International multicenter trial on clinical natural orifice surgery--NOTES IMTN study: preliminary results of 362 patients. Surg Innov 2010; 17:142-58. [PMID: 20504792 DOI: 10.1177/1553350610370968] [Citation(s) in RCA: 122] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
OBJECTIVES Natural orifice translumenal endoscopic surgery (NOTES) is evolving as a promising alternative for abdominal surgery. IMTN Registry was designed to prospectively document early results of natural orifice surgery among a large group of clinical cases. METHODS Sixteen centers from 9 countries were approved to participate in the study, based on study protocol requirements and local institutional review board approval. Transgastric and transvaginal endoscopic natural orifice surgery was clinically applied in 362 patients. Intraoperative and postoperative parameters were prospectively documented. RESULTS Mean operative time for transvaginal cholecystectomy was 96 minutes, compared with 111 minute for transgastric cholecystectomy. A general complication rate of 8.84% was recorded (grade I-II representing 5.8%, grade III-IV representing 3.04%). No requirement for any analgesia was found in one fourth of cholecystectomy and appendectomy patients. CONCLUSIONS Results of clinical applications of NOTES in the IMTN Study showed the feasibility of different methods of this new minimally invasive alternative for laparoscopic and open surgery.
Collapse
Affiliation(s)
- Ricardo Zorron
- Department of Surgery, University Hospital Teresopolis HCTCO-FESO, Rio de Janeiro, Brazil.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
|
34
|
Turner BG, Cizginer S, Kim MC, Mino-Kenudson M, Ducharme RW, Surti VC, Sylla P, Brugge WR, Rattner DW, Gee DW. Stent placement provides safe esophageal closure in thoracic NOTES(TM) procedures. Surg Endosc 2010; 25:913-8. [PMID: 20820811 DOI: 10.1007/s00464-010-1297-2] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2010] [Accepted: 07/26/2010] [Indexed: 11/30/2022]
Abstract
BACKGROUND Safe esophageal closure remains a challenge in transesophageal Natural Orifice Transluminal Endoscopic Surgery (NOTES). Previously described methods, such as suturing devices, clips, or submucosal tunneling, all have weaknesses. In this survival animal series, we demonstrate safe esophageal closure with a prototype retrievable, antimigration stent. METHODS Nine Yorkshire swine underwent thoracic NOTES procedures. A double-channel gastroscope equipped with a mucosectomy device was used to create an esophageal mucosal defect. A 5-cm submucosal tunnel was created and the muscular esophageal wall was incised with a needle-knife. Mediastinoscopy and thoracoscopy were performed in all swine; lymphadenectomy was performed in seven swine. A prototype small intestinal submucosal (SurgiSIS(®)) covered stent was deployed over the mucosectomy site and tunnel. Three versions of the prototype stent were developed. Prenecropsy endoscopy confirmed stent location and permitted stent retrieval. Explanted esophagi were sent to pathology. RESULTS Esophageal stenting was successful in all animals. Stent placement took 15.8 ± 4.8 minuted and no stent migration occurred. Prenecropsy endoscopy revealed proximal ingrowth of esophageal mucosa and erosion with Stent A. Mucosal inflammation and erosion was observed proximally with Stent B. No esophageal erosion or pressure damage from proximal radial forces was seen with Stent C. On necropsy, swine 5 had a 0.5-cm periesophageal abscess. Histology revealed a localized inflammatory lesion at the esophageal exit site in swine 1, 3, and 9. The mucosectomy site was partially healed in three swine and poorly healed in six. All swine thrived clinically, except for a brief period of mild lethargy in swine 9 who improved with short-term antibiotic therapy. The submucosal tunnels were completely healed and no esophageal bleeding or stricture formation was observed. All swine survived 13.8 ± 0.4 days and gained weight in the postoperative period. CONCLUSIONS Esophageal stenting provides safe closure for NOTES thoracic procedures but may impede healing of the mucosectomy site.
Collapse
|
|
35
|
Abstract
PURPOSE OF REVIEW Since its introduction in 2000, natural orifice translumenal endoscopic surgery (NOTES) has gained a great deal of attention from gastroenterologists and surgeons all over the world. In this article, we will review the progress in the field of NOTES and present the latest publications that provide some answers and solutions to the barriers suggested by the Natural Orifice Surgery Consortium for Assessment and Research white paper. RECENT FINDINGS Because of the first human NOTES procedure by Rao and Reddy, more pioneering procedures, including transgastric and transvaginal cholecystectomies, appendectomies, and hernia repairs, have been performed. Although NOTES researchers continue to experiment with new innovative equipment and procedures in the lab, more structured work, including randomized controlled trials, has been published. SUMMARY In the last several years, there has been growing interest in NOTES, which has translated into exciting animal research work and publication of randomized controlled trials. Additionally, preliminary NOTES human procedures have been successfully performed. When suitable instruments become available, the subsequent step should be comparing NOTES with current laparoscopic approaches. Superiority or even equality of NOTES to laparoscopic surgery would be the best argument for advancing and integrating implementation into clinical practice.
Collapse
|
|
36
|
|
|
37
|
Mediastinal surgery in connective tissue tunnels using flexible endoscopy. Surg Endosc 2010; 24:2120-7. [DOI: 10.1007/s00464-010-0908-2] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2009] [Accepted: 01/14/2010] [Indexed: 11/27/2022]
|
|
38
|
Turner BG, Gee DW. Natural orifice transesophageal thoracoscopic surgery: A review of the current state. World J Gastrointest Endosc 2010; 2:3-9. [PMID: 21160671 PMCID: PMC2998863 DOI: 10.4253/wjge.v2.i1.3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2009] [Revised: 10/07/2009] [Accepted: 10/14/2009] [Indexed: 02/05/2023] Open
Abstract
Since the concept of Natural Orifice Translumenal Endoscopic Surgery (NOTES) was introduced, it has continued to gain significantly in popularity and enthusiasm for its potential clinical applications. The ability to perform conventional laparoscopic and thoracoscopic procedures without the creation of scars and perhaps faster and less painful recovery has prompted a worldwide devotion to further this field. While intra-abdominal NOTES has rapidly transitioned from animal models to human trials, applying the NOTES concept to perform thoracic procedures has been slower to gain momentum. The goal of this review is to summarize the current state of transesophageal NOTES thoracoscopy by looking at its potential for diagnostic and therapeutic interventions as well as the challenges in transitioning to human trials.
Collapse
Affiliation(s)
- Brian G Turner
- Brian G Turner, Gastrointestinal Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02114, United States
| | | |
Collapse
|
|
39
|
Abstract
As limited as are the studies regarding peritoneal Natural Orifice Trans-Luminal Endoscopic Surgery, mediastinal transluminal experiments are certainly in their infancy. The authors evaluate the parallel development of minimally invasive thoracic surgery with regard to its counterpart in peritoneal laparoscopy to NOTES. Transesophageal interventions by both endosonographic and direct visualization are examined in the context of minimally invasive surgery and mediastinal NOTES. Techniques of viscerotomy creation, visualization, and closure are examined with particular emphasis on mediastinal structures. The state of current interventions is examined. Finally, current morbidity (including infectious complications) and survival outcomes are examined in those animals that have undergone transesophageal exploration.
Collapse
|
|
40
|
Turner BG, Gee DW, Cizginer S, Konuk Y, Karaca C, Willingham F, Mino-Kenudson M, Morse C, Rattner DW, Brugge WR. Feasibility of endoscopic transesophageal thoracic sympathectomy (with video). Gastrointest Endosc 2010; 71:171-5. [PMID: 19879572 DOI: 10.1016/j.gie.2009.07.016] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2009] [Accepted: 07/09/2009] [Indexed: 02/08/2023]
Abstract
BACKGROUND Thoracoscopic sympathectomy is the preferred surgical treatment for patients with disabling palmar hyperhidrosis. Current methods require a transthoracic approach to permit ablation of the thoracic sympathetic chain. OBJECTIVE To develop a minimally invasive, transesophageal endoscopic technique for a sympathectomy in a swine model. DESIGN Nonsurvival animal study. SETTING Animal trial at a tertiary care academic center. SUBJECTS This study involved 8 healthy Yorkshire swine. INTERVENTIONS After insertion of a double-channel gastroscope, a Duette Band mucosectomy device was used to create a small esophageal mucosal defect. A short, 5-cm submucosal tunnel was created by using the tip of the endoscope and biopsy forceps. Within the submucosal space, a needle-knife was used to incise the muscular esophageal wall and permit entry into the mediastinum and chest. The sympathetic chain was identified at the desired thoracic level and was ablated or transected. The animals were killed at the completion of the procedure. MAIN OUTCOME MEASUREMENTS Feasibility of endoscopic transesophageal thoracic sympathectomy. RESULTS The sympathetic chain was successfully ablated in 7 of 8 swine, as confirmed by gross surgical pathology and histology. In 1 swine, muscle fibers were inadvertently transected. On average, the procedure took 61.4+/-24.5 minutes to gain access to the chest, whereas the sympathectomy was performed in less than 3 minutes in all cases. One animal was killed immediately after sympathectomy, before the completion of the observation period, because of hemodynamic instability. LIMITATIONS Nonsurvival series, animal study. CONCLUSIONS Endoscopic transesophageal thoracic sympathectomy is technically feasible, simple, and can be performed in a porcine model.
Collapse
Affiliation(s)
- Brian G Turner
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
|
41
|
Fritscher-Ravens A, Cuming T, Jacobsen B, Seehusen F, Ghanbari A, Kahle E, von Herbay A, Koehler P, Milla P. Feasibility and safety of endoscopic full-thickness esophageal wall resection and defect closure: a prospective long-term survival animal study. Gastrointest Endosc 2009; 69:1314-20. [PMID: 19249776 DOI: 10.1016/j.gie.2008.09.031] [Citation(s) in RCA: 30] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2008] [Accepted: 09/17/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND The first experiences with endoscopic closure of esophageal perforations in animal survival studies encouraged us to extend these procedures to full-thickness resections of pieces of the esophageal wall (FTEW). OBJECTIVE To learn the feasibility, safety, and long-term effects of FTEW removal and defect closure. DESIGN Feasibility animal study. SETTING Approved animal facility. INTERVENTIONS Twelve pigs were used for 3-month survival studies, autopsy, and histologic examination. Resection of a 2-cm piece of wall was performed with needle-knife and forceps/snare. Closure was performed by using prototype endoscopic suturing. MAIN OUTCOME MEASUREMENTS Feasibility and complication assessment of this new endoscopic method. RESULTS There were no complications relating to incision, resection, or closure. All pigs recovered quickly. In 2 animals a larger piece of wall causing a larger defect was removed, resulting in much air penetrating into the mediastinum, causing difficult ventilation. This was resolved with thoracic drain. In 3 of 12 animals a toxic substance slipped into the mediastinum, resulting in an abscess in 1 pig and misfire of an anchor as a result of obscured vision. This caused temporary illness of the animal but not death. Autopsy and histologic study confirmed no mediastinitis and well-healed scars in all but one. LIMITATION Animal study. CONCLUSION FTEW has proven to be feasible. Long-term survival demonstrated no mediastinitis and only 1 abscess after contamination of the mediastinum. These first experiences encourage further animal studies because the prospect of endoscopic full-thickness removal of esophageal lesions in patients might be very advantageous.
Collapse
|
|
42
|
Perretta S, Allemann P, Dallemagne B, Marescaux J. Natural orifice transluminal endoscopic surgery (N.O.T.E.S.) for neoplasia of the chest and mediastinum. Surg Oncol 2009; 18:177-180. [PMID: 19162473 DOI: 10.1016/j.suronc.2008.12.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Indications for Natural Orifice Transluminal Endoscopic Surgery or NOTES have so far mainly concerned intra-abdominal surgery. The next question to be addressed was whether this access can be extended into other body cavities and, in particular, whether there is a significant role for NOTES above the diaphragm? Using the esophagus, one of the mediastinal organs, as a direct carrier to access the mediastinum and the pleural cavity would eliminate the dissection of the pretracheal fascia required by mediastinoscopy and would give access to the inner part of lung parenchyma. Alternatively, transgastric (or even transvaginal) transhiatal approaches could supplement standard operative techniques in order to minimize abdominal wall ingression. Furthermore, conventional techniques seem disproportionate measures for relatively simple procedures such as evaluating the outcome of chemotherapy and restaging of medically treated mediastinal lesions. As a truly minimal access technique, NOTES could therefore find new indications for intervention. The obvious limiting factor in all of this is assurance of 'leak proof' mural closure. However, if safety of access-site sealing can be established in clinical studies, we could have found an easier, reproducible alternative to the access to mediastinum. This review examines the rationale and evidence for proposing such a venture and deliberates its likely clinical applicability and thereby its potential to become a reality.
Collapse
Affiliation(s)
- S Perretta
- IRCAD - EITS, University of Strasbourg, 1, Place de l'hopital-Hopitaux Universitaires, 67091 Strasbourg Cedex, France
| | | | | | | |
Collapse
|
|
43
|
Clark J, Sodergren M, Correia-Pinto J, Zacharakis E, Teare J, Yang GZ, Darzi A, Athanasiou T. Natural Orifice Translumenal Thoracoscopic Surgery. Surg Innov 2009; 16:9-15. [DOI: 10.1177/1553350608330712] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023]
Abstract
Context. Natural orifice translumenal endoscopic surgery (NOTES) is an emerging new technique but with much of the focus for the clinical applications of this technique centered on the abdomen. Concequently, its adaptation to the chest has been overlooked. The evidence for safe access, periprocedural complications and potential thoracic applications needs to be evaluated. Objective. This study systematically reviews the evidence for the feasibility and potential clinical applications of natural orifice translumenal thoracoscopic surgery. Data sources. MEDLINE and the Cochrane central database of controlled trials, from the earliest available date to July 2008. Study selection and data extraction. All studies evaluating the use of NOTES involving the thoracic cavity or structures therein were identified. The minimum inclusion criterion for each study was the extraction of discernible trial data. No restrictions were placed on language. Results. The literature search identified 197 citations. Review of abstracts led to 10 full-text articles for assessment; 7 articles were considered for this review, reporting on a total of 37 cases. All cases used the porcine model in both survival (7 to 42 days; mean 16; n = 5) and nonsurvival studies (n = 2). Mortality was 5% (n = 2) and morbidity 19% (n = 7); histopathological leak was detected on autopsy in 1 case. Conclusion. No human trials have currently been performed using NOTES within the thoracic cavity. There is a wide diversity of clinical applications from which cardiothoracic surgery could potentially benefit. There is a great deal of technical improvement that is still required before the technique is viable as an alternative surgical approach in humans.
Collapse
Affiliation(s)
- James Clark
- Department of Biosurgery and Surgical Technology, Imperial College, London, United Kingdom,
| | - Mikael Sodergren
- Department of Biosurgery and Surgical Technology, Imperial College, London, United Kingdom
| | - Jorge Correia-Pinto
- Life and Health Sciences Research Institute (ICVS), University of Minho, Braga, Portugal
| | - Emmanouil Zacharakis
- Department of Biosurgery and Surgical Technology, Imperial College, London, United Kingdom
| | - Julian Teare
- Department of Gastroenterology, Imperial Healthcare Trust, London, United Kingdom
| | - Guang-Zhong Yang
- Institute of Biomedical Engineering, Imperial College London, United Kingdom
| | - Ara Darzi
- Department of Biosurgery and Surgical Technology, Imperial College, London, United Kingdom
| | - Thanos Athanasiou
- Department of Biosurgery and Surgical Technology, Imperial College, London, United Kingdom
| |
Collapse
|
|
44
|
Willingham FF, Gee DW, Sylla P, Lauwers GY, Rattner DW, Brugge WR. En bloc esophageal mucosectomy for concentric circumferential mucosal resection (with video). Gastrointest Endosc 2009; 69:147-51. [PMID: 19111695 DOI: 10.1016/j.gie.2008.09.010] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/11/2008] [Accepted: 09/05/2008] [Indexed: 12/10/2022]
Abstract
BACKGROUND With conventional EMR, specimens are fragmented, metaplasia may be left behind, and invasive lesions could be missed because of incomplete sampling. Concentric subtotal esophageal mucosectomy would address these limitations. OBJECTIVE To examine en bloc esophageal mucosectomy (EEM). DESIGN A prospective case series. SETTING An academic hospital. SUBJECTS Nine swine. INTERVENTIONS Conventional EMR was performed in the proximal esophagus. The submucosal space was entered, and the distal two thirds of the esophageal mucosa was freed with blunt dissection. A snare was threaded over the column of mucosa to the gastroesophageal junction. The column was resected, and the mucosa was retrieved. MAIN OUTCOME AND MEASUREMENTS Clinical examination, follow-up endoscopy, necropsy, and gross and histopathologic examination. RESULTS EEM permitted subtotal esophageal mucosectomy in 9 of 9 swine (tissue specimens removed ranged 9-15 cm in length). The mean procedure duration was 110 minutes. In the survival series, 4 of 4 swine thrived after surgery, for 9 to 13 days. At 9 days, there was no evidence of a perforation, stricture, or leak. At 13 days, 2 swine had a mild proximal stricture, which was easily traversed with a 9.8-mm gastroscope. On necropsy, the mediastinal and thoracic cavities were unremarkable in 3 of 4 swine. One swine was found to have a contained abscess containing cellulose, presumably secondary to ingestion of wood-chip bedding material postoperatively. Reepithelialization was present on histologic examination. LIMITATIONS An animal study. CONCLUSIONS EEM is feasible and enabled concentric subtotal esophageal mucosal resection. The technique could completely and circumferentially excise intramucosal lesions. Longer follow-up and larger studies are needed to evaluate infection, stricture, and safety.
Collapse
Affiliation(s)
- Field F Willingham
- Gastrointestinal Unit, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA
| | | | | | | | | | | |
Collapse
|
|
45
|
Natural orifice transesophageal mediastinoscopy and thoracoscopy: a survival series in swine. Surg Endosc 2008; 22:2117-22. [PMID: 18636291 DOI: 10.1007/s00464-008-0073-z] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2008] [Revised: 06/16/2008] [Accepted: 06/20/2008] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Transesophageal endoscopic mediastinoscopy (MX) and thoracoscopy (TX) could reduce pain, eliminate intercostal neuralgia, provide better access to the posterior mediastinal compartment and pulmonary hilum, and improve cosmesis. The purpose of this study was to demonstrate the feasibility of transesophageal natural orifice translumenal endoscopic surgery (NOTES) and to determine the complications that might be seen in surviving animals. METHODS Using cap endoscopic mucosal resection and blunt dissection, a 15-20 cm submucosal tunnel was created in the esophagus and an endoscope passed through the tunnel into the mediastinum. One swine underwent MX; three swine underwent both MX and TX. The mediastinal compartment, hilar lymph nodes, pleura, lung, and esophagus were identified. Esophageal closure was obtained via submucosal tunnel flap-valve alone (two swine) or reinforcement with mucosal clips (two swine). The esophagus, mediastinum, and thorax were examined at necropsy. The esophagus was excised and sent for pathological examination. RESULTS NOTES MX and TX provided excellent visualization of mediastinal and thoracic structures. Pleural biopsy was easily accomplished. All animals survived the procedure, ate well, and showed no ill effects. Swine were sacrificed at either 8 or 12 days postoperatively. At necropsy, mild atelectasis was noted in each animal. One animal (mucosal clip closure) developed a fluid collection in the submucosal tunnel. There was no evidence of mediastinitis or thoracic contamination in any animals. CONCLUSIONS Transesophageal endoscopic mediastinoscopy and thoracoscopy provide excellent visualization of mediastinal and intrathoracic structures. Pleural biopsy can be easily obtained under direct visualization. Structures that are difficult to visualize via traditional cervical mediastinoscopy and thoracoscopy are seen well with this approach. The submucosal tunnel creates a flap-valve that, alone, may be sufficient for preventing esophageal leak. These procedures can be performed safely in swine with short-term survival. Further study with a larger sample size and longer survival is warranted.
Collapse
|