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Gostout CJ. Historical notes: The road to peroral endoscopic myotomy. TECHNIQUES IN GASTROINTESTINAL ENDOSCOPY 2013. [DOI: 10.1016/j.tgie.2013.06.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Abstract
INTRODUCTION Laparoscopic Heller myotomy has become the therapy of choice for achalasia. In the last three years, clinical experience with a novel approach to this disease, Per-Oral Endoscopic Myotomy (POEM), has grown. METHODS Herein, we describe the technical steps in the POEM procedure. CONCLUSION In our experience, the method appears to be a safe alternative to standard laparoscopic Heller myotomy, but further assessment is needed to understand long-term outcomes.
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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.
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Lee SH, Cho WY, Cho JY. Submucosal endoscopy, a new era of pure natural orifice translumenal endoscopic surgery (NOTES). Clin Endosc 2012; 45:4-10. [PMID: 22741129 PMCID: PMC3363116 DOI: 10.5946/ce.2012.45.1.4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2011] [Revised: 11/28/2011] [Accepted: 12/29/2011] [Indexed: 12/21/2022] Open
Abstract
Natural orifice translumenal endoscopic surgery (NOTES) involves the intentional perforation of the viscera with an endoscope to access the abdominal cavity and perform an intraabdominal operation. In a brief time period, NOTES has been shown to be feasible in laboratory animal and human studies. Easy access to the peritoneal cavity and complete gastric closure should be secured before NOTES can be recommended as an acceptable alternative in clinical practice. The concept of submucosal endoscopy has been introduced as a solution to overcome these two primary barriers to human NOTES application. Its offset entry/exit access method effectively prevents contamination and allows the rapid closure of the entry site with a simple mucosal apposition. In addition, it could be used as an endoscopic working space for various submucosal conditions. Herein, the detailed procedures, laboratory results and human application of the submucosal endoscopy will be reviewed.
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Affiliation(s)
- Suck-Ho Lee
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
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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
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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.
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Rao PP, Rao PP, Bhagwat S. Single-incision laparoscopic surgery - current status and controversies. J Minim Access Surg 2011; 7:6-16. [PMID: 21197236 PMCID: PMC3002008 DOI: 10.4103/0972-9941.72360] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2010] [Accepted: 09/20/2010] [Indexed: 12/15/2022] Open
Abstract
Scarless surgery is the Holy Grail of surgery and the very raison d’etre of Minimal Access Surgery was the reduction of scars and thereby pain and suffering of the patients. The work of Muhe and Mouret in the late 80s, paved the way for mainstream laparoscopic procedures and it rapidly became the method of choice for many intra-abdominal procedures. Single-incision laparoscopic surgery is a very exciting new modality in the field of minimal access surgery which works for further reducing the scars of standard laparoscopy and towards scarless surgery. Natural orifice translumenal endoscopic surgery (NOTES) was developed for scarless surgery, but did not gain popularity due to a variety of reasons. NOTES stands for natural orifice translumenal endoscopic surgery, a term coined by a consortium in 2005. NOTES remains a research technique with only a few clinical cases having been reported. The lack of success of NOTES seems to have spurred on the interest in single-incision laparoscopy as an eminently doable technique in the present with minimum visible scarring, rendering a ‘scarless’ effect. Laparo-endoscopic single-site surgery (LESS) is, a term coined by a multidisciplinary consortium in 2008 for single-incision laparoscopic surgery. These are complementary technologies with similar difficulties of access, lack of triangulation and inadequate instrumentation as of date. LESS seems to offer an advantage to surgeons with its familiar field of view and instruments similar to those used in conventional laparoscopy. LESS remains a evolving special technique used successfully in many a centre, but with a significant way to go before it becomes mainstream. It currently stands between standard laparoscopy and NOTES in the armamentarium of minimal access surgery. This article outlines the development of LESS giving an overview of all the techniques and devices available and likely to be available in the future.
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Affiliation(s)
- Prashanth P Rao
- Department of Minimally Invasive Surgery, Mamata Hospital, Dombivli, Mumbai, India
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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.
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Affiliation(s)
- Daniel von Renteln
- Department of Gastroenterology, Medizinische Klinik I, Klinikum Ludwigsburg, Ludwigsburg, Germany.
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Reliability of gastric access closure with the self-approximating transluminal access technique (STAT) for NOTES. Surg Endosc 2011; 25:2718-24. [PMID: 21487879 DOI: 10.1007/s00464-011-1659-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2010] [Accepted: 02/20/2011] [Indexed: 12/21/2022]
Abstract
BACKGROUND STAT, or the self-approximating transluminal access technique, has been previously described and involves the dissection of a submucosal tunnel for peritoneal or mediastinal access from the esophagus and stomach. The objective of this study was to assess the safety and reliability of gastric access and closure in a porcine experience using STAT for natural orifice transluminal endoscopic surgery (NOTES). METHODS A review of the experience using STAT access tunnels for intraperitoneal access was performed in 39 female pigs at a university animal lab. All animals underwent a predetermined NOTES surgical procedure using a STAT transgastric access tunnel based on a specific protocol. Details of the procedure, complications, and clinical course were documented. Necropsy was performed at 2 weeks. The main outcome measurements were clinical or necropsy evidence of gastrostomy site leak or inadequate access site closure. RESULTS STAT was successful in providing safe peritoneal access in all animals. The width of the tunnel ranged from 1.5 to 5.5 cm and the length was up to 27 cm. There was no evidence of gastrostomy site leak in any animals. One animal required a single laparoscopic suture to help with tunnel closure. CONCLUSION STAT provides safe transgastric access and allows secure closure of the gastrotomy site.
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Kopelman Y, Triadafilopoulos G. Endoscopy in the diagnosis and management of motility disorders. Dig Dis Sci 2011; 56:635-54. [PMID: 21286936 DOI: 10.1007/s10620-011-1584-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2010] [Accepted: 01/14/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND Gastrointestinal illness may result from either an underlying structural abnormality (e.g. neoplastic obstruction), or a functional disorder (e.g. motor diarrhea), or both (e.g. achalasia with squamous esophageal cancer). AIMS The purpose of this study was to highlight the potential value and role of endoscopy in the recognition and management of patients with functional and motility disorders. METHODS We performed a literature review in PubMed. RESULTS Diagnostic and therapeutic endoscopy may be under-used by motility-oriented gastroenterologists; in contrast, motility and other functional studies may be under-used by endoscopists. Yet, many areas of cross-exchange exist. CONCLUSIONS This review aims to guide the appropriate indications for the use of endoscopy in diagnosing and treating functional GI and motility disorders and serve as a bridge and a forum of exchange between endoscopists and motility specialists.
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Affiliation(s)
- Yael Kopelman
- Stanford University School of Medicine, Stanford, CA, USA
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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.
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Affiliation(s)
- Karl E Grund
- Department for General, Visceral, and Transplantation Surgery, Surgical Endoscopy, University Hospital Tübingen, Waldhörnlestrasse 22, Tübingen, Germany.
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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: 16] [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.
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Affiliation(s)
- Brian G Turner
- Gastrointestinal Unit, Massachusetts General Hospital, Boston, Massachusetts 02114, USA
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Dray X, Marteau P. [The future of gastrointestinal therapeutic endoscopy: NOTES]. ACTA ACUST UNITED AC 2009; 33:758-66. [PMID: 19683406 DOI: 10.1016/j.gcb.2009.07.010] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Natural orifice translumenal endoscopic surgery (NOTES) allows access into the peritoneal cavity with a flexible endoscope, through the wall of the digestive or urogenital tracts. NOTES can be combined to laparoscopic surgery in so-called << hybrid >> techniques. In the absence of any incision of the abdominal wall, NOTES procedures provide perfect cosmetic results, with virtually no risk of parietal complications, and with decreased postoperative pain. NOTES could particularly benefit to overweight patients and to patients receiving intensive or palliative care. Most NOTES studies have been performed on animal models, with great interest for both transgastric and transpelvic approaches. Successful NOTES peritoneoscopy, hysterectomy, oophorectomy, tubal ligation, gastrojejunal anastomosis, cholecystectomy, splenectomy, nephrectomy, and abdominal-wall hernia repair have been described. In human studies, the transvaginal route is preferred. NOTES clinical research focuses on low-morbidity procedures, such as cholecystectomy, appendectomy, and peritoneoscopy. Indirect benefits are expected from this research, with possible technological innovations in the field of endoscopic instrumentation (including sutures, anastomosis, traction and triangulation). Overall, NOTES is believed to make evolve both interventional endoscopy and minimally invasive surgery.
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Affiliation(s)
- X Dray
- Conservatoire National des Arts et Métiers, Assistance Publique-Hôpitaux de Paris, Université Diderot-Paris-7, Paris, France.
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Oláh T. [Surgery of oesophagus]. Magy Seb 2009; 62:204-212. [PMID: 19679529 DOI: 10.1556/maseb.62.2009.4.5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/28/2023]
Affiliation(s)
- Tibor Oláh
- Kaposi Mór Oktató Kórház Altalános Sebészeti, Er- és Mellkassebészeti Osztály Siófok
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