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Uehara S, Sasaki F, Sahara H, Tanaka A, Hinokuchi M, Maeda H, Arima S, Hashimoto S, Kanmura S, Ido A. Establishment of a swine model of delayed bleeding after endoscopic procedure. DEN OPEN 2025; 5:e411. [PMID: 39050142 PMCID: PMC11266432 DOI: 10.1002/deo2.411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Revised: 07/01/2024] [Accepted: 07/06/2024] [Indexed: 07/27/2024]
Abstract
Objectives Although delayed bleeding after endoscopic procedures has become a problem, currently, there are no appropriate animal models to validate methods for preventing it. This study aimed to establish an animal model of delayed bleeding after endoscopic procedures of the gastrointestinal tract. Methods Activated coagulation time (ACT) was measured using blood samples drawn from a catheter inserted into the external jugular vein of swine (n = 7; age, 6 months; mean weight, 13.8 kg) under general anesthesia using the cut-down method. An upper gastrointestinal endoscope was inserted orally, and 12 mucosal defects were created in the stomach by endoscopic mucosal resection using a ligating device. Hemostasis was confirmed at this time point. The heparin group (n = 4) received 50 units/kg of unfractionated heparin via a catheter; after confirming that the ACT was ≥200 s 10 min later, continuous heparin administration (50 units/kg/h) was started. After 24 h, an endoscope was inserted under general anesthesia to evaluate the blood volume in the stomach and the degree of blood adherence at the site of the mucosal defect. Results Delayed bleeding was observed in three swine (75%) in the heparin-treated group, who had a maximum ACT of >220 s before the start of continuous heparin administration. In the non-treated group (n = 3), no prolonged ACT or delayed bleeding was observed at 24 h. Conclusion An animal model of delayed bleeding after an endoscopic procedure in the gastrointestinal tract was established using a single dose of heparin and continuous heparin administration after confirming an ACT of 220 s.
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Affiliation(s)
- Shohei Uehara
- Digestive and Lifestyle DiseasesKagoshima University Graduate School of Medical and Dental SciencesKagoshimaJapan
| | - Fumisato Sasaki
- Digestive and Lifestyle DiseasesKagoshima University Graduate School of Medical and Dental SciencesKagoshimaJapan
| | - Hisashi Sahara
- Division of Experimental Large Animal ResearchLife Science and Laboratory Animal Research UnitCenter for Advanced Science Research and PromotionKagoshima UniversityKagoshimaJapan
| | - Akihito Tanaka
- Digestive and Lifestyle DiseasesKagoshima University Graduate School of Medical and Dental SciencesKagoshimaJapan
| | - Makoto Hinokuchi
- Digestive and Lifestyle DiseasesKagoshima University Graduate School of Medical and Dental SciencesKagoshimaJapan
| | - Hidehito Maeda
- Digestive and Lifestyle DiseasesKagoshima University Graduate School of Medical and Dental SciencesKagoshimaJapan
| | - Shiho Arima
- Digestive and Lifestyle DiseasesKagoshima University Graduate School of Medical and Dental SciencesKagoshimaJapan
| | - Shinichi Hashimoto
- Digestive and Lifestyle DiseasesKagoshima University Graduate School of Medical and Dental SciencesKagoshimaJapan
| | - Shuji Kanmura
- Digestive and Lifestyle DiseasesKagoshima University Graduate School of Medical and Dental SciencesKagoshimaJapan
| | - Akio Ido
- Digestive and Lifestyle DiseasesKagoshima University Graduate School of Medical and Dental SciencesKagoshimaJapan
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Masunaga T, Sasaki M, Sato M, Minezaki D, Morioka K, Tojo A, Sakurai H, Iwata K, Miyazaki K, Kubosawa Y, Mizutani M, Akimoto T, Takatori Y, Kawasaki S, Matsuura N, Nakayama A, Sujino T, Takabayashi K, Yahagi N, Nakajima K, Kato M. Intraoperative bleeding model for swine gastric endoscopic submucosal dissection via heparinization. Endosc Int Open 2024; 12:E1360-E1365. [PMID: 39610944 PMCID: PMC11604307 DOI: 10.1055/a-2411-9979] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 09/09/2024] [Indexed: 11/30/2024] Open
Abstract
Background and study aims: Live swine have a high degree of coagulation and aggregation and using them for training about how to manage intraoperative bleeding during endoscopic submucosal dissection (ESD) is unsatisfactory. This study aimed to identify the appropriate heparin dose in an intraoperative bleeding model and validate its applicability. Methods: First, we explored the dose of heparin required for a swine bleeding model in which the activated clotting time reached and maintained the upper limit of measurement (1500 s) after 10 minutes. Second, we compared intraoperative bleeding and hematoma frequency during ESD for 2-cm lesions between the heparinized bleeding model and control groups. Intraoperative bleeding was classified according to the Forrest classification. Results: The combination of a bolus (300 U/kg), continuous infusion (300 U/kg/h), and a bolus dose (150 U/kg) of heparin 10 minutes after the first infusion was identified as the dose for the bleeding model. Five ESDs were performed in each heparinized bleeding model and the control group. The median number of intraoperative bleeds was significantly higher in the heparinized model than in the control group (5 interquartile range [IQR] 4-7 vs. 3 [IQR 0-4, P = 0.028). All of the intraoperative bleeding events oozing (Forrest Ib) rather than spurting (Forrest Ia). The median number of hematomas was significantly higher in the heparinized model group than in the control group (3 [IQR 1-4] vs. 0 [IQR 0-1], P = 0.023). Conclusions: High doses of heparin significantly increased intraoperative bleeding and hematoma during swine ESD.
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Affiliation(s)
- Teppei Masunaga
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Motoki Sasaki
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Moe Sato
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Daisuke Minezaki
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Kohei Morioka
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Anna Tojo
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Hinako Sakurai
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kentaro Iwata
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Kurato Miyazaki
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Yoko Kubosawa
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Mari Mizutani
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Keio University School of Medicine, Tokyo, Japan
| | - Teppei Akimoto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Yusaku Takatori
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Shintaro Kawasaki
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Noriko Matsuura
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Atsushi Nakayama
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Tomohisa Sujino
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Kaoru Takabayashi
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, Keio University School of Medicine, Tokyo, Japan
| | - Kiyokazu Nakajima
- Department of Next Generation Endoscopic Intervention (Project ENGINE), Osaka University Graduate School of Medicine, Osaka, Japan
| | - Motohiko Kato
- Center for Diagnostic and Therapeutic Endoscopy, Keio University School of Medicine, Tokyo, Japan
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3
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Ghandour B, Bhullar FA, Szvarca D, Bejjani M, Brenner T, McKee K, Kamal A, Steinway SN, Kamal M, Ricourt E, Singh VK, Khashab MA, Akshintala VS. Effective, safe and efficient porcine model of Forrest Ib bleeding gastric and colonic ulcers. Indian J Gastroenterol 2023; 42:118-127. [PMID: 36701035 DOI: 10.1007/s12664-022-01299-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 09/15/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Developing effective gastrointestinal (GI) bleeding animal models is necessary to advance endoscopic hemostasis methods and train endoscopists on their use. Our aim, therefore, was to develop an effective and safe porcine GI bleeding model in the stomach and colon of large and small-sized oozing-type ulcers. METHODS Gastric and colonic bleeding ulcers were created using either a hybrid endoscopic submucosal dissection (ESD) technique or a cap-assisted endoscopic mucosal resection (EMR-C) technique in 14 pigs. Prior to ulcer creation, animals were treated with either oral apixaban or intravenous (IV) unfractionated heparin anticoagulation in combination with clopidogrel and aspirin. The primary outcome was the technical success of inducing oozing-type Forrest Ib bleeding ulcers. Secondary outcomes included ulcer diameter, number, creation time and the number of complications associated with each technique. RESULTS Using hybrid ESD and IV heparin anticoagulation, bleeding was observed in 21/23 (91.3%) gastric ulcers and 6/7 (85.7%) colonic ulcers created. The mean diameter and ulcer creation time were 2.3 ± 0.3 cm and 5.3 ± 0.5 min, respectively, for gastric ulcers and 2.2 ± 0.4 cm and 4.06 ± 0.6 min, respectively, for colonic ulcers. Using EMR-C and IV heparin anticoagulation, bleeding was observed in 14/15 (93.3%) gastric ulcers and 6/6 (100%) colonic ulcers created. The mean diameter and ulcer creation time were 0.8 ± 0.2 cm and 2.1 ± 0.5 min, respectively, for gastric ulcers and 0.7 ± 0.2 cm and 1.7 ± 0.3 min, respectively, for colonic ulcers. None of the ulcers created in animals anticoagulated with apixaban developed bleeding. None of the 14 pigs developed any complications. CONCLUSION We have demonstrated the effectiveness and safety of a porcine GI bleeding model utilizing IV heparin anticoagulation and either hybrid ESD or EMR-C techniques to create oozing-type bleeding ulcers in the stomach and colon with customizable size.
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Affiliation(s)
- Bachir Ghandour
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Furqan A Bhullar
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Daniel Szvarca
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Michael Bejjani
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Todd Brenner
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Katherine McKee
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Ayesha Kamal
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Steven N Steinway
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Mustafa Kamal
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Ernesto Ricourt
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Vikesh K Singh
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Mouen A Khashab
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA
| | - Venkata S Akshintala
- Division of Gastroenterology and Hepatology, Johns Hopkins Medicine, 600 N. Wolfe Street, Blalock 466, Baltimore, MD, 21205, USA.
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Kalvach J, Ryska O, Martinek J, Hucl T, Pazin J, Hadac J, Foltan O, Kristianova H, Ptacnik J, Juhasova J, Ryska M, Juhas S. Randomized experimental study of two novel techniques for transanal repair of dehiscent low rectal anastomosis. Surg Endosc 2022; 36:4050-4056. [PMID: 34495386 DOI: 10.1007/s00464-021-08726-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 08/30/2021] [Indexed: 01/29/2023]
Abstract
BACKGROUND Anastomotic leak after low anterior rectal resection is a dreadful complication. Early diagnosis, prompt management of sepsis followed by closure of anastomotic defect may increase chances of anastomotic salvage. In this randomized experimental study, we evaluated two different methods of trans-anal anastomotic repair. METHODS A model of anastomotic leak was created in 42 male pigs. Laparoscopic low anterior resection was performed with anastomosis created using a circular stapler with half of the staples removed. Two days later, animals were randomized into a TAMIS (trans-anal minimally invasive surgery) repair, endoscopic suture (ENDO) or control group with no treatment (CONTROL). Signs of intraabdominal infection (IAI), macroscopic anastomotic healing and burst tests were evaluated to assess closure quality after animals were sacrificed on the ninth postoperative day. RESULTS Closure was technically feasible in all 28 animals. Two animals had to be euthanized due to progressive sepsis at four and five days after endoscopic closure. Healed anastomosis with no visible defect was observed in 10/14 and 11/14 animals in TAMIS and ENDO groups, respectively, versus 2/14 in CONTROL (p < 0.05). Overall IAI rate was significantly lower in TAMIS (4/14; p = 0.006) and ENDO (5/14; p = 0.018) compared to CONTROL (12/14). Burst tests confirmed sealed closure in healed anastomosis with a median failure pressure of 190 (110-300) mmHg in TAMIS and 200 (100-300) mmHg in ENDO group (p = 0.644). CONCLUSION In this randomized experimental study, we found that both evaluated techniques are effective in early repair of dehiscent colorectal anastomosis with a high healing rate.
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Affiliation(s)
- J Kalvach
- Institute of Animal Physiology and Genetics, Czech Academy of Science, Libechov, Czech Republic. .,Surgery Department 2nd Faculty of Medicine, Charles University and Central Military Hospital, Severovýchodní II 580/22, Záběhlice, Prague, 14100, Czech Republic.
| | - O Ryska
- Institute of Animal Physiology and Genetics, Czech Academy of Science, Libechov, Czech Republic.,Royal Lancaster Infirmary, University Hospitals of Morecambe Bay, NHS Foundation Trust, Lancaster, UK
| | - J Martinek
- Institute of Animal Physiology and Genetics, Czech Academy of Science, Libechov, Czech Republic.,Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - T Hucl
- Institute of Animal Physiology and Genetics, Czech Academy of Science, Libechov, Czech Republic.,Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - J Pazin
- Institute of Animal Physiology and Genetics, Czech Academy of Science, Libechov, Czech Republic.,Surgery Department 2nd Faculty of Medicine, Charles University and Central Military Hospital, Severovýchodní II 580/22, Záběhlice, Prague, 14100, Czech Republic
| | - J Hadac
- Institute of Animal Physiology and Genetics, Czech Academy of Science, Libechov, Czech Republic.,Surgery Department 2nd Faculty of Medicine, Charles University and Central Military Hospital, Severovýchodní II 580/22, Záběhlice, Prague, 14100, Czech Republic
| | - O Foltan
- Institute of Animal Physiology and Genetics, Czech Academy of Science, Libechov, Czech Republic.,1st Department of Surgery, The General University Hospital in Prague, Prague, Czech Republic
| | - H Kristianova
- Institute of Animal Physiology and Genetics, Czech Academy of Science, Libechov, Czech Republic.,1st Department of Surgery, The General University Hospital in Prague, Prague, Czech Republic
| | - J Ptacnik
- Institute of Animal Physiology and Genetics, Czech Academy of Science, Libechov, Czech Republic.,1st Department of Surgery, The General University Hospital in Prague, Prague, Czech Republic
| | - J Juhasova
- Institute of Animal Physiology and Genetics, Czech Academy of Science, Libechov, Czech Republic
| | - M Ryska
- Surgery Department 2nd Faculty of Medicine, Charles University and Central Military Hospital, Severovýchodní II 580/22, Záběhlice, Prague, 14100, Czech Republic
| | - S Juhas
- Institute of Animal Physiology and Genetics, Czech Academy of Science, Libechov, Czech Republic
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5
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Kubo Y, Yamashita K, Saito T, Tanaka K, Makino T, Takahashi T, Kurokawa Y, Yamasaki M, Eguchi H, Doki Y, Nakajima K. Heparinized swine models for better surgical/endoscopic training. DEN OPEN 2022; 2:e64. [PMID: 35310757 PMCID: PMC8828249 DOI: 10.1002/deo2.64] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/24/2021] [Revised: 08/30/2021] [Accepted: 09/06/2021] [Indexed: 11/06/2022]
Affiliation(s)
- Yuto Kubo
- Department of Next‐Generation Endoscopic Intervention (Project ENGINE) Center of Medical Innovation and Translational Research, Graduate School of Medicine, Osaka University Osaka Japan
- Department of Gastroenterological Surgery Graduate School of Medicine Osaka University Osaka Japan
| | - Kotaro Yamashita
- Department of Gastroenterological Surgery Graduate School of Medicine Osaka University Osaka Japan
| | - Takuro Saito
- Department of Gastroenterological Surgery Graduate School of Medicine Osaka University Osaka Japan
| | - Koji Tanaka
- Department of Gastroenterological Surgery Graduate School of Medicine Osaka University Osaka Japan
| | - Tomoki Makino
- Department of Gastroenterological Surgery Graduate School of Medicine Osaka University Osaka Japan
| | - Tsuyoshi Takahashi
- Department of Gastroenterological Surgery Graduate School of Medicine Osaka University Osaka Japan
| | - Yukinori Kurokawa
- Department of Gastroenterological Surgery Graduate School of Medicine Osaka University Osaka Japan
| | - Makoto Yamasaki
- Department of Gastroenterological Surgery Graduate School of Medicine Osaka University Osaka Japan
| | - Hidetoshi Eguchi
- Department of Gastroenterological Surgery Graduate School of Medicine Osaka University Osaka Japan
| | - Yuichiro Doki
- Department of Gastroenterological Surgery Graduate School of Medicine Osaka University Osaka Japan
| | - Kiyokazu Nakajima
- Department of Next‐Generation Endoscopic Intervention (Project ENGINE) Center of Medical Innovation and Translational Research, Graduate School of Medicine, Osaka University Osaka Japan
- Department of Gastroenterological Surgery Graduate School of Medicine Osaka University Osaka Japan
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6
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Abe H, Kamimura K, Arao Y, Kohisa J, Terai S. Advances in the Treatment of Gastrointestinal Bleeding: Safety and Efficiency of Transnasal Endoscopy. MEDICINES (BASEL, SWITZERLAND) 2021; 8:53. [PMID: 34564095 PMCID: PMC8471608 DOI: 10.3390/medicines8090053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 09/02/2021] [Accepted: 09/10/2021] [Indexed: 11/16/2022]
Abstract
Acute upper gastrointestinal bleeding (UGIB) is a common disorder and a gastroenterological emergency. With the development of new techniques and devices, the survivability after gastrointestinal bleeding is improving. However, at the same time, we are facing the difficulty of severely complicated cases with various diseases. For example, while endoscopic examination with a normal diameter endoscope is essential for the diagnosis and treatment of UGIB, there are several cases in which it cannot be used. In these cases, transnasal endoscopy (TNE) may be a viable treatment option. This report reviews current hemostatic devices for endoscopic treatment and the safety and efficiency of using TNE in complicated cases. The latter will be demonstrated in a case report where TNE was employed in a patient with severe esophageal stenosis. This review summarizes the advances made in the devices used and will provide further ideas for the physician in terms of combining these devices and TNE.
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Affiliation(s)
- Hiroyuki Abe
- Division of Gastroenterology and Hepatology, Sado General Hospital, 161 Chigusa, Sado 952-1209, Japan;
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachido-ri, Chuo-ku, Niigata 950-2181, Japan; (Y.A.); (J.K.); (S.T.)
| | - Kenya Kamimura
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachido-ri, Chuo-ku, Niigata 950-2181, Japan; (Y.A.); (J.K.); (S.T.)
- Department of General Medicine, Niigata University School of Medicine, 1-757 Asahimachido-ri, Chuo-ku, Niigata 951-8510, Japan
| | - Yoshihisa Arao
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachido-ri, Chuo-ku, Niigata 950-2181, Japan; (Y.A.); (J.K.); (S.T.)
| | - Junji Kohisa
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachido-ri, Chuo-ku, Niigata 950-2181, Japan; (Y.A.); (J.K.); (S.T.)
| | - Shuji Terai
- Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, 1-757 Asahimachido-ri, Chuo-ku, Niigata 950-2181, Japan; (Y.A.); (J.K.); (S.T.)
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7
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Ai L, Song C, Mao L, Ge S, Pan Z. Design Optimization of a Novel Multifiring Clip Applicator System for Endoscopic Closure of Large Perforations. J Med Device 2021. [DOI: 10.1115/1.4051191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Abstract
Endoscopic closure has become the first choice for closing iatrogenic perforations. Previously, we reported a self-developed endoscopic multifiring clip applicator (EMFCA) system. In this paper, a new EMFCA system for endoscopic closure of large perforations with a redesigned clip, the less traumatic grasper, and a highly efficient driving system was presented, and its efficacy was evaluated. The behaviors of the new clip and grasper were verified through finite element analysis (FEA). The capability of pushing transmission for the EMFCA system was identified by the proposed model and the validation experiment. Ex-vivo studies were conducted on porcine stomachs to compare the outcomes of the closures. The FEA results showed that the deformation of the clip was safe and smoother, with a maximum stress of 640.0 MPa. The less traumatic grasper could increase the grasping force and avoid trauma by exerting uniform stress along the axis. The capability of pushing transmission was enhanced by the double-nested tendon-sheath actuation system with an efficiency of 0.45–0.48. The mechanical strength, the leakage pressure, and the operating time for the closures with the new EMFCA system and the previous EMFCA system were 6.1 N ± 0.8 N, 37.1 mmHg ± 6.8 mmHg, 7.3 min ± 0.4 min and 5.1 N ± 1.0 N, 27.4 mmHg ± 6.4 mmHg, 11.4 min ±0.8 min, respectively. The new EMFCA system can realize a superior, reliable, and high-efficiency endoscopic closure of large perforations.
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Affiliation(s)
- Liaoyuan Ai
- School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai 200093, China
| | - Chengli Song
- School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai 200093, China
| | - Lin Mao
- School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai 200093, China
| | - Shuchen Ge
- School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai 200093, China
| | - Zhen Pan
- School of Medical Instrument and Food Engineering, University of Shanghai for Science and Technology, Shanghai 200093, China
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8
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Lau LHS, Sung JJY. Treatment of upper gastrointestinal bleeding in 2020: New techniques and outcomes. Dig Endosc 2021; 33:83-94. [PMID: 32216134 DOI: 10.1111/den.13674] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2020] [Revised: 03/15/2020] [Accepted: 03/19/2020] [Indexed: 02/08/2023]
Abstract
The clinical outcome of upper gastrointestinal bleeding has improved due to advances in endoscopic therapy and standardized peri-endoscopy care. Apart from validating clinical scores, artificial intelligence-assisted machine learning models may play an important role in risk stratification. While standard endoscopic treatments remain irreplaceable, novel endoscopic modalities have changed the landscape of management. Over-the-scope clips have high success rates as rescue or even first-line treatments in difficult-to-treat cases. Hemostatic powder is safe and easy to use, which can be useful as temporary control with its high immediate hemostatic ability. After endoscopic hemostasis, Doppler endoscopic probe can offer an objective measure to guide the treatment endpoint. In refractory bleeding, angiographic embolization should be considered before salvage surgery. In variceal hemorrhage, banding ligation and glue injection are first-line treatment options. Endoscopic ultrasound-guided therapy is gaining popularity due to its capability of precise localization for treatment targets. A self-expandable metal stent may be considered as an alternative option to balloon tamponade in refractory bleeding. Transjugular intrahepatic portosystemic shunting should be reserved as salvage therapy. In this article, we aim to provide an evidence-based comprehensive review of the major advancements in endoscopic hemostatic techniques and clinical outcomes.
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Affiliation(s)
- Louis H S Lau
- Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong
| | - Joseph J Y Sung
- Institute of Digestive Disease, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong.,Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Shatin New Territories, Hong Kong
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9
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Abstract
Endoscopic suturing device for flexible endoscopy was conceptualized by Apollo Group in collaboration with Olympus Optical Ltd. The first modification of suturing device for flexible endoscopy (Eagle Claw) was manufactured by Olympus engineers and extensively used by members of Apollo Group in numerous bench-top experiments on isolated pig stomachs and in live porcine model. The suturing system for flexible endoscopy in humans (Overstitch) was cleared for general clinical use in the United States in 2008. The latest model is compatible with more than 20 single-channel flexible endoscopes with diameters ranging from 8.8 mm to 9.8 mm made by major endoscope manufacturers.
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10
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Chiu PW. Endoscopic Management of Peptic Ulcer Bleeding: Recent Advances. Clin Endosc 2019; 52:416-418. [PMID: 31405266 PMCID: PMC6785411 DOI: 10.5946/ce.2018.182] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2018] [Accepted: 05/30/2019] [Indexed: 12/16/2022] Open
Abstract
Bleeding peptic ulcers remained as one of the commonest causes of hospitalization worldwide. While endoscopic hemostasis serves as primary treatment for bleeding ulcers, rebleeding after endoscopic hemostasis becomes more and more difficult to manage as patients are usually poor surgical candidates with multiple comorbidities. Recent advances in management of bleeding peptic ulcers aimed to further reduce the rate of rebleeding through-(1) identification of high risk patients for rebleeding and mortality; (2) improvement in primary endoscopic hemostasis and; (3) prophylactic angiographic embolization of major arteries. The technique and clinical evidences for these approaches will be reviewed in the current article.
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Affiliation(s)
- Philip Wy Chiu
- Department of Surgery, Institute of Digestive Disease, The Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
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11
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Siddiqi S, Schraufnagel DP, Siddiqui HU, Javorski MJ, Mace A, Elnaggar AS, Elgharably H, Vargo PR, Steffen R, Hasan SM, Raja S. Recent advancements in the minimally invasive management of esophageal perforation, leaks, and fistulae. Expert Rev Med Devices 2019; 16:197-209. [PMID: 30767693 DOI: 10.1080/17434440.2019.1582329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Historically, the gold standard management of esophageal perforations, leaks, and fistulae has been traditional open surgery, but it is associated with significant morbidity and mortality. Minimally invasive approaches offer alternatives to surgery in treating hemodynamically stable patients with such defects. In this review article, we will discuss the recent advancements in the minimally invasive management of esophageal perforations, leaks, and fistulas. AREAS COVERED This review includes information from case reports, case series, and clinical trials on minimally invasive management of esophageal perforations, leaks, and fistulas. The focus is on the devices, outcomes, and application of the technology. EXPERT COMMENTARY Minimally invasive treatment represents significant progress in the management of esophageal perforations, leaks, and fistulas. Based on current evidence, it seems safe and effective but it is evolving and more studies are needed to help draw definitive conclusions.
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Affiliation(s)
- Shirin Siddiqi
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Dean P Schraufnagel
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Hafiz Umair Siddiqui
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Michael J Javorski
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Adam Mace
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Abdulrhman S Elnaggar
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Haytham Elgharably
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Patrick R Vargo
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Robert Steffen
- b Department of Cardiovascular Surgery , Minneapolis Heart Institute Foundation , Minneapolis , MN , USA
| | - Saad M Hasan
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
| | - Siva Raja
- a Thoracic and Cardiovascular Surgery , Cleveland Clinic Foundation , Cleveland , OH , USA
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Akimoto T, Goto O, Nishizawa T, Yahagi N. Endoscopic closure after intraluminal surgery. Dig Endosc 2017; 29:547-558. [PMID: 28181699 DOI: 10.1111/den.12839] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2016] [Accepted: 02/06/2017] [Indexed: 02/06/2023]
Abstract
Endoscopic submucosal dissection is established as a curative endoscopic method for gastrointestinal epithelial neoplasms with a high possibility of complete en bloc resection; however, postoperative adverse events of bleeding and delayed perforation remain. To prevent or minimize them, several techniques for endoscopic mucosal closure have been introduced, such as using endoscopic clips, combined use of hemoclips and supplement devices, and specially designed endoscopic suturing devices. Furthermore, endoscopic full-thickness suturing technique for gastrointestinal wall defect has been developed based on the concept in natural orifice transluminal endoscopic surgery and endoscopic full-thickness resection. Several closure techniques, including over-the-scope clip, threaded bars inserted in a hollow needle, stitches or staplers, and a curved needle and thread are reported. Secure closure of the iatrogenic defect may further expand the range of therapeutic endoscopy. Accumulation of evidence for the efficacy of endoscopic closure and establishment of these techniques are desired.
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Affiliation(s)
- Teppei Akimoto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, School of Medicine, Keio University, Tokyo, Japan
| | - Osamu Goto
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, School of Medicine, Keio University, Tokyo, Japan
| | - Toshihiro Nishizawa
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, School of Medicine, Keio University, Tokyo, Japan
| | - Naohisa Yahagi
- Division of Research and Development for Minimally Invasive Treatment, Cancer Center, School of Medicine, Keio University, Tokyo, Japan
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Yip HC, Chiu PWY. Recent advances in natural orifice transluminal endoscopic surgery†. Eur J Cardiothorac Surg 2015; 49 Suppl 1:i25-30. [PMID: 26494866 DOI: 10.1093/ejcts/ezv364] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 09/03/2015] [Indexed: 12/11/2022] Open
Abstract
Natural orifice transluminal endoscopic surgery (NOTES) has emerged as one of the most exciting areas in the field of minimally invasive surgery during the last decade. NOTES comprises a wide spectrum of procedures from various natural accesses such as transgastric or transvaginal routes, and different direct-target or distant-target organs. Since polypectomy was first performed in 1955, major advances in technology and refinement of endoscopic technique have allowed endoscopic surgeons to perform complex endoscopic interventions such as endoscopic submucosal dissection. Recognizing the safety and feasibility of submucosal tunnelling and mucosal closure, endoscopic resection beyond the level of mucosa has been increasingly reported. One of these procedures, peroral endoscopic myotomy for achalasia, has gained much popularity and excellent results have been published comparable with that of traditional Heller's cardiomyotomy. Submucosal tunnelling endoscopic resection has also been reported for tumours situated in the muscular layer of the gastrointestinal tract. To overcome the difficulty of intestinal closure after NOTES, researchers have collaborated with the industry in developing different endoscopic suturing devices such as the Eagle Claw (Olympus Medical Systems, Tokyo, Japan) and Overstitch™ (Apollo Endosurgery, Austin TX, USA). These devices allow precise and secure suture application with the ordinary flexible endoscope, achieving tissue approximation similar to open surgical suturing. To further expand the potential of NOTES, investigators had also developed multitasking platforms enabling the performance of surgical procedures of even higher complexity. Recently, a novel endoscopic robotic system 'Master and Slave Transluminal Endoscopic Robot' (MASTER) has been developed. Early results of endoscopic resection utilizing this system have been encouraging, allowing both experts and novices in endoscopy to perform difficult endoscopic resection with a high degree of flexibility.
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Affiliation(s)
- Hon-chi Yip
- Department of Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China
| | - Philip Wai-yan Chiu
- Department of Surgery, Chinese University of Hong Kong, Prince of Wales Hospital, Hong Kong, China Department of Surgery, Institute of Digestive Disease, Chinese University of Hong Kong, Hong Kong, China
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Prosst RL, Schurr MO, Schostek S, Krautwald M, Gottwald T. Porcine survival model to simulate acute upper gastrointestinal bleedings. Lab Anim 2015; 50:217-20. [PMID: 26306615 DOI: 10.1177/0023677215600946] [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: 11/16/2022]
Abstract
The existing animal models used for the simulation of acute gastrointestinal bleedings are usually non-survival models. We developed and evaluated a new porcine model (domestic pig, German Landrace) in which the animal remains alive and survives the artificial bleeding without any cardiovascular impairment. This consists of a bleeding catheter which is implanted into the stomach, then subcutaneously tunnelled from the abdomen to the neck where it is exteriorized and fixed with sutures. Using the injection of porcine blood, controllable and reproducible acute upper gastrointestinal bleeding can be simulated while maintaining normal gastrointestinal motility and physiology. Depending on the volume of blood applied through the gastric catheter, the bleeding intensity can be varied from traces of blood to a massive haemorrhage. This porcine model could be valuable, e.g. for testing the efficacy of new bleeding diagnostics in large animals before human use.
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Affiliation(s)
- Ruediger L Prosst
- novineon Healthcare Technology Partners GmbH, Tübingen, Germany Proctological Institute Stuttgart, Stuttgart, Germany
| | - Marc O Schurr
- novineon Healthcare Technology Partners GmbH, Tübingen, Germany Ovesco Endoscopy AG, Tübingen, Germany Steinbeis University Berlin, IHCI Institute, Tübingen, Germany
| | | | | | - Thomas Gottwald
- Ovesco Endoscopy AG, Tübingen, Germany Medical Faculty, University of Tübingen, Tübingen, Germany
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Stavropoulos SN, Modayil R, Friedel D. Current applications of endoscopic suturing. World J Gastrointest Endosc 2015; 7:777-789. [PMID: 26191342 PMCID: PMC4501968 DOI: 10.4253/wjge.v7.i8.777] [Citation(s) in RCA: 73] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2014] [Revised: 02/13/2015] [Accepted: 04/29/2015] [Indexed: 02/05/2023] Open
Abstract
Endoscopic suturing had previously been considered an experimental procedure only performed in a few centers and often by surgeons. Now, however, endoscopic suturing has evolved sufficiently to be easily implemented during procedures and is more commonly used by gastroenterologists. We have employed the Apollo OverStitch suturing device in a variety of ways including closure of perforations, closure of full thickness defects in the gastrointestinal wall created during endoscopic full thickness resection, closure of mucosotomies during peroral endoscopic myotomy, stent fixation, fistula closure, post endoscopic submucosal dissection, endoscopic mucosal resection and Natural Orifice Transluminal Endoscopic Surgery defect closures, post-bariatric surgery gastrojejunal anastomosis revision and primary sleeve gastroplasty.
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Endoluminal flexible endoscopic suturing for minimally invasive therapies. Gastrointest Endosc 2015; 81:262-9.e19. [PMID: 25440675 DOI: 10.1016/j.gie.2014.09.013] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 09/03/2014] [Indexed: 12/12/2022]
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Chiu PWY, Lau JYW. What if endoscopic hemostasis fails?: Alternative treatment strategies: surgery. Gastroenterol Clin North Am 2014; 43:753-63. [PMID: 25440923 DOI: 10.1016/j.gtc.2014.08.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023]
Abstract
Management of bleeding peptic ulcers is increasingly challenging in an aging population. Endoscopic therapy reduces the need for emergency surgery in bleeding peptic ulcers. Initial endoscopic control offers an opportunity for selecting high-risk ulcers for potential early preemptive surgery. However, such an approach has not been supported by evidence in the literature. Endoscopic retreatment can be an option to control ulcer rebleeding and reduce complications. The success of endoscopic retreatment largely depends on the severity of rebleeding and ulcer characteristics. Large chronic ulcers with urgent bleeding are less likely to respond to endoscopic retreatment. Expeditious surgery is advised.
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Affiliation(s)
- Philip Wai Yan Chiu
- Department of Surgery, Institute of Digestive Disease, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, NT, Hong Kong, China.
| | - James Yun Wong Lau
- Department of Surgery, Institute of Digestive Disease, Prince of Wales Hospital, The Chinese University of Hong Kong, 30-32 Ngan Shing Street, Shatin, NT, Hong Kong, China
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Current innovations in endoscopic therapy for the management of colorectal cancer: from endoscopic submucosal dissection to endoscopic full-thickness resection. BIOMED RESEARCH INTERNATIONAL 2014; 2014:925058. [PMID: 24877148 PMCID: PMC4022075 DOI: 10.1155/2014/925058] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/30/2014] [Revised: 04/11/2014] [Accepted: 04/14/2014] [Indexed: 12/11/2022]
Abstract
Endoscopic submucosal dissection (ESD) is accepted as a minimally invasive treatment for colorectal cancer. However, due to technical difficulties and an increased rate of complications, ESD is not widely used in the colorectum. In some cases, endoscopic treatment alone is insufficient for disease control, and laparoscopic surgery is required. The combination of laparoscopic surgery and endoscopic resection represents a new frontier in cancer treatment. Recent developments in advanced polypectomy and minimally invasive surgical techniques will enable surgeons and endoscopists to challenge current practice in colorectal cancer treatment. Endoscopic full-thickness resection (EFTR) of the colon offers the potential to decrease the postoperative morbidity and mortality associated with segmental colectomy while enhancing the diagnostic yield compared to current endoscopic techniques. However, closure is necessary after EFTR and natural transluminal endoscopic surgery (NOTES). Innovative methods and new devices for EFTR and suturing are being developed and may potentially change traditional paradigms to achieve minimally invasive surgery for colorectal cancer. The present paper aims to discuss the complementary role of ESD and the future development of EFTR. We focus on the possibility of achieving EFTR using the ESD method and closing devices.
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Liu L, Chiu PWY, Teoh AYB, Lam CCH, Ng EKW, Lau JYW. Endoscopic suturing is superior to endoclips for closure of gastrotomy after natural orifices translumenal endoscopic surgery (NOTES): an ex vivo study. Surg Endosc 2013; 28:1342-7. [DOI: 10.1007/s00464-013-3280-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2013] [Accepted: 10/06/2013] [Indexed: 12/17/2022]
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Camus M, Dray X, Marteau P. Enseignement de la prise en charge endoscopique des hémorragies digestives. ACTA ENDOSCOPICA 2013; 43:275-282. [DOI: 10.1007/s10190-013-0348-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/21/2025]
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Feasibility of full-thickness gastric resection using master and slave transluminal endoscopic robot and closure by Overstitch: a preclinical study. Surg Endosc 2013; 28:319-24. [PMID: 23990156 DOI: 10.1007/s00464-013-3149-3] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2013] [Accepted: 07/22/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Gastric submucosal tumors are often treated by laparoscopic wedge resection. This study aimed to examine the feasibility of gastric full-thickness resection through a totally endoscopic approach using the master and slave transluminal endoscopic robot (MASTER), and closure of the luminal defect with an endoscopic suturing device. METHODS The operation was performed in two live porcine models under general anesthesia. First, the anterior wall of the stomach was slung to the abdominal wall using a percutaneous suturing device. An imaginary 5-cm lesion was marked using a needle knife. After the initial mucosal incision was made using an IT knife, the MASTER was introduced through a long overtube. A circumferential mucosal incision was completed with the MASTER to expose the muscularis propria which was grasped and incised to the serosal layer by electrocautery applied through the hook of the MASTER. The full-thickness resection of the gastric wall was completed with retraction using the grasper and dissection using the hook. While the defect was being created, the luminal space was maintained with traction of the percutaneous sutures. The defect was closed with suture plication using an Apollo Overstitch device. RESULTS Two full-thickness gastric resections were performed in two nonsurvival porcine models (body weight = 30 and 35 kg, respectively) using the MASTER. The total procedure time was 56 min for the first model and 70 min for the second model. The luminal view was maintained during the whole procedure, and there was no damage to surrounding organs throughout the whole procedure. The gastric defects were closed successfully using Overstitch, with satisfactory gastric distension and no gas leakage afterward. CONCLUSION The current experiment demonstrated the feasibility and safety of a totally endoscopic approach for the treatment of gastric submucosal tumors: full-thickness resection with the MASTER and successful closure of the defect using Overstitch.
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Ishikawa S, Inaba T, Wato M, Takashima S, Mizushige T, Izumikawa K, Miyoshi M, Kawai K. Exposed blood vessels of more than 2 mm in diameter are a risk factor for rebleeding after endoscopic clipping hemostasis for hemorrhagic gastroduodenal ulcer. Dig Endosc 2013; 25:13-9. [PMID: 23286251 DOI: 10.1111/j.1443-1661.2012.01333.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/23/2011] [Accepted: 04/10/2012] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND AIM There are few clinical studies on the risk factors for rebleeding based on the endoscopic hemostatic procedure carried out, including ulcer characteristics such as exposed blood vessels. The present study aims to clarify the risk factors for rebleeding after endoscopic clipping hemostasis for hemorrhagic gastroduodenal ulcers. METHODS A retrospective study was carried out with data collected during the 10-year period from January 2000 to December 2009 for 312 consecutive patients with hemorrhagic gastroduodenal ulcer. Two hundred and ninety-three patients (216 men and 77 women; mean age, 67.0 ± 15.0 years) who underwent endoscopic clipping as the initial hemostatic treatment were analyzed. The risk factors for rebleeding were determined by comparing 271 patients who did not rebleed after initial treatment with 22 patients who developed rebleeding. RESULTS The success rate of initial clipping hemostasis was 100%; however, rebleeding occurred in 7.5% (22/293) and a multivariate analysis identified exposed blood vessels of more than 2 mm in diameter as independent risk factors for rebleeding (P = 0.0124, odds ratio 6.25 [95% CI: 1.53-13.62]). CONCLUSIONS Endoscopic clipping monotherapy is effective for hemorrhagic gastroduodenal ulcers; however, exposed blood vessels of more than 2 mm in diameter in the initial endoscopic procedure are a risk factor for rebleeding.
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Affiliation(s)
- Shigenao Ishikawa
- Department of Gastroenterology, Kagawa Prefectural Central Hospital, Takamatsu, Japan
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Chung IK. How can we maximize skills for non-variceal upper gastrointestinal bleeding: injection, clipping, burning, or others? Clin Endosc 2012; 45:230-4. [PMID: 22977808 PMCID: PMC3429742 DOI: 10.5946/ce.2012.45.3.230] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 07/25/2012] [Accepted: 07/25/2012] [Indexed: 01/30/2023] Open
Abstract
Endoscopy has its role in the primary diagnosis and management of acute non-variceal upper gastrointestinal bleeding. Main roles of endoscopy are identifying high risk stigmata lesion, and performing endoscopic hemostasis to lower the rebleeding and mortality risks. Early endoscopy within the first 24 hours enables risk classification according to clinical and endoscopic criteria, which guide safe and prompt discharge of low risk patients, and improve outcomes of high risk patients. Techniques including injection therapy, ablative therapy and mechanical therapy have been studied over the recent decades. Combined treatment is more effective than injection treatment, and single treatment with mechanical or thermal method is safe and effective in peptic ulcer bleeding. Specific treatment and correct decisions are needed in various situations depending on the site, location, specific characteristics of lesion and patient's clinical conditions.
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Affiliation(s)
- Il Kwun Chung
- Department of Internal Medicine, Soonchunhyang University Cheonan Hospital, Soonchunhyang University College of Medicine, Cheonan, Korea
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Leung Ki EL, Lau JYW. New endoscopic hemostasis methods. Clin Endosc 2012; 45:224-9. [PMID: 22977807 PMCID: PMC3429741 DOI: 10.5946/ce.2012.45.3.224] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2012] [Revised: 07/23/2012] [Accepted: 07/23/2012] [Indexed: 02/03/2023] Open
Abstract
Endoscopic treatment for non-variceal upper gastrointestinal bleeding has evolved over decades. Injection with diluted epinephrine is considered as a less than adequate treatment, and the current standard therapy should include second modality if epinephrine injection is used initially. Definitive hemostasis rate following mono-therapy with either thermo-coagulation or hemo-clipping compares favorably with dual therapies. The use of adsorptive powder (Hemo-spray) is a promising treatment although it needs comparative studies between hemospray and other modalities. Stronger hemo-clips with better torque control and wider span are now available. Over-the-scope clips capture a large amount of tissue and may prove useful in refractory bleeding. Experimental treatments include an endoscopic stitch device to over-sew the bleeding lesion and targeted therapy to the sub-serosal bleeding artery as guided by echo-endoscopy. Angiographic embolization of bleeding artery should be considered in chronic ulcers that fail endoscopic treatment especially in elderly patients with a major bleed manifested in hypotension.
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Affiliation(s)
- En-Ling Leung Ki
- Department of Medicine and Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
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Banerjee S, Barth BA, Bhat YM, Desilets DJ, Gottlieb KT, Maple JT, Pfau PR, Pleskow DK, Siddiqui UD, Tokar JL, Wang A, Song LMWK, Rodriguez SA. Endoscopic closure devices. Gastrointest Endosc 2012; 76:244-51. [PMID: 22658920 DOI: 10.1016/j.gie.2012.02.028] [Citation(s) in RCA: 90] [Impact Index Per Article: 6.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2012] [Accepted: 02/17/2012] [Indexed: 02/08/2023]
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Teoh AYB, Chiu PWY, Ng EKW. Current developments in natural orifices transluminal endoscopic surgery: An evidence-based review. World J Gastroenterol 2010; 16:4792-9. [PMID: 20939107 PMCID: PMC2955248 DOI: 10.3748/wjg.v16.i38.4792] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Tremendous advances have been made in recent years addressing the key obstacles to safe performance and introduction of human natural orifice transluminal endoscopic surgery (NOTES). Animal studies have focused on identifying optimal solutions to these obstacles, in particular methods of creating transluminal access, safe closure of the point of access, and development of a multitasking platform with dedicated instruments. Whether the performance data generated from these animal studies can be reproduced in humans has yet to be determined. Reports of human NOTES procedures are emerging, and the possibility of accomplishing human NOTES based on existing technology has been demonstrated. However, dedicated platforms and devices are still lacking to allow for pure NOTES procedures, and whether NOTES can deliver the postulated benefits of earlier recovery and improved cosmesis remains uncertain.
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Abstract
Bleeding peptic ulcer remains the commonest cause of emergency hospital admission worldwide and carries a mortality of up to 10%. Ulcer rebleeding is one of the important risk factors for mortality, and numerous strategies were examined to prevent ulcer rebleeding including the performance of scheduled second endoscopy and adjunctive proton pump inhibitor infusion. This article reviews the current management of bleeding peptic ulcer, including the prediction of clinical outcomes for bleeding peptic ulcer; the use of second-look endoscopy and adjunctive proton pump inhibitor infusion for prevention of rebleeding; and potential future development in achieving better primary endoscopic hemostasis with the use of endoscopic suturing.
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Affiliation(s)
- Philip Wai Yan Chiu
- Department of Surgery, Institute of Digestive Disease, The Chinese University of Hong Kong, Hong Kong, China.
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28
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Porcine models for the metabolic syndrome, digestive and bone disorders: a general overview. Animal 2010; 4:899-920. [DOI: 10.1017/s1751731110000200] [Citation(s) in RCA: 124] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
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Chen VK, Marks JM, Wong RCK, McGee MF, Faulx AL, Isenberg GA, Schomisc SJ, Deng CX, Ponsky JL, Chak A. Creation of an effective and reproducible nonsurvival porcine model that simulates actively bleeding peptic ulcers. Gastrointest Endosc 2008; 68:548-53. [PMID: 18620348 PMCID: PMC6198669 DOI: 10.1016/j.gie.2008.03.1087] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/21/2006] [Accepted: 03/17/2008] [Indexed: 01/23/2023]
Abstract
BACKGROUND Efforts to develop improved endoscopic therapeutic methods for upper GI bleeding require an effective animal model. OBJECTIVE To develop a nonsurvival porcine model that simulates acute peptic ulcer bleeding. DESIGN Prospective animal (porcine) study. SETTING Animal laboratory. INTERVENTIONS A surgical seromyotomy was created along the external surface of the greater curvature of the stomach in anesthesized pigs. A submucosal plane was developed and the gastroepiploic bundle, in continuity, was placed adjacent to the mucosa, and the seromuscular tissues were re-approximated over the vascular bundle. By using EGD, a needle-knife with electrocautery was then used to incise the mucosal tissue overlying the vascular bundle. Standard endoscopic methods for bleeding control were then tested in this animal model. MAIN OUTCOME MEASUREMENTS To evaluate whether successful bleeding that simulates submucosal arterial bleeding from peptic ulcer disease could be achieved in a porcine animal model. RESULTS Successful simulation of active peptic ulcer bleeding was achieved with this nonsurvival porcine model in a total of 5 sequential pigs. Other porcine models for bleeding were tested and found to be unsatisfactory. Hemoclips and combination injection-thermal therapy were used to stop bleeding over Doppler-positive areas, with subsequent endoscopic nonimaging Doppler US probe examination of the ulcer bed revealing a negative Doppler signal. LIMITATIONS This was an animal laboratory study. Further human studies would be ideal once any future endoscopic interventions are proven to be safe in animals. CONCLUSIONS This active bleeding ulcer model can be used to develop future endoscopic therapies and for training purposes.
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Affiliation(s)
- Victor K Chen
- Division of Gastroenterology, Department of Medicine, Case Advanced Surgical Endoscopy Team (CASE-T), University Hospitals Case Medical Center, Cleveland, USA
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30
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Chiu PW, Lau JY, Ng EK, Lam CC, Hui M, To KF, Sung JJ, Chung SS. Closure of a gastrotomy after transgastric tubal ligation by using the Eagle Claw VII: a survival experiment in a porcine model (with video). Gastrointest Endosc 2008; 68:554-9. [PMID: 18635172 DOI: 10.1016/j.gie.2008.03.1110] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2007] [Accepted: 03/25/2008] [Indexed: 02/08/2023]
Abstract
BACKGROUND Transgastric access to the peritoneal cavity presents new opportunities for novel endoscopic surgery. Secure closure of the gastrotomy site is critical to the success of transgastric endoscopic surgery. OBJECTIVE To study the safety and efficacy of closure of a gastrotomy by using the Eagle Claw VII endoscopic suturing device after transgastric bilateral tubal ligation. DESIGN A prospective survival study in a porcine model with ten 30-kg pigs. INTERVENTIONS The gastrotomies were made by using a needle-knife and balloon dilation. Bilateral fallopian tube ligation was performed with detachable snares, and the tubes were transected by using the needle-knife. The gastrotomies were closed with endoscopic suturing by using the Eagle Claw VII. MAIN OUTCOME MEASUREMENTS Included the survival of the pigs, security of the closure, number of plicating sutures used, operative time, peritoneal contamination, and histopathologic confirmation of the full-thickness healing of the gastrotomy. RESULTS Transgastric fallopian-tube ligation was performed in 10 pigs, and all of the gastrotomies were successfully closed by using the Eagle Claw VII endoscopic suturing device. The operative time for bilateral tubal ligation was 38.2 minutes (range 18-50 minutes), whereas, the operative time for gastrotomy closure was 25.5 minutes (range 15-35 minutes). Three endoscopic sutures were necessary to achieve a secure gastrotomy closure. All the pigs survived and tolerated a full diet 24 hours after the operation. A postmortem confirmed full-thickness healing for all gastrotomies, with no evidence of leakage. One pig had an overtube-related esophageal perforation, which was successfully managed with endoscopic clip closure. LIMITATIONS The porcine gastric wall is thicker than the human gastric wall, and the posterior wall of the porcine stomach becomes the anterior-inferior wall after gaseous distention. Hence, all the gastrotomies were made through the posterior wall. The tissue tolerance and healing of the porcine stomach may be different from that of the human stomach. CONCLUSIONS Endoscopic suturing by using the Eagle Claw VII device is a feasible method for gastrotomy closure after a natural orifice transluminal endoscopic surgery procedure.
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Affiliation(s)
- Philip W Chiu
- Institute of Digestive Disease, Department of Surgery, The Chinese University of Hong Kong, Hong Kong
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Cronin JA, Frecker MI, Mathew A. Design of a Compliant Endoscopic Suturing Instrument. J Med Device 2008. [DOI: 10.1115/1.2931551] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
This paper describes the initial design and optimization of a compliant endoscopic suturing instrument. The emerging field of Natural Orifice Transluminal Endoscopic Surgery (NOTES) requires innovative instruments to meet the size limitations inherent in this type of minimally invasive surgery; using compliant mechanisms is proposed as one method of meeting this requirement. The compliant design was modeled and optimized to maximize the distal opening and provide a puncture force of at least 4.6N, while being small enough to fit within a 3.3mm working channel. The design utilizes contact for stress relief and intertwining parts for added deflection. ANSYS® was used for finite element analysis including contact and nonlinear deformations. A prototype was fabricated from the optimized geometry and experimentally tested. The best geometry is predicted to have a distal opening of 14.6mm at the tips and supply a puncturing force of 4.83N. The force supplied at the tip was measured and was found to exceed the required 4.6N. The prototype successfully passed two complete sutures and qualitative results are provided. The results of the study will lead to further refinements and improvements in future designs.
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Affiliation(s)
- James A. Cronin
- Department of Mechanical and Nuclear Engineering, Pennsylvania State University, 326 Leonhard Building, University Park, PA 16802
| | - Mary I. Frecker
- Department of Mechanical and Nuclear Engineering, Pennsylvania State University, 326 Leonhard Building, University Park, PA 16802
| | - Abraham Mathew
- Department of Medicine, Penn State Milton S. Hershey Medical Center, Department of Gastroenterology, Hershey, PA 17033
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Cappell MS, Friedel D. Acute nonvariceal upper gastrointestinal bleeding: endoscopic diagnosis and therapy. Med Clin North Am 2008; 92:511-viii. [PMID: 18387375 DOI: 10.1016/j.mcna.2008.01.001] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute upper gastrointestinal bleeding is a relatively common,potentially life-threatening condition that causes more than 300,000 hospital admissions and about 30,000 deaths per annum in America. Esophagogastroduodenoscopy is the procedure of choice for the diagnosis and therapy of upper gastrointestinal bleeding lesions. Endoscopic therapy is indicated for lesions with high risk stigmata of recent hemorrhage, including active bleeding, oozing, a visible vessel, and possibly an adherent clot. Endoscopic therapies include injection therapy, such as epinephrine or sclerosant injection; ablative therapy, such as heater probe or argon plasma coagulation; and mechanical therapy, such as endoclips or endoscopic banding. Endoscopic therapy reduces the risk of rebleeding,the need for blood transfusions, the requirement for surgery, and patient morbidity.
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Affiliation(s)
- Mitchell S Cappell
- Division of Gastroenterology, Department of Medicine, William Beaumont Hospital, MOB 233, 3601 West Thirteen Mile Road, Royal Oak, MI 48073, USA.
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Abstract
PURPOSE OF REVIEW This review provides an update on the management of upper gastrointestinal bleeding with special attention to patient preparation, sedation, hemostatic techniques, and postprocedure care. RECENT FINDINGS In a large multicenter clinical trial, nurse-administered propofol sedation had a complication rate of less than 0.2%. The optimal management for an ulcer with adherent clot was confirmed by a meta-analysis to be clot removal and endoscopic treatment of the underlying lesion. A number of prospective studies have demonstrated that capsule endoscopy is the most sensitive imaging modality for identifying lesions in the small bowel and that double-balloon enteroscopy is the least invasive modality available for the management of these lesions. SUMMARY This update describes many recent advances in the diagnosis and management of upper gastrointestinal bleeding. However, clearly, much work needs to be done in this field. Since propofol is not available for use in all endoscopy units, is there a better alternative for deep sedation? Rebleeding occurs in 20% of patients after endoscopic therapy, and so can we provide better outcomes with newer technologies (endoscopic suturing devices)? Finally, what is the best management for Helicobacter pylori-negative, nonsteroidal antiinflammatory drug-negative ulcer patients?
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Affiliation(s)
- Noel B Martins
- University of Massachusetts Medical School, Worcester, Massachusetts, USA
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