Betadine solution irrigation of gastrointestinal tract for infection prevention during natural orifice transluminal endoscopic surgery / 中华消化内镜杂志

Objective To evaluate the feasibility and efficacy of betadine solution irrigation of gastrointestinal tract for infection prevention during the procedure of natural orifice transluminal endoscopic surgery(NOTES).Methods Twelve female porcine were divided into control group(n =4)to receive lavage with 500 ml normal saline and experimental group(n =8)to undergo lavage with 500 ml normal saline followed by 200 ml betadine solution.Fluid from gastrointestinal tract(5 ml)were collected before and after lavage,and after NOTES for culture.Endoscopy was performed 24 hours after NOTES to observe possible existence of inflammation,ulcer or bleeding.The animals were sacrificed 3 weeks after NOTES to explore intra-peritoneal adhesions,abscesses and other infections.Results One swine died of diaphragmatic injury and the other 11 animals successfully survived for 3 weeks.In trans-gastric approach,the average bacterial load of the fluid was 17.5 x 103 CFU/ml before lavage.In control group,the average bacterial load of the fluid was 2.5 × 103 CFU/ml after lavage and 5.5 × 103 CFU/ml after NOTES,while those in experimental group were 0 CFU/ml and 7.5 CFU/ml,respectively.In trans-colonic approach,the average bacterial load of the fluid before lavage was 76.2 × 103 CFU/ml.In control group,the average bacterial load of the fluid was 19.5 × 103 CFU/ml after lavage and 21 × 103 CFU/ml after NOTES,while those in experimental group were 2.25 × 103 CFU/ml and 1 × 103 CFU/ml,respectively.No inflammation,ulcer or bleeding were observed by endoscopy at 24 hours after NOTES.More adhesion and abscess were found in the control group than in the experimental group.In experimental group with trans-colonic approach,only one case of adhesion was observed.Conclusion It is effective and feasible of using betadine solution irrigation of gastrointestinal tract in infection prevention during the procedure of NOTES.However,further clinical studies assessing the effectiveness and safety are still necessary.

Natural orifice transluminal endoscopic surgery in non-survival porcine models: access and technique / 中华消化内镜杂志

Objective To evaluate the feasibility, advantages and pitfalls of trans-gastric, trans-colonic and trans-umbilical peritoneoscopy, and to compare pure natural orifice transluminal endoscopic surgery (NOTES) with hybrid NOTES. Methods Two female pigs of 30kg were used in the study, one for pure NOTES, the other for hybrid NOTES. Each pig received trans-gastric, trans-colonic and trans-umbilical peritoneoscopy, respectively, followed by postmortem examination for organic lesions and closure of incisions.The two approaches were compared in terms of intra-operative situation and manipulation. Results The vital signs of the pigs were stable during the procedures, with no peri-incision organic lesions. There were blind areas in trans-gastric as well as in trans-colonic peritoneoscopy. It was easier to close the colonic incision than the gastric one. The situation in trans-umbilical peritoneoscopy was similar to laparoscopic surgery. Hybrid NOTES seemed superior to pure NOTES with regard to safe access, stable pneumo-peritoneum and adequate visualization. Conclusion Three routes for NOTES appear to be reasonable and feasible. Hybrid NOTES is more effective and safer than pure NOTES with current instruments.

Cirurgia por orifícios naturais transcolônica: acesso NOTES peri-retal (PNA) para excisão mesoretal total / Transcolonic natural orifice surgery: peri-rectal NOTES access (PNA) for total mesorectal excision

OBJETIVOS: Cirurgia por orifícios naturais tem sido recentemente aplicada em series clínicas para cirurgia abdominal. Apesar de potenciais vantagens do acesso NOTES transcolônico para doenças colorretais, este ainda não havia sido utilizado clinicamente. O presente trabalho descreve a primeira aplicação bem-sucedida de NOTES transcolônico da literatura, em uma nova abordagem de excisão mesoretal total (TME) para cancer de reto. MÉTODOS: Foi obtida aprovação de Comitê de Ética em Pesquisa para cirurgias por orifícios naturais, e o paciente assinou termo de consentimento informado. Em um paciente de 54 anos portador de adenocarcinoma de reto, o procedimento de retossigmoidectomia e linfadenectomia, com excisão mesoretal total foi realizada utilizando um acesso posterior transcolônico pouco acima da borda anal. A dissecção mesorretal foi conseguida utilizando um colonoscópio flexível e instrumentos endoscópicos, com assistência laparoscópica. O espécime foi retirado via transanal, e anastomose foi transorificial, com estoma proximal de proteção. RESULTADOS: O tempo operatório foi de 350 min, não ocorrendo complicações operatórias. A evolução pós-operatória foi favorável, e o paciente recebeu alta no sexto dia de pós-operatório com dieta plena. CONCLUSÃO: Este primeiro relato bem sucedido de cirurgia NOTES transcolônica traz potencialmente novas fronteiras de aplicações clínicas na cirurgia minimamente invasiva. O tratamento de doenças colorretais utilizando o novo acesso flexível PNA (Perirectal NOTES Access) é uma promissora nova abordagem, paralelamente à laparoscopia e cirurgia aberta, para melhoria do tratamento dos pacientes.

OBJECTIVES: Clinical natural orifice surgery has been applied for abdominal surgery in recent years. Despite potential advantages of transcolonic NOTES for colorectal diseases, it was since now not yet clinically applied. The study describes the first successful human application of transcolonic NOTES in the literature, in a new transrectal TME procedure for rectal cancer. METHODS: IRB approval was obtained at the institution for the study, and the patient signed informed consent. In a 54yrs-old male patient with a rectal adenocarcinoma, total mesorectal resection and rectosigmoidectomy with lymphadenectomy was performed using a posterior transcolonic access 3cm from the anal verge. Mesorectal dissection was achieved using a flexible colonoscope and endoscopic instrumentation and laparoscopic assistance. The specimen was extracted transanally, and transorificial anastomosis was performed, with proximal stoma. RESULTS: Operative time was 350 min, no intraoperative complications occurred. The postoperative course was uneventful, patient was discharged after 6 days. CONCLUSION: Successful first human report on Transcolonic NOTES potentially brings new fronteers and applications for minimally invasive surgery. The treatment of colorectal diseases through a flexible Perirectal NOTES Access (PNA) is a promising new approach besides existing laparoscopic and open surgery to improve patient care.

The First Transcolonic Cholecystectomy in Korea: A NOTES Survival Study in an Animal Model

Natural orifice translumenal endoscopic surgery (NOTES) is a new and rapidly evolving hybrid procedure in which the endoscope is introduced into the peritoneal cavity through the stomach, colon, vagina or urethra. A transcolonic approach is applicable for upper abdomen surgery. The present report describes a successful transcolonic cholecystectomy performed in a pig. The total operation time was 180 minutes. The pig survived without any complications for 7 days post-operatively. Necropsy after euthanasia showed no evidence of organ injury, bleeding or suppurative peritonitis, and it revealed that the colonic wall that had been incised and then closed using multiple endoscopic clippings was water-tight and air-tight. This is the first transcolonic cholecystectomy performed in Korea. This approach may represent a promising new method for performing NOTES.

Combination of transgastric and transcolonic routes for natural orifice translumenal endoscopic surgery(NOTES) / 中华消化内镜杂志

Objective To explore the feasibility,advantages and disadvantages of combined trans- gastric and transcolonic routes for NOTES.Methods A female swine was used in this study.Transgastric entrance was the first,followed by transeolonie entrance.A dual-channel endoscope was inserted through the porcine mouth into the gastric cavity and penetrated into the peritoneal cavity through the puncture and bal- loon dilatation of the gastric wall.Then under direct visualization through the transgastric approach,the other endoseope was advanced into the peritoneum.Using the two endoscopes inside the peritoneal cavity,collabo- rative peritoneoseopy was performed by the two endoscopists.After the examination the incisions in the stom- ach and the colon wall were closed with Endoclips.The animal was sacrificed for post-mortem examination with particular attention to the entrance sites and presence of any complications related to the access or to ma- nipulations inside the peritoneal cavity.Results No hemorrhage oecurred during the puneture and balloon dilatation or bow-knife cutting of the gastric wall or the eolonic wall.The liver was damaged while a needle knife penetrated the gastric wall.On the contrary,no organs were damaged during the needle knife penetra- ted the eolonic wall under direet visualization through the transgastric approach.It was difficult to find the gallbladder or the oviduct with a"single arm",but it was easy to see them with the double routes.It was easier to close the colonic incision than to close the gastrie wall with Endoclips.Conclusion Combined transgastric and transcolonic route for NOTES is feasible and it seems to be easier to show a target compared with a single route.