Pretreatment with endothelium-derived nitric oxide synthesis modulators on gastrointestinal microcirculation during NOTES: an experimental study.

BACKGROUND AND STUDY AIMS: On-demand endoscopic insufflation during natural orifice transluminal endoscopic surgery (NOTES) adversely affects microcirculatory blood flow (MBF), even with low mean intra-abdominal pressure, suggesting that shear stress caused by time-varying flow fluctuations has a great impact on microcirculation. As shear stress is inversely related to vascular diameter, nitric oxide (NO) production acts as a brake to vasoconstriction. OBJECTIVE: To assess whether pretreatment by NO synthesis modulators protects gastrointestinal MBF during transgastric peritoneoscopy. METHODS: Fourteen pigs submitted to cholecystectomy by endoscope CO2 insufflation for 60 min were randomized into 2 groups: (1) 150 mg/kg of N-acetyl cysteine (NAC, n = 7) and (2) 4 ml/kg of hypertonic saline 7.5 % (HS, n = 7), and compared to a non-treated NOTES group (n = 7). Five animals made up a sham group. Colored microspheres were used to assess changes in MBF. RESULTS: The average level of intra-abdominal pressure was similar in all groups (9 mmHg). In NOTES group microcirculation decrease compared with baseline was greater in renal cortex, mesocolon, and mesentery (41, 42, 44 %, respectively, p < 0.01) than in renal medulla, colon, and small bowel (29, 32, 34, respectively, p < 0.05). NAC avoided the peritoneoscopy effect on renal medulla and cortex (4 and 14 % decrease, respectively) and reduced the impact on colon and small bowel (20 % decrease). HS eliminated MBF changes in colon and small bowel (14 % decrease) and modulated MBF in renal medulla and cortex (19 % decrease). Neither treatment influenced mesentery MBF decrease. CONCLUSIONS: Both pretreatments can effectively attenuate peritoneoscopy-induced deleterious effects on gastrointestinal MBF.

Effect of transgastric natural orifice transluminal endoscopic surgery peritoneoscopy on abdominal organ microcirculation: an experimental controlled study.

BACKGROUND AND AIMS: On-demand insufflation during endoscopic peritoneoscopy causes wide variations in intra-abdominal pressure. Its effects on splanchnic microcirculation may differ from those of steady intra-abdominal pressure, because pressure characteristics affect crucial intravascular hemodynamic forces--pressure and shear--adapting flow to local metabolic needs. Our aim was to assess the effect of natural orifice transluminal endoscopic surgery (NOTES) peritoneoscopy on splanchnic microcirculatory blood flow. METHODS: Twenty-one swine were randomized to the following: cholecystectomy by transgastric NOTES (n = 8), cholecystectomy by standard laparoscopy (Lap) (n = 8), and a sham group (n = 5). During NOTES, CO2 was manually insufflated with a maximum allowed pressure of 30 mm Hg. In the Lap group, intra-abdominal pressure was maintained at 14 mm Hg. Systemic hemodynamics were measured, and microcirculatory blood flow was quantified by using colored microspheres. RESULTS: Mean intra-abdominal pressure was lower in NOTES than in the Lap group (P = .038). In both groups, cardiac index and preload remained unchanged, whereas systemic vascular resistances increased over time, with a lesser increase in the Lap group (2-way analysis of variance; P = .041). In pneumoperitoneum groups, microcirculatory blood flow decreased similarly in the renal medulla, stomach, small bowel, colon, and mesocolon by 30%, 45%, 34%, 32%, and 37%, respectively. In NOTES, there was a greater microcirculatory blood flow decrease in the renal cortex (NOTES 41% vs Lap 35%; P = .044) and mesentery (NOTES 44% vs Lap 38%; P = .041). CONCLUSIONS: These findings suggest that both types of pneumoperitoneum have similar physiologic effects on microcirculatory blood flow. However, on-demand pneumoperitoneum (NOTES group) caused a greater microcirculatory blood flow decrease in areas with low metabolic needs, redistributing blood flow toward metabolically active areas.

Transanal natural orifice transluminal endoscopic surgery (NOTES) rectal resection: "down-to-up" total mesorectal excision (TME)--short-term outcomes in the first 20 cases.

BACKGROUND: The transanal minilaparoscopy-assisted natural orifice transluminal endoscopic surgery (NOTES) approach holds significant promise as a safe and less morbid alternative to conventional low anterior rectal resection. Previous reports have shown satisfactory short-term oncologic results. We evaluated the safety and short-term outcomes in rectal cancer subjects who underwent transanal minilaparoscopy-assisted natural orifice surgery total mesorectal excision (TME) rectal resection. METHODS: Twenty selected patients with rectal cancer were enrolled onto a prospective study of minilaparoscopy-assisted natural orifice surgery TME rectal resection. The study endpoints were safety of access (intra- or postoperative morbidity) and adequacy of oncological resection criteria; intact TME; distal and circumferential margins; and number of lymph nodes retrieved. RESULTS: All procedures were successfully completed with the transanal NOTES and minilaparoscopy technique. The mean age was 65 ± 10 years; 55% of patients were male; the mean body mass index was 25.3 ± 3.8 kg/m(2). Thirty-five percent of tumors were in the distal rectum, 50% in midrectum, and 15% in proximal rectum. Coloanal anastomoses were hand sewn in 65% and stapled in 35%. Mean operative time was 235 ± 56 min. There were no procedure-related complications. Pathologic analysis demonstrated negative distal and circumferential margins in all patients. An average of 15.9 ± 4.3 lymph nodes were retrieved. The mesorectal fascia was intact in all the specimens. CONCLUSIONS: This study demonstrates that transanal NOTES with minilaparoscopic assistance in the hands of a specialized team is safe; meets the oncologic requirements for high-quality rectal cancer surgery; and may offer advantages over pure laparoscopic approaches for visualizing and dissecting out the distal mesorectum. Minilaparoscopic assistance allows one to compensate for the limitations of current NOTES instrumentation to ensure the safety and adequacy of oncologic resection in these difficult cases. Careful patient selection, a specialized team, and long-term outcome evaluation are critical before this procedure can be considered for routine clinical use.

Minilaparoscopy-assisted transrectal low anterior resection (LAR): a preliminary study.

BACKGROUND: Natural orifice translumenal endoscopic surgery (NOTES) represents the evolution of surgery towards less invasive procedures. The feasibility of NOTES transrectal approach has increased its clinical applicability. This report describes a first series of minilaparoscopy-assisted transrectal low anterior resection with double purse-string end-to-end circular stapler anastomoses. METHODS: Between March and April 2012 three selected patients underwent transrectal minilaparoscopy-assisted natural orifice surgery total mesorectal excision for rectal cancer. All the oncologic principles of open/laparoscopic low anterior resection for rectal cancer were strictly fulfilled. Two patients underwent neoadjuvant treatment. Laparoscopic visualization and assistance was provided through one 10-mm umbilical port and two ports, one of which was used as stoma site (5 mm) and the other as a drain site (2 mm needle port). The specimen was transected transanally followed by the confection of double purse-string lateral/end-to-end anastomoses. There were no intraoperative complications. RESULTS: Mean operative time was 143 min. Oral intake was initiated on the second postoperative day. Patients were discharged home by day 5. The pathology unit confirmed that distal and circumferential margins were free of tumor invasion, and quality of mesorectum resection was reported satisfactory. One patient had to be readmitted because of severe dehydration due to increased ileostomy output. The patient was discharged at the third day after the readmission without renal failure. CONCLUSIONS: In this preliminary report, transrectal minilaparoscopy-assisted low anterior resection was feasible and safe. Lateral/end-to-end anastomoses can be considered an interesting alternative to the double-stapling technique. However, it is necessary to further study and develop these procedures, along with careful patient selection, before transrectal low anterior resection may be considered for routine clinical use.

Transumbilical single-port sleeve gastrectomy: initial experience and comparative study.

BACKGROUND: Sleeve gastrectomy is gaining relevance in the surgical armamentarium against obesity. The transumbilical single port has proved to be an attractive and safe alternative for a variety of minimally invasive abdominal surgeries. The purpose of this study is to evaluate the initial results of a group of patients operated by single-port sleeve gastrectomy compared with a group operated by conventional laparoscopic technique. PATIENTS AND METHODS: We present a prospective cohort study of two groups of consecutive patients with body mass index (BMI) between 35 and 55 kg/m(2), with an indication of sleeve gastrectomy. In 20 patients, we used a transumbilical single-port (TUSP) technique; in 22 patients, we used the conventional laparoscopic (CL) technique. All surgeries were performed between June and December 2009 in the Gastrointestinal Surgery Department of Hospital Clínic, Barcelona. The same medical team, in a standardized fashion, carried out all surgeries. RESULTS: There were no differences between groups in body mass index (BMI), age, sex, number and type of comorbidities, or history of previous abdominal surgery. Operative time (79.2 min) was significantly higher in the TUSP group (p = 0.002) than in the CL group (54.1 min). There were no conversions to open surgery in any of the patients operated upon via CL, but one conversion to laparoscopic surgery, requiring the addition of three trocars, in the TUSP group. There were no significant differences in morbidity or hospital stay between the groups. Percentage excess weight loss and excess BMI loss at 3 and 6 months, as indexes for improvement and resolution of comorbidities associated with obesity, showed that there were no significant differences between the groups. CONCLUSIONS: Transumbilical single-port sleeve gastrectomy has proved to be safe, technically feasible, and reproducible, with results that are similar to those obtained with conventional laparoscopic surgery.

Minilaparoscopy-assisted natural orifice total colectomy: technical report of a minilaparoscopy-assisted transrectal resection.

BACKGROUND: Experimental experience and the technological evolution of minimally invasive surgical devices have allowed initial reports describing the clinical applicability of natural orifice translumenal endoscopic surgery (NOTES). Colorectal resections are an interesting target for the NOTES platform. Theoretically, the transrectal approach could overcome the proposed limitations of transvaginal access, increasing NOTES clinical applicability. Hybrid procedures such as minilaparoscopy-assisted natural orifice surgery (MA-NOS) are the safe progression to pure NOTES. This report describes the first clinical case of a transrectal MA-NOS total colectomy. METHODS: The patient was a 36-year-old man with severe ulcerative colitis (UC) who experienced failure of immunosuppressive therapy. The standard steps of laparoscopic total colectomy were respected, with basic triangulation maintained throughout the case. A transrectal endoscopic device was used for optic assistance, colon dissection, ileum section, and specimen retrieval. Transrectal MA-NOS total colectomy was assisted by three laparoscopic ports: a 12-mm port used as the terminal ileostomy site, a 2-mm needle epigastric port, and a 5-mm umbilical port used as a drain site at the final intervention. No intraoperative complications occurred. RESULTS: The total operative time was 240 min. Oral intake was initiated on postoperative day 2. Because of UC rectal activity, a course with azathioprine was completed, and the patient was discharged receiving 1 g of rectal mesalazine for maintenance. The final pathology demonstrated pancolonic inflammatory bowel disease in the form of UC with severe activity. CONCLUSIONS: Transrectal MA-NOS total colectomy was feasible and safe in the reported case. Improvement in NOTES instrumentation and selective clinical applications are mandatory before clinical trials.

Revisional surgery after sleeve gastrectomy.

INTRODUCTION: Worldwide, morbid obesity incidence has increased dramatically in the last decade and surgery is at this moment recognized as the only effective treatment with long-term sustained weight loss and resolution or significant improvement in comorbidities. Laparoscopic sleeve gastrectomy (LSG) was successfully carried out by several groups as a bridge to future laparoscopic bariatric procedures with acceptable weight loss and reduction in comorbidities. LSG is considered a safe procedure with sporadically reported complications, such as bleeding or leakage from the staple line, strictures, delayed gastric emptying, gastric dilatation and vomiting. The aim of this publication is to describe complications of this procedure analyze different treatments of these events especially the surgical ones, reporting the technical management based on our experience and on the literature. MATERIAL AND METHODS: From March 2003 to December 2009, 294 patients underwent LSG in our Department. Complications are reported prospectively. RESULTS: In our series 294 patients were operated and stapler line leak was observed in 11 patients (3.7%). The mean time from the first surgery up to the first reintervention was 15.6±22 days (2 to 78). Only 2 patients (0.68%) had to be operated owing to severe reflux related with the sleeve gastrectomy and the symptomatology was solved with the gastric bypass. Intraabdominal bleeding was observed in 7 patients (2.38%), being reoperated 3 (1.02%) of them. All patients were reoperated by laparoscopic approach and the bleeding vessel was identified in all of them. We identified 3 of 294 patients with strictures (1.02%). One of them was located in the gastroesophageal junction and the other 2 had a central location. The patient with high stenosis required endoscopic dilatation and the other 2 were resolved by a gastric bypass cutting the stomach proximal to the stricture. The global mortality was 0%. All of the patients were reoperated by laparoscopy. CONCLUSION: LSG is a feasible bariatric procedure carried out increasingly in the last few years with low postoperative complications. Regardless, the knowledge of the potential complications associated to LSG and their management is crucial for patient's safety.