Endoscopic stenting for gastroduodenal outlet obstruction of a malignant origin, real life experience in a single center

AIM: to evaluate the safety and effectiveness of self-expandable metal stent placement for malignant gastric outlet obstruction (GOO). METHODS: a retrospective, analytic cohort study at a single, tertiary-care center. RESULTS: thirty-six patients that underwent stent placement for GOO of malignant origin were identified during the study period. Technical success was achieved in 36 (100 %) patients and clinical success was achieved in 31 patients (86.1 %). Before the procedure, 17 (54.8 %) patients had a gastric outlet obstruction score (GOOSS) of 0, which is a complete inability of oral intake. Twenty-three patients were alive 30 days after the procedure, two (8.6 %) patients had a GOOSS of 1, ten (43.3 %) had a GOOSS of 2 and eleven (47.9 %) had a GOOSS of 3. Abdominal pain was present in all 31 patients before the procedure and only seven (22.6 %) patients continued with abdominal pain 24 hours after the procedure. During follow-up, ten (30.3 %) patients developed complications related to the stents and none of them was fatal. Additional therapy due to partial occlusion of the stent was necessary in three patients. The stents functional duration had a median of 72 days (IQR 25-75 15-105 days) and was closely related to overall survival. CONCLUSION: palliative stenting for gastroduodenal obstruction is a safe, feasible and effective therapy to treat patients with malignant gastric outlet obstruction

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Endoscopic stenting for gastroduodenal outlet obstruction of a malignant origin, real life experience in a single center.

AIM: to evaluate the safety and effectiveness of self-expandable metal stent placement for malignant gastric outlet obstruction (GOO). METHODS: a retrospective, analytic cohort study at a single, tertiary-care center. RESULTS: thirty-six patients that underwent stent placement for GOO of malignant origin were identified during the study period. Technical success was achieved in 36 (100 %) patients and clinical success was achieved in 31 patients (86.1 %). Before the procedure, 17 (54.8 %) patients had a gastric outlet obstruction score (GOOSS) of 0, which is a complete inability of oral intake. Twenty-three patients were alive 30 days after the procedure, two (8.6 %) patients had a GOOSS of 1, ten (43.3 %) had a GOOSS of 2 and eleven (47.9 %) had a GOOSS of 3. Abdominal pain was present in all 31 patients before the procedure and only seven (22.6 %) patients continued with abdominal pain 24 hours after the procedure. During follow-up, ten (30.3 %) patients developed complications related to the stents and none of them was fatal. Additional therapy due to partial occlusion of the stent was necessary in three patients. The stents functional duration had a median of 72 days (IQR 25-75 15-105 days) and was closely related to overall survival. CONCLUSION: palliative stenting for gastroduodenal obstruction is a safe, feasible and effective therapy to treat patients with malignant gastric outlet obstruction.

Surgical Trauma Caused by Different Abdominal Access Routes-Comparison of Open Surgical, Laparoscopic, and NOTES Transgastric Techniques in a Porcine Model.

BACKGROUND: Investigations indicate that natural orifice translumenal endoscopic surgery (NOTES) procedures induce a less pronounced postoperative inflammatory response than open or laparoscopic surgery, inflicting less trauma. In NOTES procedures, no skin incision is performed. We compare the inflammatory response added by the type of incision by measuring C-reactive protein (CRP) and tumors necrosis factor-alfa (TNF-α). METHODS: Twenty-seven pigs were randomized to open surgical, laparoscopic, or transgastric NOTES abdominal access. After completion of the accesses, no surgery was performed. All accesses were left open for 40 minutes followed by closure, animals were survived for 7 days. Blood samples were drawn at the start of the accesses, at 20 and 40 minutes during the procedure, and at postoperative day (POD) 1, 3, and 7. Analyses of CRP and TNF-α were performed. RESULTS: CRP increased in all animals until POD1. This increase was greater in the open group (P = .006). No significant differences in CRP-levels were found at POD 1, 3, or 7. TNF-α showed a peak during the procedure, at 20 and 40 minutes, with normalization at POD1 for 1/3 of the open and laparoscopic animals, but not for the NOTES animals. Due to variations within the groups, no statistical difference was shown between them. At postmortem, 1/3 of the pigs in the laparoscopic and open groups had wound infections, while no NOTES animals showed infections. CONCLUSIONS: This study provides no statistically significant differences in inflammatory response after the different abdominal accesses. However, the lack of a TNF-α-peak in the NOTES group might indicate a less pronounced response, supporting the initial theories.

A new in vivo method for testing closures of gastric NOTES incisions using leak of the closure or gastric yield as endpoints.

BACKGROUND: We developed a non-survival in vivo model for testing of gastric natural orifice translumenal endoscopic surgery (NOTES) closures based on the gastric yield pressure. The aim of this study was to test our model comparing different endoscopic closure techniques with surgical closure of a NOTES gastric incision. METHODS: Laparotomy was performed in 30 pigs. One tube for air inflation and one manometry tube were inserted into the stomach via the pylorus, which was closed gas-tight, and the abdominal wall was closed. The stomach was inflated with air, and the gastroesophageal yield pressure was measured. A gastroscopy was performed, and a standard NOTES access was created followed by randomization to closure by surgical suturing, T-tags, Padlock-G over-the-scope (OTS)-clips, OVESCO OTS-clips, and traditional clips. All closures were tested twice with air insufflation. Gastric yield pressure or leak pressure of each closure was recorded. RESULTS: The mean baseline gastric yield pressure was 80.5 mm Hg. Post-closure yield pressure was 79.9 mm Hg. Leak test results after closure were as follows: surgery, 0/6 leaked; T-tags, 1/6 leaked before reaching yield pressure (56 mm Hg); Padlock-G, 2/5 leaked (71.5 mm Hg); OVESCO OTS-clips, 3/6 leaked (27.2 mm Hg); and traditional clips, 5/6 leaked (27.2 mm Hg). TAS T-tags and surgical closures leaked significantly less than the other groups (P=.01). Traditional clips and OVESCO OTS-clips leaked at significantly lower pressures than the other three groups (P=.007). CONCLUSION: This in vivo model using leak of the closure or the gastric yield pressure as endpoints for testing of the closure strength of a NOTES gastric access site seems to be reproducible. Our results support closure with T-tags and Padlock-G-clips over OVESCO OTS-clips and standard endoscopic clips.

Cirugía endoscópica transluminal NOTES: resultados experimentales iniciales / Natural orifice transluminal endoscopic surgery (NOTES): initial experimental results

Introducción: La aparición de la cirugía endoscópica transorificial (NOTES) y de nuevos prototipos para su realización nos llevó a diseñar un programa de cirugía experimental. Material y métodos: Se ha realizado durante 1 año cirugía de NOTES en cerdas, cumpliendo la normativa europea de experimentación animal. Se han practicado 90 intervenciones sin supervivencia animal. En este estudio se ha evaluado: a) complejidad de las vías de acceso (transgástrica, transvaginal, transesofágica y transumbilical); b) técnicas de ayuda para la orientación temporoespacial, y c) posibilidades técnicas de cierre de los orificios viscerales (clips, t-bars®, clips de Obesco® y sutura por endoscopia). Las intervenciones practicadas mediante uno o dos endoscopios han sido: anexectomía, colecistectomía, biopsia de adenopatías mediastínicas, pancreatectomía distal y gastroyeyunostomía. Resultados: Esta experiencia nos ha permitido conocer una serie de aspectos técnicos imprescindibles para el desarrollo del NOTES: a) el neumoperitoneo con CO2 es más seguro para la entrada; b) el tamaño del orificio es importante para limitar la contaminación; c) la entrada con punción y dilatación con guía es más segura; d) la buena localización de la salida gástrica facilita el abordaje de las vísceras a disecar; e) la hemorragia intrabdominal es de difícil control; f) el cierre con garantías absolutas de fuga no existe, los clips no lo garantizan, los t-bars® y clips de Obesco® y la sutura endoscópica pueden funcionar, y g) la posibilidad de utilizar endoscopios que triangulan facilita la disección. Conclusiones: La NOTES requiere de un equipo multidisciplinario con cirujanos laparoscopistas y endoscopistas. La realización de NOTES pura es compleja; posiblemente las formas híbridas o la vía transumbilical sean fases intermedias (AU)

Introduction: The advent of natural orifice endoscopic surgery (NOTES) and new prototypes for performing this surgical procedure led us to design an experimental animal surgical programme. Material and method: NOTES was performed over a period of one year, in sows, following the European guidelines on the use of experimental animals. Ninety operations were performed with no animals surviving. The following aspects were assessed: 1. Access route complexity (transgastric, transvaginal, transesophageal and transumbilical). 2. Support measures for temporal/spatial orientation. 3. Technical possibilities for visceral orifice closure (clips, T-bars®, Obesco® clips and endoscopic suture). Resections of fallopian tubes, ovaries, gallbladder, mediastinal lymph nodes, tail of the pancreas and gastrojejunal derivations were performed with one or two endoscopes. Results: This experience enabled us to highlight a series of technical aspects essential for these techniques: 1. Pneumoperitoneum with CO2 is safer for entry. 2. Orifice size is important to limit contamination. 3. Puncture entry and guided dilation is safer. 4. Good gastric exit location makes it easier to approach viscera to be resected. 5. Intra-abdominal haemorrhage is difficult to control. 6. Leak-free closure cannot be guaranteed with clips, but t-bars® and Obesco® clips may be effective. 7. Endoscopes that permit triangulation may facilitate the dissection and endoscopic suture. Conclusions: NOTES requires a multidisciplinary team comprising laparoscopic and endoscopic surgeons. Pure NOTES is complex and hybrid forms or transumbilical route could be intermediate steps (AU)

[Natural orifice transluminal endoscopic surgery (NOTES): initial experimental results]. / Cirugía endoscópica transluminal NOTES: resultados experimentales iniciales.

INTRODUCTION: The advent of natural orifice endoscopic surgery (NOTES) and new prototypes for performing this surgical procedure led us to design an experimental animal surgical programme. MATERIAL AND METHOD: NOTES was performed over a period of one year, in sows, following the European guidelines on the use of experimental animals. Ninety operations were performed with no animals surviving. The following aspects were assessed: 1. Access route complexity (transgastric, transvaginal, transesophageal and transumbilical). 2. Support measures for temporal/spatial orientation. 3. Technical possibilities for visceral orifice closure (clips, T-bars, Obesco clips and endoscopic suture). Resections of fallopian tubes, ovaries, gallbladder, mediastinal lymph nodes, tail of the pancreas and gastrojejunal derivations were performed with one or two endoscopes. RESULTS: This experience enabled us to highlight a series of technical aspects essential for these techniques: 1. Pneumoperitoneum with CO(2) is safer for entry. 2. Orifice size is important to limit contamination. 3. Puncture entry and guided dilation is safer. 4. Good gastric exit location makes it easier to approach viscera to be resected. 5. Intra-abdominal haemorrhage is difficult to control. 6. Leak-free closure cannot be guaranteed with clips, but t-bars and Obesco clips may be effective. 7. Endoscopes that permit triangulation may facilitate the dissection and endoscopic suture. CONCLUSIONS: NOTES requires a multidisciplinary team comprising laparoscopic and endoscopic surgeons. Pure NOTES is complex and hybrid forms or transumbilical route could be intermediate steps.

Fecal excretion of human deoxyribonucleic acid as an index of inflammatory activity in ulcerative colitis.

BACKGROUND & AIMS: Several indices evaluate disease activity in ulcerative colitis, but most have drawbacks to their application (invasiveness, complexity, or lack of specificity), and discrepancies between them are frequent. Assuming that desquamation of epithelial and inflammatory cells increases in damaged colonic mucosa, we hypothesized that fecal excretion of human DNA is an index of mucosal inflammation and damage. The aim of our study was to determine whether excretion of human DNA is useful in the evaluation of disease activity in ulcerative colitis. METHODS: Thirty-one controls and 36 ulcerative colitis patients were included. Ulcerative colitis patients and controls underwent colonoscopic examination after preparation by gut lavage with polyethylene-glycol electrolyte solution. In patients, disease activity was established using the clinical index of Rachmilewitz and an endoscopic score. Feces and gut lavage fluid were obtained and DNA levels were measured by quantitative polymerase chain reaction of the human beta-globin gene. RESULTS: Fecal DNA excretion correlated with the clinical index (r = 0.59, P < 0.05) and the endoscopic score (r = 0.76, P < 0.01). Gut lavage fluid DNA levels also correlated with clinical and endoscopic activity scores (r = 0.41 and 0.51, respectively, P < 0.05). Fecal DNA excretion was significantly higher in patients with endoscopically or clinically active disease than in controls or patients in remission. Fecal DNA excretion discriminates between endoscopically active disease and remission (sensitivity 0.67, specificity 1.00, P < 0.01). CONCLUSIONS: Excretion of human DNA in feces, as an expression of cellular desquamation, is a novel noninvasive technique to objectively assess disease activity in ulcerative colitis.