Efficient techniques for access site closure after transrectal NOTES procedures – results of an experimental study

Czech version

Authors: O. Ryska ¹; J. Martínek ²; R. Doležel ³; Z. Šerclová ¹; S. Juhas ⁴; J. Juhásová ⁴; E. Lásziková ⁵; T. Henlín ⁵; J. Kalvach ³; M. Ryska ³
Authors‘ workplace: Chirurgické oddělení, Nemocnice Hořovice ¹; Klinika hepatogastroenterologie, IKEM, Praha ²; Chirurgická klinika 2. LF UK a ÚVN, Praha ³; Ústav živočišné fyziologie a genetiky AV ČR, Liběchov ⁴; Klinika anesteziologie a resuscitace ÚVN, Praha ⁵
Published in: Gastroent Hepatol 2014; 68(4): 299-304
Category: Clinical and Experimental Gastroenterology: Original Article

Overview

In spite of the fact that the NOTES (natural orifice translumenal endoscopic surgery) method remains a contemporary subject of experimental and clinical trials, it still lacks common practical application. Indications of NOTES could be extended by adopting transrectal access and its closure techniques. The aim of this experimental study was to evaluate various techniques (KING closure, over-the-scope clip – OTSC) for access site closure following transrectal abdominal NOTES procedures.

Method:
All laboratories that performed transrectal intra-abdominal surgeries in the period of 2009–2013 were included. Access was performed using a needle knife followed by a balloon dilation. KING closure was acquired by approximation of an endoloop fixed to the perforation margins with endoclips. OTSC method was implemented with use of the OVESCO system with a clip diameter of 11.5–14 mm. The animals were euthanized and autopsied after 30 days.

Results:
In total 58 animals were included in the study. Rectum closure was technically feasible in 55 (94%) pigs (31× KING, 24× OTSC). A group of 50 (86%) animals completed a 30-day follow-up. Complications with the closure healing were diagnosed in three (6%) autopsies. One was a severe iatrogenic entero-colic fistula, other two were minor complications (serose defect, mucosal defect) without influence on the closure sufficiency. Intra-abdominal infection was observed in six (12%) animals postoperatively. These complications were caused by a contaminated endoscope due to the transrectal road of access and none was associated with the closure dehiscence. Closure time was significantly longer with the KING technique – 13 (4–40) vs 9 (5–15) min (p < 0.05). This method was associated with a progressive learning curve – 20 (5–40) min in the first half vs 10 (4–24) min in second half of the procedures (p < 0.05).

Conclusions:
The KING and OTSC rectal closures proved as technically feasible and efficient in a large cohort. The KING technique is safer despite a longer procedural time and training period. Both methods are potentially available for the treatment of accidental colon perforations.

Key words:
NOTES – rectum closure – endoloop – over-the-scope clip

The authors declare they have no potential conflicts of interest concerning drugs, products, or services used in the study.

The Editorial Board declares that the manuscript met the ICMJE „uniform requirements“ for biomedical papers.

Submitted:
9. 6. 2014

Accepted:
28. 7. 2014

Sources

1. Kalloo AN, Singh VK, Jagannath SB et al. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc 2004; 60(1): 114–117.

2. Autorino R, Yakoubi R, White WM et al. Natural orifice transluminal endoscopic surgery (NOTES): where are we going? A bibliometric assessment. BJU Int 2013; 111(1): 11–16. doi: 10.1111/j.1464-410X.2012.11494.x.

3. Liu L, Chiu PW, Reddy N et al. Natural orifice transluminal endoscopic surgery (NOTES) for clinical management of intra-abdominal diseases. Dig Endosc 2013; 25(6): 565–577. doi: 10.1111/den.12154.

4. Whiteford MH, Denk PM, Swanström LL. Feasibility of radical sigmoid colectomy performed as natural orifice translumenal endoscopic surgery (NOTES) using transanal endoscopic microsurgery. Surg Endosc 2007; 21(10): 1870–1874.

5. Teoh AY, Chiu PW, Ng EK. Current developments in natural orifices transluminal endoscopic surgery: an evidence-based review. World J Gastroenterol 2010; 16(38): 4792–4799.

6. Martínek J, Ryska O, Tuckova I et al. Comparing over-the-scope clip versus endoloop and clips (KING closure) for access site closure: a randomized experimental study. Surg Endosc 2013; 27(4): 1203–1210. doi: 10.1007/s00464-012-2576-x.

7. Ryska O, Šerclová Z, Martínek J et al. Experimentální model kalkulózní cholecystitidy použitelný k hodnocení přístupu NOTES. Gastroent Hepatol 2012; 66 (Suppl 2): S13.

8. Rattner D, Kalloo A. ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery. October 2005. Surg Endosc 2006; 20(2): 329–333.

9. Von Renteln D, Vassiliou MC, Rothstein RI. Randomized controlled trial comparing endoscopic clips and over-the-scope clips for closure of natural orifice transluminal endoscopic surgery gastrotomies. Endoscopy 2009; 41(12): 1056–1061. doi: 10.1055/s-0029-1215241.

10. Hookey LC, Khokhotva V, Bielawska B et al. The Queen's closure: a novel technique for closure of endoscopic gastrotomy for natural orifice transluminal endoscopic surgery. Endoscopy 2009; 41(2): 149–153. doi: 10.1055/s-0028-1119464.

11. Hucl T, Benes M, Kocik M et al. A novel double-endoloop technique for natural orifice transluminal endoscopic surgery gastric access site closure. Gastrointest Endosc 2010; 71(4): 806–811. doi: 10.1016/j.gie.2009.10.058.

12. Dray X, Gabrielson KL, Buscaglia JM et al. Air and fluid leak tests after NOTES procedures: a pilot study in a live porcine model (with videos). Gastrointest Endosc 2008; 68(3): 513–519. doi: 10.1016/j.gie.2007.12.052.

13. Chiu PW, Lau JY, Ng EK et al. 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(3): 554–559. doi: 10.1016/j.gie.2008.03.1110.

14. Voermans RP, Vergouwe F, Breedveld P et al. Comparison of endoscopic closure modalities for standardized colonic perforations in a porcine colon model. Endoscopy 2011; 43(3): 217–222. doi: 10.1055/s-0030-1256072.

15. Ryska O, Martínek J, Doležel R et al. Nový jednoduchý uzávěr gastrotomie typu loop-and-clip („King’s closure“) využitelný při NOTES výkonech v experimentu. Gastroent Hepatol 2011; 65(4): 207–210.

16. Schurr MO, Hartmann C, Ho CN et al. An over-the-scope clip (OTSC) system for closure of iatrogenic colon perforations: results of an experimental survival study in pigs. Endoscopy 2008; 40(7): 584–588. doi: 10.1055/s-2008-1077354.

17. Sun G, Yang Y, Zhang X et al. Comparison of gastrotomy closure modalities for natural orifice transluminal surgery: a canine study. Gastrointest Endosc 2013; 77(5): 774–783. doi: 10.1016/j.gie.2012.12.017.

18. Von Renteln D, Schmidt A, Vassiliou MC et al. Natural orifice transluminal endoscopic surgery gastrotomy closure with an over-the-endoscope clip: a randomized, controlled porcine study (with videos). Gastrointest Endosc 2009; 70(4): 732–739. doi: 10.1016/j.gie.2009.03.010.

19. Pai RD, Fong DG, Bundga ME et al. Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model (with video). Gastrointest Endosc 2006; 64(3): 428–434.

20. Bachman SL, Sporn E, Furrer JL et al. Colonic sterilization for natural orifice translumenal endoscopic surgery (NOTES) procedures: a comparison of two decontamination protocols. Surg Endosc 2009; 23(8): 1854–1859. doi: 10.1007/s00464-008-0295-0.

21. Ryou M, Fong DG, Pai RD et al. Evaluation of a novel access and closure device for NOTES applications: a transcolonic survival study in the porcine model (with video). Gastrointest Endosc 2008; 67(6): 964–969. doi: 10.1016/j.gie.2007.12.047.

22. Wilhelm D, Meining A, von Delius S et al. An innovative, safe and sterile sigmoid access (ISSA) for NOTES. Endoscopy 2007; 39(5): 401–406.

23. Rimonda R, Arezzo A, Arolfo S et al. Transanal minimally invasive surgery (TAMIS) with SILS port versus transanal endoscopic microsurgery (TEM): a comparative experimental study. Surg Endosc 2013; 27(10): 3762–3768. doi: 10.1007/s00464-013-2962-z.

24. Weiland T, Fehlker M, Gottwald T et al. Performance of the OTSC System in the endoscopic closure of iatrogenic gastrointestinal perforations: a systematic review. Surg Endosc 2013; 27(7): 2258–2274. doi: 10.1007/s00464-012-2754-x.