Evaluation of endoscopy in localizing transgastric access for natural orifice transluminal endoscopic surgery in humans

Linke, Georg R.; Zerz, Andreas; Kapitza, Florian; Warschkow, Rene; Lange, Jochen; Meyenberger, Christa M.; Binek, Janek

doi:10.1016/j.gie.2009.11.041

« Previous Next »Gastrointestinal Endoscopy
Volume 71, Issue 6 , Pages 907-912, May 2010

Evaluation of endoscopy in localizing transgastric access for natural orifice transluminal endoscopic surgery in humans

Poster presented at Digestive Disease Week, May 30-June 4, 2009, Chicago, Illinois, (Gastrointest Endosc 2009;69:AB165); presented orally at the 96th annual meeting of the Swiss Society for Surgery, June 10-12, 2009, Montreaux, Switzerland, at the 50th annual meeting of the Austrian Society for Surgery, June 18-20, 2009, Vienna, Austria (Eur Surg 2009;41, Supplement 230:72-73) and at the annual Meeting of the Swiss Society for Gastroenterology September 17-18, Zürich, Switzerland.

Current affiliations: Department of Surgery (G.R.L., A.Z., F.K., R.W., J.L.), Unit of Gastroenterology and Hepatology, Department of Internal Medicine (C.M.M., J.B.), Kantonsspital St. Gallen, St. Gallen, Switzerland

Received 7 July 2009; accepted 19 November 2009. published online 12 March 2010.

Background

To date, transgastric access in humans for natural orifice transluminal endoscopic surgery (NOTES) has been poorly evaluated.

Objective

To compare endoscopic visualization of the transgastric access point with the laparoscopically defined ideal entrance to the peritoneal cavity.

Design

Prospective pilot study in humans.

Setting

Single tertiary-care center.

Patients

This study involved 31 patients referred for laparoscopic cholecystectomy.

Intervention

Access points were marked by endoscopy alone, endoscopy combined with diaphanoscopy, and endoscopy after pneumoperitoneum. Points were correlated with a laparoscopically visualized, previously defined ideal access area.

Main Outcome Measurements

To choose the appropriate access point within the laparoscopically defined ideal access area to the peritoneal cavity away from major vessels and adjacent organs, by using endoscopy and to establish landmarks for the endoscopist, look for a learning curve, and identify potential problems.

Results

The percentage of access points within the laparoscopically defined ideal area was 35.5% with endoscopy alone, 13.8% using the diaphanoscopy method, and 45.2% after transcutaneous pneumoperitoneum. A safe access point (≥3 cm from major gastric vessels) could be achieved with the 3 techniques in 83.9%, 65.5%, and 87.1 % of patients, respectively. A positive learning curve for endoscopic localization was identified before (P = .008) and after (P = .014) pneumoperitoneum. Virtual complications were greater in obese patients.

Limitations

This was a small pilot study with hypothetical complications and problems, because actual transgastric access was not performed. The criteria for an ideal access area were very strict.

Conclusion

Endoscopy, especially with the use of pneumoperitoneum, can reliably locate a safe transgastric entrance point. However, the endoscopically chosen site correlates poorly with the ideal laparoscopically determined site for transgastric access.

Abbreviations: AA, access area, AP, access point, AP-Endo, endoscopic access point, AP-Endo-Dia, endoscopic access point by means of a diaphanoscopy/PEG-like technique, AP-Endo-P, endoscopic access point with existing pneumoperitoneum, BMI, body mass index, IQR, interquartile range