Добавил:
Sekretar
kiopkiopkiop18@yandex.ru
t.me/Prokururor I Вовсе не секретарь, но почту проверяю
Опубликованный материал нарушает ваши авторские права? Сообщите нам.
Вуз:
Предмет:
Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_1127_Библиотеки_им_академика_М_И_Перельмана
.pdf
SECTION 1 Development of the NOTES Concept
https://t.me/med1917
secure. A group from the University of Washington described
an experimentally reliable method for gastrotomy closure
using available clips and detachable endoscopic ligation
loops [27]. This retracted clip -assisted loop closure technique is performed by tying long sutures to standard endoscopic clips. An endoscopic balloon, advanced through the
gastrotomy and infl ated extramurally, is used to invert the
serosa into the gastric lumen and allow several clips to be
placed on the serosa around the margin of the viscotomy.
Using a double -channel endoscope, the ends of the sutures
were pulled through an open endoloop and out the biopsy
channel of the scope. While applying tension on the sutures,
the endoloop is cinched, which securely closes the gastrotomy in a full -thickness fashion. A similar procedure, called
the Queen ′s closure, described a procedure using PolyLoop
ligation devices clipped to the margins of the enterotomy.
Experimental results found suffi cient closure and leak pressures; however, the procedure took relatively long (mean
closure time: 1.2 hours) [28].
Very limited data are available on the use of an omental
pedicle pulled into the gastrotomy and fi xed to the gastric
wall by endoscopic clips [29]. Although certainly cheap,
several serious infectious complications were observed
during necropsy with their survival animal model. This
method also creates otherwise avoidable adhesions on
purpose.
Clips are often successfully used to close iatrogenic colon
perforations. Mathews et al. looked at both endoclips and
endoloops to close intentional colotomies for NOTES [30].
For their study, the colon was cleaned with sterile enemas,
antibiotics, and betadine. Transcolonic peritoneoscopies
were performed and endoloops were the primary attempted
closure technique. In case of inadequate closure additional
endoclips were used. In one animal pure endoclip colon
closure was performed. After seven days the evaluation at
necropsy demonstrated normally healing serosa in all but
one endoloop closure. Interestingly, the pure endoscopic clip
closure did not achieve microscopic continuity of granulation tissue.
Full-thickness closure clips
The inadequacy of current hemostatic endoclips for robust
NOTES closures stimulated development of a new generation of full -thickness over -the-scope clips – good for both
hemostasis and enteric closures. The fi rst over -the-scope clip
system to reach the market is called OTSC (Ovesco GmbH,
Tübingen, Germany). This clip is made of nitinol (an elastic
alloy) and imitates the U shape of a bear trap (Figure 6.3).
The system consists of a plastic cap together with the
mounted nitinol clip, which is attached to the tip of a fl exible
endoscope. A trigger thread is brought through the biopsy
channel and mounted to a wheel -handle mounted on the
scope handle. The edges of the enterotomy are grasped with
a double -action grasper and retracted into the scope cap and
the rigger -wheel turned to fi re the clip (Video 6.6). Several
studies have already shown successful closure of transgastric
defects with favorable burst pressures [31,32]. The OTSC is
on the market in Europe and the USA; however, it has not
been reportedly used for a clinical NOTES access closure.
A similar concept but differently shaped clip -device is the
Padlock-G® deployed by the Lock -It® system (Aponos
Medical, Kingston, NH, USA). Due to its more pliable material and fl at profi le, it has been shown to be removable after
potential misplacement [33], which might be a benefi cial
feature. Suffi cient burst pressure resistance after gastrotomy
closure has been demonstrated in an ex vivo study [34] as
well as in survival animal studies [35]. However this device
is not clinically available yet (Figure 6.4).
Figure 6.3 The Ovesco clip in place (commercially available USA and EU).
62
Figure 6.4 The Aponos over -the-scope closure clip (not commercially
available).
Figure 6.5 The Ethicon TAS T -bar fastener system (available for research
https://t.me/med1917
only).
T-fastener closures
CHAPTER 6 NOTES Closure Techniques
Figure 6.6 The Cook loop -fastener closure system (not commercially
available).
A T -fastener endoscopic suturing system with threads
attached and delivered through an EUS needle, was an early
method to close enterotomies. In 2007 it was successfully
used for the closure of the esophageal access into the mediastinum in an animal survival model [36]. A T -bar system
was recently also clinically used for the closure of a postoperative anastomotic esophageal leak [37]. The Tissue Apposition System (TAS, Ethicon Endo -Surgery Inc., Cincinnati,
Ohio, USA) is a commercialized version of a T -fastener
system. Initially proposed in 2003, the TAS includes a delivery needle, the T -bar/suture combination, and a suture
locking or cinching device (Figure 6.5). The system uses a
fl exible hollow needle to deliver a threaded T -tag through
tissue via a 2.8 mm channel of the endoscope. The length of
the needle can be adjusted, which allows deploying the
T-tags in a variety of gastrointestinal tissue. A series of paired
tags can be endoscopically positioned transmurally around
an enteric defect. The two suture tails are then threaded into
and through a plastic cinching plug attached to a fl exible
pushrod. The TAS device, available only on a restricted basis,
has already been used with some success in several controlled human studies [38–41] (Video 6.7). Several investigators, however, have found inadvertent and potentially
dangerous penetration of adjacent organs during the blind
placement of transmural T -tag sutures.
Similar T -bar systems (Wilson -Cook Medical, Winston Salem, NC, USA; Bard Medical Division, Covington, GA;
Olympus, Tokyo, Japan) have been reported to provide reliable closures of an experimental NOTES gastrotomy in
animals. The Cook system is a series of T -fastners looped
along a continuous suture.
The Baystate Medical Center group has described a “loop-
anchor purse -string” closure technique in a porcine model
using the Cook system [42]. The technique consisted of
transmurally placing four such loop -anchors in a square
pattern around the enterotomy. A monofi lament suture
loop is pre -attached to the loops of the fasteners. After the
viscotomy had been performed, simple cinching of the
suture with a push -rod catheter and securing it with a press fi t metal collar was used for closure. Early success of this
technique was reported in an animal study (Figure 6.6). The
T-tag system has also been successfully used for colotomy
closure [43].
Flexible endoscopic suturing devices
and systems
The need for an endoscopic closure that approximates the
security of the “gold-standard” suture or staple techniques
is a primary concern of NOTES. This has led to an intense
effort on the part of industry to develop new endoscopic
suturing devices. This is particularly important and challenging for transgastric surgery, which remains a highly demanding intervention [44–46].
One of the fi rst clinically available fl exible endoscopic
suturing systems for full -thickness closure of an intentional
63
SECTION 1 Development of the NOTES Concept
https://t.me/med1917
(a)
(b)
Figure 6.7 The g -Prox by USGI Medical. (a) The device as a large
grasper. (b) Once closed, the deployment needle transfi xes the tissue to
deploy the suture (available US and EU).
gastrotomy was the g -Prox™ (USGI Medical, San Clemente,
CA, USA) (Figure 6.7). This 5 mm fl exible grasper can be
loaded with a hollow catheter, preloaded with expandable
polyester tissue baskets/anchors (g -Cath™, USGI Medical).
Together with the use of a helical grasper (g -Lix™, USGI
Medical), the full thickness of the viscera can be pulled into
the jaws of the device, allowing full -thickness sutures to be
taken. Once the tissue is grasped, the hollow g -Cath needle
is deployed perpendicularly through the double layers of
tissue (mucosa, muscle, serosa; serosa, muscle, mucosa). As
the needle tip ends up within the lumen of the organ, the
anchors can be deployed under direct visualization. The
needle is then pulled back and a second basket, connected
to the distal anchor, can be released on the other edge of
the wound. Both baskets can then be cinched together with
Figure 6.8 The USGI TransPort scope needed to utilize the g -Prox
suturing device (available US and EU).
a one -way mechanism that securely approximates the tissue
(Video 6.8). The size of this device requires a complete set
of access instrumentation. This endoscopic delivery platform
(TransPort, USGI Medical) is 18 mm in diameter, has four
large channels, one of which is a 5 mm channel for a small,
fl exible upper endoscope for visualization, as well as a “ridgidizing” or “shape-lock function ” to maintain positioning
[46] (Figure 6.8). This novel fl exible instrumentation platform was used for the performance of the fi rst transgastric
cholecystectomy in humans in 2007 [44]. The NDO Plicator
(NDO Surgical, Mansfi eld, MA, USA) represented another
endoscopic suturing instrument, which was initially developed and used for the treatment of gastroesophageal refl ux
disease. This fl exible endoscopic tissue plicator consisted of
two jaws with a retractable corkscrew tissue grasper, and
accommodated an endoscope, which could be passed
through a channel. The jaws incorporated preloaded ePTFE pledget suture implants with attached titanium anchors,
which allowed secure U -stitches (Figure 6.9). Animal studies
have shown the feasibility of full -thickness NOTES gastrotomy closure [47]. However, today the device is no longer
clinically available.
Also not available for widespread clinical use is another
endoscopic suturing prototype (LSI Solutions, New York, NY,
USA). It represents an automated device able to suction
enteric wall tissue into a small chamber, where a 2.5 cm
linear incision and purse string suture can be created with
one application. After using the enterotomy, the purse string
suture is cinched with an additional titanium knot -cinching
device. An ex vivo animal study was able to demonstrate
quick and reliable gastric closure within a small number of
experiments [48] (Figure 6.10). The same group had also
evaluated the endoscopic suturing prototype (LSI) for colon
access closure and compared the results with endoloops and
64
Figure 6.9 The NDO endolumenal suturing device (no longer available).
https://t.me/med1917
CHAPTER 6 NOTES Closure Techniques
Figure 6.10 The LSI one -step purse string/enterotomy prototype device.
endoscopic clips [49]. Closure with the prototype device and
the endoloops were both found to achieve the inversion of
tissue, which was hypothesized to provide suffi cient closure.
A true endoscopic suturing device that does not require a
specialized delivery device is the OverStitch ™ Endoscopic
Suturing System (Apollo Endosurgery, Austin, TX, USA).
Developed by the Apollo Group with Olympus and called
the “Eagle Claw ” (Olympus Medical Systems, Tokyo, Japan),
it was initially designed to imitate the surgical oversewing
of bleeding gastric ulcers but was quickly adopted and evaluated for full -thickness tissue closure of a transgastric NOTES
access [50,51]. The OverStitch device is attached to the tip
of a double -channel endoscope and has a large curved
needle with which a full -thickness suture can be placed and
later cinched (Figure 6.11). When it was tested in a survival
animal model, full -thickness healing of all gastrotomies,
with no evidence of leakage, was observed after two weeks.
Figure 6.11 The Apollo Endosurgery OverStitch device (available US
and EU).
An average of three sutures was used for closure of the
gastrotomy. Although not yet reportedly used for the closure
of a NOTES access, its clinical versatility, including the
closure of an iatrogenic gastrotomy, has already been
described [52] (Video 6.9). Although further evaluation still
appears to be mandatory, this novel tool represents the fi rst
endoscopic suturing device directly mimicking surgical
suturing of gastrointestinal tissue.
65
SECTION 1 Development of the NOTES Concept
https://t.me/med1917
Figure 6.12 The Covidien fl exible Endo Stitch prototype device
(available for research only).
A fl exible equivalent of the laparoscopic suturing device,
the Endo Stitch (Covidien, North Haven, CT, USA) has been
recently described and provided excellent burst pressure
results in an ex vivo model for gastric defect closure [53].
This fl exible tool uses the well -known technical principle of
a thread attached to a needle, which is alternatively shuttled
between the two instrument jaws (Figure 6.12). However,
the endoscopic device has not yet been released.
Stapling devices
In open and laparoscopic surgery, staplers are a method for
gastrointestinal anastomosis or closure that are as accepted
as(and more widely used than) suturing. Using an incorporated power unit, a fl exible endoscopic linear stapler with a
60 cm long working shaft (Natural Orifi ce Linear Cutter,
Power Medical Interventions) was clinically available several
years ago and might be back on the market in the near
future (Figure 6.13). Although technical diffi culties with
deployment and maneuvering of the stapler have been
reported, this technology represents an important step in the
future development of NOTES [54]. Several preclinical
studies have shown favorable results and secure closures.
Within an ex vivo comparison with several other closure
modalities, it was, in fact, found to have the highest air leak
pressure resistance [8]. As, additionally, this device has
already been successfully used for full -thickness gastric
resection in the stomach in a clinical setting [55], a potential
feasibility for NOTES closure appears to be possible. More
recently, the use of circular EEA hemorrhoid and prolapse
staplers has been described for the closure of a rectal viscerotomy after a NOTES segmental colectomy [56].
Figure 6.13 The fl exible linear cutter stapler by Power Medical (no
longer commercially available).
Figure 6.14 The off label use of currently available percutaneus cardiac
septal occluder devices has been described in animal work.
Other closure concepts
A completely different technical approach with an already
available cardiac septal defect occluder device (Nitinol Septal
Occluder, Occlutech, Helsingborg, Sweden) has been evaluated by the IRCAD group in Strasbourg [57]. This occluder
device was developed to close cardiac artrial and ventricular
septal defects angiographically. It consists of a self -expandable
double umbrella -shaped nitinol wire mesh, which is linked
together by a short connecting -waist (Figure 6.14). Additionally, the umbrellas are fi lled with a non -permeable polyethylene terephthalate patch. Due to the nitinol ’s elastic
properties, the device can be loaded inside a hollow catheter
66
CHAPTER 6 NOTES Closure Techniques
https://t.me/med1917
and the two umbrella shaped meshes can be deployed separately, the fi rst outside the enterotomy and the second
inside. The elastic nitinol wire frames have diameters of
23 mm and 25 mm and give suffi cient transmural closure
force. In a 12 -week porcine survival study, it was found that
full-thickness gastrotomies could be successfully closed with
no related complications. Although it provides an appealing
and easy concept of NOTES access closure, the barriers to its
widespread adoption are its non -absorbability and extremely
high cost.
Tissue glue has been successfully used to close enterocutaneous fi stulas, but has been reportedly used only once for
transgastric closure and might have unreliable closure
strength.
Conclusion
The majority of currently performed clinical NOTES cases
have been hybrid, or laparoscopic -assisted, procedures. This
has been due to safety reasons and to simultaneously ensure
appropriate closure of the individual NOTES access. To
pursue pure NOTES, closure techniques have to be reliable
and simple to accomplish. As described throughout this
chapter, extensive developmental work has been done
within the past few years to accomplish this important
requirement. Safe NOTES closure in humans has been demonstrated. The clinical availability of many novel suturing
and closure devices can be expected to further facilitate
NOTES and will also enable more advanced intralumenal
endoscopy and endoscopic surgery. Despite still existing
unmet technical needs in natural orifi ce surgery, NOTES
closure techniques have been addressed extensively and
appear to be increasingly reliable and easier to accomplish.
Chapter video clips
Video 6.1 Esophageal submucosal fl ap.
Video 6.2 Transrectal/transanal delivery of sigmoid colon.
Video 6.3 Transanal endoscopic microsurgery (TEM) suture
closure.
Video 6.4 NOTES colorectal anastomosis (colotomy closure).
Video 6.5 Endoclips closure of esophageal mucosa.
Video 6.6 Over -the-scope clip (OTSC ®).
Video 6.7 Tissue apposition system (TAS ®) closure.
Video 6.8 NOTES gastrotomy closure with the g -Prox.
Video 6.9 OverStitch closure of gastric perforation.
References
1 Mühe E. [Laparoscopic cholecystectomy – late results]. Langen-
becks Arch Chir Suppl Kongressbd 1991(11):416–23 (in Russian).
2 Pasricha PJ. NOTES: a gastroenterologist ’s perspective . Gastroin-
test Endosc Clin N Am 2007;17:611–16, viii–ix.
3 Rattner D, Kalloo A. ASGE/SAGES Working Group on Natural
Orifi ce Translumenal Endoscopic Surgery. October 2005 . Surg
Endosc 2006;20(2):329–33.
4 Kalloo A, Kantsevoy ,SV , Singh, VK, et al. Flexible transgastric
peritoneoscopy: a novel approach to diagnostic and therapeutic
interventions in the peritoneal cavity . Gastroenterology 2000;118:
A1039.
5 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:
114–17.
6 Zorron R, Palanivelu C, Galvao Neto MP , et al. International
multicenter trial on clinical natural orifi ce surgery – NOTES
IMTN study: preliminary results of 362 patients . Surg Innov
2010;17:142–58.
7 Jagannath SB, Kantsevoy SV , Vaughn CA, et al. Peroral trans-
gastric endoscopic ligation of fallopian tubes with long -term
survival in a porcine model . Gastrointest Endosc 2005;61:
449–53.
8 Ryou M, Fong DG, Pai RD, Rattner DW , Thompson CC. Trans-
luminal closure for NOTES: an ex vivo study comparing leak
pressures of various gastrotomy and colotomy closure modalities. Endoscopy 2008;40:432–6.
9 Lima E, Henriques-Coelho T, Rolanda C, et al. Transvesical tho-
racoscopy: a natural orifi ce translumenal endoscopic approach
for thoracic surgery . Surg Endosc 2007;21:854–8.
10 Gettman MT , Blute ML. Transvesical peritoneoscopy: initial
clinical evaluation of the bladder as a portal for natural orifi ce
translumenal endoscopic surgery . Mayo Clin Proc 2007;82:
843–5.
11 Inoue H, Minami H, Kobayashi Y, et al. Peroral endoscopic
myotomy (POEM) for esophageal achalasia . Endoscopy 2010;42:
265–71.
12 Sumiyama K, Gostout CJ, Rajan E, et al. Submucosal endoscopy
with mucosal fl ap safety valve . Gastrointest Endosc 2007;65:
688–94.
13 Turner BG, Kim MC, Gee DW , et al. A prospective, randomized
trial of esophageal submucosal tunnel closure with a stent versus
no closure to secure a transesophageal natural orifi ce transluminal endoscopic surgery access site . Gastrointest Endosc
2011;73:785–90.
14 Sumiyama K, Gostout CJ, Rajan E, et al. Transgastric cholecys-
tectomy: transgastric accessibility to the gallbladder improved
with the SEMF method and a novel multibending therapeutic
endoscope. Gastrointest Endosc 2007;65:1028–34.
15 McGee MF , Marks JM, Onders RP , et al. Infectious implications
in the porcine model of natural orifi ce transluminal endoscopic
surgery (NOTES) with PEG -tube closure: a quantitative bacteriologic study . Gastrointest Endosc 2008;68:310–18.
16 Sporn E, Miedema BW , Astudillo JA, et al. Gastrotomy creation
and closure for NOTES using a gastropexy technique (with
video). Gastrointest Endosc 2008;68:948–53.
17 Lehmann KS, Ritz JP , Wibmer A, et al. The German registry for
natural orifi ce translumenal endoscopic surgery: report of the
fi rst 551 patients . Ann Surg 2010;252:263–70.
18 Zornig C, Emmermann A, von Waldenfels HA, Mofi d H. Laparo-
scopic cholecystectomy without visible scar: combined transvaginal and transumbilical approach . Endoscopy 2007;39:
913–15.
67
SECTION 1 Development of the NOTES Concept
https://t.me/med1917
19 Whiteford MH, Spaun GO. A colorectal surgeon ’s viewpoint on
natural orifi ce translumenal endoscopic surgery . Minerva Chir
2008;63:385–8.
20 Sylla P, Rattner DW , Delgado S, Lacy AM. NOTES transanal
rectal cancer resection using transanal endoscopic microsurgery
and laparoscopic assistance . Surg Endosc 2010;24:1205–10.
21 Denk PM, Swanstrom LL, Whiteford MH. Transanal endoscopic
microsurgical platform for natural orifi ce surgery . Gastrointest
Endosc 2008;68:954–9.
22 Gavagan JA, Whiteford MH, Swanstrom LL. Full-thickness
intraperitoneal excision by transanal endoscopic microsurgery
does not increase short -term complications . Am J Surg
2004;187:630–34.
23 Whiteford MH, Denk PM, Swanstrom LL. Feasibility of radical
sigmoid colectomy performed as natural orifi ce translumenal
endoscopic surgery (NOTES) using transanal endoscopic microsurgery . Surg Endosc 2007;21:1870–74.
24 Zorron R, Phillips HN, Coelho D, et al. Perirectal NOTES access:
“down-to-up” total mesorectal excision for rectal cancer . Surg
Innov 2011;Jul 7 [Epub ahead of print].
25 Wilhelm D, Meining A, von Delius S, et al. An innovative, safe
and sterile sigmoid access (ISSA) for NOTES . Endoscopy
2007;39:401–6.
26 Rieder E, Spaun GO, Khajanchee YS, et al. A natural orifi ce
transrectal approach for oncologic resection of the rectosigmoid:
an experimental study and comparison with conventional laparoscopy . Surg Endosc 2011;25(10):3357–63.
27 Lee SS, Oelschlager BK, Wright AS, et al. Assessment of a simple,
novel endoluminal method for gastrotomy closure in NOTES .
Surg Endosc 2011;25(10):3448–52.
28 Hookey LC, Khokhotva V, Bielawska B, et al. The Queen ’s
closure: a novel technique for closure of endoscopic gastrotomy
for natural -orifi ce transluminal endoscopic surgery . Endoscopy
2009;41:149–53.
29 Dray X, Giday SA, Buscaglia JM, et al. Omentoplasty for gas-
trotomy closure after natural orifi ce transluminal endoscopic
surgery procedures (with video) . Gastrointest Endosc 2009;70:
131–40.
30 Mathews JC, Chin MS, Fernandez-Esparrach G, et al. Early
healing of transcolonic and transgastric natural orifi ce transluminal endoscopic surgery access sites . J Am Coll Surg
2010;210:480–90.
31 Voermans RP , van Berge Henegouwen MI, Bemelman WA ,
Fockens P. Novel over -the-scope-clip system for gastrotomy
closure in natural orifi ce transluminal endoscopic surgery
(NOTES): an ex vivo comparison study . Endoscopy 2009;41:
1052–5.
32 von Renteln D, Vassiliou MC, Rothstein RI. Randomized con-
trolled trial comparing endoscopic clips and over -the-scope clips
for closure of natural orifi ce transluminal endoscopic surgery
gastrotomies. Endoscopy 2009;41:1056–61.
33 von Renteln D, Vassiliou MC, Rothstein RI. Endoscopic removal
of the Padlock -G clip . Endoscopy 2010;42(suppl 2 ):E241–2.
34 Romanelli JR, Desilets DJ, Earle DB. Natural orifi ce transluminal
endoscopic surgery gastrotomy closure in porcine explants with
the Padlock -G clip using the Lock -It system . Endoscopy 2010;42:
306–10.
35 Desilets DJ, Romanelli JR, Earle DB, Chapman CN. Gastrotomy
closure with the Lock -It system and the Padlock -G clip: a sur-
vival study in a porcine model . J Laparoendosc Adv Surg Tech A
2010;20:671–6.
36 Fritscher -Ravens A, Patel K, Ghanbari A, et al. Natural orifi ce
transluminal endoscopic surgery (NOTES) in the mediastinum:
long-term survival animal experiments in transesophageal
access, including minor surgical procedures . Endoscopy 2007;39:
870–75.
37 Hampe J, Schniewind B, Both M, Fritscher -Ravens A. Use of a
NOTES closure device for full -thickness suturing of a postoperative anastomotic esophageal leakage . Endoscopy 2010;42:595–8.
38 Ikeda K, Fritscher -Ravens A, Mosse CA, et al. Endoscopic full -
thickness resection with sutured closure in a porcine model .
Gastrointest Endosc 2005;62:122–9.
39 Park PO, Bergstrom M, Ikeda K, Fritscher -Ravens A, Swain P.
Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis (videos) . Gastroin-
test Endosc 2005;61:601–6.
40 Austin RC, Mosse CA, Swain P. A novel use of T -tag sutures for
the safe creation and closure of the NOTES gastrotomy using a
hybrid technique . Surg Endosc 2009;Aug 19 [Epub ahead of
print].
41 Lima E, Rolanda C, Osorio L, et al. Endoscopic closure of trans-
mural bladder wall perforations . Eur Urol 2009;56:151–7.
42 Romanelli JR, Desilets DJ, Chapman CN, et al. Loop-anchor
purse-string closure of gastrotomy in NOTES procedures: survival studies in a porcine model . Surg Innov 2010;17:312–17.
43 Sporn E, Bachman SL, Miedema BW , et al. Endoscopic colotomy
closure for natural orifi ce transluminal endoscopic surgery using
a T -fastener prototype in comparison to conventional laparoscopic suture closure . Gastrointest Endosc 2008;68:724–30.
44 Ujiki MB, Martinec DV , Diwan TS, et al. Video: natural orifi ce
translumenal endoscopic surgery (NOTES): creation of a gastric
valve for safe and effective transgastric surgery in humans . Surg
Endosc 2010;24:220.
45 Dallemagne B, Perretta S, Allemann P, Asakuma M, Marescaux
J. Transgastric hybrid cholecystectomy . Br J Surg 2009;96:
1162–6.
46 Horgan S, Thompson K, Talamini M, et al. Clinical experience
with a multifunctional, fl exible surgery system for endolumenal,
single-port, and NOTES procedures . Surg Endosc 2011;25:
586–92.
47 McGee MF , Marks JM, Onders RP , et al. Complete endoscopic
closure of gastrotomy after natural orifi ce translumenal endoscopic surgery using the NDO Plicator . Surg Endosc 2008;22:
214–20.
48 Ryou M, Pai RD, Sauer JS, Rattner DW , Thompson CC. Evaluat-
ing an optimal gastric closure method for transgastric surgery .
Surg Endosc 2007;21:677–80.
49 Ryou M, Fong DG, Pai RD, Sauer J, Thompson CC. Evaluation
of a novel access and closure device for NOTES applications: a
transcolonic survival study in the porcine model (with video) .
Gastrointest Endosc 2008;67:964–69.
50 Hu B, Chung SC, Sun LC, et al. Endoscopic suturing without
extracorporeal knots: a laboratory study . Gastrointest Endosc
2005;62:230–33.
51 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;68:554–9.
68
CHAPTER 6 NOTES Closure Techniques
https://t.me/med1917
52 Rieder E, Martinec DV , Dunst CM, Swanström LL. Early
clinical experience with a new endoluminal suturing device
used in multiple clinical applications . Gastrointest Endosc 2011;73:
AB108.
53 Voermans RP , Worm AM, van Berge Henegouwen MI, et al. In
vitro comparison and evaluation of seven gastric closure modalities for natural orifi ce transluminal endoscopic surgery (NOTES) .
Endoscopy 2008;40:595–601.
54 Fuchs KH, Breithaupt W, Schulz T, Reinisch A. Experience with
fl exible stapling techniques in laparoscopic and conventional
surgery . Surg Endosc 2011;25:1783–90.
55 Kaehler G, Grobholz R, Langner C, Suchan K, Post S. A new
technique of endoscopic full -thickness resection using a fl exible
stapler . Endoscopy 2006;38:86–9.
56 Leroy J, Diana M, Perretta S, et al. Original technique to close
the transrectal viscerotomy access in a NOTES transrectal and
transgastric segmental colectomy . Surg Innov 2011;18(3):
193–200.
57 Perretta S, Sereno S, Forgione A, et al. A new method to close
the gastrotomy by using a cardiac septal occluder: long -term
survival study in a porcine model . Gastrointest Endosc 2007;66:
809–13.
69
7
https://t.me/med1917
Mini-laparoscopy in the Endoscopy Unit
Arthur Hoffman & Ralf Kiesslich
Johannes Gutenberg University of Mainz, Mainz, Germany
Introduction
Although a large number of non -invasive techniques for the
diagnosis and staging of liver disease have been developed
in recent years, macroscopic and histologic evaluation still
remains the most accurate method for assessment of the
severity and stage of liver disease [1,2]. For a long time
laparoscopy was the principal diagnostic method of the gastroenterologist. The fi rst laparoscopies were performed in
1901 by Kelling, on a dog, and in 1910 by Jacobaeus [3,4].
Laparoscopy was developed into a routine investigation
technique for internal medicine in the 1930s, particularly by
Heinz Kalk [4,5]. However, following the development of
non-invasive diagnostic imaging procedures like ultrasound,
CT, MRI, and, recently, endosonography, it faded into the
background [6].
Renewed interest in this method in the 1990s was supported by the development of laparoscopic surgical techniques and new optics and instruments [7]. This, in turn,
stimulated technical progress, which has led to the numerous miniature apparatuses and mini -optics of outstanding
quality available today [8]. Thus, the gastroenterologist has
a means of utilizing the numerous advantages of laparoscopy during a minimally invasive procedure. Despite non invasive imaging techniques and diagnostic laboratory
procedures, diagnostic laparoscopy – which is performed in
sedoanalgesia – is superior to other procedures in several
respects, particularly for the purpose of differential diagnosis
and for staging hepatologic diseases and gastroenterologic
neoplasias [9].
Mini-laparoscopy using a laparoscope with a narrow
lumen is less invasive than conventional laparoscopy. A
single site of puncture is required for the pneumoperitoneum and introduction of the optical instrument [10].
Indications
Laparoscopy is the diagnostic method of choice for reliable
clarifi cation of the question as to whether a patient is suffering from liver cirrhosis or fi brosis or not. It also is the
method of choice in cases of advanced liver diseases. Furthermore, laparoscopy is the most sensitive method to identify peritoneal carcinosis or tuberculous peritonitis [11].
As liver puncture is performed under visual guidance, the
method is also suitable for use in patients with a high risk
of hemorrhage because such bleeding can be rapidly controlled by coagulation.
There are several other indications for the procedure:
biopsy of the spleen in case of suspected lymphoma, clarifi cation of surface and subsurface lesions of the liver, clarifi cation of resectability of different tumors, and as a preparatory
diagnostic procedure for patients who are potential candidates for liver transplantation [12,13].
Staging of chronic liver diseases
New therapeutic options for chronic liver disease require
accurate pre -therapeutic diagnosis, especially in terms of
identifying liver cirrhosis correctly. In addition to its prognostic signifi cance, the identifi cation of cirrhosis affects
therapy (for instance, the administration of interferon in the
presence of hepatitis C) and initiates surveillance because of
the risk of developing hepatocellular carcinoma [14]. Liver
biopsy is regarded as the gold standard for the diagnosis of
cirrhosis. However, it should be noted that neither percutaneous liver biopsy nor imaging procedures will be able to
entirely rule out the presence of cirrhosis [15]. The mean
false-negative rate for percutaneous liver biopsy with regard
to the diagnosis of liver cirrhosis was reported to be 24% in
6242 cases (range, 1 –61%) [16,17]. For laparoscopy alone,
Natural Orifi ce Translumenal Endoscopic Surgery (NOTES): Textbook and Video Atlas, First Edition. Edited by Anthony N. Kalloo, Jacques Marescaux,
Ricardo Zorron.
© 2012 John Wiley & Sons, Ltd. Published 2012 by John Wiley & Sons, Ltd.
70
CHAPTER 7 Mini-laparoscopy in the Endoscopy Unit
https://t.me/med1917
the rate of false -negative diagnoses was on average 9%
(range, 4 –18%) [16,17]. Thus, a combination of macroscopic assessment and histologic evaluation may be regarded
as the gold standard [18]. A retrospective study in 434
patients confi rmed the greater accuracy of macroscopic diagnosis of liver cirrhosis compared to histologic assessment
[18]. In 0.8% of patients with the macroscopic diagnosis of
liver fi brosis, histology revealed cirrhosis of the liver. In 32%
of patients with cirrhosis of the liver on macroscopic investigation, mere fi brosis was established by histology because
histologic criteria for cirrhosis (the presence of a regenerating nodule with perinodular fi brosis or fi brosis encompassing large areas of tissue) were not fulfi lled (histology:
sensitivity 68%; specifi city 99%; negative predictive value
83%; positive predictive value 98%) [19]. Sampling error
was noted in studies of similar magnitude also using mini laparoscopic evaluation of the liver and biopsy in 110
patients with liver cirrhosis. The sampling error was attributed to Child ’s A cirrhosis – an inhomogeneous intrahepatic
distribution of morphological changes – or macronodular
cirrhosis [19].
In diagnostic procedures for chronic viral hepatitis without
cirrhosis as well, a laparoscopic biopsy performed for the
purpose of comparison revealed, in 20 of 85 patients
(23.5%), diverse histologic outcomes as regards infl ammatory activity and damage to liver parenchyma [20]. A similar
extent of histologic lesions in both liver lobes was observed
only in 5% of patients.
These data confi rm the relevance of combined macroscopic and histological assessment of the liver with targeted
biopsy of altered regions on gross investigation.
Advanced liver diseases/focal liver diseases
One indication for laparoscopy is differential diagnosis in the
presence of ambiguous granulomatous liver diseases such as
sarcoidosis of the liver or Hodgkin ’s and non -Hodgkin’s
lymphoma [21]. For the diagnosis of hepatic invasion due
to a Hodgkin ’s or non -Hodgkin’s lymphoma, a specifi city of
100% was reported for laparoscopic assessment of the liver
and targeted biopsy of focal lesions. However, the sensitivity
was only 40% [21].
Underlying hemato -oncological diseases are another
important indication for the procedure, especially in patients
undergoing a specifi c therapy. For instance, in cases of unclear
hepatopathy after bone marrow or stem -cell transplantation,
the differential diagnoses may include graft -versus-host
disease, veno -occlusive disease, infectious liver disease, or
recurrence of the original disease [22]. Besides, patients with
HIV disease in the stage of AIDS may demonstrate infectious
or malignant involvement of the liver. As the confi rmation
of a specifi c diagnosis has a decisive impact on subsequent
treatment, laparoscopy is urgently indicated as a diagnostic
procedure for conclusive identifi cation of unclear abdominal
fi ndings such as Kaposi ’s sarcoma of the liver [23].
Staging of malignant intra-abdominal tumors
The purpose of laparoscopic investigation for staging malignant tumors of the abdomen is to avoid unnecessary surgery
[24,25]. By the use of mini -laparoscopy, the investigator is
able to assess the peritoneum but not the retroperitoneal
space. The superiority of laparoscopy with targeted biopsy
(as opposed to imaging procedures) for the diagnosis of
malignant spread of gastrointestinal (GI) tumors into the
liver or the peritoneum has been proven in several studies
[25–35]. The sensitivity and specifi city of laparoscopy were
markedly higher than those of imaging procedures. This was
because the technique permits identifi cation of infi nitesimal
lesions less than 10 mm, and provides a means of obtaining
histologic confi rmation of suspicious fi ndings by performing
a biopsy (Figure 7.1).
Figure 7.1 The superiority of laparoscopy with targeted biopsy for the diagnosis of malignant spread of gastrointestinal tumors into the peritoneum.
71
Соседние файлы в папке Библиотека им академика М.И. Перельмана