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A novel safe approach to the peritoneal cavity for per-oral transgastric endoscopic procedures
NEW METHOD: Experimental Endoscopy
A novel safe approach to the peritoneal cavity for per-oral transgastric endoscopic procedures Sergey V. Kantsevoy, MD, PhD, Sanjay B. Jagannath, MD, Hideaki Niiyama, MD, Nina V. Isakovich, BS, Sydney S. C. Chung, MD, Peter B. Cotton, MD, Christopher J. Gostout, MD, Robert H. Hawes, MD, Pankaj J. Pasricha, MD, Anthony N. Kalloo, MD Baltimore, Maryland, USA
Background: We have previously reported the feasibility and safety of per-oral transgastric endoscopic procedures in a porcine model. Objective: Our purpose was to evaluate the safety and feasibility of a PEG-like approach to the peritoneal cavity. Settings: Acute experiments on 50-kg pigs under general anesthesia. Design and Interventions: After per-oral intubation, the endoscope was positioned into the body of the stomach, the anterior abdominal wall was transilluminated and punctured with a needle, and a guidewire was inserted into the stomach through the needle. The guidewire was grasped with endoscopic forceps and pulled through the biopsy channel of the endoscope. A sphincterotome was inserted into the gastric wall over the guidewire. Gastric incision was performed and the endoscope was advanced into the peritoneal cavity. The peritoneal cavity was insufflated and endoscopic peritoneoscopy was performed. Then the animal was euthanized and necropsy was performed. Main Outcome Measures: Safety of transgastric entrance to peritoneal cavity. Results: The PEG-like approach was used in 12 pigs. The average procedure time was 11.4 3.7 minutes. There was only 1 complication related to the access: bleeding from the gastric wall incision was documented when a pure cut (without coagulation) current was used for incision of the gastric wall. There were no complications in the other 11 pigs. The necropsy did not reveal any damage to organs adjacent to the stomach. Limitations: Gastric wall incision is located on anterior gastric wall. Conclusions: The PEG-like transgastric approach to the peritoneal cavity appears technically simple and safe.
Many investigators from around the world have suggested potential benefits and advantages of per-oral transgastric endoscopic interventions.1-3 Successful procedures reported include transgastric peritoneoscopy, liver biopsy, tubal ligation, cholecystectomy, gastrojejunostomy, splenectomy, and lymphadenectomy.4-11 Several essential issues regarding per-oral access to the peritoneal cavity are still under investigation. One of the most important questions is how to puncture the gastric wall without injury to adjacent organs.1 We are now reporting a PEG– like approach to the peritoneal cavity.
METHODS
Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2006.08.029
The study was approved by the Johns Hopkins University School of Medicine Animal Care Institutional Review Board. The objective of the study was to evaluate the safety and feasibility of a PEG-like approach to the peritoneal cavity. We performed a series of acute experiments in a porcine model (50-kg pigs, Sus scrofus domesticus). All pigs were fed with 6 cans of Ensure the day before endoscopy and then fasted overnight. With the pig under general anesthesia with endotracheal intubation, a standard upper endoscope (Olympus GIF-160, Tokyo, Japan) was advanced into the pig’s stomach. The endoscope was positioned in the body of the stomach and the anterior abdominal wall was transilluminated. Pressure on the abdomen with a finger demonstrated an endoscopically
www.giejournal.org
Volume 65, No. 3 : 2007 GASTROINTESTINAL ENDOSCOPY 497
A PEG-like approach for transgastric endoscopic procedures
Kantsevoy et al
Capsule Summary What is already known on this topic d
Success has been reported with peroral transgastric peritoneoscopy, liver biopsy, tubal ligation, cholecystectomy, gastrojejunostomy, splenectomy, and lymphadenectomy, but questions remain on how to puncture the gastric wall without injuring adjacent organs.
What this study adds to our knowledge d
Figure 1. Endoscopically visible indentation to determine position of the future gastric wall incision.
When a PEG-like approach is used in the peritoneal cavity in 12 pigs, the average procedure time was 11.4 3.7 minutes with the only complication being a single case of bleeding from the gastric wall incision when a pure cut (without coagulation) current was used.
The endoscope was advanced into the gastric wall incision. The peritoneal cavity was insufflated with the endoscope and endoscopic peritoneoscopy was completed. Then the animal was euthanized and postmortem examination was performed.
RESULTS
Figure 2. Puncture of the gastric wall with a needle under the endoscopic observation.
visible indentation (Fig. 1) to determine the location of the future gastric wall incision. The abdominal wall and stomach were punctured (Fig. 2) with a 16-gauge 2.25-inch needle (Ethicon, Cincinnati, Ohio), and a guidewire (Jagwire 5658, Boston Scientific Microvasive, Natick, Mass) was inserted into the stomach through the needle. The guidewire was grasped (Fig. 3) with an endoscopic forceps (Olympus FG-47L-1) and pulled through the biopsy channel of the endoscope, as would be done in a typical PEG tube placement. A pull-type sphincterotome (Olympus 210Q-0720) was inserted into the gastric wall over the guidewire (Fig. 4). A gastric incision (approximately 1 cm long) was performed by using pure cut current at 30 W or pure coagulation at 20 W followed by pure cut current at 30 W (Valleylab SSE2L; Tyco Healthcare, Boulder, Col). To prevent any undesired cuts and to avoid a ‘‘zip-cut,’’ we made the entire 1-cm incision of the gastric wall trough several small cuts by applying cutting current for only a short period of time (1-2 seconds). 498 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 3 : 2007
The PEG-like approach was used in 12 pigs. The anterior abdominal wall was transilluminated without any difficulties in all animals. The incision was easily made in all 12 pigs. The gastric incision site was chosen at the junction of body and antrum of the stomach, closer to the greater curve. There was only 1 complication related to the access: bleeding from the gastric wall incision occurred when pure cutting current was used (without coagulation) for incision of the gastric wall. There were no complications related to the gastric wall incision and transgastric access to the peritoneal cavity in the other 11 pigs. Insufflation of air through the endoscope provided sufficient pneumoperitoneum for adequate visualization of the peritoneal cavity. Endoscopic peritoneoscopy was easily performed in all animals. There were no access-related problems during the exploration of the peritoneal cavity. The average procedure time was 11.4 3.7 minutes. Postmortem examination demonstrated in all pigs approximately a 1-cm incision of the anterior gastric wall. The PEG-like access did not cause any visible damage to organs adjacent to the stomach or anterior abdominal wall.
DISCUSSION Transgastric endoscopic interventions inside the peritoneal cavity may have several major advantages and potential benefits over open surgery and laparoscopic procedures.2,3 Several laboratory studies have reported www.giejournal.org
Kantsevoy et al
Figure 3. The guidewire is grasped with endoscopic forceps.
successful transgastric peritoneoscopy, liver biopsy, ligation and removal of uterine tubes, cholecystectomy, gastrojejunostomy, lymphadenectomy, and splenectomy.4-11 Many essential issues related to per-oral intraperitoneal interventions are still under investigation.12 One critical problem that needs to be addressed before transgastric procedures can be recommended for the clinical practice is how to puncture the gastric wall and enter the peritoneal cavity without damage to adjacent organs.1 We have developed and are now reporting a safe and simple technique that allows the performance of an endoscopic gastric wall incision without injury to the intraperitoneal organs. Our technique is a PEG-like approach to the peritoneal cavity, which is a modification of traditional endoscopic insertion of percutaneous gastrostomy tube developed and introduced into the clinical practice by one of the pioneers in endoscopic and laparoscopic surgery, Dr J. L. Ponsky.13,14 The PEG insertion is a technically simple and a very safe procedure, used by both surgeons and gastroenterologists worldwide for over 25 years with a low rate of complications.15,16 It is estimated that approximately 216,000 procedures are performed annually.16,17 Like a traditional PEG placement, our PEG-like approach to the peritoneal cavity requires transillumination of the anterior abdominal wall to exclude interposition of any organs between the stomach and the anterior abdominal wall. The transillumination allows safe introduction of a needle and a guidewire into the stomach and then incision of the gastric wall by a sphincterotome over this guidewire without any damage to organs adjacent to the stomach. Our experiments were performed on 12 animals, and we did not observe any injury to intraperitoneal organs related to the gastric wall incision. Obviously, failure to transilluminate the abdominal wall may result in the inability to perform this technique, but we have shown that EUS may be useful in these cases.18 Use of the ‘‘safe tract technique’’ can also decrease the risk of interposing bowel injury and increase the safety www.giejournal.org
A PEG-like approach for transgastric endoscopic procedures
Figure 4. The sphincterotome advanced into the gastric wall over the guidewire.
of the PEG-like approach, especially in overweight and obese patients, when transillumination can be difficult.19 We observed only one complication: bleeding from the gastric wall incision, which was related to the use of pure cut current (without any coagulation) during the incision of the stomach wall. We did not see any significant bleeding from the gastric wall incision in the other 11 cases, where a combination of coagulation and cut current was used. The limitation of the PEG-like approach is that the gastric incision is usually located on the anterior gastric wall. This location may not be optimal for certain procedures (for example, the desired site of gastrojejunostomy is on the greater curve). To overcome this limitation, we are currently working on a modification of the transgastric access, which will allow safe entrance to the peritoneal cavity through the greater curve and even the posterior gastric wall. In conclusion, the PEG-like approach to the peritoneal cavity is based on the time-tested technique of endoscopic insertion of a gastrostomy tube, familiar to the majority of gastroenterologists and surgeons around the world. Our results demonstrate that the PEG-like transgastric approach to the peritoneal cavity is technically simple and safe and will allow incision of the gastric wall and entrance to the peritoneal cavity without a significant risk of damage to adjacent organs. DISCLOSURE None of the authors have any conflicts of interest to report.
REFERENCES 1. Ponsky JL. Gastroenterologists as surgeons: what they need to know. Gastrointest Endosc 2005;61:454.
Volume 65, No. 3 : 2007 GASTROINTESTINAL ENDOSCOPY 499
A PEG-like approach for transgastric endoscopic procedures
Kantsevoy et al
2. Hochberger J, Lamade W. Transgastric surgery in the abdomen: the dawn of a new era? Gastrointest Endosc 2005;62:293-6. 3. Rattner D, Kalloo A. ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery: October 2005. Surg Endosc 2006; 20:329-33. 4. 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;60:114-7. 5. Jagannath SB, Kantsevoy SV, Vaughn CA, et al. Peroral transgastric endoscopic ligation of fallopian tubes with long-term survival in a porcine model. Gastrointest Endosc 2005;61:449-53. 6. Kantsevoy SV, Jagannath SB, Niiyama H, et al. Endoscopic gastrojejunostomy with survival in a porcine model. Gastrointest Endosc 2005;62:287-92. 7. Park PO, Bergstrom M, Ikeda K, et al. Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis (with videos). Gastrointest Endosc 2005;61:601-6. 8. Wagh MS, Merrifield BF, Thompson CC. Endoscopic transgastric abdominal exploration and organ resection: initial experience in a porcine model. Clin Gastroenterol Hepatol 2005;3:892-6. 9. Kantsevoy SV, Hu B, Jagannath SB, et al. Transgastric endoscopic splenectomy: is it possible? Surg Endosc 2006;20:522-5. 10. Fritscher-Ravens A, Mosse CA, Ikeda K, Swain P. Endoscopic transgastric lymphadenectomy by using EUS for selection and guidance. Gastrointest Endosc 2006;63:302-6. 11. Bergstrom M, Ikeda K, Swain P, et al. Transgastric anastomosis by using flexible endoscopy in a porcine model (with video). Gastrointest Endosc 2006;63:307-12. 12. Liu R, Chand B, Ponsky J. The future of surgical endoscopy. Endoscopy 2005;37:38-41. 13. Gauderer MW, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg 1980;15:872-5.
14. Ponsky JL, Gauderer MW. Percutaneous endoscopic gastrostomy: a nonoperative technique for feeding gastrostomy. Gastrointest Endosc 1981;27:9-11. 15. Ponsky JL, Gauderer MW, Stellato TA. Percutaneous endoscopic gastrostomy: review of 150 cases. Arch Surg 1983;118:913-4. 16. Baskin WN. Acute complications associated with bedside placement of feeding tubes. Nutr Clin Pract 2006;21:40-55. 17. Lynch CR, Fang JC. Prevention and management of complications of percutaneous endoscopic gastrostomy (PEG) tubes. Pract Gastroenterol 2004;28:66-76. 18. Panzer S, Harris M, Berg W, et al. Endoscopic ultrasound in the placement of a percutaneous endoscopic gastrostomy tube in the non-transilluminated abdominal wall. Gastrointest Endosc 1995;42: 88-90. 19. Foutch PG, Talbert GA, Waring JP, et al. Percutaneous endoscopic gastrostomy in patients with prior abdominal surgery: virtues of the safe tract. Am J Gastroenterol 1988;83:147-50.
500 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 3 : 2007
www.giejournal.org
Received February 26, 2006. Accepted August 21, 2006. Current affiliations: Division of Gastroenterology, Johns Hopkins Hospital (S.V.K., S.B.J., A.N.K.), Baltimore, Maryland, USA, Department of Surgery, Graduate School of Medical Sciences, Kyushu University (H.N.), Fukuoka, Japan, University of Maryland (N.V.I.), Baltimore, Maryland, USA, Chinese University of Hong King (S.S.C.C.), Hong Kong, Medical University of South Carolina (P.B.C., R.H.H.), Charleston, South Carolina, USA, Mayo College of Medicine (C.J.G.), Rochester, Minnesota, USA, and University of Texas Medical Branch at Galveston (P.J.P.), Galveston, Texas, USA. Reprint requests: Anthony N. Kalloo, MD, Johns Hopkins Hospital, Division of Gastroenterology, Cancer Research Building II, 1550 Orleans St, Suite 1M12, Baltimore, MD 21231.
A novel safe approach to the peritoneal cavity for per-oral transgastric endoscopic procedures Sergey V. Kantsevoy, MD, PhD, Sanjay B. Jagannath, MD, Hideaki Niiyama, MD, Nina V. Isakovich, BS, Sydney S. C. Chung, MD, Peter B. Cotton, MD, Christopher J. Gostout, MD, Robert H. Hawes, MD, Pankaj J. Pasricha, MD, Anthony N. Kalloo, MD Baltimore, Maryland, USA
Background: We have previously reported the feasibility and safety of per-oral transgastric endoscopic procedures in a porcine model. Objective: Our purpose was to evaluate the safety and feasibility of a PEG-like approach to the peritoneal cavity. Settings: Acute experiments on 50-kg pigs under general anesthesia. Design and Interventions: After per-oral intubation, the endoscope was positioned into the body of the stomach, the anterior abdominal wall was transilluminated and punctured with a needle, and a guidewire was inserted into the stomach through the needle. The guidewire was grasped with endoscopic forceps and pulled through the biopsy channel of the endoscope. A sphincterotome was inserted into the gastric wall over the guidewire. Gastric incision was performed and the endoscope was advanced into the peritoneal cavity. The peritoneal cavity was insufflated and endoscopic peritoneoscopy was performed. Then the animal was euthanized and necropsy was performed. Main Outcome Measures: Safety of transgastric entrance to peritoneal cavity. Results: The PEG-like approach was used in 12 pigs. The average procedure time was 11.4 3.7 minutes. There was only 1 complication related to the access: bleeding from the gastric wall incision was documented when a pure cut (without coagulation) current was used for incision of the gastric wall. There were no complications in the other 11 pigs. The necropsy did not reveal any damage to organs adjacent to the stomach. Limitations: Gastric wall incision is located on anterior gastric wall. Conclusions: The PEG-like transgastric approach to the peritoneal cavity appears technically simple and safe.
Many investigators from around the world have suggested potential benefits and advantages of per-oral transgastric endoscopic interventions.1-3 Successful procedures reported include transgastric peritoneoscopy, liver biopsy, tubal ligation, cholecystectomy, gastrojejunostomy, splenectomy, and lymphadenectomy.4-11 Several essential issues regarding per-oral access to the peritoneal cavity are still under investigation. One of the most important questions is how to puncture the gastric wall without injury to adjacent organs.1 We are now reporting a PEG– like approach to the peritoneal cavity.
METHODS
Copyright ª 2007 by the American Society for Gastrointestinal Endoscopy 0016-5107/$32.00 doi:10.1016/j.gie.2006.08.029
The study was approved by the Johns Hopkins University School of Medicine Animal Care Institutional Review Board. The objective of the study was to evaluate the safety and feasibility of a PEG-like approach to the peritoneal cavity. We performed a series of acute experiments in a porcine model (50-kg pigs, Sus scrofus domesticus). All pigs were fed with 6 cans of Ensure the day before endoscopy and then fasted overnight. With the pig under general anesthesia with endotracheal intubation, a standard upper endoscope (Olympus GIF-160, Tokyo, Japan) was advanced into the pig’s stomach. The endoscope was positioned in the body of the stomach and the anterior abdominal wall was transilluminated. Pressure on the abdomen with a finger demonstrated an endoscopically
www.giejournal.org
Volume 65, No. 3 : 2007 GASTROINTESTINAL ENDOSCOPY 497
A PEG-like approach for transgastric endoscopic procedures
Kantsevoy et al
Capsule Summary What is already known on this topic d
Success has been reported with peroral transgastric peritoneoscopy, liver biopsy, tubal ligation, cholecystectomy, gastrojejunostomy, splenectomy, and lymphadenectomy, but questions remain on how to puncture the gastric wall without injuring adjacent organs.
What this study adds to our knowledge d
Figure 1. Endoscopically visible indentation to determine position of the future gastric wall incision.
When a PEG-like approach is used in the peritoneal cavity in 12 pigs, the average procedure time was 11.4 3.7 minutes with the only complication being a single case of bleeding from the gastric wall incision when a pure cut (without coagulation) current was used.
The endoscope was advanced into the gastric wall incision. The peritoneal cavity was insufflated with the endoscope and endoscopic peritoneoscopy was completed. Then the animal was euthanized and postmortem examination was performed.
RESULTS
Figure 2. Puncture of the gastric wall with a needle under the endoscopic observation.
visible indentation (Fig. 1) to determine the location of the future gastric wall incision. The abdominal wall and stomach were punctured (Fig. 2) with a 16-gauge 2.25-inch needle (Ethicon, Cincinnati, Ohio), and a guidewire (Jagwire 5658, Boston Scientific Microvasive, Natick, Mass) was inserted into the stomach through the needle. The guidewire was grasped (Fig. 3) with an endoscopic forceps (Olympus FG-47L-1) and pulled through the biopsy channel of the endoscope, as would be done in a typical PEG tube placement. A pull-type sphincterotome (Olympus 210Q-0720) was inserted into the gastric wall over the guidewire (Fig. 4). A gastric incision (approximately 1 cm long) was performed by using pure cut current at 30 W or pure coagulation at 20 W followed by pure cut current at 30 W (Valleylab SSE2L; Tyco Healthcare, Boulder, Col). To prevent any undesired cuts and to avoid a ‘‘zip-cut,’’ we made the entire 1-cm incision of the gastric wall trough several small cuts by applying cutting current for only a short period of time (1-2 seconds). 498 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 3 : 2007
The PEG-like approach was used in 12 pigs. The anterior abdominal wall was transilluminated without any difficulties in all animals. The incision was easily made in all 12 pigs. The gastric incision site was chosen at the junction of body and antrum of the stomach, closer to the greater curve. There was only 1 complication related to the access: bleeding from the gastric wall incision occurred when pure cutting current was used (without coagulation) for incision of the gastric wall. There were no complications related to the gastric wall incision and transgastric access to the peritoneal cavity in the other 11 pigs. Insufflation of air through the endoscope provided sufficient pneumoperitoneum for adequate visualization of the peritoneal cavity. Endoscopic peritoneoscopy was easily performed in all animals. There were no access-related problems during the exploration of the peritoneal cavity. The average procedure time was 11.4 3.7 minutes. Postmortem examination demonstrated in all pigs approximately a 1-cm incision of the anterior gastric wall. The PEG-like access did not cause any visible damage to organs adjacent to the stomach or anterior abdominal wall.
DISCUSSION Transgastric endoscopic interventions inside the peritoneal cavity may have several major advantages and potential benefits over open surgery and laparoscopic procedures.2,3 Several laboratory studies have reported www.giejournal.org
Kantsevoy et al
Figure 3. The guidewire is grasped with endoscopic forceps.
successful transgastric peritoneoscopy, liver biopsy, ligation and removal of uterine tubes, cholecystectomy, gastrojejunostomy, lymphadenectomy, and splenectomy.4-11 Many essential issues related to per-oral intraperitoneal interventions are still under investigation.12 One critical problem that needs to be addressed before transgastric procedures can be recommended for the clinical practice is how to puncture the gastric wall and enter the peritoneal cavity without damage to adjacent organs.1 We have developed and are now reporting a safe and simple technique that allows the performance of an endoscopic gastric wall incision without injury to the intraperitoneal organs. Our technique is a PEG-like approach to the peritoneal cavity, which is a modification of traditional endoscopic insertion of percutaneous gastrostomy tube developed and introduced into the clinical practice by one of the pioneers in endoscopic and laparoscopic surgery, Dr J. L. Ponsky.13,14 The PEG insertion is a technically simple and a very safe procedure, used by both surgeons and gastroenterologists worldwide for over 25 years with a low rate of complications.15,16 It is estimated that approximately 216,000 procedures are performed annually.16,17 Like a traditional PEG placement, our PEG-like approach to the peritoneal cavity requires transillumination of the anterior abdominal wall to exclude interposition of any organs between the stomach and the anterior abdominal wall. The transillumination allows safe introduction of a needle and a guidewire into the stomach and then incision of the gastric wall by a sphincterotome over this guidewire without any damage to organs adjacent to the stomach. Our experiments were performed on 12 animals, and we did not observe any injury to intraperitoneal organs related to the gastric wall incision. Obviously, failure to transilluminate the abdominal wall may result in the inability to perform this technique, but we have shown that EUS may be useful in these cases.18 Use of the ‘‘safe tract technique’’ can also decrease the risk of interposing bowel injury and increase the safety www.giejournal.org
A PEG-like approach for transgastric endoscopic procedures
Figure 4. The sphincterotome advanced into the gastric wall over the guidewire.
of the PEG-like approach, especially in overweight and obese patients, when transillumination can be difficult.19 We observed only one complication: bleeding from the gastric wall incision, which was related to the use of pure cut current (without any coagulation) during the incision of the stomach wall. We did not see any significant bleeding from the gastric wall incision in the other 11 cases, where a combination of coagulation and cut current was used. The limitation of the PEG-like approach is that the gastric incision is usually located on the anterior gastric wall. This location may not be optimal for certain procedures (for example, the desired site of gastrojejunostomy is on the greater curve). To overcome this limitation, we are currently working on a modification of the transgastric access, which will allow safe entrance to the peritoneal cavity through the greater curve and even the posterior gastric wall. In conclusion, the PEG-like approach to the peritoneal cavity is based on the time-tested technique of endoscopic insertion of a gastrostomy tube, familiar to the majority of gastroenterologists and surgeons around the world. Our results demonstrate that the PEG-like transgastric approach to the peritoneal cavity is technically simple and safe and will allow incision of the gastric wall and entrance to the peritoneal cavity without a significant risk of damage to adjacent organs. DISCLOSURE None of the authors have any conflicts of interest to report.
REFERENCES 1. Ponsky JL. Gastroenterologists as surgeons: what they need to know. Gastrointest Endosc 2005;61:454.
Volume 65, No. 3 : 2007 GASTROINTESTINAL ENDOSCOPY 499
A PEG-like approach for transgastric endoscopic procedures
Kantsevoy et al
2. Hochberger J, Lamade W. Transgastric surgery in the abdomen: the dawn of a new era? Gastrointest Endosc 2005;62:293-6. 3. Rattner D, Kalloo A. ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery: October 2005. Surg Endosc 2006; 20:329-33. 4. 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;60:114-7. 5. Jagannath SB, Kantsevoy SV, Vaughn CA, et al. Peroral transgastric endoscopic ligation of fallopian tubes with long-term survival in a porcine model. Gastrointest Endosc 2005;61:449-53. 6. Kantsevoy SV, Jagannath SB, Niiyama H, et al. Endoscopic gastrojejunostomy with survival in a porcine model. Gastrointest Endosc 2005;62:287-92. 7. Park PO, Bergstrom M, Ikeda K, et al. Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis (with videos). Gastrointest Endosc 2005;61:601-6. 8. Wagh MS, Merrifield BF, Thompson CC. Endoscopic transgastric abdominal exploration and organ resection: initial experience in a porcine model. Clin Gastroenterol Hepatol 2005;3:892-6. 9. Kantsevoy SV, Hu B, Jagannath SB, et al. Transgastric endoscopic splenectomy: is it possible? Surg Endosc 2006;20:522-5. 10. Fritscher-Ravens A, Mosse CA, Ikeda K, Swain P. Endoscopic transgastric lymphadenectomy by using EUS for selection and guidance. Gastrointest Endosc 2006;63:302-6. 11. Bergstrom M, Ikeda K, Swain P, et al. Transgastric anastomosis by using flexible endoscopy in a porcine model (with video). Gastrointest Endosc 2006;63:307-12. 12. Liu R, Chand B, Ponsky J. The future of surgical endoscopy. Endoscopy 2005;37:38-41. 13. Gauderer MW, Ponsky JL, Izant RJ Jr. Gastrostomy without laparotomy: a percutaneous endoscopic technique. J Pediatr Surg 1980;15:872-5.
14. Ponsky JL, Gauderer MW. Percutaneous endoscopic gastrostomy: a nonoperative technique for feeding gastrostomy. Gastrointest Endosc 1981;27:9-11. 15. Ponsky JL, Gauderer MW, Stellato TA. Percutaneous endoscopic gastrostomy: review of 150 cases. Arch Surg 1983;118:913-4. 16. Baskin WN. Acute complications associated with bedside placement of feeding tubes. Nutr Clin Pract 2006;21:40-55. 17. Lynch CR, Fang JC. Prevention and management of complications of percutaneous endoscopic gastrostomy (PEG) tubes. Pract Gastroenterol 2004;28:66-76. 18. Panzer S, Harris M, Berg W, et al. Endoscopic ultrasound in the placement of a percutaneous endoscopic gastrostomy tube in the non-transilluminated abdominal wall. Gastrointest Endosc 1995;42: 88-90. 19. Foutch PG, Talbert GA, Waring JP, et al. Percutaneous endoscopic gastrostomy in patients with prior abdominal surgery: virtues of the safe tract. Am J Gastroenterol 1988;83:147-50.
500 GASTROINTESTINAL ENDOSCOPY Volume 65, No. 3 : 2007
www.giejournal.org
Received February 26, 2006. Accepted August 21, 2006. Current affiliations: Division of Gastroenterology, Johns Hopkins Hospital (S.V.K., S.B.J., A.N.K.), Baltimore, Maryland, USA, Department of Surgery, Graduate School of Medical Sciences, Kyushu University (H.N.), Fukuoka, Japan, University of Maryland (N.V.I.), Baltimore, Maryland, USA, Chinese University of Hong King (S.S.C.C.), Hong Kong, Medical University of South Carolina (P.B.C., R.H.H.), Charleston, South Carolina, USA, Mayo College of Medicine (C.J.G.), Rochester, Minnesota, USA, and University of Texas Medical Branch at Galveston (P.J.P.), Galveston, Texas, USA. Reprint requests: Anthony N. Kalloo, MD, Johns Hopkins Hospital, Division of Gastroenterology, Cancer Research Building II, 1550 Orleans St, Suite 1M12, Baltimore, MD 21231.