- Email: [email protected]
Complications During NOTES®: Endoscopic Management of Splenic Laceration and Hemorrhage
Abstracts
time was 37 min (26-78), mean tunnel length was 11cm (6-23) and width 4cm (2.55). The R-scope allowed significant counter traction and visibility during the procedures and all target organs were successfully resected without laparoscopic assistance. Significant operative complications: 1 STAT tunnel failure during extraction of an 8x3cm standard specimen, 2 perforations (1 due to a prototype duodenal occlusion device and 1 due to enterotomy during cholecystectomy, 1 entrapment of small bowel with an endoloop. Post-operative: All animals gained weight appropriately with 1 sacrificed POD 12 due to lethargy (cystic duct leak and biloma). Necropsy findings were significant for healed STAT tunnels without complications, minor adhesions (5), bile leaks (2), lap port abscess (1) and ventral hernia (1). Conclusions: The combination of the R-scope and STAT allows effective, single site NOTES procedures using currently available devices. The study highlights two cautionary findings: it is possible to tear a submucosal tunnel with excessive torquing of the scope during the procedure, and while the R-scope provides improved tissue manipulation and the ability to apply counter traction, the complications incurred here suggest further improvements in technique and technology will be required for safe and effective NOTES procedures.
T1480 Complications During NOTESÒ: Endoscopic Management of Splenic Laceration and Hemorrhage Lukasz M. Kowalczyk, Anand Gupte, Mihir S. Wagh Background: Accidental splenic laceration and hemorrhage during transgastric access to the peritoneal cavity or organ resection during NOTES can lead to lifethreatening consequences. The natural orifice approach may need to be aborted in these circumstances for a standard laparoscopy or laparotomy. Aim: To determine the feasibility of endoscopically managing intra-operative splenic laceration and hemorrhage from accidental trauma during NOTES. Methods: 60 - 80 lbs pigs were used for the study and underwent transcolonic endoscopic surgery under general anesthesia. The spleen was located by direct visualization and intentional lacerations were made using endoscissors and a needle-knife. Cuts of varying length (0.5 cm, 1 cm, 2 cm, and 2 cm 2 cm cruciate laceration) were made. All lacerations produced active and persistent bleeding. The site was lavaged with sterile water and persistent spurting or oozing of blood was confirmed. A standard endoscopic 7 Fr bipolar electro-hemostasis catheter (Gold Probe, Boston Scientific) at 30 - 40 W was used to achieve hemostasis. The colonic incision was then closed using endoscopic clips (Resolution Clip, Boston Scientific). Necropsy was performed immediately after surgery in acute cases and at the end of the one week survival period per protocol. Site of laceration and the peritoneal cavity was examined for bleeding, abscess and damage to surrounding structures. Results: Nine intentional splenic lacerations were performed in 6 live anesthetized animals (4 acute and 2 survival studies) to mimic accidental splenic injury. Bleeding was successfully managed endoscopically using standard bipolar cautery in all animals. Persistent pressure was applied with the bipolar probe for coaptive coagulation, and intermittent lavage was performed to visualize the site of bleeding. Maximum time required for hemostasis was 25 minutes. Survival animals had an uncomplicated post-operative course and were euthanized per protocol. There was no evidence of intraperitoneal bleeding or abscess at necropsy. The omentum was seen adherent to the spleen in one survival animal at the site of laceration. Conclusion: We demonstrate the successful management of intra-operative splenic laceration and hemorrhage during NOTES using standard endoscopic techniques, avoiding the need for laparoscopic exploration or laparotomy.
T1481 Scarlesss Intra-Retroperitoneoscopy in Human and Animal NOTESÒ Translumenal Cholecystectomy, Appendectomy and GI Anastomosis Maki Sugimoto Purpose: Natural orifice translumenal endoscopic surgery (NOTES) is a novel concept that provides the potential for performance of incisionless imaging and operations. The method of accessing the abdominal cavity through a natural orifice under endoscopic visualization might offer advantages over open and laparoscopic surgery. The purpose of this study is to develop novel endoscopic technology and procedure to overcome the limitations of intra-abdominal and retroperitoneal imaging and surgery that is used to be invisible. Methods: We performed NOTES intra-retroperitoneoscopy in 2 human cadaver and 12 survival porcine and canine studies. After perforation of the gastric, colonic, and vaginal wall, a flexible doublechannel scope was advanced into the peritoneal cavity and retroperitoneal space under endoscope-induced carbon dioxide insufflation. After performing observations and surgical procedures, the wall was closed using a suturing system or endoscopic clips. Results: The endoscope could visualize each objective organ in all 14 attempts. Following liver biopsy or lymph node removal, GI anastomosis or intestinal resection were also accomplished using a standard flexible endoscope without laparoscopic assistance. Animal NOTES cholecyctectomy was completed in 6 transgastric, 2 transcolonic, and 2 transvaginal access. Transgastric intestinal resection was performed in 4 procedures. No acute complications were recorded. The submucosal, intramuscular and retroperitoneal imaging could be allowed histological diagnosis. Human cadaver NOTES transvaginal cholecystectomy and
www.giejournal.org
appendectomy were also completed within 90 and 40 minutes without major complications. Conclusions: Our study described the use of translumenal endoscopy to accomplish intra-abdominal surgeries. This could reach to the invisible space using standard modalities. Scarlesss intra- and retroperitoneal imaging of NOTES is technically feasible and safe in either human or animal study. CLINICAL RELEVANCE/APPLICATION: NOTES procedure is enormously advantageous to the patient. This would break the physical barrier between bodily trauma and surgery, representing the revolution in surgery.
T1482 Comparing Efficiency of Transgastric and Transperineal NOTESÒ (Natural Orifice Translumenal Endoscopic Surgery) in An Appendectomy Test Bed Shiva Jayaraman, Christopher M. Schlachta Background: The purpose of this study was to establish a NOTES appendectomy test bed to evaluate whether the transgastric or transperineal (transvaginal) approach is most efficient. Methods: Using the uterine horns of female pigs as an appendectomy model, we performed 18 non survival NOTES appendectomies in two arms: 9 transgastric and 9 transvaginal. All cases were performed using a 2channel therapeutic endoscope and a standardized technique. The primary outcome was mean operative time for each technique excluding access closure. Secondary outcomes were peritoneal access and resection times. Means were compared using the students t-test. Results: Transgastric cases were significantly faster than transperineal (46 14 vs. 60 20 min, pZ0.02). Most of the improvement in transgastric times was due to faster resection (38 17 vs. 51 16 min, pZ0.03). Neither approach was faster for peritoneal access (8 3 vs. 8 4 min, pZNS). Comparing operative times for the first three and the last three cases with each technique, although operative time improved, a significant learning curve was not demonstrated for the transgastric approach (53 21 vs. 40 17 min, pZNS). A significant learning curve was demonstrated in transperineal cases (76 22 vs. 47 18 min, pZ0.02). Transperineal times improved over the study and approached transgastric (Figure 1); however, the last three transgastric cases were still significantly faster than the last three transperineal (40 17 vs. 47 18 min, pZ0.02). No complications occurred in either group. Conclusions: Transgastric as compared to transperineal NOTES appendectomy resulted in improved operative time in this model. The transperineal approach demonstrated a significant learning curve with operative times between techniques converging over time. This NOTES appendectomy test bed is suitable for evaluating NOTES innovations.
Figure 1. Operative times and learning curves.
T1483 Dual Modality Management of Symptomatic Organized Pancreatic Necrosis Reduces Inpatient Hospital Days and Radiology Resource Utilization Michael Gluck, Andrew S. Ross, Ellen Hauptmann, Shayan Irani, Mehran Fotoohi, Justin Siegal, Robert Crane, David H. Robinson, Richard A. Kozarek Background: Severe acute pancreatitis (SAP) may be complicated by organized pancreatic necrosis (ON) which can have significant clinical consequences and high medical resource utilization. At our institution, symptomatic ON is typically managed by large caliber percutaneous drains which provide both drainage and debridement. Over the past 18 months, our group has designed and implemented a combined endoscopic and percutaneous drainage technique for symptomatic ON in which CT-guided percutaneous drainage is followed immediately by endoscopic trans-gastric stent placement into the necroma. The aim of this study was to compare resource utilization in patients with symptomatic ON treated with the combined approach versus those treated by percutaneous drainage alone. Methods: A retrospective chart review was performed. Patients with SAP and symptomatic ON treated either with percutaneous drainage alone or via the combined modality approach were included. The period of review was 2006-2008. Charts were reviewed for number of inpatient hospital days related to SAP, number of radiographic and endoscopic procedures, severity of disease, patient demographics, and
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB307
time was 37 min (26-78), mean tunnel length was 11cm (6-23) and width 4cm (2.55). The R-scope allowed significant counter traction and visibility during the procedures and all target organs were successfully resected without laparoscopic assistance. Significant operative complications: 1 STAT tunnel failure during extraction of an 8x3cm standard specimen, 2 perforations (1 due to a prototype duodenal occlusion device and 1 due to enterotomy during cholecystectomy, 1 entrapment of small bowel with an endoloop. Post-operative: All animals gained weight appropriately with 1 sacrificed POD 12 due to lethargy (cystic duct leak and biloma). Necropsy findings were significant for healed STAT tunnels without complications, minor adhesions (5), bile leaks (2), lap port abscess (1) and ventral hernia (1). Conclusions: The combination of the R-scope and STAT allows effective, single site NOTES procedures using currently available devices. The study highlights two cautionary findings: it is possible to tear a submucosal tunnel with excessive torquing of the scope during the procedure, and while the R-scope provides improved tissue manipulation and the ability to apply counter traction, the complications incurred here suggest further improvements in technique and technology will be required for safe and effective NOTES procedures.
T1480 Complications During NOTESÒ: Endoscopic Management of Splenic Laceration and Hemorrhage Lukasz M. Kowalczyk, Anand Gupte, Mihir S. Wagh Background: Accidental splenic laceration and hemorrhage during transgastric access to the peritoneal cavity or organ resection during NOTES can lead to lifethreatening consequences. The natural orifice approach may need to be aborted in these circumstances for a standard laparoscopy or laparotomy. Aim: To determine the feasibility of endoscopically managing intra-operative splenic laceration and hemorrhage from accidental trauma during NOTES. Methods: 60 - 80 lbs pigs were used for the study and underwent transcolonic endoscopic surgery under general anesthesia. The spleen was located by direct visualization and intentional lacerations were made using endoscissors and a needle-knife. Cuts of varying length (0.5 cm, 1 cm, 2 cm, and 2 cm 2 cm cruciate laceration) were made. All lacerations produced active and persistent bleeding. The site was lavaged with sterile water and persistent spurting or oozing of blood was confirmed. A standard endoscopic 7 Fr bipolar electro-hemostasis catheter (Gold Probe, Boston Scientific) at 30 - 40 W was used to achieve hemostasis. The colonic incision was then closed using endoscopic clips (Resolution Clip, Boston Scientific). Necropsy was performed immediately after surgery in acute cases and at the end of the one week survival period per protocol. Site of laceration and the peritoneal cavity was examined for bleeding, abscess and damage to surrounding structures. Results: Nine intentional splenic lacerations were performed in 6 live anesthetized animals (4 acute and 2 survival studies) to mimic accidental splenic injury. Bleeding was successfully managed endoscopically using standard bipolar cautery in all animals. Persistent pressure was applied with the bipolar probe for coaptive coagulation, and intermittent lavage was performed to visualize the site of bleeding. Maximum time required for hemostasis was 25 minutes. Survival animals had an uncomplicated post-operative course and were euthanized per protocol. There was no evidence of intraperitoneal bleeding or abscess at necropsy. The omentum was seen adherent to the spleen in one survival animal at the site of laceration. Conclusion: We demonstrate the successful management of intra-operative splenic laceration and hemorrhage during NOTES using standard endoscopic techniques, avoiding the need for laparoscopic exploration or laparotomy.
T1481 Scarlesss Intra-Retroperitoneoscopy in Human and Animal NOTESÒ Translumenal Cholecystectomy, Appendectomy and GI Anastomosis Maki Sugimoto Purpose: Natural orifice translumenal endoscopic surgery (NOTES) is a novel concept that provides the potential for performance of incisionless imaging and operations. The method of accessing the abdominal cavity through a natural orifice under endoscopic visualization might offer advantages over open and laparoscopic surgery. The purpose of this study is to develop novel endoscopic technology and procedure to overcome the limitations of intra-abdominal and retroperitoneal imaging and surgery that is used to be invisible. Methods: We performed NOTES intra-retroperitoneoscopy in 2 human cadaver and 12 survival porcine and canine studies. After perforation of the gastric, colonic, and vaginal wall, a flexible doublechannel scope was advanced into the peritoneal cavity and retroperitoneal space under endoscope-induced carbon dioxide insufflation. After performing observations and surgical procedures, the wall was closed using a suturing system or endoscopic clips. Results: The endoscope could visualize each objective organ in all 14 attempts. Following liver biopsy or lymph node removal, GI anastomosis or intestinal resection were also accomplished using a standard flexible endoscope without laparoscopic assistance. Animal NOTES cholecyctectomy was completed in 6 transgastric, 2 transcolonic, and 2 transvaginal access. Transgastric intestinal resection was performed in 4 procedures. No acute complications were recorded. The submucosal, intramuscular and retroperitoneal imaging could be allowed histological diagnosis. Human cadaver NOTES transvaginal cholecystectomy and
www.giejournal.org
appendectomy were also completed within 90 and 40 minutes without major complications. Conclusions: Our study described the use of translumenal endoscopy to accomplish intra-abdominal surgeries. This could reach to the invisible space using standard modalities. Scarlesss intra- and retroperitoneal imaging of NOTES is technically feasible and safe in either human or animal study. CLINICAL RELEVANCE/APPLICATION: NOTES procedure is enormously advantageous to the patient. This would break the physical barrier between bodily trauma and surgery, representing the revolution in surgery.
T1482 Comparing Efficiency of Transgastric and Transperineal NOTESÒ (Natural Orifice Translumenal Endoscopic Surgery) in An Appendectomy Test Bed Shiva Jayaraman, Christopher M. Schlachta Background: The purpose of this study was to establish a NOTES appendectomy test bed to evaluate whether the transgastric or transperineal (transvaginal) approach is most efficient. Methods: Using the uterine horns of female pigs as an appendectomy model, we performed 18 non survival NOTES appendectomies in two arms: 9 transgastric and 9 transvaginal. All cases were performed using a 2channel therapeutic endoscope and a standardized technique. The primary outcome was mean operative time for each technique excluding access closure. Secondary outcomes were peritoneal access and resection times. Means were compared using the students t-test. Results: Transgastric cases were significantly faster than transperineal (46 14 vs. 60 20 min, pZ0.02). Most of the improvement in transgastric times was due to faster resection (38 17 vs. 51 16 min, pZ0.03). Neither approach was faster for peritoneal access (8 3 vs. 8 4 min, pZNS). Comparing operative times for the first three and the last three cases with each technique, although operative time improved, a significant learning curve was not demonstrated for the transgastric approach (53 21 vs. 40 17 min, pZNS). A significant learning curve was demonstrated in transperineal cases (76 22 vs. 47 18 min, pZ0.02). Transperineal times improved over the study and approached transgastric (Figure 1); however, the last three transgastric cases were still significantly faster than the last three transperineal (40 17 vs. 47 18 min, pZ0.02). No complications occurred in either group. Conclusions: Transgastric as compared to transperineal NOTES appendectomy resulted in improved operative time in this model. The transperineal approach demonstrated a significant learning curve with operative times between techniques converging over time. This NOTES appendectomy test bed is suitable for evaluating NOTES innovations.
Figure 1. Operative times and learning curves.
T1483 Dual Modality Management of Symptomatic Organized Pancreatic Necrosis Reduces Inpatient Hospital Days and Radiology Resource Utilization Michael Gluck, Andrew S. Ross, Ellen Hauptmann, Shayan Irani, Mehran Fotoohi, Justin Siegal, Robert Crane, David H. Robinson, Richard A. Kozarek Background: Severe acute pancreatitis (SAP) may be complicated by organized pancreatic necrosis (ON) which can have significant clinical consequences and high medical resource utilization. At our institution, symptomatic ON is typically managed by large caliber percutaneous drains which provide both drainage and debridement. Over the past 18 months, our group has designed and implemented a combined endoscopic and percutaneous drainage technique for symptomatic ON in which CT-guided percutaneous drainage is followed immediately by endoscopic trans-gastric stent placement into the necroma. The aim of this study was to compare resource utilization in patients with symptomatic ON treated with the combined approach versus those treated by percutaneous drainage alone. Methods: A retrospective chart review was performed. Patients with SAP and symptomatic ON treated either with percutaneous drainage alone or via the combined modality approach were included. The period of review was 2006-2008. Charts were reviewed for number of inpatient hospital days related to SAP, number of radiographic and endoscopic procedures, severity of disease, patient demographics, and
Volume 69, No. 5 : 2009 GASTROINTESTINAL ENDOSCOPY AB307