- Email: [email protected]
Su1598 NOTES® Versus Laparoscopy: What is the Perception of Patients Undergoing Bariatric Surgery?
Abstracts
follow-up (Table). All animals survived and full thickness closure was found in 20 (91%) animals (small serosal defects at closure site detected in 2 animals). Small intraperitoneal abscess (1x2 cm) was found in 3 (13.6%) necropsies. However, none of them was at the suture site and infection was associated with contamination during the surgery rather than with closure insufficiency. All remaining animals had normal intraabdominal findings except minor adhesions. Conclusion Single loop-and-clip rectal closure was confirmed as a simple, safe and reproducible technique and can be effectively used in NOTES procedures.Supported by a grant from IGA- NS9994-4. Table 1. Levels of inflammatory markers during 30-days follow-up Day 0 (preoperative)
POD 2
POD 7
POD 30
WBC(x109/L) 12,1 (10,9-13,6) 18,1* (16,5-20,8) 17,2* (15-20,4) 11,2 (9,6-12,6) CRP (ug/ml) 17.9 (13-26.2) 43.8* (27.9-56.1) 22.4 (23.2-64.6) 14.3 (11.4-28.3) IL-6(pg/ml) 66.1 (44.7-146.9) 55.5 (44.4-149.3) 62.2 (55.9-185.8) 46.6 (25.5-250.9) (Values are medians and confidential interval 95%. POD ⫽ post-operative day; *p ⬍ 0.005 vs. day 0)
Su1596 A Study of Endoscopic Full-Thickness Incision and Endoscopic Gastric Plication Using NOTES® Techniques Ryoji Miyahara1, Yoshiki Hirooka1, Kohei Funasaka2, Kakunori Banno2, Keiichi Sakamaki1, Hidezumi Tatematsu1, Masanao Nakamura2, Hiroki Kawashima2, Akihiro Itoh2, Naoki Ohmiya2, Osamu Watanabe2, Osamu Maeda2, Takafumi Ando2, Hidemi Goto2, 1 Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan; 2Department of Gastroenterology, Nagoya University, Graduate School of Medicine, Nagoya, Japan [Objectives] This study examined the potential to safely perform full-thickness gastric resection via a peroral endoscopic approach using a NOTES technique. The current work involves a clinical study of full-thickness incision combined with a laparoscopic approach to treat GISTs; the safety of the plication technique was examined in animal experiments. [Methods] Use of laparoscopic-endoscopic cooperative surgery (LECS) for gastric GISTs in the vicinity of the cardia or pylorus began in November 2009. In order to preserve function, a full-thickness incision was made halfway to 3/4 of the way around in the area near the cardia or pylorus using an ESD technique. The procedure has been performed on 5 patients and its usefulness was studied. 2. Using the Flexible Suturing Device, a prototype plication instrument from Olympus, gastric suturing observed with peroral endoscopy was tested in 4 experimental dogs and the safety of the procedure was studied. [Results] GISTs were located in the vicinity of the cardia, and all of the patients had the potential to lose cardia function, but functional impairment was not noted since ESD may have allowed an incision with minimal margins. Complications such as peritonitis were not noted. 2. Endoscopic fullthickness gastric suturing was tested in experimental dogs sedated with propofol. Ligation was possible following full-thickness incision of the gastric wall. On the day following surgery, the dogs began eating again, and complications like peritonitis were not noted. One to 2 weeks postoperatively, the dogs were dissected and studied pathologically; cicatrization at the puncture site was evident. [Conclusion] This study performed full-thickness incision in a clinical experiment and full-thickness suturing in an animal experiment via a peroral endoscopic approach. We could perform full-thickness gastric resection safely in near future.
Su1597 NOTES® Gastrojejunostomy With a T-Anchoring Device in a Porcine Model Tae Jun Song1, Dong Wan Seo2, Hong Jun Kim2, Choong Heon Ryu2, Do Hyun Park2, Sang Soo Lee2, Sung Koo Lee2, Myung-Hwan Kim2 1 Internal Medicine, Inje University Ilsanpaik Hospital, Goyang, Republic of Korea; 2Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea Introduction: Natural orifice transluminal endoscopic surgery (NOTES®) represents a potentially less-invasive alternative to conventional or laparoscopic surgery. Gastrojejunostomy by using NOTES® procedure may be attractive as a less invasive method to bypass duodenal obstruction. Transgastric gastrojejunostomy in malignant disease may be a good choice for a pure NOTES® procedure. Methods: From June 2010 to October 2010, we performed transgastric NOTES® gastrojejunostomy in 8 healthy minipigs weighing about 40Kg. All procedures were performed with transgastric approach using a 2channel therapeutic endoscope (2TQ260®, Olympus Optical Co. Ltd., Tokyo, Japan). Suturing of the anastomosis was accomplished with a T-anchoring device (Cook Endoscopy, Winston-Salem, NC). All animals survived one week, and then a necropsy was performed. Results: Transgastric gastrojejunostomy was
technically successful in all cases (100%, 8/8). A total of four to six stitch pairs of T-anchoring devices were used to secure the anastomosis. The median time required to enter the peritoneal cavity and pull the small bowel into the stomach was 34 minutes (15 - 41 minutes) and that required to suture the anastomosis was 65.5 minutes (44 - 78 minutes). In one case, although the efferent limb was patent, the afferent limb was obstructed. A rupture of the anastomosis site occurred in one case three days after the procedure. As a result, the functional success rate was 87.5% (7/8). Small bowel adhesion to the stomach and liver occurred in one case, but the anastomosis was intact without leakage or obstruction. In other cases, the small bowel loops of the anastomosis reached to the stomach without tension or abnormal rotation. Conclusion: NOTES® gastrojejunostomy with T-anchoring device may be technically feasible. However, a great deal of care is needed because of the risk of complications. The T-anchoring device is still in its early stage and needs further improvements, but may provide a simple and effective endoscopic suturing method.
Su1598 NOTES® Versus Laparoscopy: What is the Perception of Patients Undergoing Bariatric Surgery? Tessa Verlaan1,2, Rogier P. Voermans1,2, Bart a. Van Wagensveld3, Mirjam a. Sprangers4, Paul Fockens1, Mark I. Van Berge Henegouwen2 1 Gastroenterology, Academic Medical Center, Amsterdam, Netherlands; 2 Surgery, Academic Medical Center, Amsterdam, Netherlands; 3 Surgery, Lucas Andres Hospital, Amsterdam, Netherlands; 4Medical Psychology, Academic Medical Center, Amsterdam, Netherlands Background and Aims: Potential benefits of natural orifice transluminal endoscopic surgery (NOTES) are less incision related complications and faster recovery of the patient with minimal post-operative stress and pain. Besides safety and technical aspects of NOTES, it is important to be aware of patients’ opinion and preference for the clinical application of NOTES. Obese patients are at higher risk for perioperative complications and morbidity. Previous studies regarding patients’ opinion towards NOTES have been performed in patients undergoing surgery, interestingly no studies were performed with bariatric patients, a unique subgroup of patients. Aim of this study was to evaluate the perception of the bariatric patient towards NOTES compared to laparoscopic surgery. Methods: All consecutive patients undergoing bariatric surgery (laparoscopic gastric banding, gastric bypass, gastric sleeve) were asked to fill out a questionnaire prior to the procedure. The participants were queried about their considerations to choose NOTES or conventional laparoscopy and their thoughts on associated risks. Additionally, they were questioned about the route of entrance (mouth, anus, vagina) of the NOTES procedure. Results: The response rate of the questionnaire was 74.7% (65/87). The median age of the responders was 48.0 years (range 21-71). Of all patients, 75.4% was female. A total of 63.1% were low educated (preschool, high school) and 36.9% were high educated (secondary education, university). Laparoscopic gastric banding was planned in 30.8%, gastric bypass in 66.2% and gastric sleeve in 3.1% of cases. Eighteen patients had prior laparoscopic surgery (27.7%), forty-three (66.2%) patients had prior endoscopy. Patients rated low complication risk most important (78.1%) followed by quick recovery (60.9%), the intensity of postoperative pain (53.1%), the duration of pain (50.0%), length of hospital stay (39.1%) and postoperative scars (14.1%). Most of the patients preferred a laparoscopic procedure above NOTES (74.6 and 25.4% respectively). Patients with high education chose a NOTES procedure more often than patients with low education (39.1% versus 17.5%, p⫽ 0.058). Males chose a NOTES procedure in 37.5% of cases, females in 21.3% of cases (p⫽0.318). Conclusions: Patients undergoing bariatric surgery value conventional laparoscopic surgery above NOTES. Scars are a minor issue for bariatric patients. A trend is seen for male patients and patients with high education choosing NOTES, but the difference is not significant. Larger studies are needed to learn about the background of these preferences.
Su1599 Comparative Study of Laparoscopy With Transgastric NOTES® Peritoneoscopy Using Small and Big Sized Endoscopes on Inflammatory Response in a Dog Model Zikai Wang1, Wen Li1, Lili Wu1, Khawaja Q. Hyder2, Xiuli Zhang1, Ping Tang1 1 Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China; 2Gastroenterology Clinic, Pakistan Institute of Medical Sciences, Islamabad, Pakistan Background: Natural Orifice Translumenal Endoscopic Surgery (NOTES) seems to offer the same advantages as laparoscopic surgery without skin incisions, but it remains unclear if the NOTES technique is less invasive than laparoscopy and if a small sized endoscope is superior to a big sized one. Aims: To compare two different sizes of endoscopes for NOTES peritoneoscopy with laparoscopy by measuring Inflammatory markers (TNF-a and IL-6) and peripheral white blood cell (WBC) counts in a dog model. Methods: Fifteen weighing 12-15 kg female mongrel dogs were randomly assigned to the small sized endoscope (outside diameter 5.5mm, GIF-XT260N, Olympus, Japan) group (SG, n⫽5), the big sized endoscope (outside diameter 12.8mm, GIF-2T200, Olympus, Japan) group (BG,
AB316 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org
follow-up (Table). All animals survived and full thickness closure was found in 20 (91%) animals (small serosal defects at closure site detected in 2 animals). Small intraperitoneal abscess (1x2 cm) was found in 3 (13.6%) necropsies. However, none of them was at the suture site and infection was associated with contamination during the surgery rather than with closure insufficiency. All remaining animals had normal intraabdominal findings except minor adhesions. Conclusion Single loop-and-clip rectal closure was confirmed as a simple, safe and reproducible technique and can be effectively used in NOTES procedures.Supported by a grant from IGA- NS9994-4. Table 1. Levels of inflammatory markers during 30-days follow-up Day 0 (preoperative)
POD 2
POD 7
POD 30
WBC(x109/L) 12,1 (10,9-13,6) 18,1* (16,5-20,8) 17,2* (15-20,4) 11,2 (9,6-12,6) CRP (ug/ml) 17.9 (13-26.2) 43.8* (27.9-56.1) 22.4 (23.2-64.6) 14.3 (11.4-28.3) IL-6(pg/ml) 66.1 (44.7-146.9) 55.5 (44.4-149.3) 62.2 (55.9-185.8) 46.6 (25.5-250.9) (Values are medians and confidential interval 95%. POD ⫽ post-operative day; *p ⬍ 0.005 vs. day 0)
Su1596 A Study of Endoscopic Full-Thickness Incision and Endoscopic Gastric Plication Using NOTES® Techniques Ryoji Miyahara1, Yoshiki Hirooka1, Kohei Funasaka2, Kakunori Banno2, Keiichi Sakamaki1, Hidezumi Tatematsu1, Masanao Nakamura2, Hiroki Kawashima2, Akihiro Itoh2, Naoki Ohmiya2, Osamu Watanabe2, Osamu Maeda2, Takafumi Ando2, Hidemi Goto2, 1 Department of Endoscopy, Nagoya University Hospital, Nagoya, Japan; 2Department of Gastroenterology, Nagoya University, Graduate School of Medicine, Nagoya, Japan [Objectives] This study examined the potential to safely perform full-thickness gastric resection via a peroral endoscopic approach using a NOTES technique. The current work involves a clinical study of full-thickness incision combined with a laparoscopic approach to treat GISTs; the safety of the plication technique was examined in animal experiments. [Methods] Use of laparoscopic-endoscopic cooperative surgery (LECS) for gastric GISTs in the vicinity of the cardia or pylorus began in November 2009. In order to preserve function, a full-thickness incision was made halfway to 3/4 of the way around in the area near the cardia or pylorus using an ESD technique. The procedure has been performed on 5 patients and its usefulness was studied. 2. Using the Flexible Suturing Device, a prototype plication instrument from Olympus, gastric suturing observed with peroral endoscopy was tested in 4 experimental dogs and the safety of the procedure was studied. [Results] GISTs were located in the vicinity of the cardia, and all of the patients had the potential to lose cardia function, but functional impairment was not noted since ESD may have allowed an incision with minimal margins. Complications such as peritonitis were not noted. 2. Endoscopic fullthickness gastric suturing was tested in experimental dogs sedated with propofol. Ligation was possible following full-thickness incision of the gastric wall. On the day following surgery, the dogs began eating again, and complications like peritonitis were not noted. One to 2 weeks postoperatively, the dogs were dissected and studied pathologically; cicatrization at the puncture site was evident. [Conclusion] This study performed full-thickness incision in a clinical experiment and full-thickness suturing in an animal experiment via a peroral endoscopic approach. We could perform full-thickness gastric resection safely in near future.
Su1597 NOTES® Gastrojejunostomy With a T-Anchoring Device in a Porcine Model Tae Jun Song1, Dong Wan Seo2, Hong Jun Kim2, Choong Heon Ryu2, Do Hyun Park2, Sang Soo Lee2, Sung Koo Lee2, Myung-Hwan Kim2 1 Internal Medicine, Inje University Ilsanpaik Hospital, Goyang, Republic of Korea; 2Internal Medicine, University of Ulsan College of Medicine, Asan Medical Center, Seoul, Republic of Korea Introduction: Natural orifice transluminal endoscopic surgery (NOTES®) represents a potentially less-invasive alternative to conventional or laparoscopic surgery. Gastrojejunostomy by using NOTES® procedure may be attractive as a less invasive method to bypass duodenal obstruction. Transgastric gastrojejunostomy in malignant disease may be a good choice for a pure NOTES® procedure. Methods: From June 2010 to October 2010, we performed transgastric NOTES® gastrojejunostomy in 8 healthy minipigs weighing about 40Kg. All procedures were performed with transgastric approach using a 2channel therapeutic endoscope (2TQ260®, Olympus Optical Co. Ltd., Tokyo, Japan). Suturing of the anastomosis was accomplished with a T-anchoring device (Cook Endoscopy, Winston-Salem, NC). All animals survived one week, and then a necropsy was performed. Results: Transgastric gastrojejunostomy was
technically successful in all cases (100%, 8/8). A total of four to six stitch pairs of T-anchoring devices were used to secure the anastomosis. The median time required to enter the peritoneal cavity and pull the small bowel into the stomach was 34 minutes (15 - 41 minutes) and that required to suture the anastomosis was 65.5 minutes (44 - 78 minutes). In one case, although the efferent limb was patent, the afferent limb was obstructed. A rupture of the anastomosis site occurred in one case three days after the procedure. As a result, the functional success rate was 87.5% (7/8). Small bowel adhesion to the stomach and liver occurred in one case, but the anastomosis was intact without leakage or obstruction. In other cases, the small bowel loops of the anastomosis reached to the stomach without tension or abnormal rotation. Conclusion: NOTES® gastrojejunostomy with T-anchoring device may be technically feasible. However, a great deal of care is needed because of the risk of complications. The T-anchoring device is still in its early stage and needs further improvements, but may provide a simple and effective endoscopic suturing method.
Su1598 NOTES® Versus Laparoscopy: What is the Perception of Patients Undergoing Bariatric Surgery? Tessa Verlaan1,2, Rogier P. Voermans1,2, Bart a. Van Wagensveld3, Mirjam a. Sprangers4, Paul Fockens1, Mark I. Van Berge Henegouwen2 1 Gastroenterology, Academic Medical Center, Amsterdam, Netherlands; 2 Surgery, Academic Medical Center, Amsterdam, Netherlands; 3 Surgery, Lucas Andres Hospital, Amsterdam, Netherlands; 4Medical Psychology, Academic Medical Center, Amsterdam, Netherlands Background and Aims: Potential benefits of natural orifice transluminal endoscopic surgery (NOTES) are less incision related complications and faster recovery of the patient with minimal post-operative stress and pain. Besides safety and technical aspects of NOTES, it is important to be aware of patients’ opinion and preference for the clinical application of NOTES. Obese patients are at higher risk for perioperative complications and morbidity. Previous studies regarding patients’ opinion towards NOTES have been performed in patients undergoing surgery, interestingly no studies were performed with bariatric patients, a unique subgroup of patients. Aim of this study was to evaluate the perception of the bariatric patient towards NOTES compared to laparoscopic surgery. Methods: All consecutive patients undergoing bariatric surgery (laparoscopic gastric banding, gastric bypass, gastric sleeve) were asked to fill out a questionnaire prior to the procedure. The participants were queried about their considerations to choose NOTES or conventional laparoscopy and their thoughts on associated risks. Additionally, they were questioned about the route of entrance (mouth, anus, vagina) of the NOTES procedure. Results: The response rate of the questionnaire was 74.7% (65/87). The median age of the responders was 48.0 years (range 21-71). Of all patients, 75.4% was female. A total of 63.1% were low educated (preschool, high school) and 36.9% were high educated (secondary education, university). Laparoscopic gastric banding was planned in 30.8%, gastric bypass in 66.2% and gastric sleeve in 3.1% of cases. Eighteen patients had prior laparoscopic surgery (27.7%), forty-three (66.2%) patients had prior endoscopy. Patients rated low complication risk most important (78.1%) followed by quick recovery (60.9%), the intensity of postoperative pain (53.1%), the duration of pain (50.0%), length of hospital stay (39.1%) and postoperative scars (14.1%). Most of the patients preferred a laparoscopic procedure above NOTES (74.6 and 25.4% respectively). Patients with high education chose a NOTES procedure more often than patients with low education (39.1% versus 17.5%, p⫽ 0.058). Males chose a NOTES procedure in 37.5% of cases, females in 21.3% of cases (p⫽0.318). Conclusions: Patients undergoing bariatric surgery value conventional laparoscopic surgery above NOTES. Scars are a minor issue for bariatric patients. A trend is seen for male patients and patients with high education choosing NOTES, but the difference is not significant. Larger studies are needed to learn about the background of these preferences.
Su1599 Comparative Study of Laparoscopy With Transgastric NOTES® Peritoneoscopy Using Small and Big Sized Endoscopes on Inflammatory Response in a Dog Model Zikai Wang1, Wen Li1, Lili Wu1, Khawaja Q. Hyder2, Xiuli Zhang1, Ping Tang1 1 Department of Gastroenterology and Hepatology, Chinese PLA General Hospital, Beijing, China; 2Gastroenterology Clinic, Pakistan Institute of Medical Sciences, Islamabad, Pakistan Background: Natural Orifice Translumenal Endoscopic Surgery (NOTES) seems to offer the same advantages as laparoscopic surgery without skin incisions, but it remains unclear if the NOTES technique is less invasive than laparoscopy and if a small sized endoscope is superior to a big sized one. Aims: To compare two different sizes of endoscopes for NOTES peritoneoscopy with laparoscopy by measuring Inflammatory markers (TNF-a and IL-6) and peripheral white blood cell (WBC) counts in a dog model. Methods: Fifteen weighing 12-15 kg female mongrel dogs were randomly assigned to the small sized endoscope (outside diameter 5.5mm, GIF-XT260N, Olympus, Japan) group (SG, n⫽5), the big sized endoscope (outside diameter 12.8mm, GIF-2T200, Olympus, Japan) group (BG,
AB316 GASTROINTESTINAL ENDOSCOPY Volume 73, No. 4S : 2011
www.giejournal.org