A Rodríguez-D'Jesús

Infection during Natural Orifice Transluminal Endoscopic Surgery Peritoneoscopy: A Randomized Comparative Study in a Survival Porcine Model

BACKGROUND Infection in natural orifice transluminal endoscopic surgery (NOTES) remains controversial. OBJECTIVE To estimate the frequency of infection during NOTES peritoneoscopy with different routes of access and to compare with laparoscopy. DESIGN Prospective randomized controlled study (Canadian Classification type I). METHODS Forty female pigs were randomly assigned to 3 NOTES (transgastric, transrectal, and transvaginal) and laparoscopic groups. Antiseptic technique was used for NOTES, whereas laparoscopy was performed in a sterile environment. Preoperative and postoperative intravenous antibiotics were administered. Closure of the transluminal access site was performed in all animals. Peritoneal fluid was collected for culture at the end of surgery and at necropsy at day 14. RESULTS Thirty-nine peritoneoscopies were successfully completed. Necropsy confirmed complete healing of NOTES incisions, but 2 animals in the laparoscopy group had small abscesses in the abdominal incisions. There were no statistical differences in the presence of peritoneal adhesions. Positive culture results were seen in all groups at the end of the procedure and in all animals at necropsy, but this did not lead to clinical signs of gross infection. The most common organisms that colonized the peritoneum were gram-positive cocci and gram-negative bacilli from the normal swine gastrointestinal flora. LIMITATIONS Animal model and small sample size. CONCLUSIONS In these small series of animals and with the careful lavage and preparation used, NOTES appeared to be comparable to laparoscopy in terms of peritoneal contamination and clinical infection. Despite the adherence to a strict antiseptic protocol, peritoneal contamination occurs but does not lead to septic complications in the swine.

On-demand endoscopic CO2 insufflation with feedback pressure regulation during natural orifice transluminal endoscopic surgery (NOTES) peritoneoscopy induces minimal hemodynamic and respiratory changes

BACKGROUND Endoscopic insufflation has been associated with marked increase in intra-abdominal pressure (IAP) and hemodynamic and respiratory changes during transgastric surgery. OBJECTIVE To investigate the hemodynamic and respiratory effects during intraperitoneal cavity exploration through 3 different natural orifice transluminal endoscopic surgery (NOTES) access locations compared with laparoscopy. DESIGN AND SETTING Survival experiments using 40 female pigs randomized to transgastric, transcolonic, transvaginal, and laparoscopic peritoneoscopy. INTERVENTIONS On-demand endoscopic insufflation of CO(2) with feedback pressure regulation was used in NOTES with a maximum pressure of 14 mm Hg. In the laparoscopy group, the IAP was maintained at 14 mm Hg. NOTES procedures were performed by an endoscopist (with the assistance of a gynecologist in the transvaginal group and a second endoscopist in the transgastric and transrectal groups) and laparoscopy by 2 surgeons. MAIN OUTCOME MEASUREMENTS Invasive hemodynamic and respiratory data. Blood samples were drawn for gas analyses. RESULTS All experiments except one in the transrectal group were completed. The IAP was significantly lower in all NOTES groups compared with the laparoscopy group. A significant increase in mean systemic arterial blood pressure was observed in the laparoscopy group at 15 and 30 minutes of intraperitoneal cavity exploration, but it remained unchanged during all NOTES procedures. An increase in airway pressures was observed at 15 and 30 minutes of peritoneoscopy in the animals undergoing laparoscopy, whereas those parameters remained unchanged in the NOTES groups. The laparoscopy group showed a significant impairment in pulmonary gas exchange (decrease in Pao(2), increase in Paco(2), and decrease in arterial pH) after 30 minutes of peritoneoscopy, whereas only a slight increase in Paco(2) was observed in the transrectal and transvaginal groups. LIMITATIONS Healthy animal model. CONCLUSION On-demand endoscopic insufflation of CO(2) with feedback pressure regulation can minimize the risk of hemodynamic and respiratory compromise caused by acute changes in IAP.

Gastric emptying is delayed in transgastric NOTES: a randomized study in swine.

AIM The aim of this study was to evaluate the restoration of gastrointestinal motility after NOTES using capsule endoscopy (CE). MATERIALS AND METHODS Twenty adult Yorkshire pigs were randomly assigned to four groups: transgastric NOTES (gNOTES), transrectal NOTES (rNOTES), transvaginal NOTES (vNOTES), and laparoscopy (LAP). At the end of a 30-min peritoneoscopy with identification of seven predetermined organs, an array of eight receivers and the recorder were attached to the abdominal wall. The CE was delivered into the antrum with the help of an endoscope and a polypectomy snare. Animals were kept alive for 14 d. RESULTS Median time for surgery was longer in gNOTES (56 min, range 47-63) and vNOTES (54 min, range 44-79) than in LAP (32 min, range 32-33; P < 0.05 and P < 0.01) and in rNOTES (45.5 min, range 33-56) (P = ns). This increase was related to a larger incision and longer closure times. Images from the CE were successfully retrieved in 19 cases. The CE was retained in the stomach in all animals in gNOTES (459 min; range 360-600), but only in one animal in rNOTES and vNOTES and in none in the LAP group. Failure of passage of the CE beyond the stomach was associated with gNOTES and longer closure of the incision. Animals in the gNOTES group gained less weight than the others and this change was statistical significant when compared with vNOTES animals (1.7 kg, range -1.98 to 4.5 versus 8.4 kg, range 5.8 to 11.45; P < 0.01). CONCLUSION Gastric emptying is delayed after gNOTES peritoneoscopy compared with rNOTES, vNOTES, and LAP and this effect is associated with less weight gain.

Prevalencia y características epidemiológicas del esófago de Barrett en la provincia de Barcelona

INTRODUCTION The prevalence of Barretts esophagus (BE) varies from 0.45% to 2.2% in patients who undergo upper endoscopy and is >12% when the indication is for reflux symptoms. The prevalence has progressively increased in recent years but is unknown in the population of the province of Barcelona. OBJECTIVES To determine the prevalence of BE and its epidemiological characteristics in our population. PATIENTS AND METHODS We prospectively evaluated patients referred to the Endoscopy Unit of Hospital Clinic and Hospital General de Catalunya for an upper endoscopy. We excluded patients with known BE, prior upper endoscopy, esophagogastric surgery or refusal to participate in the study. Demographic data, alcohol intake, Helicobacter pylori infection and consumption of antisecretory agents were recorded, among other information. Participants completed a standardized questionnaire to assess the presence of gastroesophageal reflux disease (GERD) symptoms and their severity. RESULTS Between July 2010 and July 2012, we included 200 patients (100 in each center). The mean age was 48.9 ± 15.6 years and the majority were women (n=120, 60%). Symptoms of GERD were present in 46 patients (23%) and some degree of esophagitis was present in 31 (15.5%). Infection by H. pylori was present in 29.7%. BE was found endoscopically in 14 (7%) patients, but was histologically confirmed in only 8 (4%). The only variable that correlated with the finding of BE was male sex. CONCLUSION The prevalence of BE in our environment is similar to that reported in Western countries. The absence of reflux symptoms does not rule out the possibility of BE.

INCIDENCIA Y CARACTERÍSTICAS EPIDEMIOLÓGICAS DEL ESÓFAGO DE BARRETT EN CATALUÑA.

Introduccion: La incidencia del esofago de Barrett (EB) es del 0,45% al 2,2% en los pacientes que se realizan una endoscopia digestiva alta y superior al 12% si la indicacion es por sintomas de reflujo. En los ultimos anos se ha descrito un aumento progresivo del diagnostico de EB. Sin embargo, se desconoce cual es la incidencia de esta entidad en la poblacion de Cataluna. Objetivos: Determinar la incidencia del EB y sus caracteristicas epidemiologicas en nuestro medio. Material y metodo: Se evaluaron de forma prospectiva todos los pacientes mayores de 18 anos que acudieron a las Unidades de Endoscopia del Hospital Clinic y Hospital General de Catalunya para la realizacion de una endoscopia digestiva alta. Se excluyeron pacientes con EB conocido, endoscopia digestiva alta previa, cirugia esofago-gastrica o negativa de participar en el estudio. Se registraron datos demograficos, consumo de alcohol y tabaco, infeccion por Helicobacter Pylori (HP) y consumo de IBP, entre otros. Los participantes completaron un cuestionario estandarizado para valorar la presencia de sintomas de RGE y su severidad. Resultados: Entre julio 2010 y julio 2012 se incluyeron 200 pacientes (100 en cada centro). El 93% eran de nacionalidad espanola. La media de edad fue de 50±15 anos y 60% fueron mujeres. 46 pacientes (23%) tenian sintomas de RGE y 31 (16%) presentaron algun grado de esofagitis. La infeccion por HP estaba presente en 29%. En 14 (7%) pacientes hubo sospecha endoscopica de EB, con confirmacion histologica en 8 (4%). El genero masculino se asocio a un mayor hallazgo de EB (6/80 vs. 2/120, p=0,04). La presencia de sintomas de reflujo no se asocio a un mayor diagnostico de EB. Tampoco se encontro ninguna asociacion con las otras variables clasicamente consideradas de riesgo (edad, IMC, consumo de tabaco y, ausencia de HP. Conclusion: La incidencia de EB en nuestro medio es similar a la descrita en los paises occidentales y es mas frecuente en varones. La ausencia de sintomas de reflujo, no descarta la posibilidad de EB.