Candice C. Lam

Closure of a gastrotomy after transgastric tubal ligation by using the Eagle Claw VII: a survival experiment in a porcine model (with video)

BACKGROUND Transgastric access to the peritoneal cavity presents new opportunities for novel endoscopic surgery. Secure closure of the gastrotomy site is critical to the success of transgastric endoscopic surgery. OBJECTIVE To study the safety and efficacy of closure of a gastrotomy by using the Eagle Claw VII endoscopic suturing device after transgastric bilateral tubal ligation. DESIGN A prospective survival study in a porcine model with ten 30-kg pigs. INTERVENTIONS The gastrotomies were made by using a needle-knife and balloon dilation. Bilateral fallopian tube ligation was performed with detachable snares, and the tubes were transected by using the needle-knife. The gastrotomies were closed with endoscopic suturing by using the Eagle Claw VII. MAIN OUTCOME MEASUREMENTS Included the survival of the pigs, security of the closure, number of plicating sutures used, operative time, peritoneal contamination, and histopathologic confirmation of the full-thickness healing of the gastrotomy. RESULTS Transgastric fallopian-tube ligation was performed in 10 pigs, and all of the gastrotomies were successfully closed by using the Eagle Claw VII endoscopic suturing device. The operative time for bilateral tubal ligation was 38.2 minutes (range 18-50 minutes), whereas, the operative time for gastrotomy closure was 25.5 minutes (range 15-35 minutes). Three endoscopic sutures were necessary to achieve a secure gastrotomy closure. All the pigs survived and tolerated a full diet 24 hours after the operation. A postmortem confirmed full-thickness healing for all gastrotomies, with no evidence of leakage. One pig had an overtube-related esophageal perforation, which was successfully managed with endoscopic clip closure. LIMITATIONS The porcine gastric wall is thicker than the human gastric wall, and the posterior wall of the porcine stomach becomes the anterior-inferior wall after gaseous distention. Hence, all the gastrotomies were made through the posterior wall. The tissue tolerance and healing of the porcine stomach may be different from that of the human stomach. CONCLUSIONS Endoscopic suturing by using the Eagle Claw VII device is a feasible method for gastrotomy closure after a natural orifice transluminal endoscopic surgery procedure.

Chemoradiotherapy or Pharyngo-Laryngo-Esophagectomy for Cervical Esophageal Squamous Cancer

determinant of the need to tailor the type of fundoplication. The aim of this study was to determine normal values for the RBP in asymptomatic subjects and in patients before and after a Nissen fundoplication. Methods: The ramp bolus pressure (RBP) was determined by measuring the mean pressure preceding the upstroke of the contraction wave 5cm above the lower esophageal sphincter (LES) (Figure). We measured the RBP in 53 asymptomatic volunteers and 37 patients with reflux symptoms before and after a Nissen fundoplication. All of the reflux patients had an excellent outcome and none had dysphagia at the time of postoperative evaluation. Results: A RBP was present in 97% of normal subjects and 100% of patients. The mean (SD) amplitude of the RBP in normal subjects was 6.8 (3.7) mmHg. The RBP in reflux patients was significantly lower than that in normal subjects [3.6 (7.0) mmHg, p<0.003]. After Nissen fundoplication, the RBP increased to 12.0 (3.2) mmHg and was significantly greater than the preoperative values (p<0.0001). The 95th percentile value for RBP in normal subjects was 10.4 mmHg and after Nissen fundoplication was 20.0 mmHg. Conclusion: The ramp bolus pressure is a frequent manometric finding that indicates the degree of outflow resistance in the LES region. This amplitude increases after a Nissen Fundoplication. These findings suggest that a contraction amplitude above 20mmHg is necessary to overcome the resistance of a Nissen fundoplication and this threshold may be a better determinant of the need to tailor the type of fundoplication performed.