G Vanbiervliet

Gastrojejunal anastomosis using a tissue-apposing stent: a safety and feasibility study in live pigs

BACKGROUND AND STUDY AIMS Various techniques using surgical and natural orifice transluminal endoscopic surgery (NOTES) have been evaluated to create a gastrojejunal bypass. The aim of the current study was to determine the safety, feasibility, and efficacy of a new technique using a pure endoscopic approach and tissue-apposing stent placement for gastrojejunal anastomosis (GJA). MATERIALS AND METHODS This was a prospective, experimental study on six live pigs weighing 20 - 45  kg. Endoscopies were performed using a double-channel gastroscope, and included the creation of a GJA using a tissue-apposing, fully covered, self-expanding metallic stent. Antibiotic therapy was continued for 7 days after the procedure, and food was gradually reintroduced from Day 3. Changes in weight following the procedure were compared with a control group of age-matched animals. Anastomosis functionality was confirmed by endoscopy at 3 weeks (before the animals were euthanized), and during histopathological analysis. The primary outcomes were morbidity and mortality at 3 weeks. Secondary outcomes were technical feasibility, procedure time, and patency of the GJA. RESULTS The procedures were performed successfully in all animals. The mean procedure time was 26  ±  6.7 minutes (range 15 - 32 minutes). One case of stent migration occurred during the procedure; the stent was successfully replaced using the same procedure. All animals were alive after 3 weeks. The mean weight gain during follow-up was 0.85  ±  2.56  kg (range - 2 to + 2  kg) compared with 5.2  ±  1.6  kg (range 3 - 7  kg) in control animals (P = 0.007). At necropsy, the stents were still in place in all animals, without evidence of peritonitis. Histopathology confirmed permeable anastomoses with continuity of the mucosa and mucosa muscle layers. CONCLUSIONS GJA with a tissue-apposing stent is safe, feasible, and reproducible without anastomotic leakage in a porcine model using a pure endoscopic approach and standard endoscopic equipment.

Gastrojejunal Anastomosis Exclusively Using the 'NOTES' Technique in Live Pigs: A Feasibility and Reliability Study

Introduction. Natural orifice transluminal endoscopic surgery (NOTES) could reduce procedure-associated morbidity and mortality. The aim of this study was to determine the feasibility of performing a simple model of gastrojejunal anastomosis in a living porcine model exclusively using NOTES. Methods. It was a prospective experimental animal study concerning pigs weighing between 25 and 30 kg. Endoscopies were performed using a double-channel gastroscope. A preliminary phase allowed for the development of the technique on 3 animals that were immediately euthanized. The experimental phase included the implementation of a gastrojejunal anastomosis in 9 animals. Antibiotic therapy was continued for 7 days with gradual feeding. Surviving animals were euthanized after 3 weeks. Anastomosis permeability in each animal was confirmed by opacification, endoscopy, and histopathological analysis. The main outcome measurements were the feasibility and animal survival at 3 weeks postsurgery. Results. The entire procedure was performed on 9 animals (4 males and 5 females). Anastomosis required 4.7 ± 1.2 stitches (range 4-7). The average total length of the procedure was 143 ± 50.8 minutes (range 87-225 minutes). One bleeding, 2 suture dehiscences, and a poor stomach incision were the immediate complications endoscopically resolved. At 3 weeks, 5 animals had survived. Three animals died as a result of anastomotic leakage confirmed at necropsy and histopathology. In the surviving animals, histology confirmed permeable anastomoses with collagen scar tissue and continuity of the mucosa and mucosa muscle layers. Conclusion. Successful gastrojejunal anastomosis by NOTES is technically feasible but is subject to a learning curve.

Prospective randomized comparison of endoscopic submucosal tunnel dissection and conventional submucosal dissection in the resection of superficial esophageal/gastric lesions in a living porcine model

Background and study aims: To assess experimentally endoscopic submucosal tunnel dissection (ESTD) as an alternative technique of endoscopic submucosal resection. Patients and methods: This was a prospective, randomized, comparative experimental animal study carried out over a period of 9 months at the surgical research and teaching center of Aix-Marseille University, France. Virtual esophageal and gastric lesions measuring 3 cm in diameter were resected in pigs weighing 25 to 30 kg. The primary aim was to evaluate ESTD’s efficacy compared with endoscopic submucosal dissection (ESD). The secondary aims were to determine complication rates as well as to assess procedure time and procedure speed, histologic quality of the resected specimen, and procedure cost. Results: Eighteen procedures (9 ESD and 9 ESTD) were performed in nine pigs. The technical success rate was 88.9 % for both techniques, with one single failure in each. The en bloc resection rate was 100 % for ESTD and 88.9 % for ESD (one failure). The complication rate (22 %) and median procedure time were similar but dissection speed was quicker with ESTD in the esophagus (P = 0.03). Median procedure cost (728 Euros for ESD and ESTD) did not differ. On histologic examination, the lateral margins were healthy in 100 % of ESTD and in 88.9 % of ESD (P = 0.49). Deep resection margins were of better quality in ESTD (median submucosal thickness: 1307.1 µm vs. 884.7 µm; P = 0.039). Conclusions: ESTD is feasible and safe but not superior in the treatment of superficial esophageal/gastric lesions in porcine models compared with ESD. Nevertheless it provides a better quality histologic specimen.

Evaluation of feasibility, efficiency and safety of a pure NOTES gastrojejunal bypass with gastric outlet obstruction, in an in vivo porcine model

Introduction: Natural orifice transluminal endoscopic surgery (NOTES) gastrojejunal anastomosis (GJA) is a less invasive surgery for bariatric procedures and gastric outlet obstruction. The aim of this study was to evaluate the feasibility, efficacy, and safety of a pure NOTES gastrojejunal bypass using an in vivo porcine model. Material and methods: A prospective study was performed on nine swine. A double-channel scope was used. The intervention steps were: (i) gastric incision; (ii) peritoneal access; (iii) jejunal loop selection and mobilization into the stomach; (iv) stoma creation within the gastric wall and incision; (v) anastomosis suture and pylorus closure using a T-tag prototype. The animals were assessed clinically for 3 weeks including the weight gain. The patency of the GJA was assessed at necropsy and a histological analysis was performed. Results: We successfully performed all the procedures with a mean (standard deviation [SD]) operative time of 108 (26) minutes. We used a mean of 5.55 (1.30) stitches. There were no intraprocedural adverse events. Five animals survived up till euthanasia at 3 weeks (65 %). These showed a significant difference in weight curves of a loss of 3.2 kg compared with gain of 5.2 kg in a control group. Four pigs died from anastomotic dehiscence complicated by peritonitis. Conclusion: Gastrojejunal bypass with a pure NOTES approach is feasible. This procedure is effective, resulting in a patent anastomosis and a significant weight loss. However, the anastomotic dehiscence is a major concern because of its mortality rate, and further studies including improvement of the suturing device and the technique are needed.

Gestion endoscopique des complications de la chirurgie bariatrique

L’endoscopie digestive est devenue progressivement essentielle au diagnostic et au traitement des complications de la chirurgie bariatrique dont le nombre absolu ne cesse d’augmenter avec l’engouement légitime pour cette prise en charge de l’obésité. Différentes procédures endoluminales permettent de répondre aux problématiques postopératoires, notamment anastomotiques en cas de RYGB (Roux en Y Gastric bypass) et de la ligne d’agrafage pour la sleeve gastrectomy (SVG) (Tableau 1). Le point fort de l’endoscopie est son excellent profil de tolérance, y compris en situation aiguë et en période postopératoire précoce, notamment grâce à l’usage de l’insufflation au CO. De façon intéressante, les complications chirurgicales dans ce domaine ont poussé les endoscopistes à développer de nouvelles techniques, de nouveaux matériaux et concepts thérapeutiques innovants, contribuant probablement à l’avènement d’une nouvelle discipline médicochirurgicale : l’endoscopie chirurgicale.

A Newly Designed Enterocutaneous Esophageal Fistula Model in the Pig

Background. Fistulas after esophagectomy are a significant cause of morbidity and mortality. Several endoscopic treatments have been attempted, with varying success. An experimental model that could validate new approaches such as cellular therapies is highly desirable. The aim of this study was to create a chronic esophageal enterocutaneous fistula model in order to study future experimental treatment options. Methods. Eight pigs (six 35-kg young German and two 50-kg adult Yucatan pigs) were used. Through a left and right cervicotomy, under endoscopic view, 1 (group A, n = 6) or 2 (group B, n = 7) plastic catheters were introduced into the esophagus 30 cm from the dental arches bilaterally and left in place for 1 month. Radiologic and endoscopic fistula tract evaluations were performed at postoperative day (POD; 30) and at sacrifice (POD 45). Results. Three fistulas were excluded from the study because of early (POD 5) dislodgment of the catheter, with complete fistula closure. At catheter removal (POD 30), the external orifice was larger in group B (5.2 ± 1.1 mm vs 2.6 ± 0.4 mm) with more severe inflammation (72% vs 33%). At POD 45, the external orifice was closed in all fistulas in group A and in 1/7 in group B. At necropsy, the fistula tract was still present in all animals. Yucatan pigs showed more complex tracts, with a high level of necrosis and substantial fibrotic infiltration. Conclusions. In this article, we show a reproducible, safe, and effective technique to create an esophagocutaneous fistula model in a large experimental animal.