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NATURAL ORIFICE TRANSLUMINAL ENDOSCOPIC SURGERY (NOTES) VS LAPAROSCOPY FOR COLON PERFORATION AND REPAIR: FEASIBILITY AND RISK OF ADHESIONS
J Romagnuolo, K Morgan, J Morris, R Hawes, S Palesch
Digestive Disease Center, Medical University of South Carolina, SC, USA
BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) has enormous promise as a less invasive, scarless option for abdominal surgery. Adhesions are an important cause of abdominal pain and small bowel obstruction, costing a billion dollars in the US each year. Pilot data in our animal lab showed a lower adhesion score with NOTES.
AIM: To determine if colon perforation repair is feasible with NOTES and if adhesions are less common with NOTES transgastric colonic perforation and repair (TGCR) than with laparoscopic colon repair (LCR).
METHODS: 40 25kg male pigs were randomly assigned to either TGCR or LCR. TGCR involved a transgastric needleknife puncture with a double channel therapeutic endoscope, peritoneal cavity entry after balloon dilation, pneumoperitoneum with CO2, and performance of a 2cm perforation of the spiral colon with a needle-knife, and repair of the perforation with clips. The gastric hole was then closed with clips and a detachable snare with a purse-string technique. Pigs were given a colonic prep pre-op and a single dose of perioperative antibiotics, and then fed standard chow the next day. A diagnostic lavage was done after closure for cell count and culture. Necropsy was performed at 21 days. Adhesion score was a 9-point composite of (a) density/vascularity of adhesions (1 = filmy, avascular, 2 = dense or vascular, or 3 = dense and vascular); b) breadth of adhesions (0 = < 4 cm or 3 = > 4 cm); and c) extent of adhesions (1 = 1 × 2-organ pair (e.g. colon to liver), 2 = 2 × 2-organ pairs, 3 = 3 or more 2-organ pairs). Final score was a mean of the necropsy surgeon and 2 independent reviewers of necropsy video. Mann-Whitney and Fisher exact tests were used.
RESULTS: To date, preliminary composite adhesions scores are available for 13 TGCR and 14 LCR pigs. Mean scores were 4.8 (TGCR) and 4.5 (LCR); p=0.7. Subscores were similar. No pigs had significant procedure-related adverse events; weight gain and postoperative behaviour were normal in both groups. All colon perforation sites were well-healed.
CONCLUSION: NOTES colonic perforation repair is feasible. Preliminarily, there do not appear to be fewer adhesions compared with laparoscopy.
Sponsored by a NOSCAR (ASGE/SAGES) Ethicon Award