Natural orifice transluminal endoscopic surgery versus laparoscopic surgery for inadvertent colon injury repair: feasibility, risk of abdominal adhesions, and peritoneal contamination in a porcine survival model

• Published in: Gastrointestinal endoscopy 2010-04, Vol.71 (4), p.817-823
• Main Authors: Romagnuolo, Joseph, MD, FASGE, Morris, John, MD, Palesch, Seth, BEng, Hawes, Robert, MD, FASGE, Lewin, David, MD, Morgan, Katherine, MD
• Format: Article
• Language: English
• Subjects: Animals; Bacterial Infections - pathology; Biological and medical sciences; Colon - injuries; Colony-Forming Units Assay; Digestive system. Abdomen; Endoscopy; Enterococcus; Feasibility Studies; Female; Gastroenterology and Hepatology; Gastroenterology. Liver. Pancreas. Abdomen; Gram-Positive Bacterial Infections - pathology; Investigative techniques, diagnostic techniques (general aspects); Laparoscopy; Male; Medical sciences; Peritonitis - pathology; Risk Factors; Streptococcal Infections - pathology; Surgical Wound Infection - pathology; Suture Techniques; Swine; Tissue Adhesions - pathology; Wound Healing - physiology
• ISSN: 0016-5107; 1097-6779
• DOI: 10.1016/j.gie.2009.10.052

Background Adhesions are common after conventional surgery; natural orifice transluminal endoscopic surgery (NOTES) avoids peritoneal disruption and may reduce adhesions. Objectives To determine whether adhesions (and peritoneal contamination) are less common with NOTES transgastric colon injury and repair (TGCR) than with laparoscopic colon repair (LCR). Design/Setting Porcine survival study. Interventions After colon preparation and administration of antibiotics, forty 25-kg male pigs were randomly assigned to either TGCR or LCR. TGCR involved an endoscopic gastrotomy (needle-knife plus balloon dilation), CO2 pneumoperitoneum, and a 2-cm needle-knife transmural incision of spiral colon. Colotomies were repaired with clips; gastrotomies were closed with clips and a detachable snare. Main Outcome Measurements Adhesions were assessed at necropsy at 21 days; biopsy specimens were blindly reviewed. A 9-point adhesion score (density/vascularity, width, and extent) was averaged from 3 reviewers. Peritoneal lavage was sent for cell count and culture. Results Two of 20 TGCR pigs died immediately (unrecognized preoperative autopsy-proven pneumonia). The median procedure times were 70.5 and 19.0 minutes for TGCR and LCR, respectively; weight gains were 7.1 and 8.2 kg, respectively. The median adhesion scores were 4.3 and 3.7, respectively ( P = .26); subscores were similar (1.9, 1.5, 1.3 vs 1.7, 1.1, 1.0, respectively ( P = .3-.6)). Peritoneal lavage bacterial growth was nonsignificantly lower after TGCR than after LCR (38.9% vs 60.0%, respectively; P = .30); administration of intragastric antibiotics did not decrease contamination. Three TGCR (vs no LCR) pigs had histologic peritonitis. Limitations Animal model, colon prepped, injury immediately recognized. Conclusion NOTES colon repair is feasible after transmural injury. Adhesions, histologic peritonitis, and contamination were similar to those with laparoscopy and were not helped by intragastric antibiotics.