Beyond NOTES: randomized controlled study of different methods of flexible endoscopic hemostasis of artificially induced hemorrhage, via NOTES access to the peritoneal cavity

Background and study aim: Significant hemorrhage is a likely complication during natural orifice transluminal endoscopic surgery (NOTES) procedures. We tested three different prototype devices (involving endoscopic suturing, monopolar forceps, and forced argon plasma coagulation [FAPC]) for treatment of acute bleeding in a survival animal model.

Method: Using transgastric access (TGA) or transvaginal access (TVA), the endoscope was introduced into the peritoneal cavity and the first side-branch of the gastroepiploic artery (1aGE) was cut before the different hemostatic methods were applied.

Results: Sutures could not be placed quickly enough before vision was inhibited. With monopolar forceps via TGA, the time to control bleeding was 10 – 140 s (mean 58 ± 41 s) and with TVA it was 25 – 115 s (mean 57 ± 26 s) (P = 0.54). It was not possible to stop the bleeding in 4/6 animals with TGA access and in 3/6 with TVA, and FAPC was needed to entirely stop it, taking a further 10 – 280 s (TGA mean 126 ± 90 s, 34 – 242 s; TVA mean 152 ± 61 s; P = 0.42). Using FAPC with TGA took 4 – 72 s (mean 28 ± 20 s) to stop the bleeding, and 16 – 41 s (mean 24 ± 9.4 s) with TVA (P = 0.64). As the FAPC technique was relatively so much better, additional treatment of bleeding from the main gastroepiploic artery (aGe) was added in four cases for each method of access; this was successful but took significantly longer, with TGA at 10 – 260 s and with TVA at 30 – 172 s (means 98 ± 82, 117 ± 54 s, respectively; not significant).

Conclusion: Regarding the three methods tested, the new prototype FAPC device allowed hemostasis of notable bleeding from a major vessel even more quickly than forceps coagulation of a bleeding side branch. More studies are needed to further explore this potentially very valuable tool.

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