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.

• References

• 1 Ly J, O’Grady G, Mittal A et al. A systematic review of methods to palliate malignant gastric outlet obstruction. Surg Endosc 2010; 24: 290-297
• 2 Buchwald H, Avidor Y, Braunwald E et al. Bariatric surgery: a systematic review and meta-analysis. JAMA 2004; 292: 1724-1737
• 3 Podnos YD, Jimenez JC, Wilson SE et al. Complications after laparoscopic gastric bypass: a review of 3464 cases. Arch Surg 2003; 138: 957-961
• 4 Giday SA, Kantsevoy SV, Kalloo AN. Principle and history of natural orifice translumenal endoscopic surgery (NOTES). Minim Invasive Ther Allied Technol 2006; 15: 373-377
• 5 De Palma GD, Persico F, Masone S et al. Natural orifices transluminal endoscopic surgery (NOTES): an overview of technical challenges and complications of transgastric procedures in anesthetized pigs. Minerva Chir 2008; 63: 261-268
• 6 Bergstrom M, Ikeda K, Swain P et al. Transgastric anastomosis by using flexible endoscopy in a porcine model (with video). Gastrointest Endosc 2006; 63: 307-312
• 7 Kantsevoy SV, Jagannath SB, Niiyama H et al. Endoscopic gastrojejunostomy with survival in a porcine model. Gastrointest Endosc 2005; 62: 287-292
• 8 Chiu PW, Wai Ng EK, Teoh AY et al. Transgastric endoluminal gastrojejunostomy: technical development from bench to animal study (with video). Gastrointest Endosc 2010; 71: 390-393
• 9 Vanbiervliet G, Gonzalez JM, Bonin EA et al. Gastrojejunal anastomosis exclusively using the “NOTES” technique in live pigs: a feasibility and reliability study. Surg Innov. [Epub 19.11.2013; DOI: DOI: 10.1177/1553350613508016].
• 10 von Renteln D, Vassiliou MC, McKenna D et al. Endoscopic vs. laparoscopic gastrojejunostomy for duodenal obstruction: a randomized study in a porcine model. Endoscopy 2012; 44: 161-168
• 11 Binmoeller KF, Shah JN. Endoscopic ultrasound-guided gastroenterostomy using novel tools designed for transluminal therapy: a porcine study. Endoscopy 2012; 44: 499-503
• 12 Fuchs KH, Meining A, von Renteln D et al. Euro-NOTES status paper: from the concept to clinical practice. Surg Endosc 2013; 27: 1456-1467
• 13 Sporn E, Miedema BW, Astudillo JA et al. Pilot data on the endoscopic placement of covered metal stents to treat gastrojejunal leaks in a porcine model. Obes Surg 2010; 20: 226-231
• 14 Gonzalez J-M, Bonin EA, Vanbiervliet G et al. Evaluation of feasibility, efficiency and safety of a pure NOTES gastrojejunal bypass with gastric outlet obstruction, in an in vivo porcine model. Endosc Int Open 2013; 1: E31-E38
• 15 Song TJ, Seo DW, Kim SH et al. Endoscopic gastrojejunostomy with a natural orifice transluminal endoscopic surgery technique. World J Gastroenterol 2013; 19: 3447-3452
• 16 Luo H, Pan Y, Min L et al. Transgastric endoscopic gastroenterostomy using a partially covered occluder: a canine feasibility study. Endoscopy 2012; 44: 493-498
• 17 Gornals JB, De la Serna-Higuera C, Sanchez-Yague A et al. Endosonography-guided drainage of pancreatic fluid collections with a novel lumen-apposing stent. Surg Endosc 2013; 27: 1428-1434
• 18 Itoi T, Itokawa F, Uraoka T et al. Novel EUS-guided gastrojejunostomy technique using a new double-balloon enteric tube and lumen-apposing metal stent (with videos). Gastrointest Endosc 2013; 78: 934-939
• 19 Jeurnink SM, Steyerberg EW, van Hooft JE et al. Surgical gastrojejunostomy or endoscopic stent placement for the palliation of malignant gastric outlet obstruction (SUSTENT study): a multicenter randomized trial. Gastrointest Endosc 2010; 71: 490-499
• 20 No JH, Kim SW, Lim CH et al. Long-term outcome of palliative therapy for gastric outlet obstruction caused by unresectable gastric cancer in patients with good performance status: endoscopic stenting versus surgery. Gastrointest Endosc 2013; 78: 55-62
• 21 van Hooft JE, Vleggaar FP, Le Moine O et al. Endoscopic magnetic gastroenteric anastomosis for palliation of malignant gastric outlet obstruction: a prospective multicenter study. Gastrointest Endosc 2010; 72: 530-535
• 22 Verdam FJ, Schouten R, Greve JW et al. An update on less invasive and endoscopic techniques mimicking the effect of bariatric surgery. J Obes 2012; 2012: 597871
• 23 Kantsevoy SV, Niiyama H, Jagannath SB et al. The endoscopic transilluminator: an endoscopic device for identification of the proximal jejunum for transgastric endoscopic gastrojejunostomy. Gastrointest Endosc 2006; 63: 1055-1058