A new stapler-based full-thickness transgastric access closure: results from an animal pilot trial

P. Magno; S. A. Giday; X. Dray; S. S. Chung; P. B. Cotton; C. J. Gostout; R. H. Hawes; A. N. Kalloo; P. J. Pasricha; J. J. White; L. Assumpcao; M. R. Marohn; K. L. Gabrielson; S. V. Kantsevoy

doi:10.1055/s-2007-966896

Endoscopy 2007; 39(10): 876-880
DOI: 10.1055/s-2007-966896

Original article

A new stapler-based full-thickness transgastric access closure: results from an animal pilot trial

P. Magno¹ , S. A. Giday² , X. Dray^1, ² , S. S. Chung³ , P. B. Cotton⁴ , C. J. Gostout⁵ , R. H. Hawes⁴ , A. N. Kalloo¹ , P. J. Pasricha⁶ , J. J. White⁷ , L. Assumpcao⁸ , M. R. Marohn⁸ , K. L. Gabrielson⁹ , S. V. Kantsevoy¹

¹Division of Gastroenterology, Johns Hopkins Hospital, Baltimore, Maryland, USA
²Department of Digestive Diseases, Lariboisière Hospital, APHP, Paris, France
³Department of Surgery, Prince of Wales Hospital, Hong Kong, China
⁴Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina, USA
⁵Division of Gastroenterology and Hepatology, Mayo Clinic and Foundation, Rochester, Minnesota, USA
⁶Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, California, USA
⁷Power Medical Interventions, Langhorne, Pennsylvania, USA
⁸Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland, USA
⁹Department of Molecular and Comparative Pathobiology, Johns Hopkins University, Baltimore, Maryland, USA

Abstract

Background and study aims: Reliable closure of the translumenal incision is the crucial step for natural orifice translumenal endoscopic surgery (NOTES) procedures. The aim of this study was to evaluate the feasibility and effectiveness of transgastric access closure with a flexible stapling device in a porcine survival model.

Patients and methods: We carried out four experiments (two sterile and two nonsterile) on 50 kg pigs. The endoscope was passed through a gastrotomy made with a needle knife and an 18-mm controlled radial expansion dilating balloon. After peritoneoscopy, a flexible linear stapling device (NOLC60, Power Medical Interventions®, Langhorne, Pennsylvania, USA) was perorally advanced over a guide wire into the stomach, positioned under endoscopic guidance, and opened to include the site of gastrotomy between its two arms; four rows of staples were fired. One animal was sacrificed 24 hours after the procedure (progression of pre-existing pneumonia). The remaining animals were survived for 1 week and then underwent repeat endoscopy and postmortem examination.

Results: Peroral delivery and positioning of the stapling device involved some technical difficulties, mostly due to the short length (60 cm) of the stapling device. The stapler provided complete leak-resistant gastric closure in all pigs. None of the surviving animals had any clinical signs of infection. Necropsy demonstrated an intact staple line with full-thickness healing of the gastrotomy in all animals. Histologic examination confirmed healing, but also revealed intramural micro-abscesses within the gastric wall after nonsterile procedure.

Conclusions: Gastrotomy closure with a perorally delivered flexible stapling device created a leak-resistant transmural line of staples followed by full-thickness healing of the gastric wall incision. Increasing the length of the instrument and adding device articulation will further facilitate its use for NOTES procedures.

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S. V. Kantsevoy, MD

Division of Gastroenterology

Johns Hopkins Hospital

1830 East Monument Street Room 423

Baltimore, MD 21205

USA

Fax: +1-410-614-2490

eMail: svkan@jhmi.edu