Comparative study of NOTES rectosigmoidectomy in a swine model: E-NOTES vs. P-NOTES

Background and study aims: Several reports have demonstrated the safety of pure natural-orifice transluminal endoscopic surgery (P-NOTES) using transanal endoscopic microsurgery (TEM) and embryonic NOTES (E-NOTES; laparoscopic surgery through the umbilicus). This study was performed to compare the safety and applicability of NOTES rectosigmoidectomy between E-NOTES and P-NOTES in a swine model.

Patients and methods: E-NOTES was conducted through a single port using laparoscopic instruments (n = 11). P-NOTES was performed using TEM with transgastric endoscopic assistance (n = 11). Gastrotomies were created using a needle knife and the balloon dilatation technique, and closed using T-anchors. Blood samples were collected to evaluate changes in systemic cytokine levels during the preoperative and postoperative periods; operative outcomes were also evaluated and compared between the groups. The necropsy findings were recorded after sacrifice at 1 week after the procedure.

Results: The mean operative time for P-NOTES was significantly longer than that for E-NOTES (239 vs. 103 minutes, P < 0.001). The mean distance from the anal verge to colorectal anastomosis in the P-NOTES group was significantly less than that in the E-NOTES group (2.9 vs. 17.6 cm, P < 0.001). On necropsy, the complication rate of P-NOTES was higher than that of E-NOTES, but without statistical significance (54.5 % vs. 18.2 %, P = 0.091). The differences in changes in TNF-α, C-reactive protein, interleukin-6, and interleukin-1β between P-NOTES and E-NOTES were not significant.

Conclusions: E-NOTES rectosigmoidectomy in the swine model is safe, but remains challenging for use in pelvic dissection. P-NOTES rectosigmoidectomy using TEM may be a promising tool for pelvic dissection, but the transgastric approach involves a high degree of risk.

References

• 1 Kalloo A N, Singh V K, Jagannath S B et al. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity.  Gastrointest Endosc. 2004;  60 114-117
• 2 Canes D, Desai M M, Aron M et al. Transumbilical single-port surgery: evolution and current status.  Eur Urol. 2008;  54 1020-1029
• 3 Lim M C, Kim T J, Kang S et al. Embryonic natural orifice transumbilical endoscopic surgery (E-NOTES) for adnexal tumors.  Surg Endosc. 2009;  23 2445-2449
• 4 Rattner D W. NOTES: Where have we been and where are we going?.  Surg Endosc. 2008;  22 1143-1145
• 5 Knol J, D’Hondt M, Dozois E J et al. Laparoscopic-assisted sigmoidectomy with transanal specimen extraction: a bridge to NOTES?.  Tech Coloproctol. 2009;  13 65-68
• 6 Bucher P, Ostermann S, Pugin F, Morel P. E-NOTES appendectomy versus transvaginal appendectomy: similar cosmetic results but shorter complete recovery?.  Surg Endosc. 2009;  23 916-917
• 7 Navarra G, Pozza E, Occhionorelli S et al. One-wound laparoscopic cholecystectomy.  Br J Surg. 1997;  84 695
• 8 Podolsky E R, Rottman S J, Poblete H et al. Single port access (SPA) cholecystectomy: a completely transumbilical approach.  J Laparoendosc Adv Surg Tech. A2009;  19 219-222
• 9 Zhu J F. Which term is better: SILS, SPA, LESS, E-NOTES, or TUES?.  Surg Endosc. 2009;  23 1164-1165
• 10 Whiteford M H, Denk P M, Swanstrom L L. Feasibility of radical sigmoid colectomy performed as natural orifice translumenal endoscopic surgery (NOTES) using transanal endoscopic microsurgery.  Surg Endosc. 2007;  21 1870-1874
• 11 Sylla P, Willingham F F, Sohn D K et al. NOTES rectosigmoid resection using transanal endoscopic microsurgery (TEM) with transgastric endoscopic assistance: a pilot study in swine.  J Gastrointest Surg. 2008;  12 1717-1723
• 12 Leroy J, Cahill R A, Peretta S, Marescaux J. Single port sigmoidectomy in an experimental model with survival.  Surg Innov. 2008;  15 260-265
• 13 Leroy J, Cahill R A, Asakuma M et al. Single-access laparoscopic sigmoidectomy as definitive surgical management of prior diverticulitis in a human patient.  Arch Surg. 2009;  144 173-179
• 14 Zorron R, Maggioni L C, Pombo L et al. NOTES transvaginal cholecystectomy: preliminary clinical application.  Surg Endosc. 2008;  22 542-547
• 15 Decarli L A, Zorron R, Branco A et al. New hybrid approach for NOTES transvaginal cholecystectomy: preliminary clinical experience.  Surg Innov. 2009;  16 181-186
• 16 Horgan S, Cullen J P, Talamini M A et al. Natural orifice surgery: initial clinical experience.  Surg Endosc. 2009;  23 1512-1518
• 17 Gill I S, Canes D, Aron M et al. Single port transumbilical (E-NOTES) donor nephrectomy.  J Urol. 2008;  180 637-641
• 18 Leroy J, Cahill R A, Perretta S et al. Natural orifice translumenal endoscopic surgery (NOTES) applied totally to sigmoidectomy: an original technique with survival in a porcine model.  Surg Endosc. 2009;  23 24-30
• 19 Sohn D K, Turner B G, Gee D W et al. Reducing the unexpectedly high rate of injuries caused by NOTES gastrotomy creation.  Surg Endosc. 2010;  24 277-282
• 20 Sylla P, Sohn D K, Cizginer S et al. Survival study of natural orifice translumenal endoscopic surgery for rectosigmoid resection using transanal endoscopic microsurgery with or without transgastric endoscopic assistance in a swine model.  Surg Endosc. 2010;  24 2022-2030
• 21 Willingham F F, Turner B G, Gee D W et al. Leaks and endoscopic assessment of break of integrity after NOTES gastrotomy: the LEAKING study, a prospective, randomized, controlled trial.  Gastrointest Endosc. 2010;  71 1018-1024
• 22 Wagh M S, Merrifield B F, Thompson C C. Survival studies after endoscopic transgastric oophorectomy and tubectomy in a porcine model.  Gastrointest Endosc. 2006;  63 473-478
• 23 Auyang E D, Hungness E S, Vaziri K et al. Natural orifice translumenal endoscopic surgery (NOTES): dissection for the critical view of safety during transcolonic cholecystectomy.  Surg Endosc. 2009;  23 1117-1118
• 24 von Delius S, Gillen S, Doundoulakis E et al. Comparison of transgastric access techniques for natural orifice transluminal endoscopic surgery.  Gastrointest Endosc. 2008;  68 940-947
• 25 Denk P M, Swanstrom L L, Whiteford M H. Transanal endoscopic microsurgical platform for natural orifice surgery.  Gastrointest Endosc. 2008;  68 954-959
• 26 Swanstrom L L, Whiteford M, Khajanchee Y. Developing essential tools to enable transgastric surgery.  Surg Endosc. 2008;  22 600-604
• 27 Sylla P, Rattner D W, Delgado S, Lacy A M. NOTES transanal rectal cancer resection using transanal endoscopic microsurgery and laparoscopic assistance.  Surg Endosc. 2010;  24 1205-1210
• 28 Leung K L, Lai P B, Ho R L et al. Systemic cytokine response after laparoscopic-assisted resection of rectosigmoid carcinoma: a prospective randomized trial.  Ann Surg. 2000;  231 506-511
• 29 Delgado S, Lacy A M, Filella X et al. Acute phase response in laparoscopic and open colectomy in colon cancer: randomized study.  Dis Colon Rectum. 2001;  44 638-646
• 30 Dunker M S, Ten Hove T, Bemelman W A et al. Interleukin-6, C-reactive protein, and expression of human leukocyte antigen-DR on peripheral blood mononuclear cells in patients after laparoscopic vs. conventional bowel resection: a randomized study.  Dis Colon Rectum. 2003;  46 1238-1244
• 31 Leblanc F, Champagne B J, Augestad K M et al. Single incision laparoscopic colectomy: technical aspects, feasibility, and expected benefits.  Diagn Ther Endosc. published online 2010;  doi 10.1155/2010/913216
• 32 Delaney C P, Chang E, Senagore A J, Broder M. Clinical outcomes and resource utilization associated with laparoscopic and open colectomy using a large national database.  Ann Surg. 2008;  247 819-824
• 33 Böhm B, Milsom J W. Animal models as educational tools in laparoscopic colorectal surgery.  Surg Endosc. 1994;  8 707-713
• 34 Fleshman J W, Brunt L M, Fry R D et al. Laparoscopic anterior resection of the rectum using a triple stapled intracorporeal anastomosis in the pig.  Surg Laparosc Endosc. 1993;  3 119-126
• 35 Kopelman D, Lelcuk S, Sayfan J et al. End-to-end compression anastomosis of the rectum: a pig model.  World J Surg. 2007;  31 532-537