Background and study aims: Natural orifice transluminal endoscopic surgery (NOTES) within the peritoneal
cavity is rapidly evolving, using transgastric, transcolonic, or transvaginal
access. There is little experience with transesophageal NOTES access to the mediastinum.
This prospective long-term animal survival study was performed to explore the
feasibility and safety of transesophageal intrathoracic procedures including
minor surgery.
Material and methods: Nine pigs were used for acute (n = 2) and up to 6-week survival studies (n
= 7), followed by autopsy and histological investigation. The esophageal incision
site was chosen using EUS; this was followed by endoscopic mediastinoscopy and
therapeutic procedures such as mediastinal lymph node removal, saline injection
into myocardium, and pericardial fenestration. The wall was closed using a suturing
system or endoscopic clips.
Results: No acute complications were recorded with respect to mediastinal structures,
pericardium, cardiac rhythm, or circulatory parameters. Removal of small mediastinal
lymph nodes (n = 2) was feasible, but proved to be difficult. Other procedures,
specifically at the heart were all successfully performed. Endoscopy after 4 -
6 weeks showed a well-healed esophageal incision. Autopsy with histology revealed
no signs of mediastinitis, infection, bleeding, or pericarditis. The esophageal
scar was found to be well healed in all cases, but with a muscular gap where clip
closure had been used.
Conclusions: Transmural esophageal incision and endoscopic partial mediastinoscopy including
therapeutic procedures on the heart or mediastinum proved feasible in long-term
survival animal studies. Clip closure of the defect was effective, but did not
close the esophageal muscle layer. Other means such as endoscopic suturing appear
to be preferable.
References
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