Trangastric access to the chest: opening a new vista?

The NOTES approach to the peritoneal cavity is well established today and procedures in humans have already been performed. The next question to be addressed is whether this access can be extended further. This video shows the feasibility of feasibility of transgastric access to the thoracic cavity in the porcine model.
Materials and methods:
A series of transgastric thoracic procedures were performed on 5 pigs:3 pulmonary biopsies and 2 pericardial windows. Under general anesthesia a 1.5 cm gastrotomy was made on the anterior gastric wall using a double channel flexible endoscope. In retroflexed view, the diaphragm was identified. A 1.5 cm incision was performed at the junction between the right and left domes of the diaphragm using cautery and endoscopic scissors. Once the incision was made, the endoscope was anchored onto the pleura with an atraumatic endoscopic grasper and gently eased into the mediastinum. The right and left lung and the pericardium were identified. In 2 pigs a pericardial window was created. The pericardium was opened with endoscopic scissors and a 4x4cm square opening was made.
In 3 pigs pulmonary biopsies were performed using standard biopsy forceps on the right and left lung. The first 2 pigs served to establish the technique. The last pig of the series was survived for 4 weeks. In this animal the gastrotomy was closed using a cardiac septal occluder device with a previously described method. The diaphragmatic defect was left open.
Trangastric acces to the thorax was achieved in all 5 animals with no intaoperative complications. The animals were hemodynamically stable throughout the procedure. No bleeding or injury to the heart and other mediastinal structures occurred. Post-operative course was uneventful in the survived pig and the 4 weeks post-operatively laparoscopic exploration showed no adhesions and complete closure of the diaphragmatic defect.
Transgastric access to the thoracic cavity is feasible and safe. Transgastric thoracoscopy, bilateral lung biopsies and pericardial window creation can be performed in the pig model. Further survival studies are neccessary to establish the key steps of these procedures before clinical application can be considered.

Session: Podium Presentation

Program Number: V010

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