Cristians A Gonzalez, MD1, Jung-Myun Kwak, MD1, Federico Davrieux, MD1, Ryohei Watanabe, MD2, Jacques Marescaux, MD, FACS, HON, FRCS, HON, FJSES, HON, FASA2, Lee L Swanstrom, MD, FACS, FASGE, Hon, FRCS1. 1IHU-Strasbourg, Institute for Image-Guided Surgery (Strasbourg, France), 2IRCAD, Research Institute against Cancer of the Digestive System (Strasbourg, France)
INTRODUCTION: Gastroparesis is a rapidly increasing problem with sometimes devestating patient consequenses. Surgical treatments, particularly laparoscopic pyloroplasty, have recently gained popularity but require general anesthesia, advanced skills and create risk of leaks. Peroral Pyloromyotomy (POP) is a less invasive alternative but is technically demanding and not widely available. We propose an hybrid laparo-endoscopic collaborative approach using a novel gastric access device to allow a endoluminal stapled pyloroplasty as an alternative treatment option for functional gastric outlet obstruction.
METHODS AND PROCEDURES: Under general anesthesia six female pigs (mean weight 33 kg) had endoscopic placement of 2 or 3 5mm intragastric ports (TAGGS, Kansas, USA) using a technique similar to percutaneous endoscopic gastrostomy. A 5mm laparoscope was used for visualization. EndoFLIP (Crospon, Inc., Galway, Ireland) was used to measure cross sectional area (CSA) and compliance of the pylorus before intervention, immediately after and at 1 week survival. Pyloroplasty was performed using a 5mm articulating laparoscopic stapler (Dextera MicroCutter). After removing the TAGGS ports, the gastrotomies were closed by either endoscopic clip, endoscopic suture or suture under laparoscopic vision. The animals were survived for 1 week. After 6-8 days, a second laparo-endoscopic procedure was performed to verify healing of the pyloroplasty as well as intraluminal dimensions. At the end of the protocol, animals were euthanized.
RESULTS: Six endoluminal linear stapled pyloroplasty were performed. The mean operative time was 112 min. In all cases, this technique was effective in achieving optimal pyloric dilatation. Median pyloric diameter (D) and median cross-sectional area (CSA) pre-pyloroplasty were 8mm (4.9-11.6 mm) and 58.6 mm2 (19-107 mm2). After the procedure, these values were increased to 13.41 mm (9.8-17.6 mm) and 147.7 mm2 (76-244 mm2) respectively (p= 0.0152). No intraoperative events were observed, except one case that presented bleeding in the stapling line that merited transfixing suture with laparoscopic instruments. Postoperatively, all animals did well, with an adequate oral intake and without relevant complications. At follow-up endoscopy, all incisions were healed and the pylorus widely patent. There were no significant changes in the EndoFlip values [D: 13.2 mm (10.6-16.1 mm). CSA: 141.3 mm2 (88-204 mm2). p= 0.9372]. At explant, one animal had periampulary inflamation with a serous collection however testing showed no perforation.
CONCLUSION: Hybrid endoluminal stapled pyloroplasty appears a safe and effective treatment for gastroparesis and may be easier to learn and perform than alternatives such as POP and laparoscopic pyloroplasty.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 86777
Program Number: P379
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster
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