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: Flexible endoscopy has evolved to include multiple endoluminal procedures such as anti-reflux procedures, pyloromyotomy, and mucosal and submucosal tumor resections. However, these remain technically demanding procedures as they are hindered by the state of flexible technology which has difficult imaging, limited energy devices, no staplers, and cumbersome suturing abilities. An alternative approach is transgastric laparoscopy, which for almost 2 decades has been shown to be a good procedure for pancreatic pseudocyst drainage and full-thickness and mucosal resection of various lesions. We propose to expand the indications of transgastric laparoscopy by using novel endoscopically placed transgastric laparoscopy ports (TAGGS, Kansa, USA) to replicate endoscopic procedures such as endoluminal antireflux surgery.
METHODS AND PROCEDURES: Under general anesthesia 5 female pigs (mean weight 27.6 kg) had endoscopic placement of 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 gastroesophageal junction (GEJ) before and after intervention. Laparoendoscopic-assited suture plication of the GEJ was performed using 3-0 sutures (Polysorb®). Once the TAGGS ports were removed, the gastrotomies were closed by using endoscopic clip. At the end of the protocol, animals were euthanized.
RESULTS: Five laparoendoscopic-assited sewing plication were performed. The mean operative time was 65,6 min (Endoscopic Evaluation: 3.2 min, TAGSS Insertion: 11 min, EndoFLIP Evaluation + GEJ Plication: 43,25 min, Gastric Wall Closure: 15 min). In all cases, this technique was effective in achieving adequate GEJ plication. Median GEJ diameter (D) and median cross-sectional area (CSA) pre-plication were 11.42 mm (8.6-13.6 mm) and 104.8 mm2 (58-146 mm2). After the procedure, these values were decreased to 6.14 mm (5.7-6.6 mm) and 29.8 mm2 (25-34 mm2) respectively (p= 0,0079). Median distensibility (d) and median compliance (C) pre-plication were 7.87 mm2/mmHg (2.4-22.69 mm2/mmHg) and 190.56 mm3/mmHg (70,9-502,8 mm3/mmHg). After the procedure, these values were decreased to 1,5 mm2/mmHg (0.7-2.2 mm2/mmHg) and 52.17 mm3/mmHg (21.9-98.7 mm3/mmHg) respectively (p= 0,0317). No intraoperative events were observed.
CONCLUSION: A hybrid laparoendoscopic approach is a feasible alternative for performing intragastric procedures with the assistance of conventional laparoscopic instruments; especially in cases where the location of the intervention limits the access of standard endoscopy or where endoscopic technology is inadequate. Further evaluation is planned in survival models and clinical trials.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 86786
Program Number: P382
Presentation Session: iPoster Session (Non CME)
Presentation Type: Poster