Novel Approach to NOTES Gastrotomy Creation Using the Endoscopic Cap Suction Technique

BACKGROUND: Numerous methods have been described for gastrotomy creation during Natural Orifice Translumenal Endoscopic Surgery (NOTES). These techniques are often blind, difficult to perform, or require temporary placement of a gastrostomy tube. The objective of this study is to create a safer method of NOTES gastrotomy creation.
METHODS: A novel endoscopic cap suction technique was used for gastrotomy creation in 10 swine (6 non-survival, 4 survival). The prototype cap device (similar to an endoscopic mucosal resection (EMR) cap) was secured to the distal end of a gastroscope and easily inserted into the stomach. At the desired site, the gastric wall was suctioned into the cap. A straight cystotome was advanced through the full thickness of the gastric wall while holding continuous suction. A guidewire was advanced through the cystotome sheath followed by balloon dilatation. The gastroscope was then advanced easily into the peritoneal cavity and peritoneoscopy was performed. In six swine, immediate sacrifice and necropsy were performed. In four survival swine, the gastrotomy was closed with endoclips and necropsy was performed on postoperative day 10.
RESULTS: Gastrotomies with easy peritoneal access were successfully created in all 10 animals. At necropsy, there was no evidence of cautery injury to surrounding organs in any of the animals. Two (20%) small splenic hematomas were found that appeared to be due to guidewire trauma. These injuries were subclinical. All 4 survived animals thrived in the postoperative period and gained weight.
CONCLUSION: The endoscopic cap suction technique allows for a controlled, safe method of NOTES gastrotomy creation. Its benefits include ease of gastrotomy site localization from within the gastric lumen, protection from blind advancement of a cautery instrument, and elimination of the need to traverse the abdominal wall. While guidewire injury remains a concern, continued refinement of this approach may eliminate such risks. Larger studies will be needed in the future to study this promising technique.

Session: Poster

Program Number: P278