Background: Evaluation of a potential source of abdominal sepsis in a critically ill patient can be challenging. With flexible endoscopy being readily available in this setting, we sought to evaluate the diagnostic efficacy of a trans-gastric NOTES peritoneoscopy vs. laparoscopic exploration in the identification of common intra-abdominal pathology in a porcine model.
Methods: In this acute study, 15 pigs were randomized to demonstrate 0 to 4 pathologic lesions: small bowel ischemia (SBI), Small bowel perforation (SBP), Recto-sigmoid colon perforation (CP), and gangrenous cholecystitis (GC). Two blinded surgeons were allowed 60 minutes to perform NOTES or laparoscopy (LAP) to correctly identify or exclude each lesion. A prototype endoscope (NOTES-scope, Olympus, Inc), which incorporates two independently mobile channels for aided technical ability, was used in the NOTES arm.
Results: When considering all potential lesions, LAP correctly indentified or ruled out pathology only slightly better than NOTES (85% vs. 80%). LAP was also more sensitive diagnostically (77.4% vs. 61.3%), overall. However, NOTES was 100% specific with 100% positive predictive value (PPV) compared to 93.1% and 92.3% with LAP, respectively. Individually, NOTES was best at CP identification and fared poorest for SBP (see table, NPV=negative predictive value).
Conclusion: The utilization of NOTES as a diagnostic tool may have an important role in the critically ill patient population when operative intervention is highly morbid. While it may be inferior in detecting all pathology compared to laparoscopy, a positive identification was highly specific with a strong predictive value. Further investigation addressing an improved small bowel evaluation technique, however, would be beneficial and warranted. A human trial considered in the current state would still mandate laparoscopic confirmation.
Program Number: P268