Background and study aim: Secure and reliable endoscopic closure is of paramount importance before clinical
introduction of transgastric natural orifice transluminal endoscopic surgery (NOTES).
Gastrotomy closure in humans using standard endoclips has been reported. The aim of
this study was to assess the safety of standard endoclip closure and to compare it
to a new over-the-scope clip (OTSC) specifically designed for gastrotomy closure.
Material and methods: Gastric wall puncture and balloon dilation followed by peritoneoscopy was carried
out in 20 female swine. After randomization, closure of the gastric incision was performed
using a tissue approximation grasper and either endoclips or OTSCs.
Results: Mean (± SD) time for gastrotomy closure using endoclips was 31.5 ± 24.2 minutes (range
8 – 88 minutes) compared with 8.5 ± 9.1 minutes (range 2 – 31 minutes) using OTSC
(P = 0.002). No intraoperative complications occurred. Laparoscopic leak tests with
insufflation and saline immersion demonstrated three minor leaks and one major leak
in the endoclip closures. No leaks were observed in the OTSC group. At necropsy, complete
sealing of the gastrotomy sites was found in all OTSC closures. Small, localized perigastric
abscesses were observed in two animals in the OTSC group and in three animals in the
endoclip group. One animal in the endoclip group was sacrificed prematurely due to
signs of sepsis and was found to have gross peritonitis secondary to a leak. At necropsy,
evidence of peritonitis was identified in two other animals in the endoclip group.
Conclusion: NOTES gastrotomy closure using standard endoclips, even with a tissue approximation
grasper, is associated with an increased risk of leakage and intra-abdominal infection
compared with OTSC. The significance of perigastric abscesses, which were seen in
both groups, warrants further investigation.
References
richard.rothstein@dartmouth.edu
