Endoscopy 2012; 44(06): 596-604
DOI: 10.1055/s-0031-1291790
Original article
© Georg Thieme Verlag KG Stuttgart · New York

Standard diagnostic laparoscopy is superior to NOTES approaches: results of a blinded, randomized controlled porcine study

D. von Renteln
1   Department of Interdisciplinary Endoscopy, Hamburg-Eppendorf University Hospital, Hamburg, Germany
,
T. E. Gutmann
2   Mannheim University Hospital, Heidelberg University Medical School, Mannheim, Germany
,
A. Schmidt
3   Department of Gastroenterology, Hepatology and Oncology, Ludwigsburg Hospital, Ludwigsburg, Germany
,
M. C. Vassiliou
4   Department of Surgery, McGill University Health Centre, Montreal, Quebec, Canada
,
H. U. Rudolph
5   Department of Surgery, Mannheim University Hospital, Mannheim, Germany
,
K. Caca
3   Department of Gastroenterology, Hepatology and Oncology, Ludwigsburg Hospital, Ludwigsburg, Germany
› Author Affiliations
Further Information

Publication History

submitted 21 July 2011

accepted after revision 09 January 2012

Publication Date:
08 March 2012 (online)

Background and study aim: The use of transluminal endoscopic access via the stomach or colon for flexible diagnostic peritoneoscopy has been proposed, although the diagnostic value of the technique has not yet been fully clarified. In this animal trial, the two main natural orifice transluminal endoscopic surgery (NOTES) approaches – transgastric (TG) and transcolonic (TC) – were compared with standard transabdominal access using both rigid (TAR) and flexible instruments (TAF) for diagnostic laparoscopy.

Methods: A total of 48 peritoneoscopies were performed using two randomly assigned approaches in 24 anesthetized pigs. The ability of the examinations to detect 576 electrocautery markings simulating intraperitoneal metastases, to achieve complete organ visualization, and to simulate organ biopsies was analyzed.

Results: Sensitivities for the detection of lesions were 78.5 %, 59.7 %, 48.6 %, and 38.9 % for TAR, TAF, TC, and TG, respectively; standard laparoscopy was superior to all other approaches (P < 0.01). Among the NOTES approaches, TC was superior for examining the upper abdomen (P = 0.03). Complete organ visualization was better with the transabdominal approach (visual analogue scale TAR 7.15, TAF 6.71) than with the NOTES access routes (TC 5.07, TG 4.35); standard rigid laparoscopy was superior to both NOTES approaches (P < 0.01). Organ biopsy simulation was possible in 87 %, 85 %, 72 %, and 65 % of cases with TAR, TAF, TC, and TG, respectively. Standard rigid laparoscopy was again superior to both NOTES approaches (TAR vs. TC, P = 0.03; TAR vs. TG, P < 0.01).

Conclusions: In this experimental trial, rigid standard laparoscopy provided better organ visualization, better lesion detection, and better biopsy capability than the transgastric and transcolonic NOTES approaches. In its current form, NOTES appears to be unsuitable for diagnostic laparoscopy.

 
  • References

  • 1 Awad SS, Colletti L, Mulholland M et al. Multimodality staging optimizes resectability in patients with pancreatic and ampullary cancer. Am Surg 1997; 63: 634-638
  • 2 Bonavina L, Incarbone R, Lattuada E et al. Preoperative laparoscopy in management of patients with carcinoma of the esophagus and of the esophagogastric junction. J Surg Oncol 1997; 65: 171-174
  • 3 Burke EC, Karpeh MS, Conlon KC et al. Laparoscopy in the management of gastric adenocarcinoma. Ann Surg 1997; 225: 262-267
  • 4 Cesana BM. Prospective comparison of laparoscopy, ultrasonography and computed tomography in the staging of gastric cancer. Br J Surg 1997; 84: 1170
  • 5 Chang L, Stefanidis D, Richardson WS et al. The role of staging laparoscopy for intraabdominal cancers: an evidence-based review. Surg Endosc 2009; 23: 231-241
  • 6 Conlon KC, Dougherty E, Klimstra DS et al. The value of minimal access surgery in the staging of patients with potentially resectable peripancreatic malignancy. Ann Surg 1996; 223: 134-140
  • 7 Hori Y. Diagnostic laparoscopy guidelines: This guideline was prepared by the SAGES Guidelines Committee and reviewed and approved by the Board of Governors of the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES), November 2007. Surg Endosc 2008; 22: 1353-1383
  • 8 Kapadia CR. Pancreatic cancer: diagnosis and staging at one sitting. Gastroenterology 1997; 113: 1417-1418
  • 9 Minnard EA, Conlon KC, Hoos A et al. Laparoscopic ultrasound enhances standard laparoscopy in the staging of pancreatic cancer. Ann Surg 1998; 228: 182-187
  • 10 Possik RA, Franco EL, Pires DR et al. Sensitivity, specificity, and predictive value of laparoscopy for the staging of gastric cancer and for the detection of liver metastases. Cancer 1986; 58: 1-6
  • 11 Vollmer CM, Drebin JA, Middleton WD et al. Utility of staging laparoscopy in subsets of peripancreatic and biliary malignancies. Ann Surg 2002; 235: 1-7
  • 12 Lo CM, Lai EC, Liu CL et al. Laparoscopy and laparoscopic ultrasonography avoid exploratory laparotomy in patients with hepatocellular carcinoma. Ann Surg 1998; 227: 527-532
  • 13 Baccarani U, Carroll BJ, Hiatt JR et al. Comparison of laparoscopic and open staging in Hodgkin disease. Arch Surg 1998; 133: 517-521 discussion 521-512
  • 14 Thaler K, Kanneganti S, Khajanchee Y et al. The evolving role of staging laparoscopy in the treatment of colorectal hepatic metastasis. Arch Surg 2005; 140: 727-734
  • 15 Jarnagin WR, Conlon K, Bodniewicz J et al. A clinical scoring system predicts the yield of diagnostic laparoscopy in patients with potentially resectable hepatic colorectal metastases. Cancer 2001; 91: 1121-1128
  • 16 Harewood GC, Wiersema MJ, Nelson H et al. A prospective, blinded assessment of the impact of preoperative staging on the management of rectal cancer. Gastroenterology 2002; 123: 24-32
  • 17 Talwalkar JA, Gores GJ. Diagnosis and staging of hepatocellular carcinoma. Gastroenterology 2004; 127: 126-S132
  • 18 Silecchia G, Raparelli L, Perrotta N et al. Accuracy of laparoscopy in the diagnosis and staging of lymphoproliferative diseases. World J Surg 2003; 27: 653-658
  • 19 Vazquez-Sequeiros E, Wiersema MJ, Clain JE et al. Impact of lymph node staging on therapy of esophageal carcinoma. Gastroenterology 2003; 125: 1626-1635
  • 20 Nord HJ, Brady PG, Lightdale CJ et al. Diagnostic laparoscopy guidelines for clinical application. Gastrointest Endosc 2001; 54: 818-820
  • 21 D’Ugo DM, Persiani R, Caracciolo F et al. Selection of locally advanced gastric carcinoma by preoperative staging laparoscopy. Surg Endosc 1997; 11: 1159-1162
  • 22 Young-Fadok TM, Smith CD, Sarr MG. Laparoscopic minimal-access surgery: where are we now? Where are we going?. Gastroenterology 2000; 118: 148-165
  • 23 ASGE/SAGES Working Group on Natural Orifice. Translumenal Endoscopic Surgery White Paper October 2005. Gastrointest Endosc 2006; 63: 199-203
  • 24 Kalloo AN, Singh VK, Jagannath SB et al. Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc 2004; 60: 114-117
  • 25 Merrifield BF, Wagh MS, Thompson CC. Peroral transgastric organ resection: a feasibility study in pigs. Gastrointest Endosc 2006; 63: 693-697
  • 26 Park PO, Bergstrom M, Ikeda K et al. Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis (videos). Gastrointest Endosc 2005; 61: 601-606
  • 27 Steele K, Schweitzer MA, Lyn-Sue J et al. Flexible transgastric peritoneoscopy and liver biopsy: a feasibility study in human beings (with videos). Gastrointest Endosc 2008; 68: 61-66
  • 28 Hazey JW, Narula VK, Renton DB et al. Natural-orifice transgastric endoscopic peritoneoscopy in humans: Initial clinical trial. Surg Endosc 2008; 22: 16-20
  • 29 Kantsevoy SV, Jagannath SB, Niiyama H et al. A novel safe approach to the peritoneal cavity for per-oral transgastric endoscopic procedures. Gastrointest Endosc 2007; 65: 497-500
  • 30 Sohn DK, Turner BG, Gee DW et al. Reducing the unexpectedly high rate of injuries caused by NOTES gastrotomy creation. Surg Endosc 2010; 24: 277-282
  • 31 Stell DA, Carter CR, Stewart I et al. Prospective comparison of laparoscopy, ultrasonography and computed tomography in the staging of gastric cancer. Br J Surg 1996; 83: 1260-1262
  • 32 Voermans RP, Sheppard B, van Berge Henegouwen MI et al. Comparison of transgastric NOTES and laparoscopic peritoneoscopy for detection of peritoneal metastases. Ann Surg 2009; 250: 255-259
  • 33 Clark J, Gillen S, James DR et al. Transgastric or trans-sigmoidal? The impact of the choice of access on task performance in target natural orifice translumenal endoscopic surgery procedures.. J Laparoendosc Adv Surg Tech A 2011; 21: 237-242
  • 34 Denzer U, Hoffmann S, Helmreich-Becker I et al. Minilaparoscopy in the diagnosis of peritoneal tumor spread: prospective controlled comparison with computed tomography. Surg Endosc 2004; 18: 1067-1070
  • 35 Denzer U, Arnoldy A, Kanzler S et al. Prospective randomized comparison of minilaparoscopy and percutaneous liver biopsy: diagnosis of cirrhosis and complications. J Clin Gastroenterol 2007; 41: 103-110
  • 36 Helmreich-Becker I, Meyer zum Buschenfelde KH, Lohse AW. Safety and feasibility of a new minimally invasive diagnostic laparoscopy technique. Endoscopy 1998; 30: 756-762
  • 37 Schneider AR, Benz C, Adamek HE et al. Minilaparoscopy versus conventional laparoscopy in the diagnosis of hepatic diseases. Gastrointest Endosc 2001; 53: 771-775
  • 38 Voermans RP, Faigel DO, van Berge Henegouwen MI et al. Comparison of transcolonic NOTES and laparoscopic peritoneoscopy for the detection of peritoneal metastases. Endoscopy 2010; 42: 904-909