Pilot comparison of adhesion formation following colonic perforation and repair in a pig model using a transgastric, laparoscopic, or open surgical technique

Background and study aim: Postoperative adhesions create significant morbidity and mortality. Natural orifice transluminal endoscopic surgery (NOTES) procedures may reduce or eliminate adhesions by avoiding disruption of the parietal peritoneum. The primary aim of this pilot study was to compare adhesion formation after performance and subsequent repair of colonic perforation via transgastric, laparoscopic, or open surgical techniques. The secondary aim was to test the feasibility and outcome of transgastric management of bowel perforation in a prepared model.

Material and methods: 15 Yorkshire pigs were divided into three groups of five: transgastric (needle-knife entry with balloon dilation over a wire), laparoscopic, and open surgical. Aspects of adhesion formation (density/vascularity, width of bands, and number of organ pairs involved) were compared after perforation and repair during the same procedure. Intra- and postoperative complications were documented during the 21-day survival period.

Results: All 15 pigs recovered fully with no immediate procedural complications. After 21 days, there was a trend towards a lower adhesion burden regarding density/vascularity and number of organ pairs involved, and a significant reduction in the width of the adhesive bands, when the transgastric group was compared with the surgical groups. Additionally, there was a trend towards decreased adhesions to the peritoneum in the transgastric group.

Conclusions: Repair of colonic perforation during transgastric (NOTES) procedures appear feasible and safe in a porcine model. There appears to be a trend towards a lower rate of adhesion formation with the transgastric approach compared with laparoscopic or open surgery.

References

• 1 Senthilkumar M P, Dreyer J S. Peritoneal adhesions: pathogenesis, assessment and effects.  Trop Gastroenterol. 2006;  27 11-18
• 2 Peritoneal adhesiolysis. In: National Inpatient Profile 1993. Baltimore; HCIA Inc 1994: 635-655
• 3 Gutt C N, Oniu T, Schemmer P. et al . Fewer adhesions induced by laparoscopic surgery?.  Surg Endosc. 2004;  18 898-906
• 4 Scott-Conner C E. Laparoscopic gastrointestinal surgery.  Med Clin N Am. 2002;  86 1401-1422
• 5 Polymeneas G, Theodosopoulos T, Stamatiadis A, Kourias A. A comparative study of postoperative adhesion formation after laparoscopic vs. open cholecystectomy.  Surg Endosc. 2001;  15 41-43
• 6 ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery . White Paper October 2005.  Gastrointest Endosc. 2006;  63 199-203
• 7 Ferland R, Mulani D, Campbell K. Evaluation of a sprayable polyethylene glycol adhesion barrier in a porcine efficacy model.  Hum Reprod. 2001;  16 2718-2723
• 8 Garrard C L, Clements R H, Nanney L. et al . Adhesion formation is reduced after laparoscopic surgery.  Surg Endosc. 1999;  13 10-13
• 9 Tarhan O R, Eroglu A, Cetin R. et al . Effects of seprafilm on peritoneal fibrinolytic system.  ANZ J Surg. 2005;  75 690-692
• 10 Zamir G, Bloom A I, Reissman P. Prevention of intestinal adhesions after laparotomy in a rat model – a randomized prospective study.  Res Exp Med (Berl). 1998;  197 349-353
• 11 Eller R, Bukhari R, Poulos E. et al . Intraperitoneal adhesions in laparoscopic and standard open herniorrhaphy. An experimental study.  Surg Endosc. 1997;  11 24-28
• 12 Eroglu A, Demirci S, Kurtman C. et al . Prevention of intra-abdominal adhesions by using Seprafilm in rats undergoing bowel resection and radiation therapy.  Colorect Dis. 2001;  3 33-37
• 13 Kramer K, Senninger N, Herbst H, Probst W. Effective prevention of adhesions with hyaluronate.  Arch Surg. 2002;  137 278-282
• 14 Reissman P, Teoh T A, Skinner K. et al . Adhesion formation after laparoscopic anterior resection in a porcine model: a pilot study.  Surg Laparosc Endosc. 1996;  6 136-139
• 15 Schippers E, Tittel A, Ottinger A, Schumpelick V. Laparoscopy versus laparotomy: comparison of adhesion-formation after bowel resection in a canine model.  Dig Surg. 1998;  15 145-147
• 16 Lundorff P, Hahlin M, Källfelt B. et al . Adhesion formation after laparoscopic surgery in tubal pregnancy: a randomized trial versus laparotomy.  Fertil Steril. 1991;  55 911-915
• 17 Moore R G, Partin A W, Adams J B, Kavoussi L R. et al . Adhesion formation after transperitoneal nephrectomy: laparoscopic vs. open approach.  J Endourol. 1995;  9 277-280
• 18 Jagannath S B, Kantsevoy S W, Vaughn C A. et al . Peroral transgastric endoscopic ligation of fallopian tubes with long-term survival in a porcine model.  Gastrointest Endosc. 2005;  61 449-453
• 19 Kalloo A N, Singh V K, Jagannath S B. et al . Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity.  Gastrointest Endosc. 2004;  60 114-117
• 20 Kantsevoy S V, Hu B, Jagannath S B. et al . Technical feasibility of endoscopic gastric reduction: a pilot study in a porcine model.  Gastrointest Endosc. 2007;  65 510-513
• 21 Wagh M S, Merrifield B F, Thompson C C. Survival studies after endoscopic transgastric oophorectomy and tubectomy in a porcine model.  Gastrointest Endosc. 2006;  63 473-478