Evaluation of feasibility, efficiency and safety of a pure NOTES gastrojejunal bypass with gastric outlet obstruction, in an in vivo porcine model

Abstract

Introduction: Natural orifice transluminal endoscopic surgery (NOTES) gastrojejunal anastomosis (GJA) is a less invasive surgery for bariatric procedures and gastric outlet obstruction. The aim of this study was to evaluate the feasibility, efficacy, and safety of a pure NOTES gastrojejunal bypass using an in vivo porcine model.

Material and methods: A prospective study was performed on nine swine. A double-channel scope was used. The intervention steps were: (i) gastric incision; (ii) peritoneal access; (iii) jejunal loop selection and mobilization into the stomach; (iv) stoma creation within the gastric wall and incision; (v) anastomosis suture and pylorus closure using a T-tag prototype. The animals were assessed clinically for 3 weeks including the weight gain. The patency of the GJA was assessed at necropsy and a histological analysis was performed.

Results: We successfully performed all the procedures with a mean (standard deviation [SD]) operative time of 108 (26) minutes. We used a mean of 5.55 (1.30) stitches. There were no intraprocedural adverse events. Five animals survived up till euthanasia at 3 weeks (65 %). These showed a significant difference in weight curves of a loss of 3.2 kg compared with gain of 5.2 kg in a control group. Four pigs died from anastomotic dehiscence complicated by peritonitis.

Conclusion: Gastrojejunal bypass with a pure NOTES approach is feasible. This procedure is effective, resulting in a patent anastomosis and a significant weight loss. However, the anastomotic dehiscence is a major concern because of its mortality rate, and further studies including improvement of the suturing device and the technique are needed.

Fig. 1

Longitudinal, plane-by-plane gastric incision using the needle-knife at the anterior wall of the stomach in the pre-antral region.

Fig. 2

Selection, grasping and mobilization of an appropriate jejunal loop toward the gastric incision with a Twin-Grasper forceps.

Fig. 3

Puncture of the mesentery under the raised loop with the rigid end of a 0035'' guidewire , which was then advanced within a sphincterotome and through the mesentery.

Fig. 4

Placement of a fully-covered biliary self-expandable metallic stents(SEMS) (10 cm length), with its free ends being within the mesentery on both sides of the loop.

Fig. 5

The Brace Bar suturing system. Needle, handle, and T-tag recharge.

Fig. 6

Achievement of the complete anastomosis using four to seven stitches equally distributed along the anastomotic perimeter.

Fig. 7

Time required (minutes) for completion of each technical step of the gastrojejunal anastomosis procedure (9 animals).

Fig. 8

Macroscopic examination of the gastrojejunal anastomosis during necropsy at 3 weeks post-surgery. Catheterization of each loop with surgical clamps.

Fig. 9

Histological assessment of the gastrojejunal anastomosis at 3 weeks post-surgery. 1 Apparent scar formation is seen at the level of the mucosa (GM, JM) and beginning of the collagenization of the entire gut wall with presence of discrete inflammatory infiltrate (HES, × 1 magnification). 2 Continuity of muscular mucosa layer is seen at the level of the gut wall presenting with highly polymorphic granulomatous tissue (HES, × 1 10magnification).