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a hepatologie

Gastroenterology and Hepatology

Gastroent Hepatol 2014; 68(4): 299-304.

Efficient techniques for access site closure after transrectal NOTES procedures – results of an experimental study

Ondřej Ryska  1, Jan Martínek  2,3, Radek Doležel  4, Zuzana Šerclová  1, Štefan Juhás  5, Jana Juhásová  6, Eva Lásziková  7, Tomáš Henlín8, Jaroslav Kalvach9, Miroslav Ryska10

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In spite of the fact that the NOTES (natural orifice translumenal endoscopic surgery) method remains a contemporary subject of experimental and clinical trials, it still lacks common practical application. Indications of NOTES could be extended by adopting transrectal access and its closure techniques. The aim of this experimental study was to evaluate various techniques (KING closure, over-the-scope clip – OTSC) for access site closure following transrectal abdominal NOTES procedures. Method: All laboratories that performed transrectal intra-abdominal surgeries in the period of 2009–2013 were included. Access was performed using a needle knife followed by a balloon dilation. KING closure was acquired by approximation of an endoloop fixed to the perforation margins with endoclips. OTSC method was implemented with use of the OVESCO system with a clip diameter of 11.5– 14 mm. The animals were euthanized and autopsied after 30 days. Results: In total 58 animals were included in the study. Rectum closure was technically feasible in 55 (94%) pigs (31× KING, 24× OTSC). A group of 50 (86%) animals completed a 30-day follow-up. Complications with the closure healing were diagnosed in three (6%) autopsies. One was a severe iatrogenic entero-colic fistula, other two were minor complications (serose defect, mucosal defect) without influence on the closure sufficiency. Intra-abdominal infection was observed in six (12%) animals postoperatively. These complications were caused by a contaminated endoscope due to the transrectal road of access and none was associated with the closure dehiscence. Closure time was significantly longer with the KING technique – 13 (4–40) vs 9 (5–15) min (p < 0.05). This method was associated with a progressive learning curve – 20 (5–40) min in the first half vs 10 (4–24) min in second half of the procedures (p < 0.05). Conclusions: The KING and OTSC rectal closures proved as technically feasible and efficient in a large cohort. The KING technique is safer despite a longer procedural time and training period. Both methods are potentially available for the treatment of accidental colon perforations.


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