Comparison of gastrotomy closure modalities for natural orifice transluminal surgery: a canine study

Abstract

Background: Reliable closure of the gastrotomy after transgastric natural orifice transluminal endoscopic surgery (NOTES) remains unresolved.

Objective: To compare the technical aspects and clinical and histologic outcomes of NOTES gastrotomy closure techniques.

Design: Experimental study.

Setting: Animal laboratory.

Patients: Thirty-four dogs, 14 for nonsurvival study and 20 for survival study.

Interventions: The animals randomly received different gastrotomy closures after NOTES: endoclip, omentoplasty, over-the-scope-clip (OTSC), and hand-suturing.

Main outcome measurements: Procedure time, closure strength, survival, postoperative adverse events, and histologic evaluation of wound healing.

Results: Omentoplasty and OTSC groups needed shorter procedure times and fewer clips than the endoclip group. The endoclip and omentoplasty groups generated similar leakage pressures (34.5 ± 2.6 vs 42.2 ± 4.1 mm Hg, P > .05), both lower than OTSC and hand-suturing groups (81.5 ± 2.1 and 87.0 ± 3.0 mm Hg, respectively, P < .001). Of the 20 animals in the survival study (all 4 groups), only 2 of 6 in the endoclip group were killed prematurely due to sepsis. Necropsy revealed the OTSC group reached a 100% clip retention rate, higher than the endoclip (47.9%) and omentoplasty groups (44.4%, P < .05) rates. Complete healing, defined as intact and continuous gastric layers microscopically, was seen in 83.3% of animals (5 of 6) in the omentoplasty group, comparable with OTSC (4 of 6, 66.7%, P = .500) but higher than the endoclip group (1 of 6, 16.7%, P = .04).

Limitations: Animal study.

Conclusions: Omentoplasty is easier and safer for NOTES gastrotomy closure than endoclips and offers safety profile and efficacy similar to OTSC and hand-suturing.