title: Natural orifice transluminal endoscopic surgery (NOTES) as a diagnostic tool in the intensive care unit.
abstract: BACKGROUND
  Autopsy studies confirm that many intensive care unit (ICU) patients die from unrecognized sources of abdominal sepsis or ischemia. Computed tomography (CT) scans can be of limited use for these diagnoses and difficult to obtain in critically ill patients who require significant support for transport. Bedside laparoscopy has been described but still is cumbersome to perform. Bedside flexible endoscopy as a diagnostic tool or for placement of gastrostomy tubes is a standard ICU procedure. Natural orifice transluminal endoscopic surgery (NOTES) can provide access to the peritoneal cavity as a bedside procedure and may decrease the number of patients with unrecognized intra-abdominal catastrophic events.
  
  
  METHODS
  Pigs were anesthetized and peritoneal access with the flexible endoscope was obtained using a guidewire, needle knife cautery, and balloon dilatation. The transgastric endoscope was used to explore all quadrants of the abdominal cavity. The small bowel was visualized to complete the exploration. The transgastric access location was then managed with the use of a gastrostomy tube. The animals were euthanized and analyzed.
  
  
  RESULTS
  Eight pigs were studied and complete abdominal exploration, including diaphragm visualization, was possible in all cases. Endoscopy-guided biopsies were performed, adhesions lysed, and the gallbladder successfully drained percutaneously. The small bowel was run successfully with percutaneous needlescopic suture graspers.
  
  
  CONCLUSIONS
  These animal studies support the concept that NOTES, with management of the gastric opening with a gastrostomy tube, may be another approach for finding unrecognized sources of abdominal sepsis or mesenteric ischemia in difficult ICU patients. These encouraging results warrant a prospective human trial to assess safety and efficacy.
authors.affiliation: Department of Surgery, Case Western Reserve University and University Hospitals of Cleveland, Cleveland, OH, USA. Raymond.onders@uhhs.com
authors.forename: Raymond P
authors.initials: RP
authors.lastname: Onders
authors.forename: Michael F
authors.initials: MF
authors.lastname: McGee
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Marks
authors.forename: Amitabh
authors.initials: A
authors.lastname: Chak
authors.forename: Michael J
authors.initials: MJ
authors.lastname: Rosen
authors.forename: Anthony
authors.initials: A
authors.lastname: Ignagni
authors.forename: Ashley
authors.initials: A
authors.lastname: Faulx
authors.forename: Steve
authors.initials: S
authors.lastname: Schomisch
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Ponsky
mesh_terms: D000818:Animals; D004195:Disease Models, Animal; D004630:Emergencies; D016099:Endoscopy, Gastrointestinal / Q000379:methods; D005773:Gastroscopy / Q000379:methods*; D005774:Gastrostomy / Q000379:methods*; D006801:Humans; D007362:Intensive Care Units; D019060:Minimally Invasive Surgical Procedures / Q000379:methods; D012680:Sensitivity and Specificity; D013552:Swine