title: Transgastric cholecystectomy: transgastric accessibility to the gallbladder improved with the SEMF method and a novel multibending therapeutic endoscope.
abstract: BACKGROUND
  Transgastric cholecystectomy is thought to technically and anatomically challenge a single entry flexible endoscopic approach.
  
  
  OBJECTIVE
  To examine the feasibility of a transgastric-only cholecystectomy, endoscope performance in an upper-abdominal operation, and the usefulness of an offset gastrotomy.
  
  
  METHODS
  Animal survival study.
  
  
  METHODS
  Animal research laboratory.
  
  
  METHODS
  Six domestic pigs.
  
  
  METHODS
  Transgastric access to the gallbladder and technical feasibility of unassisted transgastric cholecystectomy.
  
  
  METHODS
  A cephalad submucosal tunnel was created in the anterior gastric wall with a high-pressure CO2 injection. An EMR-cap myotomy was performed distally within the submucosal space and created an offset gastrotomy. An endoscope was inserted into the peritoneal cavity through the myotomy. Access to the gallbladder was compared by using a multibending therapeutic endoscope (R-scope), with a standard double-channel endoscope. A cholecystectomy was performed by using both types of endoscopes. The myotomy site was sealed with the overlying mucosal flap. The mucosal entry point was closed with clips or tissue anchors.
  
  
  RESULTS
  A standard double-channel endoscope could access the gallbladder in 2 of 4 attempts. A multibending endoscope accessed the gallbladder in all 4 attempts, including 2 pigs in which the standard scope failed to access the gallbladder. In 4 pigs, a cholecystectomy was completed. Two pigs died during surgery, with air embolization observed in 1. Two pigs survived a planned 1-week survival period.
  
  
  CONCLUSIONS
  Transgastric cholecystectomy is technically feasible. Transgastric access to the gallbladder may be improved by using submucosal endoscopy with an offset exit gastrotomy by means of the mucosal flap safety-valve technique and a multibending gastroscope.
authors.affiliation: Developmental Endoscopy Unit, Division of Gastroenterology and Hepatology, Mayo Clinic College of Medicine, Rochester, Minnesota 55905, USA.
authors.forename: Kazuki
authors.initials: K
authors.lastname: Sumiyama
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Gostout
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Rajan
authors.forename: Timothy A
authors.initials: TA
authors.lastname: Bakken
authors.forename: Mary A
authors.initials: MA
authors.lastname: Knipschield
authors.forename: Sydney
authors.initials: S
authors.lastname: Chung
authors.forename: Peter B
authors.initials: PB
authors.lastname: Cotton
authors.forename: Robert H
authors.initials: RH
authors.lastname: Hawes
authors.forename: Anthony N
authors.initials: AN
authors.lastname: Kalloo
authors.forename: Sergey V
authors.initials: SV
authors.lastname: Kantsevoy
authors.forename: Pankaj J
authors.initials: PJ
authors.lastname: Pasricha
mesh_terms: D000818:Animals; D002763:Cholecystectomy / Q000379:methods* / Q000401:mortality; D004195:Disease Models, Animal; D020776:Endoscopes, Gastrointestinal; D016099:Endoscopy, Gastrointestinal; D004867:Equipment Design; D005240:Feasibility Studies; D005705:Gallbladder Diseases / Q000601:surgery; D015996:Survival Rate; D013552:Swine; D016896:Treatment Outcome