title: Transgastric instrumentation and bacterial contamination of the peritoneal cavity.
abstract: BACKGROUND
  Natural orifice transluminal endoscopic surgery (NOTES) is a rapidly evolving technique providing access to the peritoneum utilizing an endoscope via a natural orifice. One of the most significant requirements of this technique is the need to minimize the risk of clinically significant peritoneal contamination. We report the bacterial load and contamination of the peritoneal cavity in patients requiring a gastrotomy Roux-en-Y gastric bypass (LSRYGB).
  
  
  METHODS
  We prospectively studied 50 patients undergoing a gastrotomy with creation of a gastrojejunostomy during LSRYGB. We recorded the patient's proton-pump inhibitor (PPI) utilization preoperatively and sampled gastric contents without lavage. We also sampled peritoneal fluid prior to and after gastrotomy, noting the length of time the gastrotomy was open to the peritoneum. Each of the three samples was sent for bacterial colony counts, and culture with identification of species.
  
  
  RESULTS
  Fifty patients underwent LSRYGB with a mean operative time of 93 min. The gastrotomy was open to the peritoneal cavity for an average of 18 min. Seventeen of 50 patients were on PPIs preoperatively, resulting in a significant difference in postgastrostomy peritoneal bacterial counts. The average number of colony-forming units (CFU) of the gastric aspirate was 22,303 CFU/ml. Peritoneal aspirates obtained for examination prior to creation of a gastrotomy showed no CFUs in 44 of 50 patients. Peritoneal sampling after gastrotomy showed contamination of the abdomen with an average of 1102 CFU/ml. There was no correlation between the bacterial load in the stomach and peritoneal load after gastrotomy. No infectious complications or leaks developed. One complication of rhabdomyolysis in a patient with no peritoneal bacterial contamination developed.
  
  
  CONCLUSIONS
  Transgastric instrumentation does contaminate the abdominal cavity but pathogens are clinically insignificant due to species or bacterial load. Patients on PPIs do have an increased bacterial load in the gastric aspirate, with no clinical significant infection.
authors.affiliation: Division of General Surgery, The Ohio State University School of Medicine and Public Health, 410 West 10th Avenue, Ohio, Columbus, 43210-1228, USA. vknarula1@yahoo.com
authors.forename: Vimal K
authors.initials: VK
authors.lastname: Narula
authors.forename: Jeffrey W
authors.initials: JW
authors.lastname: Hazey
authors.forename: David B
authors.initials: DB
authors.lastname: Renton
authors.forename: Kevin M
authors.initials: KM
authors.lastname: Reavis
authors.forename: Christopher M
authors.initials: CM
authors.lastname: Paul
authors.forename: Kristen E
authors.initials: KE
authors.lastname: Hinshaw
authors.forename: Bradley J
authors.initials: BJ
authors.lastname: Needleman
authors.forename: Dean J
authors.initials: DJ
authors.lastname: Mikami
authors.forename: E Christopher
authors.initials: EC
authors.lastname: Ellison
authors.forename: W Scott
authors.initials: WS
authors.lastname: Melvin
mesh_terms: D000328:Adult; D000368:Aged; D000704:Analysis of Variance; D000713:Anastomosis, Roux-en-Y / Q000009:adverse effects / Q000379:methods; D001424:Bacterial Infections / Q000453:epidemiology / Q000209:etiology*; D016001:Confidence Intervals; D004866:Equipment Contamination; D005260:Female; D005500:Follow-Up Studies; D015390:Gastric Bypass / Q000009:adverse effects* / Q000379:methods; D020699:Gastroscopes / Q000009:adverse effects / Q000382:microbiology*; D005773:Gastroscopy / Q000009:adverse effects* / Q000379:methods; D006801:Humans; D015994:Incidence; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D010529:Peritoneal Cavity / Q000382:microbiology*; D011183:Postoperative Complications / Q000175:diagnosis; D011336:Probability; D011446:Prospective Studies; D018570:Risk Assessment; D018709:Statistics, Nonparametric; D016896:Treatment Outcome