title: Beyond NOTES: randomized controlled study of different methods of flexible endoscopic hemostasis of artificially induced hemorrhage, via NOTES access to the peritoneal cavity.
abstract: OBJECTIVE
  Significant hemorrhage is a likely complication during natural orifice transluminal endoscopic surgery (NOTES) procedures. We tested three different prototype devices (involving endoscopic suturing, monopolar forceps, and forced argon plasma coagulation [FAPC]) for treatment of acute bleeding in a survival animal model.
  
  
  METHODS
  Using transgastric access (TGA) or transvaginal access (TVA), the endoscope was introduced into the peritoneal cavity and the first side-branch of the gastroepiploic artery (1aGE) was cut before the different hemostatic methods were applied.
  
  
  RESULTS
  Sutures could not be placed quickly enough before vision was inhibited. With monopolar forceps via TGA, the time to control bleeding was 10 - 140 s (mean 58 +/- 41 s) and with TVA it was 25 - 115 s (mean 57 +/- 26 s) (P = 0.54). It was not possible to stop the bleeding in 4/6 animals with TGA access and in 3/6 with TVA, and FAPC was needed to entirely stop it, taking a further 10 - 280 s (TGA mean 126 +/- 90 s, 34 - 242 s; TVA mean 152 +/- 61 s; P = 0.42). Using FAPC with TGA took 4 - 72 s (mean 28 +/- 20 s) to stop the bleeding, and 16 - 41 s (mean 24 +/- 9.4 s) with TVA ( P = 0.64). As the FAPC technique was relatively so much better, additional treatment of bleeding from the main gastroepiploic artery (aGe) was added in four cases for each method of access; this was successful but took significantly longer, with TGA at 10 - 260 s and with TVA at 30 - 172 s (means 98 +/- 82, 117 +/- 54 s, respectively; not significant).
  
  
  CONCLUSIONS
  Regarding the three methods tested, the new prototype FAPC device allowed hemostasis of notable bleeding from a major vessel even more quickly than forceps coagulation of a bleeding side branch. More studies are needed to further explore this potentially very valuable tool.
authors.affiliation: Department of Academic Medical and Surgical Gastroenterology, Homerton University Hospital, London, UK. fri.rav@btopenworld.com
authors.forename: A
authors.initials: A
authors.lastname: Fritscher-Ravens
authors.forename: A
authors.initials: A
authors.lastname: Ghanbari
authors.forename: C
authors.initials: C
authors.lastname: Holland
authors.forename: F
authors.initials: F
authors.lastname: Olagbeye
authors.forename: K G
authors.initials: KG
authors.lastname: Hardeler
authors.forename: F
authors.initials: F
authors.lastname: Seehusen
authors.forename: B
authors.initials: B
authors.lastname: Jacobsen
authors.forename: K
authors.initials: K
authors.lastname: Mannur
mesh_terms: D004564:Electrocoagulation; D024405:Gastroepiploic Artery / Q000601:surgery; D006470:Hemorrhage / Q000601:surgery*; D006488:Hemostasis, Surgical / Q000379:methods*; D006801:Humans; D010535:Laparoscopy; D017075:Laser Coagulation; D054020:Lasers, Gas; D019060:Minimally Invasive Surgical Procedures; D023421:Models, Animal; D010529:Peritoneal Cavity; D010865:Pilot Projects; D013536:Suture Techniques