title: Endoscopic closure of the natural orifice transluminal endoscopic surgery (NOTES) access site to the peritoneal cavity by means of transmural resorbable sutures: an animal survival study.
abstract: OBJECTIVE
  Endoscopic closure of the transgastric access site is still a critical area of active research and development into natural orifice transluminal surgery (NOTES). To date, no endoscopic technique has utilized resorbable transmural sutures for closure of the NOTES gastrostomy.
  
  
  METHODS
  Endoscopic gastrostomy closure by means of resorbable sutures was performed in ten female domestic pigs in an animal survival study. Peritoneal cavity access was gained through the anterior gastric wall using the percutaneous endoscopic gastrostomy (PEG) technique and an 18-mm balloon dilator. NOTES exploration of the gallbladder and tubal ligation were performed prior to endoscopic gastrostomy closure. Necropsy was performed 3 weeks post procedure.
  
  
  RESULTS
  Mean suturing time was 26 minutes (range 14 - 35 minutes). In total 90 % (9/10) of gastrostomy closures were performed by means of two transmural resorbable sutures. One gastrostomy was closed using a single resorbable suture. One case of gallbladder perforation occurred during peritoneoscopy and the pig was sacrificed due to subsequent peritonitis 2 days after the procedure. All other pigs (9/10) were found to be healthy 3 weeks after the NOTES procedure and were sacrificed as planned per protocol. Of all the 17 sutures that were applied in the remaining nine pigs, 16 (94 %) had been absorbed, releasing the pledgets intraluminally. During laparotomy no signs of injury to adjacent organs were found in any of these nine animals. In 8/10 pigs (80 %) the gastrostomy site did not burst with pressures exceeding 100 mmHg. Two suturing sites did burst at pressures of 57 and 62 mmHg, respectively.
  
  
  CONCLUSIONS
  Endoscopic transmural suturing enables rapid and easy placement of leak-proof resorbable sutures and is suitable for closure of the NOTES transgastric access.
authors.affiliation: Department of Gastroenterology, Medizinische Klinik I, Klinikum Ludwigsburg, Ludwigsburg, Germany. renteln@gmx.net
authors.forename: D
authors.initials: D
authors.lastname: von Renteln
authors.forename: A
authors.initials: A
authors.lastname: Eickhoff
authors.forename: G
authors.initials: G
authors.lastname: Kaehler
authors.forename: B
authors.initials: B
authors.lastname: Riecken
authors.forename: K
authors.initials: K
authors.lastname: Caca
mesh_terms: D034861:Abdominal Wall / Q000473:pathology / Q000601:surgery*; D020341:Absorbable Implants; D000818:Animals; D004724:Endoscopy; D005260:Female; D005774:Gastrostomy; D010529:Peritoneal Cavity; D011138:Polytetrafluoroethylene; D013270:Stomach / Q000601:surgery*; D013528:Surgical Staplers; D013536:Suture Techniques; D013537:Sutures; D013552:Swine
chemical_list: D011138:Polytetrafluoroethylene