title: Peritoneal inflammatory response of natural orifice translumenal endoscopic surgery (NOTES) versus laparoscopy with carbon dioxide and air pneumoperitoneum.
abstract: BACKGROUND
  The immunologic and physiologic effects of natural orifice translumenal endoscopic surgery (NOTES) versus traditional surgical approaches are poorly understood. Previous investigations have shown that NOTES and laparoscopy share similar inflammatory cytokine profiles except for a possible late-phase tissue necrosis factor-alpha (TNF-alpha) depression with NOTES. The local peritoneal reaction and immunomodulatory influence of pneumoperitoneum agents in NOTES also are not known and may play an important role in altering the physiologic insult induced by NOTES.
  
  
  METHODS
  In this study, 51 animals were divided into four study groups, which respectively underwent abdominal exploration via transgastric NOTES using room air (AIR) or carbon dioxide (CO(2)) or via laparoscopy (LX) using AIR or CO(2) for pneumoperitoneum. Laparotomy and sham surgeries were additionally performed as control conditions. Measurements of TNF-alpha, interleukin-1beta (IL-1beta), and IL-6 were performed for peritoneal fluid collected after 0, 2, 4, and 6 h and on postoperative days (PODs) 1, 2, and 7.
  
  
  RESULTS
  Of the 45 animals assessed, 6 were excluded because of technical operative complications. The findings showed that LX-CO(2) generated the most pronounced response with all three inflammatory markers. However, no significant differences were detected between LX-CO(2) and either NOTES group at these peak points. No differences were encountered between NOTES-CO(2) and NOTES-AIR. Subgroup comparisons showed significantly higher levels of TNF-alpha and IL-6 with NOTES-CO(2) than with LX-AIR on POD 1 (p = 0.022) and POD 2 (p = 0.002). The LX-CO(2) subgroup had significantly higher levels of TNF-alpha than the LX-AIR subgroup at 4 h (p = 0.013) and on POD 1 (p = 0.021). No late-phase TNF-alpha depression occurred in the NOTES animals.
  
  
  CONCLUSIONS
  The local inflammatory reaction to NOTES was similar to that with traditional laparoscopy, and the previously described late-phase systemic TNF-alpha depression in serum was not reproduced. At the peritoneal level, NOTES is no more physiologically stressful than laparoscopy. Furthermore, regardless of which gas was used, the role of the pneumoperitoneum agent did not affect the cytokine profile after NOTES, suggesting that air pneumoperitoneum is adequate for NOTES.
authors.affiliation: Department of Surgery, University Hospitals Case Medical Center, Case Western Reserve University School of Medicine, 11100 Euclid Avenue, Lakeside Building 7th Floor, Cleveland, OH 44106, USA. joseph.trunzo@uhhospitals.org
authors.forename: Joseph A
authors.initials: JA
authors.lastname: Trunzo
authors.forename: Michael F
authors.initials: MF
authors.lastname: McGee
authors.forename: Leandro T
authors.initials: LT
authors.lastname: Cavazzola
authors.forename: Steve
authors.initials: S
authors.lastname: Schomisch
authors.forename: Mehrdad
authors.initials: M
authors.lastname: Nikfarjam
authors.forename: Jessica
authors.initials: J
authors.lastname: Bailey
authors.forename: Tripurari
authors.initials: T
authors.lastname: Mishra
authors.forename: Benjamin K
authors.initials: BK
authors.lastname: Poulose
authors.forename: Young-Joon
authors.initials: YJ
authors.lastname: Lee
authors.forename: Jeffrey L
authors.initials: JL
authors.lastname: Ponsky
authors.forename: Jeffrey M
authors.initials: JM
authors.lastname: Marks
mesh_terms: D000388:Air; D000818:Animals; D001202:Ascitic Fluid / Q000737:chemistry; D015415:Biomarkers / Q000032:analysis; D002245:Carbon Dioxide / Q000008:administration & dosage*; D004724:Endoscopy; D005260:Female; D005740:Gases / Q000008:administration & dosage*; D007249:Inflammation; D007327:Insufflation; D010535:Laparoscopy; D019060:Minimally Invasive Surgical Procedures; D023421:Models, Animal; D010537:Peritoneum / Q000276:immunology*; D011028:Pneumoperitoneum, Artificial / Q000379:methods*; D013552:Swine
chemical_list: D015415:Biomarkers; D005740:Gases; D002245:Carbon Dioxide