title: Natural orifice transluminal endoscopic surgery versus laparoscopic surgery for inadvertent colon injury repair: feasibility, risk of abdominal adhesions, and peritoneal contamination in a porcine survival model.
abstract: BACKGROUND
  Adhesions are common after conventional surgery; natural orifice transluminal endoscopic surgery (NOTES) avoids peritoneal disruption and may reduce adhesions.
  
  
  OBJECTIVE
  To determine whether adhesions (and peritoneal contamination) are less common with NOTES transgastric colon injury and repair (TGCR) than with laparoscopic colon repair (LCR).
  
  
  METHODS
  Porcine survival study.
  
  
  METHODS
  After colon preparation and administration of antibiotics, forty 25-kg male pigs were randomly assigned to either TGCR or LCR. TGCR involved an endoscopic gastrotomy (needle-knife plus balloon dilation), CO(2) pneumoperitoneum, and a 2-cm needle-knife transmural incision of spiral colon. Colotomies were repaired with clips; gastrotomies were closed with clips and a detachable snare.
  
  
  METHODS
  Adhesions were assessed at necropsy at 21 days; biopsy specimens were blindly reviewed. A 9-point adhesion score (density/vascularity, width, and extent) was averaged from 3 reviewers. Peritoneal lavage was sent for cell count and culture.
  
  
  RESULTS
  Two of 20 TGCR pigs died immediately (unrecognized preoperative autopsy-proven pneumonia). The median procedure times were 70.5 and 19.0 minutes for TGCR and LCR, respectively; weight gains were 7.1 and 8.2 kg, respectively. The median adhesion scores were 4.3 and 3.7, respectively (P = .26); subscores were similar (1.9, 1.5, 1.3 vs 1.7, 1.1, 1.0, respectively (P = .3-.6)). Peritoneal lavage bacterial growth was nonsignificantly lower after TGCR than after LCR (38.9% vs 60.0%, respectively; P = .30); administration of intragastric antibiotics did not decrease contamination. Three TGCR (vs no LCR) pigs had histologic peritonitis.
  
  
  CONCLUSIONS
  Animal model, colon prepped, injury immediately recognized.
  
  
  CONCLUSIONS
  NOTES colon repair is feasible after transmural injury. Adhesions, histologic peritonitis, and contamination were similar to those with laparoscopy and were not helped by intragastric antibiotics.
authors.affiliation: Division of Gastroenterology and Hepatology, Department of Medicine, Digestive Disease Center, Medical University of South Carolina, Charleston, South Carolina 29425, USA.
authors.forename: Joseph
authors.initials: J
authors.lastname: Romagnuolo
authors.forename: John
authors.initials: J
authors.lastname: Morris
authors.forename: Seth
authors.initials: S
authors.lastname: Palesch
authors.forename: Robert
authors.initials: R
authors.lastname: Hawes
authors.forename: David
authors.initials: D
authors.lastname: Lewin
authors.forename: Katherine
authors.initials: K
authors.lastname: Morgan
mesh_terms: D000818:Animals; D001424:Bacterial Infections / Q000473:pathology*; D003106:Colon / Q000293:injuries*; D003114:Colony-Forming Units Assay; D016983:Enterococcus; D005240:Feasibility Studies; D005260:Female; D016908:Gram-Positive Bacterial Infections / Q000473:pathology; D010535:Laparoscopy; D008297:Male; D010538:Peritonitis / Q000473:pathology*; D012307:Risk Factors; D013290:Streptococcal Infections / Q000473:pathology; D013530:Surgical Wound Infection / Q000473:pathology*; D013536:Suture Techniques; D013552:Swine; D000267:Tissue Adhesions / Q000473:pathology*; D014945:Wound Healing / Q000502:physiology