Infection during natural orifice transluminal endoscopic surgery: a randomized, controlled study in a live porcine model.
BACKGROUND
Currently reported natural orifice transluminal endoscopic surgery (NOTES) procedures in animals have been done in heterogeneous milieus ranging from nonsterile to sterile procedures, with mixed results, including no infection in those performed in nonsterile settings.


OBJECTIVE
To establish the potential frequency of infection during NOTES, comparing sterile to nonsterile approaches.


METHODS
Survival experiments on sixteen 50-kg pigs.


METHODS
From pilot data (100% infection frequency after nonsterile procedures), sample size (8 animals in each group) was calculated by using a power of 95% and an alpha risk of 0.05. The animals were randomly assigned to two groups: In the transgastric peritoneoscopy study group, liver and ovarian biopsies were performed with sterile overtubes, endoscopes, and accessories and the use of preoperative intravenous antibiotics and antiseptic gastric lavage. In the nonsterile (control) group, the same procedures were performed with nonsterile endoscopes and accessories without the use of gastric lavage and preoperative antibiotics. Complete transmural closure of the transgastric access site was made in all animals. After a 1-week survival time, all animals were killed for necropsy, which included Gram staining and peritoneal cultures.


METHODS
Intraperitoneal infection on necropsy.


RESULTS
All necropsies revealed intraperitoneal infection (abscesses, fibrinopurulent exudates, and adhesions) in the control group (frequency of infection 100%). Peritoneal bacterial culture grew various aerobic and anaerobic organisms. No gross or bacteriological evidence of infection was seen in the sterile group (frequency of infection 0%, P value = <.0002).


CONCLUSIONS
Animal experiments.


CONCLUSIONS
Nonsterile conditions invariably lead to intraperitoneal infection. Aseptic techniques during NOTES can prevent intra-abdominal infection. Future studies will determine which infection prevention steps are mandatory and which can be omitted during NOTES procedures.
Giday
Samuel A
SA
Division of Gastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Dray
Xavier
X
Magno
Priscilla
P
Buscaglia
Jonathan M
JM
Shin
Eun Ji
EJ
Surti
Vihar C
VC
Assumpcao
Lia
L
Marohn
Michael R
MR
Ruben
Dawn
D
Zhigalin
Andrew
A
Pipitone
Laurie J
LJ
Kantsevoy
Sergey V
SV
D000818:Animals; D001207:Asepsis / Q000379:methods*; D001706:Biopsy; D005260:Female; D010535:Laparoscopy / Q000379:methods*; D008099:Liver / Q000473:pathology; D010053:Ovary / Q000473:pathology; D010538:Peritonitis / Q000209:etiology* / Q000473:pathology; D013530:Surgical Wound Infection / Q000209:etiology* / Q000473:pathology; D013552:Swine