title: Stent placement provides safe esophageal closure in thoracic NOTES(TM) procedures.
abstract: BACKGROUND
  Safe esophageal closure remains a challenge in transesophageal Natural Orifice Transluminal Endoscopic Surgery (NOTES). Previously described methods, such as suturing devices, clips, or submucosal tunneling, all have weaknesses. In this survival animal series, we demonstrate safe esophageal closure with a prototype retrievable, antimigration stent.
  
  
  METHODS
  Nine Yorkshire swine underwent thoracic NOTES procedures. A double-channel gastroscope equipped with a mucosectomy device was used to create an esophageal mucosal defect. A 5-cm submucosal tunnel was created and the muscular esophageal wall was incised with a needle-knife. Mediastinoscopy and thoracoscopy were performed in all swine; lymphadenectomy was performed in seven swine. A prototype small intestinal submucosal (SurgiSIS(®)) covered stent was deployed over the mucosectomy site and tunnel. Three versions of the prototype stent were developed. Prenecropsy endoscopy confirmed stent location and permitted stent retrieval. Explanted esophagi were sent to pathology.
  
  
  RESULTS
  Esophageal stenting was successful in all animals. Stent placement took 15.8 ± 4.8 minuted and no stent migration occurred. Prenecropsy endoscopy revealed proximal ingrowth of esophageal mucosa and erosion with Stent A. Mucosal inflammation and erosion was observed proximally with Stent B. No esophageal erosion or pressure damage from proximal radial forces was seen with Stent C. On necropsy, swine 5 had a 0.5-cm periesophageal abscess. Histology revealed a localized inflammatory lesion at the esophageal exit site in swine 1, 3, and 9. The mucosectomy site was partially healed in three swine and poorly healed in six. All swine thrived clinically, except for a brief period of mild lethargy in swine 9 who improved with short-term antibiotic therapy. The submucosal tunnels were completely healed and no esophageal bleeding or stricture formation was observed. All swine survived 13.8 ± 0.4 days and gained weight in the postoperative period.
  
  
  CONCLUSIONS
  Esophageal stenting provides safe closure for NOTES thoracic procedures but may impede healing of the mucosectomy site.
authors.affiliation: Massachusetts General Hospital, Boston, MA 02114, USA.
authors.forename: Brian G
authors.initials: BG
authors.lastname: Turner
authors.forename: Sevdenur
authors.initials: S
authors.lastname: Cizginer
authors.forename: Min-Chan
authors.initials: MC
authors.lastname: Kim
authors.forename: Mari
authors.initials: M
authors.lastname: Mino-Kenudson
authors.forename: Richard W
authors.initials: RW
authors.lastname: Ducharme
authors.forename: Vihar C
authors.initials: VC
authors.lastname: Surti
authors.forename: Patricia
authors.initials: P
authors.lastname: Sylla
authors.forename: William R
authors.initials: WR
authors.lastname: Brugge
authors.forename: David W
authors.initials: DW
authors.lastname: Rattner
authors.forename: Denise W
authors.initials: DW
authors.lastname: Gee
mesh_terms: D000038:Abscess / Q000209:etiology; D000818:Animals; D004867:Equipment Design; D004941:Esophagitis / Q000209:etiology; D004947:Esophagus / Q000473:pathology / Q000601:surgery*; D005548:Foreign-Body Migration / Q000517:prevention & control; D020699:Gastroscopes; D008197:Lymph Node Excision; D009092:Mucous Membrane / Q000473:pathology / Q000601:surgery; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D011183:Postoperative Complications / Q000209:etiology; D015607:Stents; D034421:Sus scrofa; D013552:Swine; D014945:Wound Healing
references.citation: Gastrointest Endosc. 2007 Apr;65(4):679-83
references.pmid: 17383463
references.citation: Surg Laparosc Endosc Percutan Tech. 2008 Jun;18(3):283-5
references.pmid: 18574417
references.citation: Surg Endosc. 2008 Apr;22(4):1042-7
references.pmid: 18030521
references.citation: Gastrointest Endosc. 2005 Jun;61(7):897-900
references.pmid: 15933697
references.citation: Surg Innov. 2009 Mar;16(1):26-37
references.pmid: 19223383
references.citation: Hernia. 2007 Aug;11(4):321-6
references.pmid: 17443270
references.citation: Ann Thorac Surg. 2005 Feb;79(2):398-403; discussion 404
references.pmid: 15680802
references.citation: Surg Endosc. 2009 Jul;23(7):1526-30
references.pmid: 19301070
references.citation: Gastrointest Endosc. 2010 Jan;71(1):171-5
references.pmid: 19879572
references.citation: J Thorac Cardiovasc Surg. 2007 Feb;133(2):333-8
references.pmid: 17258558
references.citation: Endoscopy. 2007 May;39(5):385-9
references.pmid: 17516342
references.citation: Surg Endosc. 2008 Oct;22(10):2117-22
references.pmid: 18636291
references.citation: Ann Thorac Surg. 2007 Jun;83(6):2003-7; discussion 2007-8
references.pmid: 17532387
references.citation: J Laparoendosc Adv Surg Tech A. 2008 Oct;18(5):743-5
references.pmid: 18803520
references.citation: Endoscopy. 2007 Oct;39(10):870-5
references.pmid: 17968802
references.citation: Ann Surg. 2006 Oct;244(4):481-90
references.pmid: 16998356
references.citation: Hernia. 2008 Dec;12(6):609-12
references.pmid: 18584282