title: Endoscopic management of intraoperative small bowel laceration during natural orifice translumenal endoscopic surgery: a blinded porcine study.
abstract: BACKGROUND
  Natural orifice translumenal endoscopic surgery (NOTES) has recently gained great enthusiasm, but there is concern regarding the ability to endoscopically manage complications purely via natural orifices.
  
  
  OBJECTIVE
  To assess the feasibility of endoscopically managing enteral perforation during NOTES using currently available endoscopic accessories.
  
  
  METHODS
  Twelve pigs underwent transgastric or transcolonic endoscopic exploration. Full-thickness enterotomies were intentionally created to mimic accidental small bowel lacerations during NOTES. These lacerations were then closed with endoclips. In the blinded arm of the study, small bowel repair was performed by a second blinded endoscopist. Adequate closure of the laceration was confirmed with a leak test. Primary access sites were closed with endoclips or T-anchors. At necropsy, the peritoneal cavity was inspected for abscesses, bleeding, or damage to surrounding structures. The enterotomy site was examined for adequacy of closure, adhesions, or evidence of infection.
  
  
  RESULTS
  Fifteen small bowel lacerations were performed in 12 animals. Successful closure was achieved in all 10 cases in the nonblinded arm. Survival animals had an uncomplicated postoperative course and all enterotomy sites were well healed without evidence of necrosis, adhesions, abscess, or bleeding at necropsy. Leak test was negative in all animals. In the blinded arm, both small intestinal lacerations could not be identified by the blinded endoscopist. Necropsy revealed open small bowel lacerations.
  
  
  CONCLUSIONS
  Small intestinal injuries are difficult to localize with currently available flexible endoscopes and accessories. Endoscopic clips, however, may be adequate for closure of small bowel lacerations if the site of injury is known.
authors.affiliation: Division of Gastroenterology, University of Florida, Gainesville, Florida 32610, USA.
authors.forename: Christopher J
authors.initials: CJ
authors.lastname: Fyock
authors.forename: Chris E
authors.initials: CE
authors.lastname: Forsmark
authors.forename: Mihir S
authors.initials: MS
authors.lastname: Wagh
mesh_terms: D000818:Animals; D016099:Endoscopy, Gastrointestinal; D005240:Feasibility Studies; D007421:Intestine, Small / Q000293:injuries* / Q000601:surgery*; D007431:Intraoperative Complications / Q000601:surgery*; D022125:Lacerations / Q000601:surgery*; D057605:Natural Orifice Endoscopic Surgery; D013552:Swine