title: Assessing the invasiveness of NOTES perforated viscus repair: a comparative study of NOTES and laparoscopy.
abstract: BACKGROUND
  Natural orifice transluminal endoscopic surgery (NOTES) repair of perforated peptic ulcers may decrease surgical invasiveness and improve patient outcomes.
  
  
  METHODS
  Full thickness gastrotomy was created laparoscopically in swine followed by soilage time. Repair proceeded with a laparoscopic (n = 14) or the NOTES (n = 14) approach. For NOTES repair, the omentum was endoscopically pulled into the gastric lumen and clipped. Intraoperative and postoperative parameters were recorded, including arterial blood gas (ABG) analysis and serum samples for white blood cell (WBC), TNF-α, IL-1, and IL-6 analysis.
  
  
  RESULTS
  Twenty-four of 28 animals thrived to study completion. NOTES repair could not be accomplished in one animal. At necropsy, all repairs were intact. Blood pressure was equivalent between groups. Pulse examined during the last 30 min of each procedure revealed a slightly higher mean pulse in the animals undergoing NOTES procedures (NOTES, 102 ± 28; laparoscopy, 83 ± 24). ABG obtained at the conclusion of the procedure revealed a pH of 7.47 in NOTES animals and 7.43 in the laparoscopy animals (p = 0.06), a change from baseline in both groups. The final pCO(2) was lower in the NOTES group (NOTES, 40.62; laparoscopy, 47.49, p = 0.03). WBC counts were comparable on postoperative day (POD) 1 (NOTES, 21.1; laparoscopy, 19.0; p = 0.49). Mean TNF-α serum levels were equivalent at all time points between groups; however, TNF-α varied significantly from baseline to POD 7 (p = 0.002).
  
  
  CONCLUSIONS
  NOTES omental repair appears comparable to that of laparoscopy. The lower arterial pCO(2) at the conclusion of the NOTES procedure may be advantageous in critically ill patients.
authors.affiliation: Department of Surgery, Mayo Clinic, 200 First Street SW, Rochester, MN 55905, USA.
authors.forename: E A
authors.initials: EA
authors.lastname: Moran
authors.forename: C J
authors.initials: CJ
authors.lastname: Gostout
authors.forename: A L
authors.initials: AL
authors.lastname: McConico
authors.forename: J
authors.initials: J
authors.lastname: Michalek
authors.forename: M
authors.initials: M
authors.lastname: Huebner
authors.forename: Juliane
authors.initials: J
authors.lastname: Bingener
mesh_terms: D000818:Animals; D001794:Blood Pressure / Q000502:physiology; D004195:Disease Models, Animal; D005240:Feasibility Studies; D005774:Gastrostomy / Q000379:methods; D010535:Laparoscopy / Q000379:methods*; D007958:Leukocyte Count; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D010439:Peptic Ulcer Perforation / Q000601:surgery; D011897:Random Allocation; D013276:Stomach Ulcer / Q000601:surgery; D013552:Swine; D014409:Tumor Necrosis Factor-alpha / Q000378:metabolism; D014781:Viscera / Q000293:injuries / Q000601:surgery*
chemical_list: D014409:Tumor Necrosis Factor-alpha