title: Gastrojejunostomy by pure natural orifice transluminal endoscopic surgery using a newly designed anastomosing metal stent in a porcine model.
abstract: BACKGROUND
  The accepted palliative treatment for malignant gastric outlet obstruction (GOO) is surgical bypass or placement of self-expandable metal stents. We developed a safe and simple natural orifice transluminal endoscopic surgery (NOTES) technique for gastrojejunostomy using a fully covered, anastomosing metal stent in a porcine model.
  
  
  METHODS
  Under general anesthesia, 11 pigs underwent gastrojejunostomy with a 4 cm length anastomosing metal stent. After gastrotomy formation using a needle knife, the jejunum was drawn into the stomach with alligator forceps. A jejunotomy was then performed in the gastric cavity, which was followed by deployment of an anastomosing metal stent under fluoroscopic guidance. Next, the first portion of the duodenum was resected by an endoscopic linear stapler via laparoscopy, thereby creating the model of GOO. Oral feeding was resumed 24 h after the procedure, and animals were euthanized at 1, 2, and 4 weeks after the operation.
  
  
  RESULTS
  Side-to-side gastrojejunostomy was successfully completed through NOTES in 10/11 animals. Ten pigs stayed healthy until the planned sacrifice. The mean gastrojejunostomy procedure time was 41 min (range 15-94 min). By postmortem examination, anastomoses were still intact without intraperitoneal necrosis or adhesion. Histological examination revealed adequate submucosal apposition in all ten experimental pigs undergoing successful endoscopic gastrojejunostomy.
  
  
  CONCLUSIONS
  Creating a gastrojejunostomy by NOTES using an anastomosing metal stent seems to be a safe, feasible, durable, and reproducible method for GOO.
authors.affiliation: Department of Internal Medicine, Institute of Gastroenterology, Yonsei University College of Medicine, 50 Yonsei-ro, Seodaemun-gu, Seoul, 120-752, Korea.
authors.forename: Seung Woo
authors.initials: SW
authors.lastname: Yi
authors.forename: Moon Jae
authors.initials: MJ
authors.lastname: Chung
authors.forename: Jung Hyun
authors.initials: JH
authors.lastname: Jo
authors.forename: Kyong Joo
authors.initials: KJ
authors.lastname: Lee
authors.forename: Jeong Youp
authors.initials: JY
authors.lastname: Park
authors.forename: Seungmin
authors.initials: S
authors.lastname: Bang
authors.forename: Seung Woo
authors.initials: SW
authors.lastname: Park
authors.forename: Si Young
authors.initials: SY
authors.lastname: Song
mesh_terms: D000818:Animals; D004195:Disease Models, Animal; D005260:Female; D015390:Gastric Bypass / Q000379:methods*; D017219:Gastric Outlet Obstruction / Q000601:surgery*; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D010166:Palliative Care / Q000379:methods; D011474:Prosthesis Design; D015607:Stents; D013552:Swine