title: Evaluation of feasibility, efficiency and safety of a pure NOTES gastrojejunal bypass with gastric outlet obstruction, in an in vivo porcine model.
abstract: BACKGROUND
  Natural orifice transluminal endoscopic surgery (NOTES) gastrojejunal anastomosis (GJA) is a less invasive surgery for bariatric procedures and gastric outlet obstruction. The aim of this study was to evaluate the feasibility, efficacy, and safety of a pure NOTES gastrojejunal bypass using an in vivo porcine model.
  
  
  METHODS
  A prospective study was performed on nine swine. A double-channel scope was used. The intervention steps were: (i) gastric incision; (ii) peritoneal access; (iii) jejunal loop selection and mobilization into the stomach; (iv) stoma creation within the gastric wall and incision; (v) anastomosis suture and pylorus closure using a T-tag prototype. The animals were assessed clinically for 3 weeks including the weight gain. The patency of the GJA was assessed at necropsy and a histological analysis was performed.
  
  
  RESULTS
  We successfully performed all the procedures with a mean (standard deviation [SD]) operative time of 108 (26) minutes. We used a mean of 5.55 (1.30) stitches. There were no intraprocedural adverse events. Five animals survived up till euthanasia at 3 weeks (65 %). These showed a significant difference in weight curves of a loss of 3.2 kg compared with gain of 5.2 kg in a control group. Four pigs died from anastomotic dehiscence complicated by peritonitis.
  
  
  CONCLUSIONS
  Gastrojejunal bypass with a pure NOTES approach is feasible. This procedure is effective, resulting in a patent anastomosis and a significant weight loss. However, the anastomotic dehiscence is a major concern because of its mortality rate, and further studies including improvement of the suturing device and the technique are needed.
authors.affiliation: Department of Gastroenterology, Public Assistance Hospitals of Marseille, North Hospital, Marseille, France ; Department of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States.
authors.forename: J-M
authors.initials: JM
authors.lastname: Gonzalez
authors.affiliation: Department of Gastroenterology, Public Assistance Hospitals of Marseille, North Hospital, Marseille, France.
authors.forename: E A
authors.initials: EA
authors.lastname: Bonin
authors.affiliation: Department of Endoscopy, University Hospital of Nice, Nice, France.
authors.forename: G
authors.initials: G
authors.lastname: Vanbiervliet
authors.affiliation: Aix-Marseille University, CERC, Faculty of Medicine, Marseille, France.
authors.forename: E
authors.initials: E
authors.lastname: Garnier
authors.affiliation: Department of Digestive Surgery, Public Assistance Hospitals of Marseille, Marseille, France.
authors.forename: S
authors.initials: S
authors.lastname: Berdah
authors.affiliation: Department of Gastroenterology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, United States.
authors.forename: K
authors.initials: K
authors.lastname: Matthes
authors.affiliation: Department of Gastroenterology, Public Assistance Hospitals of Marseille, North Hospital, Marseille, France.
authors.forename: M
authors.initials: M
authors.lastname: Barthet