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Infection during natural orifice transluminal endoscopic surgery: a randomized, controlled study in a live porcine
Samuel A Giday1, Xavier Dray, Priscilla Magno
1Division of Gastroenterology, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA.
Background:
Currently reported natural orifice transluminal endoscopic surgery (NOTES) procedures in animals have been done in heterogeneous milieus ranging from nonsterile to sterile procedures, with mixed results, including no infection in those performed in nonsterile settings.
Objective:
To establish the potential frequency of infection during NOTES, comparing sterile to nonsterile approaches.
Setting:
Survival experiments on sixteen 50-kg pigs.
Design And Interventions:
From pilot data (100% infection frequency after nonsterile procedures), sample size (8 animals in each group) was calculated by using a power of 95% and an alpha risk of 0.05. The animals were randomly assigned to two groups: In the transgastric peritoneoscopy study group, liver and ovarian biopsies were performed with sterile overtubes, endoscopes, and accessories and the use of preoperative intravenous antibiotics and antiseptic gastric lavage. In the nonsterile (control) group, the same procedures were performed with nonsterile endoscopes and accessories without the use of gastric lavage and preoperative antibiotics. Complete transmural closure of the transgastric access site was made in all animals. After a 1-week survival time, all animals were killed for necropsy, which included Gram staining and peritoneal cultures.
Main Outcome Measurements:
Intraperitoneal infection on necropsy.
Results:
All necropsies revealed intraperitoneal infection (abscesses, fibrinopurulent exudates, and adhesions) in the control group (frequency of infection 100%). Peritoneal bacterial culture grew various aerobic and anaerobic organisms. No gross or bacteriological evidence of infection was seen in the sterile group (frequency of infection 0%, P value = <.0002).
Limitations:
Animal experiments.
Conclusion:
Nonsterile conditions invariably lead to intraperitoneal infection. Aseptic techniques during NOTES can prevent intra-abdominal infection. Future studies will determine which infection prevention steps are mandatory and which can be omitted during NOTES procedures.
Insights
Nonsterile natural orifice transluminal endoscopic surgery (NOTES) invariably causes infection. Employing aseptic techniques during NOTES prevents intra-abdominal infections, as demonstrated in animal studies.
Area of Science:
- Surgical Innovation
- Minimally Invasive Procedures
- Infection Control in Surgery
Background:
- Natural orifice transluminal endoscopic surgery (NOTES) has been performed in varied settings with inconsistent outcomes.
- Previous animal studies on NOTES have yielded mixed results regarding infection rates.
Purpose of the Study:
- To determine the infection frequency in animal models undergoing NOTES.
- To compare the outcomes of sterile versus nonsterile approaches during NOTES procedures.
Main Methods:
- Survival experiments were conducted on sixteen pigs, randomly assigned to sterile or nonsterile transgastric peritoneoscopy groups.
- Procedures included liver and ovarian biopsies, with the sterile group receiving antibiotics and antiseptic lavage.
- All animals were observed for one week before necropsy, including Gram staining and peritoneal cultures.
Main Results:
- The nonsterile (control) group exhibited a 100% infection rate, with abscesses, exudates, and adhesions.
- Bacterial cultures from the nonsterile group revealed diverse aerobic and anaerobic organisms.
- The sterile group showed no evidence of infection (0% frequency, P < .0002).
Conclusions:
- Nonsterile conditions during NOTES consistently lead to intraperitoneal infection.
- Aseptic techniques are crucial for preventing intra-abdominal infections in NOTES procedures.
- Further research is needed to identify essential and optional infection prevention steps in NOTES.