NOTES: 'pre-dilatation' as a remedy for technical issues during transgastric access

Area of Science:

• Minimally Invasive Surgery
• Gastroenterology
• Surgical Innovation

Background:

• Natural Orifice Translumenal Endoscopic Surgery (NOTES) offers a minimally invasive approach, but challenges in achieving transgastric access, specifically viscerotomy, can lead to delays and failures.
• Establishing safe and efficient procedural techniques is crucial for the advancement of NOTES.

Purpose of the Study:

• To identify and resolve procedural issues encountered during transgastric access for NOTES.
• To evaluate the efficacy of percutaneous endoscopic gastrotomy (PEG) with pre-dilatation techniques in canine models.

Main Methods:

• Gastrotomy was performed in canine models using either a needle knife or percutaneous endoscopic gastrotomy (PEG) technique.
• Over-the-wire (OTW) balloon dilators were used for visceral aperture creation, following initial puncture and pre-dilatation with plastic bougies.
• Complications and failure causes were analyzed, leading to the abandonment of the needle knife method in favor of PEG with pre-dilatation.

Main Results:

• Initial attempts using needle knife and PEG techniques resulted in 5 failures due to organ damage or inability to insert dilators.
• The needle knife method was associated with significant complications, including bleeding and liver rupture, leading to its discontinuation.
• Successful viscerotomy was achieved in 17 consecutive cases using PEG with pre-dilatation, with no mortality observed.

Conclusions:

• Pre-dilatation of the initial puncture site with over-the-wire plastic dilators is a critical step for successful gastrotomy.
• This technique enhances safety and efficacy in creating transgastric access for NOTES procedures.
• The study recommends pre-dilatation as a standard procedure for gastrotomy creation in NOTES.