Trans-umbilical endoscopic cholecystectomy with a water-jet hybrid-knife: a pilot animal study.

AIM: To investigate the feasibility and safety of Natural orifice trans-umbilical endoscopic cholecystectomy with a water-jet hybrid-knife in a non-survival porcine model. METHODS: Pure natural orifice transluminal endoscopic surgery (NOTES) cholecystectomy was performed on three non-survival pigs, by transumbilical approach, using a water-jet hybrid-knife. Under general anesthesia, the following steps detailed the procedure: (1) incision of the umbilicus followed by the passage of a double-channel flexible endoscope through an overtube into the peritoneal cavity; (2) establishment of pneumoperitoneum; (3) abdominal exploration; (4) endoscopic cholecystectomy: dissection of the gallbladder performed using water jet equipment, ligation of the cystic artery and duct conducted using nylon loops; and (5) necropsy with macroscopic evaluation. RESULTS: Transumbilical endoscopic cholecystectomy was successfully completed in the first and third pig, with minor bleedings. The dissection times were 137 and 42 min, respectively. The total operation times were 167 and 69 min, respectively. And the lengths of resected specimen were 6.5 and 6.1 cm, respectively. Instillation of the fluid into the gallbladder bed produced edematous, distended tissue making separation safe and easy. Reliable ligation using double nylon loops insured the safety of cutting between the loops. There were no intraoperative complications or hemodynamic instability. Uncontrolled introperative bleeding occurred in the second case, leading to the operation failure. CONCLUSION: Pure NOTES trans-umbilical cholecystectomy with a water-jet hybrid-knife appears to be feasible and safe. Further investigation of this technique with long-term follow-up in animals is needed to confirm the preliminary observation.

Carbon dioxide insufflation during endoscopic retrograde cholangiopancreatography: a review and meta-analysis.

OBJECTIVES: The role of carbon dioxide (CO2) insufflation during endoscopic retrograde cholangiopancreatography (ERCP) is debated. A meta-analysis was performed to evaluate the efficacy and safety of CO2 insufflation for ERCP. METHODS: Searches were conducted in multiple databases composed of Pub-Medline, EMBASE, the Cochrane Library, science citation index expanded, Google scholar, and CNKI China series full-text database. Outcome measurements are listed below: ERCP procedural data, post-ERCP abdominal discomfort, radiographic evaluation of bowel gas volume, and CO2 safety data concerning CO2 elimination. RESULTS: Seven published randomized clinical trials involving 756 patients fulfilling the inclusion criteria were selected for meta-analysis, almost all of high quality. The incidence of ERCP-related complications was reduced by CO2 insufflation, so were the events of 1-hour, 3-hour, and 6-hour post-ERCP abdominal pain, based on their corresponding statistical results. Besides, CO2 insufflation was associated with less gas volume in the bowel lumen after the procedure. There were no significant differences between CO2 and air insufflation in total procedure time, the success rate of selective cannulation, post-ERCP abdominal distension, respectively. Subsequent sensitivity and subgroup analyses produced conflicting results. CONCLUSIONS: Compared with air insufflation, CO2 insufflation during ERCP reduces post-ERCP abdominal pain, post-ERCP bowel remnant gas volume, and ERCP-related complications, without clinically significant systematic CO2 retention.