Endoscopic stenting for gastroduodenal outlet obstruction of a malignant origin, real life experience in a single center.

AIM: to evaluate the safety and effectiveness of self-expandable metal stent placement for malignant gastric outlet obstruction (GOO). METHODS: a retrospective, analytic cohort study at a single, tertiary-care center. RESULTS: thirty-six patients that underwent stent placement for GOO of malignant origin were identified during the study period. Technical success was achieved in 36 (100 %) patients and clinical success was achieved in 31 patients (86.1 %). Before the procedure, 17 (54.8 %) patients had a gastric outlet obstruction score (GOOSS) of 0, which is a complete inability of oral intake. Twenty-three patients were alive 30 days after the procedure, two (8.6 %) patients had a GOOSS of 1, ten (43.3 %) had a GOOSS of 2 and eleven (47.9 %) had a GOOSS of 3. Abdominal pain was present in all 31 patients before the procedure and only seven (22.6 %) patients continued with abdominal pain 24 hours after the procedure. During follow-up, ten (30.3 %) patients developed complications related to the stents and none of them was fatal. Additional therapy due to partial occlusion of the stent was necessary in three patients. The stents functional duration had a median of 72 days (IQR 25-75 15-105 days) and was closely related to overall survival. CONCLUSION: palliative stenting for gastroduodenal obstruction is a safe, feasible and effective therapy to treat patients with malignant gastric outlet obstruction.

Surgical Trauma Caused by Different Abdominal Access Routes-Comparison of Open Surgical, Laparoscopic, and NOTES Transgastric Techniques in a Porcine Model.

BACKGROUND: Investigations indicate that natural orifice translumenal endoscopic surgery (NOTES) procedures induce a less pronounced postoperative inflammatory response than open or laparoscopic surgery, inflicting less trauma. In NOTES procedures, no skin incision is performed. We compare the inflammatory response added by the type of incision by measuring C-reactive protein (CRP) and tumors necrosis factor-alfa (TNF-α). METHODS: Twenty-seven pigs were randomized to open surgical, laparoscopic, or transgastric NOTES abdominal access. After completion of the accesses, no surgery was performed. All accesses were left open for 40 minutes followed by closure, animals were survived for 7 days. Blood samples were drawn at the start of the accesses, at 20 and 40 minutes during the procedure, and at postoperative day (POD) 1, 3, and 7. Analyses of CRP and TNF-α were performed. RESULTS: CRP increased in all animals until POD1. This increase was greater in the open group (P = .006). No significant differences in CRP-levels were found at POD 1, 3, or 7. TNF-α showed a peak during the procedure, at 20 and 40 minutes, with normalization at POD1 for 1/3 of the open and laparoscopic animals, but not for the NOTES animals. Due to variations within the groups, no statistical difference was shown between them. At postmortem, 1/3 of the pigs in the laparoscopic and open groups had wound infections, while no NOTES animals showed infections. CONCLUSIONS: This study provides no statistically significant differences in inflammatory response after the different abdominal accesses. However, the lack of a TNF-α-peak in the NOTES group might indicate a less pronounced response, supporting the initial theories.

A new in vivo method for testing closures of gastric NOTES incisions using leak of the closure or gastric yield as endpoints.

BACKGROUND: We developed a non-survival in vivo model for testing of gastric natural orifice translumenal endoscopic surgery (NOTES) closures based on the gastric yield pressure. The aim of this study was to test our model comparing different endoscopic closure techniques with surgical closure of a NOTES gastric incision. METHODS: Laparotomy was performed in 30 pigs. One tube for air inflation and one manometry tube were inserted into the stomach via the pylorus, which was closed gas-tight, and the abdominal wall was closed. The stomach was inflated with air, and the gastroesophageal yield pressure was measured. A gastroscopy was performed, and a standard NOTES access was created followed by randomization to closure by surgical suturing, T-tags, Padlock-G over-the-scope (OTS)-clips, OVESCO OTS-clips, and traditional clips. All closures were tested twice with air insufflation. Gastric yield pressure or leak pressure of each closure was recorded. RESULTS: The mean baseline gastric yield pressure was 80.5 mm Hg. Post-closure yield pressure was 79.9 mm Hg. Leak test results after closure were as follows: surgery, 0/6 leaked; T-tags, 1/6 leaked before reaching yield pressure (56 mm Hg); Padlock-G, 2/5 leaked (71.5 mm Hg); OVESCO OTS-clips, 3/6 leaked (27.2 mm Hg); and traditional clips, 5/6 leaked (27.2 mm Hg). TAS T-tags and surgical closures leaked significantly less than the other groups (P=.01). Traditional clips and OVESCO OTS-clips leaked at significantly lower pressures than the other three groups (P=.007). CONCLUSION: This in vivo model using leak of the closure or the gastric yield pressure as endpoints for testing of the closure strength of a NOTES gastric access site seems to be reproducible. Our results support closure with T-tags and Padlock-G-clips over OVESCO OTS-clips and standard endoscopic clips.