Bone disease in patients with primary sclerosing cholangitis.

BACKGROUND & AIMS: Osteopenic bone disease occurs frequently among patients with chronic liver disease but has not been well studied in those with primary sclerosing cholangitis (PSC). We investigated the prevalence, rate of progression, and independent predictors of bone disease in a large number of patients with all stages of PSC. METHODS: Bone mineral density of the lumbar spine, hip, and total body was measured yearly for 10 years in 237 patients with PSC. RESULTS: Osteoporosis (T-score less than -2.5) was found in 15% of patients and occurred 23.8-fold (95% confidence interval [CI], 4.6-122.8) more frequently in those with PSC than expected from a matched population. By multivariate analysis, age 54 years or older (odds ratio [OR], 7.8; 95% CI, 3.3-18.3), body mass index ≤ 24 kg/m(2) (OR, 4.9; 95% CI, 1.9-12.6), and inflammatory bowel disease for ≥ 19 years (OR, 3.6; 95% CI, 1.5-8.4) correlated with the presence of osteoporosis. Osteoporosis was present in 75% of patients with all 3 risk factors but in only 3.1% of those without all of them. Patients with PSC lost 1% of bone mass per year; this rate of bone loss was significantly associated with duration of inflammatory bowel disease. CONCLUSIONS: Osteoporosis occurs frequently among patients with PSC. Old age, low body mass index, and long duration of inflammatory bowel disease can be used to identify patients with PSC who might derive the most benefit from measurements of bone density and treatments for bone diseases.

Evaluation of a novel access and closure device for NOTES applications: a transcolonic survival study in the porcine model (with video).

BACKGROUND: Natural orifice transluminal endoscopic surgery (NOTES) is a novel, potentially less invasive alternative to laparoscopic surgery. However, the problems of transluminal access and closure represent significant obstacles to its successful introduction in humans. OBJECTIVE: Our purpose was to evaluate the feasibility and safety of a novel device designed for transluminal access and closure. DESIGN: Experimental endoscopic study of transcolonic incision and closure with use of a prototype device in a survival porcine model. SUBJECTS: Four adult female Yorkshire pigs were used in the study. INTERVENTIONS: While under general anesthesia, the animals were prepped with multiple tap water enemas followed by instillation of an antibiotic suspension and povidone-iodine lavage. At a distance of 15 to 20 cm from the anus, the prototype device deployed a circumscribing purse-string suture around the planned incision site and subsequently used a blade mechanism to create a 2.5-cm linear incision. The peritoneum was then accessed with a standard double-channel enodoscope. The transcolonic incision was then closed by cinching and securing the purse-string suture with a titanium knot by use of a separate hand-activated suture-locking device. All animals were allowed to eat immediately after recovering from general anesthesia. MAIN OUTCOME MEASUREMENTS: The animals were monitored daily for signs of peritonitis and sepsis and were electively killed on day 14. The peritoneal cavity was examined for peritonitis, and the colonic incision site was examined for wound dehiscence, pericolic abscess formation, and gross adhesions. Tissue samples from both incisional and random peritoneal sites were obtained for histologic examination. RESULTS: Transcolonic incision and closure were successful in all 4 animals. The device performed in a rapid and reproducible fashion. All animals recovered without septic complications. At necropsy, there was no evidence of peritonitis, abscesses, or wound dehiscence. Salpingocolonic and colovesicular adhesions were noted in 3 of 4 animals. Histologic examination revealed microabscesses at the incision site in all animals. CONCLUSIONS: The prototype incision and closure device represents a promising solution to the problems of transluminal access for NOTES. The presence of incision-related adhesions and microabscesses signal the need for further refinement in aseptic technique.

Transcolonic endoscopic abdominal exploration: a NOTES survival study in a porcine model.

BACKGROUND: Published reports on NOTES (natural orifice transluminal endoscopic surgery) have thus far been limited to the transgastric method. OBJECTIVE: The aim of this study was to assess the transcolonic approach as a means of accessing and systematically exploring the abdominal cavity in a survival study design. DESIGN: Six pigs were placed under general anesthesia and were prepped with multiple tap-water enemas, followed by instillation of a cefazolin suspension and a povidone-iodine lavage. Equipment was prepared with a high-level chemical disinfection, and an aseptic technique was used. An incision was made in the anterior colonic wall, and abdominal exploration was performed by using a double-channel endoscope. The incision was subsequently closed with endoscopic clips, endoloops, or a prototype closure device. PATIENTS: Six female Yorkshire pigs that weighed 25 to 30 kg. RESULTS: Stomach, liver, gallbladder, spleen, small bowel, colon, and peritoneal surfaces were identified in all animals in less than 3 minutes. The lower pelvic organs were not consistently visualized. All animals were alive for 14 days without apparent complications. At necropsy, the colonic incision sites were completely closed and appeared well healed. Microscopic inflammatory changes were seen at the closure site in all animals, including microabscesses. Incision-related adhesions were identified in 4 of 6 animals. CONCLUSIONS: This study demonstrated the use of a novel transcolonic approach to successfully access and explore the abdominal cavity. In contrast to the transgastric method, a transcolonic approach provides more consistent identification of structures in the upper abdomen and provides better en face orientation and scope stability. Therapeutic interventions in the upper abdomen, including organ resection, may be more tenable by using a transcolonic method; however, further studies are needed to address issues of sterility and colonic closure.

Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model (with video).

BACKGROUND: Transgastric cholecystectomy is a natural orifice transluminal endoscopic surgery (NOTES) procedure that has been reported in 2 nonsurvival studies. Both studies detail substantial technical limitations, with only a 33% success rate when limited to 1 gastric incision site, despite the use of a multichannel locking endoscope. OBJECTIVE: The aim of this study was to evaluate the feasibility and technical limitations of transcolonic cholecystectomy in a survival model. DESIGN: Animal feasibility study. INTERVENTIONS: Five pigs, under general anesthesia, were prepared with tap-water enemas, a peranal antibiotic lavage, and a Betadine rinse. A dual-channel endoscope was advanced into the peritoneum through an anterior, transcolonic incision 15 to 20 cm from the anus. After cystic duct and artery ligation, dissection of the gallbladder was achieved by using grasping and cutting instruments. After removing the gallbladder, the colonic incision was closed by using Endoloops and/or endoclips. The animals lived for 2 weeks after the procedure, then they were euthanized, and a necropsy was performed. RESULTS: All 5 gallbladders were successfully resected. Four of the 5 animals flourished in the postoperative period, with appropriate weight gain. In 1 animal, complete closure of the colonic incision was not possible, and it was euthanized at 48 hours for suspected peritonitis. CONCLUSIONS: This study reports the first transcolonic organ resection and demonstrates the first successful NOTES cholecystectomy in a survival model. The transcolonic approach provided improved endoscope stability and biliary exposure compared with the transgastric route, and complete incision closure appeared critical for procedural success.