Endoscopy :: New Simple Flexible Endoscopic Suturing Method for Intra-Luminal and Transgastric Surgery

With the emergence of the novel surgical technique known as Natural Orifice Transluminal Endoscopic Surgery (NOTESTM), physicians and researchers are discovering new and minimally-invasive ways to conduct abdominal operations.

NOTES is performed by passing an endoscope through a natural orifice, such as the mouth or anus, then making an internal incision in the stomach, colon, bladder or vagina, thus avoiding external incisions or scarring.

Since its introduction in 2004, many physicians have tested this concept to determine its strengths, weaknesses and potential solutions.

In this study, researchers from Gothenberg and London tested new technology applicable to NOTES as well as intraluminal endosurgery ? specifically, a new flexible endoscopic suturing method for intraluminal and transgastric surgery. Researchers evaluated the technique in porcine models and then reported the first clinical results in three patients. While many devices have been constructed to perform endoscopic suturing, most are complicated, expensive and difficult to use. Researchers evaluated the new method and found that it was not only easy to employ, but allowed for successful closure of perforations and approximate tissue without laparoscopic or open surgery.

The method involves passing flexible needles constrained within a plastic catheter loaded with metal tags down the working channel of a conventional endoscope. Two tags are placed into the wall of the stomach, one on each side of the defect. The threads are then locked together and cut. Precise stitch positioning is performed in the middle of the visual field and multiple stitches can be placed quickly without the need to remove the endoscope during the procedure.

Using this technique, researchers were able to close a perforated duodenal ulcer (ulcer in the small intestine) and leaking anastomosis (surgical connection of separate or severed parts of a tubular organ, such as the intestine) and stop upper gastrointestinal bleeding in patients when other methods had failed. They were also able to close perforations and perform gastro-jejunostomies (surgical formation of a passage between the stomach and small intestine) and pyloroplasty (surgery to open up narrowing of the junction between the stomach and duodenum) in porcine models.

“This method makes endoscopic suturing possible almost anywhere in the GI tract that can be reached by a flexible endoscope,” said C. Paul Swain, M.D., of Royal London Hospital in London, UK and lead author of the study. “More studies are needed to provide further evidence that this and other types of natural orifice transluminal endoscopic surgery techniques are safe and effective. Randomized studies comparing this flexible suturing method with conventional surgery have been undertaken by our group in combination with others to examine the effect on closure of four centimeter incisions in the pig colon. Another randomized study has been undertaken to test the efficacy of this system in closing gastrotomy incisions for NOTES procedures. More human studies are planned.”

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