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Stent placement provides safe esophageal closure in thoracic NOTESTM procedures

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Abstract

Background

Safe esophageal closure remains a challenge in transesophageal Natural Orifice Transluminal Endoscopic Surgery (NOTES). Previously described methods, such as suturing devices, clips, or submucosal tunneling, all have weaknesses. In this survival animal series, we demonstrate safe esophageal closure with a prototype retrievable, antimigration stent.

Methods

Nine Yorkshire swine underwent thoracic NOTES procedures. A double-channel gastroscope equipped with a mucosectomy device was used to create an esophageal mucosal defect. A 5-cm submucosal tunnel was created and the muscular esophageal wall was incised with a needle-knife. Mediastinoscopy and thoracoscopy were performed in all swine; lymphadenectomy was performed in seven swine. A prototype small intestinal submucosal (SurgiSIS®) covered stent was deployed over the mucosectomy site and tunnel. Three versions of the prototype stent were developed. Prenecropsy endoscopy confirmed stent location and permitted stent retrieval. Explanted esophagi were sent to pathology.

Results

Esophageal stenting was successful in all animals. Stent placement took 15.8 ± 4.8 minuted and no stent migration occurred. Prenecropsy endoscopy revealed proximal ingrowth of esophageal mucosa and erosion with Stent A. Mucosal inflammation and erosion was observed proximally with Stent B. No esophageal erosion or pressure damage from proximal radial forces was seen with Stent C. On necropsy, swine 5 had a 0.5-cm periesophageal abscess. Histology revealed a localized inflammatory lesion at the esophageal exit site in swine 1, 3, and 9. The mucosectomy site was partially healed in three swine and poorly healed in six. All swine thrived clinically, except for a brief period of mild lethargy in swine 9 who improved with short-term antibiotic therapy. The submucosal tunnels were completely healed and no esophageal bleeding or stricture formation was observed. All swine survived 13.8 ± 0.4 days and gained weight in the postoperative period.

Conclusions

Esophageal stenting provides safe closure for NOTES thoracic procedures but may impede healing of the mucosectomy site.

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Acknowledgments

The authors thank Cook Medical Inc. for their help in designing and supplying the prototype stents used in this study and for their donation of additional endoscopic tools. We also thank Ethicon for their donation of prototype instruments in support of this project. Funding for this project was provided by support from the Center for Integrative Medicine and Technology (CIMIT).

Disclosures

Drs. Turner, Cizginer, Kim, Mino-Kenudson, Sylla, and Gee have no conflicts of interest or financial ties to disclose. Dr. Rattner has received an honorarium from Olympus for a speaking engagement. Dr. Brugge has served as a consultant for Boston Scientific.

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Authors and Affiliations

  1. Gastrointestinal Unit, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA

    Brian G. Turner, Sevdenur Cizginer & William R. Brugge

  2. Department of Surgery, Dong-A University College of Medicine, Minimally Invasive and Robot Center, 3-1 Dongdaeshin-Dong, Seo-gu, Busan, 602-715, Korea

    Min-Chan Kim

  3. Department of Pathology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, USA

    Mari Mino-Kenudson

  4. Cook Medical Inc, 4900 Bethania Station Road, Winston-Salem, NC, 27105-1203, USA

    Richard W. Ducharme & Vihar C. Surti

  5. Department of Surgery, Massachusetts General Hospital, 15 Parkman Street, WACC 460, Boston, MA, 02114, USA

    Patricia Sylla, David W. Rattner & Denise W. Gee

Authors
  1. Brian G. Turner
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  2. Sevdenur Cizginer
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  3. Min-Chan Kim
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  4. Mari Mino-Kenudson
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  5. Richard W. Ducharme
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  6. Vihar C. Surti
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  7. Patricia Sylla
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  8. William R. Brugge
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  9. David W. Rattner
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  10. Denise W. Gee
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Corresponding author

Correspondence to Denise W. Gee.

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Turner, B.G., Cizginer, S., Kim, MC. et al. Stent placement provides safe esophageal closure in thoracic NOTESTM procedures. Surg Endosc 25, 913–918 (2011). https://doi.org/10.1007/s00464-010-1297-2

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  • DOI: https://doi.org/10.1007/s00464-010-1297-2

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