Original Article
Experimental Endoscopy
Transgastric cholecystectomy: transgastric accessibility to the gallbladder improved with the SEMF method and a novel multibending therapeutic endoscope

https://doi.org/10.1016/j.gie.2007.01.010Get rights and content

Background

Transgastric cholecystectomy is thought to technically and anatomically challenge a single entry flexible endoscopic approach.

Objectives

To examine the feasibility of a transgastric-only cholecystectomy, endoscope performance in an upper-abdominal operation, and the usefulness of an offset gastrotomy.

Study Design

Animal survival study.

Setting

Animal research laboratory.

Patients

Six domestic pigs.

Main Outcome Measurements

Transgastric access to the gallbladder and technical feasibility of unassisted transgastric cholecystectomy.

Interventions

A cephalad submucosal tunnel was created in the anterior gastric wall with a high-pressure CO2 injection. An EMR-cap myotomy was performed distally within the submucosal space and created an offset gastrotomy. An endoscope was inserted into the peritoneal cavity through the myotomy. Access to the gallbladder was compared by using a multibending therapeutic endoscope (R-scope), with a standard double-channel endoscope. A cholecystectomy was performed by using both types of endoscopes. The myotomy site was sealed with the overlying mucosal flap. The mucosal entry point was closed with clips or tissue anchors.

Results

A standard double-channel endoscope could access the gallbladder in 2 of 4 attempts. A multibending endoscope accessed the gallbladder in all 4 attempts, including 2 pigs in which the standard scope failed to access the gallbladder. In 4 pigs, a cholecystectomy was completed. Two pigs died during surgery, with air embolization observed in 1. Two pigs survived a planned 1-week survival period.

Conclusions

Transgastric cholecystectomy is technically feasible. Transgastric access to the gallbladder may be improved by using submucosal endoscopy with an offset exit gastrotomy by means of the mucosal flap safety-valve technique and a multibending gastroscope.

Section snippets

Multibending endoscope

The endoscope used (XGIF-2TQ260ZMY, R-scope; Olympus Optical Co, Ltd, Tokyo, Japan) has 2 bending sections: the proximal section can be deflected in a single plane (up–down); the distal section can be deflected in 2 planes (up-down, right-left). There also are 2 actuated instrument channels: 1 allows vertical elevation, the other allows a horizontal “swing” movement (Fig. 1, Table 1).

CO2 tissue separation

For CO2 injection, a commercially available CO2 cylinder (CO2 Duster; American Recorder Technology Inc, Simi

SEMF with CO2 insufflation

A bowl-shaped giant submucosal bleb over 8 cm in diameter was created by several milliseconds (estimated only) of CO2 injection for 5 animals (Fig. 4), completely separating the submucosal layer from the mucosa, thereby forming a true space (Fig. 5). In 1 pig, a complete submucosal dissection failed, despite CO2 injections in 5 different locations. The submucosal space was eventually created with supplemental balloon dissection.

Gallbladder access

Myotomies with the attached serosa could be performed inside the

Discussion

A pure transgastric cholecystectomy is feasible when using a cephalad directional exit from the stomach to allow access to the gallbladder. Although the overall outcomes may not have been ideal, they proved instructional with regard to moving forward with NOTES research and development.

Modifying the anterior gastric exit with the SEMF technique directed cephalad could effectively create a biologic endoscope and instrument guide for the upper abdominal cavity. Furthermore, the R-type endoscope

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