Abstract
Background
Extraction of a gallbladder through an endoscopic overtube during natural orifice translumenal endoscopic surgery (NOTES®) transgastric cholecystectomy avoids potential injury to the esophagus. This study examined the rate of successful gallbladder specimen extraction through an overtube and hypothesized that preoperative ultrasound findings could predict successful specimen passage.
Methods
Gallbladder specimens from patients undergoing laparoscopic cholecystectomy were measured, and an attempt was made to pull the specimens through a commercially available overtube with an inner diameter of 16.7-mm. A radiologist blinded to the outcomes reviewed the available preoperative ultrasound measurements from these patients. Ultrasound dimensions including gallbladder length, width, and depth; wall thickness; common bile duct diameter; and size of the largest gallstone (LGS) were recorded. Multiple logistic regression analysis was performed to determine whether ultrasound findings and patient characteristics (age, body mass index [BMI], and sex) could predict the ability of a specimen to pass through the overtube.
Results
Of 57 patients, 44 (77%) who had preoperative ultrasounds available for electronic review were included in the final analysis. Gallstones were present in 35 (79%) of these 44 patients. Intraoperative gallbladder perforation occurred in 18 (41%) of the 44 patients, and 16 (36%) of the 44 gallbladders could be extracted through the overtube. Measurement of LGS was possible for 23 patients, and indeterminate gallstone size (IGS) was determined for 12 patients. The rate for passage of perforated versus intact gallbladders was similar (40% vs. 23%; p = 0.054). The LGS (odds ratio [OR], 1.17; 95% confidence interval [CI], 1.02–1.33; p = 0.021) and IGS (OR, 22.97; 95% CI, 1.99–265.63; p = 0.025) predicted failed passage on multivariate logistic regression analysis. The passage rate was 80% for LGS smaller than 10 mm or no stones present, 18% for LGS 10 mm or larger, and 8% for IGS (p < 0.001).
Conclusion
A majority of cholecystectomy specimens cannot pass through an endoscopic overtube. Preoperative ultrasound findings can predict successful specimen extraction. An IGS or a gallstone 10 mm or larger should be considered a relative contraindication to transgastric NOTES cholecystectomy.
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References
Sodergren MH, Clark J, Athanasiou T, Teare J, Yang GZ, Darzi A (2009) Natural orifice translumenal endoscopic surgery: critical appraisal of applications in clinical practice. Surg Endosc 23:680–687
Flora ED, Wilson TG, Martin IJ, O’Rourke NA, Maddern GJ (2008) A review of natural orifice translumenal endoscopic surgery (NOTES) for intra-abdominal surgery: experimental models, techniques, and applicability to the clinical setting. Ann Surg 247:583–602
Asakuma M, Perretta S, Allemann P, Cahill R, Con SA, Solano C, Pasupathy S, Mutter D, Dallemagne B, Marescaux J (2009) Challenges and lessons learned from NOTES cholecystectomy initial experience: a stepwise approach from the laboratory to clinical application. J Hepatobiliary Pancreat Surg 16:249–254
Salinas G, Saavedra L, Agurto H, Quispe R, Ramirez E, Grande J, Tamayo J, Sanchez V, Malaga D, Marks JM (2009) Early experience in human hybrid transgastric and transvaginal endoscopic cholecystectomy. Surg Endosc 24:1092–1098
Branco Filho AJ, Noda RW, Kondo W, Kawahara N, Rangel M, Branco AW (2007) Initial experience with hybrid transvaginal cholecystectomy. Gastrointest Endosc 66:1245–1248
Davila F, Tsin DA, Dominguez G, Davila U, Jesus R, Gomez de Arteche A (2009) Transvaginal cholecystectomy without abdominal ports. JSLS 13:213–216
de Sousa LH, de Sousa JA, de Sousa Filho LH, de Sousa MM, de Sousa VM, de Sousa AP, Zorron R (2009) Totally NOTES (T-NOTES) transvaginal cholecystectomy using two endoscopes: preliminary report. Surg Endosc 23:2550–2555
Decarli LA, Zorron R, Branco A, Lima FC, Tang M, Pioneer SR, Sanseverino JI, Menguer R, Bigolin AV, Gagner M (2009) New hybrid approach for NOTES transvaginal cholecystectomy: preliminary clinical experience. Surg Innov 16:181–186
Forgione A, Maggioni D, Sansonna F, Ferrari C, Di Lernia S, Citterio D, Magistro C, Frigerio L, Pugliese R (2008) Transvaginal endoscopic cholecystectomy in human beings: preliminary results. J Laparoendosc Adv Surg Tech A 18:345–351
Gumbs AA, Fowler D, Milone L, Evanko JC, Ude AO, Stevens P, Bessler M (2009) Transvaginal natural orifice translumenal endoscopic surgery cholecystectomy: early evolution of the technique. Ann Surg 249:908–912
Horgan S, Cullen JP, Talamini MA, Mintz Y, Ferreres A, Jacobsen GR, Sandler B, Bosia J, Savides T, Easter DW, Savu MK, Ramamoorthy SL, Whitcomb E, Agarwal S, Lukacz E, Dominguez G, Ferraina P (2009) Natural orifice surgery: initial clinical experience. Surg Endosc 23:1512–1518
Noguera J, Dolz C, Cuadrado A, Olea J, Vilella A, Morales R (2009) Hybrid transvaginal cholecystectomy, NOTES, and minilaparoscopy: analysis of a prospective clinical series. Surg Endosc 23:876–881
Pugliese R, Forgione A, Sansonna F, Ferrari GC, Di Lernia S, Magistro C (2009) Hybrid NOTES transvaginal cholecystectomy: operative and long-term results after 18 cases. Langenbecks Arch Surg 395:241–245
Rao GV, Reddy DN, Banerjee R (2008) NOTES: human experience. Gastrointest Endosc Clin North Am 18:361–370; x
Rossi P, Bugiantella W, Graziosi L, Cavazzoni E, Donini A (2008) Transvaginal laparoscopically assisted endoscopic cholecystectomy: report of 3 cases. Gastrointest Endosc 68:1226–1228
Tsin DA, Colombero LT, Lambeck J, Manolas P (2007) Minilaparoscopy-assisted natural orifice surgery. JSLS 11:24–29
Zornig C, Mofid H, Siemssen L, Emmermann A, Alm M, von Waldenfels HA, Felixmuller C (2009) Transvaginal NOTES hybrid cholecystectomy: feasibility results in 68 cases with mid-term follow-up. Endoscopy 41:391–394
Conway WC, Sugawa C, Ono H, Lucas CE (2007) Upper GI foreign body: an adult urban emergency hospital experience. Surg Endosc 21:455–460
Auyang ED, Hungness ES, Vaziri K, Martin JA, Soper NJ (2009) Human NOTES cholecystectomy: transgastric hybrid technique. J Gastrointest Surg 13:1149–1150
National Institutes of Health (US) (2000) ClinicalTrials.gov [Internet], Bethesda, MD. Available from http://clinicaltrials.gov/ct2/search. Cited 1 Apr 2010
Swanstrom LL, Volckmann E, Hungness E, Soper NJ (2009) Patient attitudes and expectations regarding natural orifice translumenal endoscopic surgery. Surg Endosc 23:1519–1525
Volckmann ET, Hungness ES, Soper NJ, Swanstrom LL (2009) Surgeon perceptions of natural orifice translumenal endoscopic surgery (NOTES). J Gastrointest Surg 13:1401–1410
Moriai T, Hasegawa T, Fuzita M, Kimura A, Tani T, Makino I (1991) Successful removal of massive intragastric gallstones by endoscopic electrohydraulic lithotripsy and mechanical lithotripsy. Am J Gastroenterol 86:627–629
Acknowledgment
We acknowledge Khashayar Vaziri, M.D., for his assistance in the completion of the study.
Disclosures
Eric S. Hungness has consulting agreements with Ethicon Endo-Surgery, Olympus, Terumo, and Boston Scientific. Nathaniel J. Soper is a member of scientific advisory boards for Covidien, Terumo, Transenterix, Boston Scientific, and EndoGastric Solutions, Inc. Byron F. Santos, Edward D. Auyang, Kush R. Desai, Edward S. Chan, Darren B. van Beek, and Edward C. Wang have no conflicts of interest or financial ties to disclose.
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Santos, B.F., Auyang, E.D., Hungness, E.S. et al. Preoperative ultrasound measurements predict the feasibility of gallbladder extraction during transgastric natural orifice translumenal endoscopic surgery cholecystectomy. Surg Endosc 25, 1168–1175 (2011). https://doi.org/10.1007/s00464-010-1334-1
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DOI: https://doi.org/10.1007/s00464-010-1334-1