Abstract
Background
Thoracoscopy and mediastinoscopy are common procedures with painful incisions and prominent scars. A natural orifice transesophageal endoscopic surgical (NOTES) approach could reduce pain, eliminate intercostal neuralgia, provide access to the posterior mediastinal compartment, and improve cosmesis. In addition NOTES esophageal access routes also have the potential to replace conventional thoracoscopic approaches for medial or hilar lesions.
Methods
Five healthy Yorkshire swine underwent nonsurvival natural orifice transesophageal mediastinoscopy and thoracoscopy under general anesthesia. An 8- to 9.8-mm video endoscope was introduced into the esophagus, and a 10-cm submucosal tunnel was created with blunt dissection. The endoscope then was passed through the muscular layers of the esophagus into the mediastinal space. The mediastinal compartment, pleura, lung, mediastinal lymph nodes, thoracic duct, vagus nerves, and exterior surface of the esophagus were identified. Mediastinal lymph node resection was easily accomplished. For thoracoscopy, a small incision was created through the pleura, and the endoscope was introduced into the thoracic cavity. The lung, chest wall, pleura, pericardium, and diaphragmatic surface were identified. Pleural biopsies were obtained with endoscopic forceps. The endoscope was withdrawn and the procedure terminated.
Results
Mediastinal and thoracic structures could be identified without difficulty via a transesophageal approach. Lymph node resection was easily accomplished. Pleural biopsy under direct visualization was feasible. Selective mainstem bronchus intubation and collapse of the ipsilateral lung facilitated thoracoscopy. In one animal, an inadvertent 4-mm lung incision resulted in a pneumothorax. This was decompressed with a small venting intercostal incision, and the remainder of the procedure was completed without difficulty.
Conclusions
Transesophageal endoscopic mediastinoscopy, lymph node resection, thoracoscopy, and pleural biopsy are feasible and provide excellent visualization of mediastinal and intrathoracic structures. Survival studies will be needed to confirm the safety of this approach.
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References
Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV (2004) Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc 60:114–117
Fong DG, Pai RD, Thompson CC (2007) Transcolonic endoscopic abdominal exploration: a NOTES survival study in a porcine model. Gastrointest Endosc 65:312–318
Jagannath SB, Kantsevoy SV, Vaughn CA, Chung SS, Cotton PB, Gostout CJ, Hawes RH, Pasricha PJ, Scorpio DG, Magee CA, Pipitone LJ, Kalloo AN (2005) Peroral transgastric endoscopic ligation of fallopian tubes with long-term survival in a porcine model. Gastrointest Endosc 61:449–453
Wagh MS, Merrifield BF, Thompson CC (2005) Endoscopic transgastric abdominal exploration and organ resection: initial experience in a porcine model. Clin Gastroenterol Hepatol 3:892–896
Wagh MS, Merrifield BF, Thompson CC (2006) Survival studies after endoscopic transgastric oophorectomy and tubectomy in a porcine model. Gastrointest Endosc 63:473–478
Kantsevoy SV, Jagannath SB, Niiyama H, Chung SS, Cotton PB, Gostout CJ, Hawes RH, Pasricha PJ, Magee CA, Vaughn CA, Barlow D, Shimonaka H, Kalloo AN (2005) Endoscopic gastrojejunostomy with survival in a porcine model. Gastrointest Endosc 62:287–292
Bergstrom M, Ikeda K, Swain P, Park PO (2006) Transgastric anastomosis by using flexible endoscopy in a porcine model (with video). Gastrointest Endosc 63:307–312
Park PO, Bergstrom M, Ikeda K, Fritscher-Ravens A, Swain P (2005) Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis (videos). Gastrointest Endosc 61:601–606
Pai RD, Fong DG, Bundga ME, Odze RD, Rattner DW, Thompson CC (2006) Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model (with video). Gastrointest Endosc 64:428–434
Rolanda C, Lima E, Pego JM, Henriques-Coelho T, Silva D, Moreira I, Macedo G, Carvalho JL, Correia-Pinto J (2007) Third-generation cholecystectomy by natural orifices: transgastric and transvesical combined approach (with video). Gastrointest Endosc 65:111–117
Kantsevoy SV, Hu B, Jagannath SB, Vaughn CA, Beitler DM, Chung SS, Cotton PB, Gostout CJ, Hawes RH, Pasricha PJ, Magee CA, Pipitone LJ, Talamini MA, Kalloo AN (2006) Transgastric endoscopic splenectomy: is it possible? Surg Endosc 20:522–525
Fritscher-Ravens A, Mosse CA, Ikeda K, Swain P (2006) Endoscopic transgastric lymphadenectomy by using EUS for selection and guidance. Gastrointest Endosc 63:302–306
Merrifield BF, Wagh MS, Thompson CC (2006) Peroral transgastric organ resection: a feasibility study in pigs. Gastrointest Endosc 63:693–697
Matthes K, Yusuf TE, Willingham FF, Mino-Kenudson M, Rattner DW, Brugge WR (2007) Feasibility of endoscopic transgastric distal pancreatectomy in a porcine animal model. Gastrointest Endosc 66:762–766
ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery (2006) White paper, October 2005. Gastrointest Endosc 63:199–203
Pearl JP, Onders RP, Marks JM, Chak A, McGee MF, Rosen M, Ponsky JL (2007) Transgastric endoscopic peritoneoscopy in humans under laparoscopic visualization: a bridge to NOTES. Gastrointest Endosc 65:AB292
Bessler M, Stevens P, Milone L, Fowler D (2007) Transvaginal cholecystectomy, laparoscopically assisted, for gallstones, a human case. Surg Endosc ET017 p 318
Blanc FX, Atassi K, Bignon J, Housset B (2002) Diagnostic value of medical thoracoscopy in pleural disease: a 6-year retrospective study. Chest 121:1677–1683
Roviaro GC, Varoli F, Vergani C, Maciocco M (2002) State of the art in thoracospic surgery: a personal experience of 2,000 videothoracoscopic procedures and an overview of the literature. Surg Endosc 16:881–892
Landreneau RJ (1997) Role of thoracoscopy in thoracic surgical practice. West J Med 166:59–60
Krasna MJ, Deshmukh S, McLaughlin JS (1996) Complications of thoracoscopy. Ann Thorac Surg 61:1066–1069
Sumiyama K, Gostout CJ, Rajan E, Bakken TA, Knipschield MA (2007) Transesophageal mediastinoscopy by submucosal endoscopy with mucosal flap safety valve technique. Gastrointest Endosc 65:679–683
Wolfsen HC (2007) Endoluminal therapy for Barrett’s esophagus. Gastrointest Endosc Clin North Am 17:59–82, vi–vii
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Willingham, F.F., Gee, D.W., Lauwers, G.Y. et al. Natural orifice transesophageal mediastinoscopy and thoracoscopy. Surg Endosc 22, 1042–1047 (2008). https://doi.org/10.1007/s00464-007-9668-z
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DOI: https://doi.org/10.1007/s00464-007-9668-z