Transgastric endoscopic splenectomy

Surg Endosc (2006) 20: 522–525 DOI: 10.1007/s00464-005-0263-x Ó Springer Science+Business Media, Inc. 2006

Transgastric endoscopic splenectomy Is it possible? S. V. Kantsevoy, B. Hu, S. B. Jagannath, C. A. Vaughn, D. M. Beitler, S. S. C. Chung, P. B. Cotton, C. J. Gostout, R. H. Hawes, P. J. Pasricha, C. A. Magee, L. J. Pipitone, M. A. Talamini, A. N. Kalloo Division of Gastroenterology, Johns Hopkins Hospital, 1830 East Monument Street, Room 422, Baltimore, MD 21205, USA Received: 15 April 2005/Accepted: 29 July 2005/Online publication: 21 January 2006

Abstract Background: We have previously reported the feasibility of diagnostic and therapeutic peritoneoscopy including liver biopsy, gastrojejunostomy, and tubal ligation by an oral transgastric approach. We present results of peroral transgastric splenectomy in a porcine model. The goal of this study was to determine the technical feasibility of per-oral transgastric splenectomy using a flexible endoscope. Methods: We performed acute experiments on 50-kg pigs. All animals were fed liquids for 3 days prior to procedure. The procedures were performed under general anesthesia with endotracheal intubation. The flexible endoscope was passed per orally into the stomach and puncture of the gastric wall was performed with a needle knife. The puncture was extended to create a 1.5-cm incision using a pull-type sphincterotome, and a double-channel endoscope was advanced into the peritoneal cavity. The peritoneal cavity was insufflated with air through the endoscope. The spleen was visualized. The splenic vessels were ligated with endoscopic loops and clips, and then mesentery was dissected using electrocautery. Results: Endoscopic splenectomy was performed on six pigs. There were no complications during gastric incision and entrance into the peritoneal cavity. Visualization of the spleen and other intraperitoneal organs was very good. Ligation of the splenic vessels and mobilization of the spleen were achieved using commercially available devices and endoscopic accessories. Conclusion: Transgastric endoscopic splenectomy in a porcine model appears technically feasible. Additional long-term survival experiments are planned.

Presented at the Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) meeting, Fort Lauderdale, FL, USA, April 2005 Correspondence to: A. N. Kalloo

Laparoscopic procedures have many advantages over traditional surgery: they reduce the postoperative pain and risk of ventral hernias, shorten hospital stay and recovery period, and allow early return to regular physical activity [5–7, 15, 16]. We have previously reported the feasibility of transgastric diagnostic and therapeutic peritoneoscopy, including liver biopsy, gastrojejunostomy, and tubal ligation [10, 11, 13]. Here, we present results of transgastric splenectomy in a porcine model.

Materials and methods This study was approved by the Johns Hopkins University School of Medicine animal care institutional review board. The aim of the study was to determine the technical feasibility of per oral transgastric splenectomy using a flexible endoscope. We performed a series of acute experiments on 50-kg pigs (Sus scrofus domesticus). All pigs were fed eight 16-oz. cans of Ensure (Abbott Laboratories, North Chicago, IL, USA) for 2 days prior to endoscopy and then fasted overnight. Under general anesthesia with endotracheal intubation, an adult forwardviewing, double-channel endoscope (GIF-2T160, Olympus, Tokyo) was advanced into the esophagus and stomach. Puncture of the gastric wall was performed with a triple-lumen, 4-mm cutting-wire needle knife (Wilson-Cook Medical, WinstonSalem, NC, USA) using pure cautery at 20 W followed by pure cut current at 30 W (Valleylab SSE2L, Tyco Healthcare Group, Boulder, CO, USA). The puncture was enlarged to 1.5 cm with a pull-type sphincterotome (210Q-0720, Olympus) and the endoscope was advanced into the peritoneal cavity (Fig. 1). The peritoneal cavity was insufflated with air through the endoscope. The spleen was easily visualized by retroflexion of the endoscope and directing its tip toward the upper left quadrant of the abdomen. Using grasping endoscopic forceps (FG-47L-1, Olympus) and standard electrocautery equipment (needle knife, Wilson-Cook Medical) or endoscopic polypectomy snare (Sensation M00562650, Boston Scientific, Natick, MA, USA), the omentum was separated from the spleen (Fig. 2). All major splenic vessels were ligated with detachable endoloops (Olympus) (Fig. 3) and endoscopic clips (Resolution M00522610, Boston Scientific) (Fig. 4) and then cut by endoscopic polypectomy snare (Sensation M00562650, Boston Scientific) using pure cautery at 20 W followed by pure cut current at 30 W. The spleen was pulled into the stomach (Fig. 5). The animals were sacrificed and necropsy was performed.

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Fig. 1. Gastric wall incision by the pull-type sphincterotome.

Fig. 3. Splenic vessels are ligated by two endoscopic loops.

Fig. 2. Omentum grasped by endoscopic forceps and divided from the spleen by endoscopic polypectomy snare.

Fig. 4. Splenic vessel is ligated by endoscopic loop and is secured by endoscopic clip.

Results

the medial surface at approximately half the length of the spleen). The second splenic artery and vein are located at the upper pole of the spleen. Both sets of splenic vessels were ligated with two endoloops (Olympus) and in addition the mesenteric (remaining) portion of the vessel was secured with an endoscopic clip. After the spleen was mobilized, the gastric incision was enlarged with the sphincterotome and the spleen was pulled into the stomach. Necropsy did not reveal any damage to the intraperitoneal organs related to the transgastric access to the peritoneal cavity. The porcine spleen was approxi-

Endoscopic splenectomy was performed on six pigs. There were no complications during gastric wall incision and entrance into the peritoneal cavity. Visualization of the spleen and other intraperitoneal organs was very good. Ligation of the splenic vessels and mobilization of the spleen were achieved using standard endoscopic devices and accessories. The omentum was cauterized and cut by endoscopic snare to gain access to the splenic vessels. The pigÕs spleen has two sets of major vessels. The first splenic artery and vein are located at the hilum (on

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Fig. 5. Mobilized spleen pulled inside the stomach.

gery [12]. Later, several studies confirmed the technical feasibility of transgastric diagnostic and therapeutic peritoneoscopy, including liver biopsy, gastrojejunostomy, tubal ligation, and cholecystectomy [10, 11, 13, 18]. Here, we report per-oral transgastric splenectomy on a porcine model. Potential advantages of the per-oral transgastric approach compared to traditional surgical or laparoscopic splenectomy include that it is minimally invasive without need for skin and anterior abdominal wall incisions, thus eliminating the risk of skin wound infection and postoperative hernias. Furthermore, peroral transgastric splenectomy may be especially useful in morbidly obese patients or patients with large areas of scars (post chemical or thermal burns) or infection of the anterior abdominal wall. Our experiments were performed on a porcine model, and it is important to note that the porcine model is not optimal for splenectomy because the pig spleen is significantly larger than the human spleen. We used a standard flexible double-channel endoscope and commercially available accessories: needle knife and pulltype sphincterotomes for gastric wall puncture and incision, and grasping endoscopic forceps, polypectomy snare with electrocautery equipment, endoscopic detachable loops, and clips for ligation of the splenic vessels and mobilization of the spleen. Special devices such as a retrieval bag and morselation equipment adapted for use with a flexible endoscope must be developed. Due to lack of a morselation device, we extended the gastric wall incision to 3 or 4 cm and pulled the spleen into the stomach. The gastric wall incision can easily be closed endoscopically using endoclips (Olympus) [13]. An endoscopic suturing device can also be used to close the gastric wall incision [9]. Transgastric endoscopic splenectomy in a porcine model is technically feasible despite the relatively large size of the porcine spleen. Additional long-term survival experiments are planned.

Fig. 6. Necropsy of the porcine spleen.

References mately twice the size of the human spleen (usually approximately 36 cm long and 6 cm wide) (Fig. 6), so it would probably be less difficult to remove the human spleen.

Discussion Laparoscopic splenectomy was first reported by Delaitre and Maignien in 1991 and soon became one of the most frequently performed laparoscopic solid organ procedures [2–4, 8, 14]. Multiple studies have confirmed the advantages of laparoscopic splenectomy compared to the open procedure, which include decreased blood loss, shorter hospital stay, rapid recovery and return to physical activity, and excellent cosmetic results [1, 14, 17, 19]. Our group was the first to describe a new approach to minimally invasive procedures—natural orifices sur-

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