Transgastric Endoscopic Pyloroplasty with Full-Thickness Gastric and Duodenal Myotomy and Sutured Closure

摘要

Background: Pyloroplasty is a common surgical procedure which may be performed for gastric outlet obstruction due a variety of causes including duodenal ulceration, hypertrophic and generalized smooth muscle disorders, vagal nerve injury following upper GI surgery including esophagectomy, proximal gastrectomy and fundoplication. Materials and Methods: Pyloroplasty was performed in acute and survival studies in 4 pigs (28-35 kg). A double channel gastroscope was used for the procedure. In pigs more retroflexion is required for pyloric intubation than in humans since the lesser curve is shorter and greater curve more distensible. The position of the bile duct orifice was checked first since this is located in the proximal bulb in pigs and is in line with the prepyloric bulge, which is a prominent feature of pig anatomy. Using grasping forceps to hold the duodenal side of the tissue and expose the deep muscle a needle knife incision was made through the full thickness of the pyloric muscle. A stitch was placed in the deep muscle at the apex of the duodenal incision and another at the proximal edge of the gastric incision. These were tied together thus opening up the pylorus. Further stitches were placed on either side of the first stitch until the defect was effectively closed and water-tight. Suturing was performed using a 19 gauge needle on a flexible shaft passed through one channel of the double channel gastroscope. The threads were locked together in pairs. Results: The technique was used in 4 pigs including two survival studies. Incisions were 1.5-2 cm in length. 3 or 4 pairs of stitches were placed in each animal. Intra-peritoneal pressure measurements in 2 animals using a Verres needle technique indicated a rise or retro-peritoneal pressure indicating that the incisions were full-thickness. There was no significant bleeding or other complications. Grasping forceps were found helpful to hold the tissue during suturing. Stitch placement was not limited by the markedly retroflexed position of the endoscope. The surviving animals appeared fully recovered on awaking from the anesthetic and there were no complications. It was demonstrably easier to enter the pylorus after these experiments. The average time for these procedures was 30 minutes. Post-mortem examination showed effective healing of the incision and there was no evidence of leakage, peritoneal inflammation or peritonitis. Conclusions: Pyloroplasty with full-thickness pyloromyotomy and transverse closure of the linear incision thus substantially increasing the diameter of the pylorus was accomplished using a simple flexible endosurgical technique testing a new flexible suturing system.