Moreover, flexible gastroscope was useful to show some parts of the thoracic cavity that could not be visualized with the 0�� optic of the operative thoracoscope, namely, lateral thoracic wall and the entire diaphragm. With exception of the one acute experiment which was terminated because of LAA rupture, all the other animals were kept alive until the end of the experiment. www.selleckchem.com/products/chir-99021-ct99021-hcl.html No adverse event occurred during the survival period. Complete LAA ligation was verified on necropsy, as LAA was fibrotic with the nylon endo-loop in place. The NOTES revolution permitted evolution of the different natural orifices approaches themselves. The performance of endoscopic submucosal transesophageal myotomy is a perfect example of this. Pasricha et al. used SEMF to perform peroral endoscopic myotomy (POEM) in an experimental setting [25].
Soon after this, Inoue et al. reported the first clinical experience of POEM for the treatment of achalasia [26]. In 17 consecutive patients, there were no intraoperative or postoperative complications, and the occasions of inadvertent entry into the cardiac mucosa (2 patients) and the exposure of mediastinal tissue (4 patients) were without incident. Although POEM might not be considered a true NOTES procedure because it does not divide all the layers of the esophagus, it does use readily available endoscopic equipment and techniques and directly competes with a laparoscopic procedure [27]. 3. Esophagotomy Closure When SEMF is used to create transesophageal access, esophagotomy closure is easy, as the overlying mucosa serves as a sealant flap.
Most authors use endoclips to close the defect of the mucosa, but in the early studies the mucosa was left open with good clinical outcomes [7, 12�C14]. Turner et al. published a study comparing esophageal submucosal tunnel closure with a stent versus no closure [28]. In this study, the unstented group achieved endoscopic and histologic evidence of complete reepithelialization and healing (100%) at the mucosectomy site compared with the stented group (20%, P = .048). So, it seems that the placement of a covered esophageal stent prejudices healing of the mucosectomy site. When direct incision esophagotomy is performed, a full-thickness healing of the mucosal and muscular layer must be achieved. Fritscher-Raves et al. compared endoscopic clip-closure (ECC) versus endoscopic suturing (ECS) versus thoracoscopic (TC) repair of a 2�C2.
5cm esophageal incision [29]. ECS was achieved using a prototype suturing system that deploys a metal anchor with a nonabsorbable polypropylene thread (T-bar) on each side of the esophageal defect (CR Bard, Murray Hill, NJ; Ethicon Endosurgery, Cincinnati, OH, USA). The two threads were joined together using a small cylindrical suture-locking device, approximating Entinostat both sides of the incision. Three to 5 pairs of T-bars were used to close the defect.