Transgastric endoluminal gastrojejunostomy: technical development from bench to animal study (with video)

BackgroundGastrojejunal anastomosis is commonly performed for palliative management of malignant gastric outlet obstruction and bariatric surgery. Natural orifice transluminal endoscopic surgery revolutionized the surgical approach to intra-abdominal surgery. This study explored the possibility of performing gastrojejunostomy (GJ) by using a hybrid natural orifice transluminal endoscopic surgery approach.ObjectiveTo develop a surgical technique for the performance of transgastric endoscopic GJ (TGEJ) in a porcine model.DesignProspective series of animal experiments.SettingUniversity hospital animal laboratory.AnimalsThirteen female domestic pigs.InterventionsWith the animals under general anesthesia, the endoscope is passed through the gastrotomy and a segment of small bowel is retrieved into the stomach. An enterotomy is then created, and an EndoGIA stapler is introduced through an intragastric port and passed between the small bowel and stomach wall. A GJ is formed after firing of the EndoGIA stapler. The pigs are allowed to resume their diet 1 day after the operation and are allowed to survive for 2 weeks before they are euthanized. The patency of the GJ is confirmed with a repeat endoscopy, contrast study, and postmortem examination.ResultsA total of 13 TEGJs were performed, 11 of which were successful. The mean operative time was 53.6 ± 45.7 minutes. The mean time for gastrotomy was 4.7 minutes, and that for GJ was 42.5 minutes. One TEGJ was converted to open surgery because of malpositioning of the intragastric port, and the other failed because the enterotomy was too extensive. Ten of 11 pigs survived for 2 weeks, and endoscopic examination with contrast study confirmed that all the gastrojejunostomies were patent. On postmortem examination, the average size of the GJ was 30 mm.LimitationsThe length between duodenojejunal flexure and the site chosen to perform the GJ could not be determined.ConclusionsTEGJ is technically feasible with a patent and sizable anastomosis.