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Leak-resistant closure of transluminal access is a major challenge facing natural orifice transluminal endoscopic surgery (NOTES).To evaluate a hydrogen (H(2))-based leak test for assessment of transluminal-access closure integrity after NOTES procedures.Nine acute porcine experiments.After gastric-wall puncture and balloon dilation, peritoneoscopy was performed, followed by transmural closure of the gastric opening. The animals were randomly assigned to complete or incomplete closure groups. The H(2) leak test was performed by using 1000 mL of 4% H(2) gas mixture and the Hydrogen Leak Detector H2000+. The animals were then euthanized for a methylene blue (MB) test of gastric closure integrity.Intraperitoneal H(2) concentration after gastric insufflation with H(2).The H(2) leak test was quick and easy. Intraperitoneal H(2) concentrations in parts per million in both groups were similar at baseline (mean +/- SD, 0.18 +/- 0.29 parts per million [ppm] vs 0.22 +/- 0.35 ppm, P = .97) and after balloon dilation (414.8 +/- 198.5 ppm vs 601.3 +/- 116.1 ppm, P.99). Postclosure intraperitoneal H(2) concentrations dropped to 0.01 +/- 0.77 ppm in the complete-closure group, similar (P = .81) to matched-pairs preopening levels and significantly lower than in the incomplete-closure group (162.0 +/- 83.0 ppm, P.02). On necropsy, the MB test was negative in all 5 animals of the complete-closure group and positive in all 4 animals of the incomplete-closure group. A cutoff of 25 ppm in intraperitoneal H(2) concentration after closure gave 100% sensitivity, specificity, and positive and negative predictive values for MB leakage.Nonsurvival animal experiments.The H(2) leak test is highly accurate for detection of leakage after NOTES procedures and could become a substitute for currently used MB leak tests.

Transluminal access site closure remains a major challenge in natural orifice transluminal endoscopic surgery (NOTES).Our purpose was to develop in vivo leak tests for evaluation of the integrity of transgastric access closure.Survival experiments on 12 50-kg pigs.After a standardized transgastric approach to the peritoneal cavity and peritoneoscopy, the gastric wall incision was closed with T-bars (Wilson-Cook Medical, Winston-Salem, NC) deployed on both sides of the incision and then cinched together. Gastrotomy closure was assessed with air and fluid leak tests. The animals were observed for 1 week and then underwent endoscopic evaluation and necropsy.(1) Leak-proof closure of the gastric wall incision. (2) Gastric incision healing 1 week after the procedure.The mean intraperitoneal pressure increased 10.7 +/- 3.7 mm Hg during gastric insufflation when the air leak test was performed before closure compared with 0.9 +/- 0.8 mm Hg after transmural closure of the transgastric access site with T-bars (P.001). Fluid leak tests demonstrated no leakage of liquid contrast from the stomach into the peritoneal cavity after closure. Necropsy in 1 week confirmed completeness of the gastric closure in all animals with full-thickness healing and no spillage of the gastric contents into the peritoneal cavity.Leak tests were only evaluated on an animal model.Fluid and air leak tests are simple techniques to evaluate in vivo the adequacy of the transluminal access site closure after NOTES procedures. Leak-proof gastric closure resulted in adequate tissue approximation and full-thickness healing of the gastric wall incision.

Introduction L’etancheite d’une suture doit pouvoir etre appreciee apres chirurgie endoscopique transviscerale (NOTES) afin de prevenir la contamination postoperatoire de la cavite peritoneale. L’hydrogene (H 2 ) est un gaz non toxique, non inflammable a basse concentration, volatile et detectable. Objectif Evaluer un test d’etancheite a l’H 2 pour la NOTES transgastrique. Materiels et Methodes Une NOTES transgastrique standardisee (creation d’un pneumoperitoine au CO 2 a travers une aiguille minilaparoscopique, ponction transgastrique a l’aiguille de coupe, dilation au ballonnet de 20 mm, peritoneoscopie souple, suture endoscopique) etait realisee chez 21 porcs. Le test d’etancheite consistait a 1) insuffler endoscopiquement l’estomac a l’H 2 (dilution a 4 %, volume 1 000 ml, pression 30 mmHg) ; 2) prelever un echantillon de 20 ml de pneumoperitoine a travers l’aiguille minilaparoscopique ; 3) analyser la concentration intraperitoneale en H 2 (CIPH 2 ) ; 4) exsuffler le pneumoperitoine. Dans une serie d’experiences sans survie (9 animaux), des tests a l’H 2 etaient repetes aux differentes etapes de l’intervention (basal, post-ponction, avant fermeture) et apres suture de l’abord transgastrique. La suture etait realisee par 2 paires de points en T de facon aleatoirement complete (2 points serres) ou incomplete (1 point serre, 1 lâche). Une necropsie avec test au bleu de methylene (BM) etait realisee. Dans une serie d’experiences avec survie (12 animaux), l’abord transgastrique etait ferme par clips ou points serres, puis un test a l’H 2 realise. Les resultats du test a l’H 2 etaient compares a l’evaluation endoscopique et necropsique a 15 jours. Resultats Les peritoneoscopies et sutures endoscopiques etaient realisees avec succes chez les 21 animaux. Les echantillonages et mesures de CIPH 2 (donnees en ppm) etaient realisees en moins de 2 minutes. Experiences sans survie : les CIPH 2 etaient similaires entre les 2 groupes avant ponction (0,18 ± 0,29 vs 0,22 ± 0,35, p = 0,97) et avant suture (414,8 ± 198,5 vs 601,3 ± 116,1, p > 0,99). Apres suture complete, la CIPH 2 etait significativement plus basse qu’en cas de suture complete incomplete (0,01 ± 0,77 vs 162,0 ± 83,0, p 2 a 25 ppm determinait une correlation parfaite avec les resultats du test au BM. Experiences avec survie : Le test a l’H 2 etait negatif chez 11 animaux (moyenne 4,3 ± 8,1), positif chez 1 animal (106,7 ppm). Aucun animal ne developpait de complication postoperatoire. L’endoscopie et la necropsie confirmaient l’integrite de la fermeture de la gastrotomie chez les 12 animaux. La specificite et la valeur predictive negative du test etaient de 100 % et 95 %, respectivement. Conclusion Le test d’etancheite a l’H 2 est un outil non-invasif, rapide, quantitatif et specifique, adapte a la NOTES. Remerciements, financements, autres Xavier Dray remercie la SNFGE, l’AGA et l’AP-HP.