World J. Surg. 23, 368 –377, 1999
WOR L D
Journal of
SURGERY
© 1999 by the Socie´te´
Internationale de Chirurgie
Endoluminal Surgery
Toma´s Martı´nez-Serna, M.D., Charles J. Filipi, M.D.
Department of Surgery, Creighton University, 601 North 30th Street, Suite 3740, Omaha, Nebraska 68154, USA
Abstract. The development of laparoscopic surgery has provided mini-
mally invasive surgeons with advanced laparoscopic instrumentation and
high definition imaging. The resulting surgical expertise and technology
has now been extended to gastric endoluminal surgery. Laboratory and
clinical investigations have been initiated for various applications of this
new form of surgery. Endoluminal gastric wall excision surgery is the
most widely utilized and includes the removal of superficial gastric
malignancies, benign gastric wall leiomyomas, and gastric polyps. Clini-
cal experience has increased, and the initial results have been satisfac-
tory. Pancreaticocystogastrostomy can be successfully performed using
intraluminal surgery, but gastric wall bleeding and lack of fusion of the
stomach to the cyst wall have complicated some cases. There are case
reports of foreign body removal and intraluminal surgical procedures for
patients with bleeding gastric ulcers. Of primary importance at this stage
of development is the surgeon’s familiarity with appropriate indications
for gastric endoluminal surgery and the access devices currently avail-
able. Future considerations include the application of this approach to
patients with gastroesophageal reflux disease, occult gastrointestinal
bleeding, intractable bleeding from a duodenal ulcer, and multiinstitu-
tional trials of gastric excision procedures.
Interventional endoscopy comprises a wide range of procedures
that often can be substituted for open surgical techniques, per-
mitting less invasiveness. Interventional techniques began in 1939
when sclerotherapy of esophageal varicosities was first described,
employing the rigid esophagoscope [1]. It was not until the early
1970s when fiberoptic technology emerged and Sugawa et al.
described the endoscopic application of monopolar cautery [2].
Other hemostatic techniques such a bipolar electrocoagulation,
laser photocoagulation, heater probe, and endoscopic variceal
band ligation evolved [3, 4]. Diagnostic endoscopic retrograde
cholangiopancreatography and sphincterotomy [5, 6], biliary stent
placement [7], and removal of gastric polyps [8] or small superfi-
cial gastric malignancies by snare cauterization [9] constitute some
of the most effective endotherapeutic maneuvers performed cur-
rently. However, the ability to manipulate tissues is reduced with
these procedures because of instrument limitations and space
confinement. Open surgery is required when excision or hemo-
stasis cannot be accomplished. A totally intraluminal surgical
approach may reduce the pain, rehabilitation, morbidity, and
mortality associated with the laparotomy.
The first open gastrostomy was performed by Sedillot in 1849
[10], but it was not until 1981 that Ponsky and Gauderer described
the technique of percutaneous endoscopic gastrostomy (PEG) in
adults [11] from which noninvasive gastric access for medium- to
long-term enteral feeding or decompression was obtained. Its
relative ease, low incidence of serious complications, and patient
acceptance has helped extend its applications beyond the area of
nutritional support [12]. The development and broad acceptance
of laparoscopic surgery during the 1990s has provided minimally
invasive surgeons with advanced laparoscopic instrumentation
and high definition imaging [13]. A modified PEG could be used
to gain gastric lumen access and employing laparoscopic technol-
ogy intraluminal microsurgery may be performed. Laboratory
endoluminal surgery investigation began with that possibility in
mind.
Laboratory Investigations of Gastric Endoluminal Surgery
In 1991 Frimberger and Classen first described a pull-through
trocar technique for percutaneous access to the stomach for the
performance of intraluminal surgery. They used a metallic oper-
ative port 11.5 mm in diameter and 150 mm in length that was
placed in a fashion similar to that of a PEG. Operative instru-
ments introduced through the trocar permitted endoluminal
gastric procedures. Nevertheless, a laparotomy was required for
extracting a metallic 2.5 cm diameter intraluminal ring from the
stomach, adding invasiveness to the procedure [14].
Intraluminal Antireflux Surgery
In 1987 Thor et al. first described the concept of intraluminal
valvuloplasty in a study performed on cadavers [15]. The flap valve
mechanism at the gastroesophageal (GE) junction was augmented
by a valvuloplasty done through a gastrotomy. The flap valve
present was lengthened by caudal traction and fixed by sutures
placed through the greater and lesser curvature. The stomach was
filled with water in a stepwise manner (50 ml) demonstrating an
increment of the GE pressure gradient from 4.6 Ϯ 1.6 cm H
2
O
before valvuloplasty to 12.5 Ϯ 3.1 cm H
2
O afterward (p Ͻ 0.05).
Therefore it was proven that the increase at the angle of His and
lower esophageal sphincter (LES) length achieved with the val-
vuloplasty prevented gastroesophageal reflux disease (GERD).
Jennings et al. described utilization of a transgastric endoscopic
approach for construction of an antireflux valve [16]. Six pigs
underwent endoscope-guided, large-diameter gastrostomy place-
Correspondence to: C.J. Filipi, M.D.