Endoscopic closure after full thickness colonic wall excision is feasible with both the TAS and the IMCA. Closure times are significantly shorter and handling is easier with the TAS. Combined use of both systems might be beneficial.

This study evaluated whether twice daily isotonic perfusion of the bypassed ileum for six weeks would enhance its motor activity and its absorption of fluids, electrolytes, and vitamin B12. The study also determined if patients undergoing perfusion had improved bowel function and decreased hospital stay after ileostomy closure. Following proctocolectomy, ileal pouch-anal canal anastomosis, and diverting loop ileostomy, six patients self-infused an isotonic solution (sucrose and sodium chloride) into the bypassed ileum twice daily, while seven patients did not (controls). Two months following proctocolectomy, and just prior to ileostomy closure, a manometric catheter assembly was placed into the unused distal ileum via the stoma and the distal ileum perfused with an isotonic sodium chloride solution for 3 hr during fasting and 3 hr after a meal. Absorption was measured, single and clustered pressure waves were identified, and a motility index was calculated. Water absorption, motility index, and cluster parameters did not improve in perfused patients compared to controls during fasting or after a meal, nor did perfused patients have improved vitamin B12 absorption. The perfused patients also did no better clinically following ileostomy takedown; the onset of bowel movements, their frequency, time to tolerate a diet, and hospital stay were similar to controls. We conclude that six weeks of twice daily isotonic perfusion did not improve motor activity or water, electrolyte, and vitamin B12 absorption in the bypassed distal ileum after proctocolectomy, ileal pouch-anal canal anastomosis, and loop ileostomy. The perfusion also did not improve bowel function after ileostomy takedown.

We sought to determine the safety, efficacy, and outcome of percutaneous cholecystostomy (PC) in all patients undergoing the procedure at our institutions. We reviewed 53 consecutive cases of acute cholecystitis seen at our hospitals over 5.5 years in which PC was performed at the initial treatment. Follow-up was obtained by chart review and telephone questionnaire. Acute cholecystitis was the primary admitting diagnosis in 18 cases. In the remaining 35, cholecystitis developed during hospitalization. All patients were considered high surgical risks on the basis of the presence of comorbid conditions. The gallbladder was successfully catheterized under radiologic guidance in all patients and with no immediate procedure-related morbidity. Acute cholecystitis resolved in 44 of 53 patients (83%), whereas nine patients (17%) did not improve clinically after PC and died during the same hospitalization. A total of 33 (62%) eventually survived hospitalization. Elective cholecystectomy was done in 25 patients with no mortality. After cholecystectomy, three of these patients subsequently died of other causes, whereas 22 are alive. Eight patients did not undergo cholecystectomy because of underlying medical conditions or because they had acalculous cholecystitis. These patients remained free of biliary problems after removal of their cholecystostomy tube, but two have subsequently died of nonbiliary conditions. Percutaneous cholecystostomy is a safe, effective treatment for high-risk patients with acute cholecystitis. Cholecystostomy can be followed by elective cholecystectomy at a later time if the patient's condition permits or by expectant conservative management in patients who have had acalculous cholecystitis or have a very high mortality risk with surgery.

To the editor:We read with interest the report on Natural Orifice Transluminal Endoscopic Surgery: Transgastric Cholecystectomy in a survival porcine model by Perretta et al. The NOTES team at the University of Missouri, Columbia has also been performing transgastric cholecystectomy in a porcine model. Our experience is very similar to that described by Perretta et al. [1]. We also believe that the widespread use of NOTES cholecystectomy is near.We believe that some of the techniques used in this study will not be applicable in humans. The first is the cardiac septal occluder. This is a permanent prosthesis with all the complications of erosion and migration that come with prosthesis in and around the bowel. We have developed a safe gastrotomy closure in the porcine model that may be applicable to man (SAGES Abstract 2008). The use of a Veress needle as a retractor also appears to introduce undue risk of gallbladder and liver injury. A mini laparoscopic port and grasper would appear to be safer. In addition, a Veress needle is not needed to obtain and maintain a pneumoperitoneum. We have performed CO 2 insufflation and intra-abdominal pressure monitoring through the working channel of the endoscope. This is consistent with findings of McGee et al. [2] who showed that endoscope pressure monitoring is reliable and predictive of true intra-abdominal pressures.The primary difficulty we have found with transgastric cholecystectomy is the precision of movement of the instrument tip during dissection. This must be improved prior to widespread use in humans. Do the authors have any thoughts on how best to accomplish this?We congratulate the authors on their contribution to the development of NOTES cholecystectomy. References1. Perretta S, Dallemagne B, Coumaros D, Marescaux J (2007) Natural orifice transluminal endoscopic surgery: transgastric cholecystectomy in a survival porcine model. Surg Endosc. doi: 10.1007/s00464-007-9582-4 [Epub ahead of print] 2. McGee MF, Rosen MJ, Marks J, Chak A, Onders R, Faulx A, Ignagni A, Schomisch S, Ponsky J (2007) A reliable method for monitoring intraabdominal pressure during natural orifice translumenal endoscopic surgery. Surg Endosc 21(4):672-676