Even though, the transesophageal has been preferred selleckchem Vandetanib as a direct entry to the thorax and permited several procedures in porcine model (Table 1) [11�C19]. Table 1 Transesophageal NOTES procedures in animal studies. The main goal of NOTES is to avoid skin incisions and its associated complications, such as wound infections and hernias. Theoretical advantages of NOTES include reduction in hospital stay, faster return to bowel function, decreased post-operative pain, reduction/elimination of general anesthesia, performance of procedures in an outpatient or even office setting, possibly cost reduction, improved cosmetic outcomes, and increased overall patient satisfaction [1]. 2. Transesophageal Approach When Sumyiama et al. presented transesophageal access to the thorax and mediastinum, they used submucosal endoscopy with mucosal flap (SEMF) [7].

The authors injected saline into the esophageal submucosal layer creating a bleb and high-pressure carbon dioxide was used to perform a submucosal dissection. A biliary retrieval balloon was then inserted into the submucosal layer and was distended to enlarge the mucosal hole and create a 10cm long submucosa tunnel. Subsequently, they used an endoscopic mucosal resection (EMR) cap (Olympus, Tokyo, Japan) to create a defect in the muscularis propria and the mediastinum was entered. The key of the method is the overlying mucosa which serves as a sealant flap minimizing the risk of soiling a body cavity with lumenal contents and the ease by which the entry point into the submucosal working space can be closed [20].

Several modifications have been described to SEMF (Figure 1). Mucosa can be incised using either needle knife, a prototype flexible CO2 laser fiber (OmniGuide Inc., Cambridge, MA, USA), or a Duette Multiband mucosectomy device (Cook Medical, Winston-Salem, NC, USA) [12]. Besides biliary retrieval balloons, the creation of the submucosal tunnel has been achieved with air and blunt dissection using snare tips, closed forceps, EMR caps [12�C15]. Division of the muscular layer has been described using needle knife, although the aspiration method of the EMR cap may reduce the risk of injury to any adjacent mediastinal structure [13]. The SEMF procedure has also been applied in the stomach to safely perform NOTES in the abdominal cavity [21]. Figure 1 Transesophageal submucosal endoscopy with mucosal flap (SEMF) in a porcine model.

(a) Saline is injected Dacomitinib into the submucosal layer of the esophagus. (b) The mucosa of the bleb is incised using a needle knife. (c) A 10cm tunnel is created using … According to von Renteln et al. working with the endoscope through a dissection tunnel limits endoscope movements and degrees of freedom, and major procedures tend to stretch open the submucosal tunnel resulting in a major defect or laceration [22]. On the other hand, Moyer et al.