Background: A modified percutaneous endoscopic gastrostomy (PEG) technique has been widely used as a safe alternative for gaining peritoneal access in transgastric (TG) natural orifice translumenal endoscopic surgery (NOTES). The authors developed a novel insufflating guidewire (IGW) system, which further maximizes the safety of the modified PEG technique by preparation of a preliminary pneumoperitoneum (PP) before TG route creation. This study aimed to assess the feasibility and safety of the modified PEG technique under PP using the IGW system. Methods: The IGW system was evaluated in porcine models (n = 5). The process of PP creation was monitored with either laparoscopy or real-time magnetic resonance imaging. The times required to create PP and to establish the TG route were prospectively registered. The animals were killed at the end of each experiment for evaluation of any injuries to adjacent organs. Results: Preliminary pneumoperitoneum was successfully created in all the animals (median procedural time, 240 s) in rapid and highly reproducible fashion. The creation of the TG route also was quick and straightforward (median procedural time, 100 s). No injuries to the adjacent organs were noted at necropsy. Conclusions: The establishment of the TG route under PP is feasible and safe with the authors' newly developed IGW system. The device seems to be advantageous because the entire session is endoscopically controlled. The device may become one of the useful alternatives for adopting TG NOTES in daily practice. Further assessment with human subjects is necessary to make this system practical and universal.
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