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What is NOTES and what happened so far?

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What is NOTES and what happened so far?

MOREL, Philippe

MOREL, Philippe. What is NOTES and what happened so far? Swiss Knife , 2008, no. 1, p.

12-13

Available at:

http://archive-ouverte.unige.ch/unige:34446

Disclaimer: layout of this document may differ from the published version.

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Research 1

What is NOTES and what happened so far?

Natural Orifice Transluminal Endoscopie Surgery (NOTES)

Philippe Morel, phîlippe.morellahcuge.ch

Natural orifice transluminal endoscopie surgery (NOTES) represents the intentional puncture of one of the visee ra with an endoscope (flexible and/or rigid) to access the abdominal cavity and perform an intraab­

dominai operation'. Although the expression "NOTES" and the above concept only gained momentum after Kalloo's first publication describ­

ing access of the peritoneal cavity through a transgastric incision in 20042, the method of using flexible instrumentation and perforation of the viscera is not new and probably less disastrous than emotially at­

tributed:

Flexible endoscopie pseudocyst drainage has been praetieed for 30 years-1, percutaneous endoscopie gastrastomy for 25 years·. Transgastrie retro­

peritoneal necrosectomy has been used for 5 years~, EUS needle guided transgastric endosurgery has been published for transgastric gastropexy to the diaphragm. Just as weil as hiatus hernia repair and endosurgieal an asto­

mosis of the gallbladder to the stomach6,7, However. alter 2004 number of experiments, fnterested doctors and publications has grawn rapidly. Rao and Reddy from India have removed appendices with flexible scopes trangastri­

cally ln a signifieant number of patients only shortly after Kallo"s first report (presented at several conferences),

Many other trials have been condueted ln animais: Performance of anasto­

mosesB, Ilver biopsies', fallopian tube ligalion', removal of celiae axis Iymph nodes'o. Several other abdominal operations have evaluated for transgas­

tric approachn Thompson et al has reported survival studies of abdomi­

nal organs'2 , including transgastric fallopian tubectomy and oophorectomy_

Transcolonic cholecystectomy has Just been recently published13During the last year, cholecystectomy has moved to ellnical application14,15_ Altogehter, an estlmated number of over 70 patients have been treated with NOTES worldwide untll now (Presented at the UCSD NOTES course in San Diego.

December 2007).

What are the limitations of NOTES

Still, besides of ail enthusiams, NOTES has still major limitations: Flexible en­

doscopes are the currently used for that kind of surgery. Unfortunately, flexi­

ble endoscopes can not dellver a stable platform and the concept of triangu­

lation. Both issues are extremely important for effective surgery. Furthermore.

flexible Instrumentation is hardly sufficient for surgery at present: suturlng is at it's beginnlng and specially design devlces are difiicult to use. Aiso. such devices only exist as prototypes and production for the open market would be very expensive. Flexible stapling on the other hand barely exists right now_

Endoscopic hemostatis rnethods still mostly Involve injection and thermal probe me'lhods. which are almost totally ineffective if used on large vessels during intra-abdominal surgery, Flexible endoscopie clips are very smail and

mostly have gaps which make them useless for hemostasis. A great variety of surgical graspers, dissectors, effective scissors do not exist in flexible en­

doscopy at present and if, they are too small and too weak for surgery_

Still, the Indrustry is working on new inventions for NOTES: Semi-rigld scopes, a toolbox of more effective flexible instruments for surgery and ro­

bots in the field of NOTES are currently ln development.

Gastroenterologists or surgeons - who should do NOTES?

The initial use of flexible scopes also arase the question weather the surgeon or the gastroenterologist will be the future practitioner of NOTES. The ideal NOTES exeeutive should be an expert in abdominal anatomy, surgery and the handling of necessary instrumentation - that means at present: flexible scopes. The NOTES physielan also has to be able to manage patients pre­

and postoperatively and to treat complications. n1is includes full knowledge of how to con vert a NOTES procedure into laparoscopy or open surgery. A considerable number of "older" surgeons have leamed flexible endoscopy durlng their training, However, new curricula for NOTES have to be created.

Surgeons of the future have to learn agaln techniques of advanced endos­

copy. Even if flexible scopes are not used in NOTES sometimes in the future.

knowledge in this field will still be mandatory for accessing the intraabdomi­

nal cavity_

We have have conducted a study comparing the initial performance of sur­

geons and surgically untrained individ.uals with flexible endoscopie equlp­

ment to the one of endoscopists in an easy, medium and difficult task. We fouM tha! the learning curve of surgeons Is extermely fast and only alter a short period their performance for the easy and medium task was compa­

rable to the one of experieneed endoscoplsts. Both initial performance and early learning curve of surgeons was superior when compared to surgical­

Iy untralned Individuals. These results underline that surgeons will leam the handling of a flexible scope quickly just the way they are able 10 integrate ally other new surgical device Into their daily practise. Alter ail, abdominal operations are typieally under the purview of the surgeons, not of the ga8­

troenterologist.

Why should we do NOTES?

Still, one major question remains: Why should we do NOTES. what Is the benefit? It seems likely that ln the future NOTES will be performed wilhou\

any abdominal wall incisions which could potentially lead to less or no wound infections, hernias, postoperative pain when compared to traditlo­

nal approaches through the abdominal wa11'6. Sorne physiclans have even suggested that NOTES cases might be performed without anaesthesia. Fur­

thermore, endoscopie. transluminal surgery might resuit in fewer adhesions

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, ReSe~rCh 1

intra-abdominally". However, ail of these potential benefits have yet to be confirmed in sclentific trials and are the subject of ongoing research now and in the future. Whatever results trom these studies, one important ou!come of NOTES appears already certain: NOTES will result ln ';scarless surgery".

Various articles report that less invasive surgery result ln better cosmetlc out­

comes from a patient's point of view16,19,2Q21 and superior cosmesis is Iinked to better body image scores and better quality of lite"? Therefore, cosmesls should be rated as an important issue in abdominal surgery and might cur­

rently be underestimated. We have conducted a study concerning potentlal patient's opinion regardlng scarless surgery by an onsite poli at the day of the open ward in 2007.

We have found that people favor scarless abdominal surgery even If risks are increased. Not only therefore. cosmetic issues of NOTES are a major justi­

fication and a rationale for further research and investments. We are certain tha! the medical field will be once more - just Iike when laparoscopy star­

led - pushed by the demands of the patient. We are convinced that NOTES will happen. However, even if none of the transluminal procedures become common, benefits will be galned by thls ongoing surgieal movement: Lapa­

roscopic surgery will Improve under this competition and become iess Inva­

sive by resulting in smaller and fewer inciSions. Gastroenterologist will profit greately by the development of stronger, more surgically oriented instrumen­

tation for secure and effictive Intraiumenal procedures such as treatment of perforations and gastro-inestinal bleeding. However. besides ail enthusiams, patienfs welltare has to remaln our primary concern.

References

1 Pwrl JP. Ponsky JL Natural Orifice Translumrnal Endoscopie Surgery: A CnUcaJ A ­ view. J. Gastromlest Surg, 2007

2 Kalloo AN. Singh VK, Jagannalh SB el 1 Flexibifl lransgastnc peritoneoscopy: a novai app eh 10 diagnostic and /herapeulic inlerventlons ln the peritone<J1 cavlty.

Gastrolntest Endosc. 2004; 60: 114-117

3 Rogers BH. C/curel NJ, Seed RW Transgastnc needle aspiration of pancreatic psoo­

docyst through an endoscope, Gastrol11tesl E:ndose. 1975, 21 /33-134

4 Gauderer MW. Ponsky JL, lzanl RJ Jr. GasrrOslomy WI(hout laparoromy: a percutane­

ous endoscoplc techruQue 1980. NutnUon 1998; 14: 736-738

5 Seifert H, Wehrmann T Schmitt T t 1. Retropentoneal endoscop,c debndement for Infected penpencreatic necrosis. Lancet 2000; 356: 653-655

6 Fntscller-Ravens A. Mosse CA Mukt1 rj e D et al Translumlnal endosurgery- single lumen aceess anastomotJC dewce for flexIble endoscopy Gastrolntest. Endosc 2003.

58.585-591

7 Fntscher-Ravens A. Masse CA. MukhefJet! D el al Tmnsgastnc gasrropexy end hletal hemia repalr for GERD under EUS control: 11 porcme model, Gastromtest. Endose.

2004; 59: 89-95

8 Kantsevoy Sv. Jag nnath SB, Nliyama H et al. Endoscoplc gastrolejunostomy wlth sUrYlVal tn a porcme model Gastromlest. E:ndose. 2005; 62. 287-292

9 JagannaUl SB, Kantsevoy Sv. Vauglln CA el al Perora! lransga tnc endoscoplC ligali­

on of falloPian tubes wrth Iong-reml survlvelln a porcine model GastrolnCest, EnOOSc.

2005; 61 449-453

IOFritsch r-Revens A, Mosse CA, Ikeda K et al Endoscopie transgastnc Iymphadenec­

tomy by using E:US for selection and guidance, Gilstrointest E:ndosc. 2006. 63' 302­

306

/1 Kentsevoy Sv. Hu B Jagannath SB et al Transgastric endoscopic splenectomy is Il possible? Surg. Endosc 2006; 20: 522-525

12 Merrifield BF, Wegh MS, Thompson Cc. Perorai tronsg stne organ resee/lon: a feasl­

bJlity study ln pigs. Gastroin/est. Endosc. 2006; 63: 693-697

13Pal RD, Fong DG, Bundga ME et al. Transcolofllc endoscopie cholecystectomy: a NOTES sUrYival study ln a porcme model ~Nlth video) Gastromtest. E:ndosc, 2006; 64' 428-434

1420rron R. Filguelras M. Maggloni LG et al NOTES Transva.glnal Cho/ecystectomy' Report of the First

ca

e Surg.lnnov. 2007: 14: 279-283

15 Mare ~uxJ. Dal/emagne B, Perrette S et al. SUrgèry wlthout scars: report of lranslu­

minai cholecystectomy ma human being Arch. Surg. 2007; 142: 823-826

16 Giday SA. Kantsevoy Sv. Kalloo AN. PrmcipIe and hlstory of Nalu Orifice Translu­

minai Endoscoplc Surgery (NOTES), Mimm. Invasive Tller. Allied Technol 2006: 15' 373-377

t 7Ponsl<y JL E:ndolummal surgery: pasto presenl and future. Surg. Endosc, 2006: 20 Suppl2 S500-SS02

18 Sarll L. lusco D, Gobbl S et al Randomlzed cllrl/ca! tna! of laparoscoplc cholecysrec­

tomy pe.rformed wlth mlm-instfllments. Br. J. Surg. 2003; 90: 1345-1348

19&((1 L. Gost! R, &nsebastiano G. Mim-leparosco{)1c eholecystectomy VS laparosco­

piC cholecystectomy Su/g, Endosc. 2001, 15: 614-678

20Schwenk lN, NoodecJœr J, Mail J et al. ProspectlVS randomlzed blmded trial of pul­

monary luncflon. pilm. and cosme/lc results alter 1 paroscopic vs. microlaparoscopic cholecysrectorny Surg. Endosc, 2000; 14: 345-348

21 U~ nus S. Peflg Z, Kronberger L et al LaparoSCOplC cho/ecystectomy usmg 2-mm Instruments. J Laparoendosc. Adv Surg Tech A 1998: 8: 255-259

22Dunker MS, Stigg lbout AM. van Hogezand RA et al, Cosmesls and body Image after laparoscopie-asslsted and open lleocolic resec/lon for Crolm's dlsease Surg Endosc. 1998. 12: 1334-1340

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