Article
Reference
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
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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 published13• During 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: 279-28315 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