by Juliane Bingener, MD
Natural Orifice Translumenal
Endoscopic Surgery (NOTESTM)
is a new therapeutic technique that
seeks to avoid the abdominal wall for
intraabdominal procedures. Avoiding
the abdominal wall for an appendectomy
or cholecystectomy might confer
the benefits of decreased invasiveness
and decreased pain, in addition to
creating fewer visible scars.
The concept was first introduced by
a team of forward thinking gastroenterologists
(Apollo group) who provided
porcine experimental data about the
feasibility of the transgastric approach
for diagnostic laparoscopy. The Apollo
group’s NOTESTM procedure involves
inserting an endoscope through the
mouth into the stomach. An opening
in the stomach wall is then created by
applying a technique used for pancreatic
pseudocyst drainage. The endoscope
is advanced through this opening and
the peritoneal cavity is accessed.
Exploration of the abdomen and surgical
procedures such as tubal ligation,
cholecystectomy, splenectomy, and gastrojejunostomy
can be performed using
endoscopic instrumentation. After the
exploration is completed, the endoscope
is withdrawn and the gastrotomy
closed by endoscopic means (clips).
Other groups have replicated the experiments.
In addition, access through
other natural orifices was explored,
including transcolonic, transvaginal
and transvesical procedures. The transgastric
and transvaginal routes have
seen initial clinical applications.
Many barriers for widespread clinical
acceptance still exist. The prevention
of infection, spatial orientation,
instrument development, the physiologic
aspects of the new technique, and
the safe closure of intestinal access
sites all require further analysis and
innovation. The American Society for
Gastrointestinal Endoscopy (ASGE)
and the Society of American
Gastrointestinal and Endoscopic
Surgeons (SAGES) have partnered to
form NOSCARTM, the Natural Orifice
Surgery Consortium for Assessment
and Research. The group has outlined
and funded necessary research projects
and mandated IRB and IACUC oversight
and data sharing for any research
on and application of the new procedure.
In addition, training needs and
pathways are being addressed at this
early stage to avoid the mistakes made
at the introduction of laparoscopic
cholecystectomy.
Rightfully, and similar to the introduction
of laparoscopic cholecystectomy,
NOTESTM has caused much discussion
in surgical and gastroenterology
circles. David Rattner, in his presidential
address to SAGES, predicted the
mainstream use of the new technique
within 5 to 10 years. Others feel that it
may lead down the road to a “translumenal
misadventure.”
The first clinical application of the
concept was reported two years ago by
Drs. Rao and Reddy from Hyderabad,
India, for a patient with severe abdominal
wall burns and the need for an
appendectomy. Now they have accumulated
experiences with 12 patients for
appendectomy or tubal ligation. Hybrid
transvaginal cholecystectomies have
been performed by teams in Rio de
Janeiro, Brazil, Strasbourg, France, New
York, Portland, Oregon and San Diego,
California, combining transvaginal
endoscopy and limited transabdominal
laparoscopic assistance. Anecdotal evidence
from the teams performing the
procedures suggests that the patients
may experience less discomfort. Another
clinical application is a percutaneous
gastrostomy (PEG) rescue procedure
after a recently placed PEG was pulled
out. Using the transgastric NOTESTM technique under local anesthesia and
conscious sedation, the tube was
replaced, avoiding the need for general
anesthesia to evaluate for peritoneal
contamination and to replace the feeding
access. Surveys performed amongst
patients and surgeons revealed a high
acceptance rate of the NOTESTM concept,
even with a small increase in morbidity.
At UTHSCSA, a team of surgeons
and gastroenterologists has embarked
on carefully researching the issues
involved and to transfer the new technology
to the clinical environment.
Dr. Juliane Bingener is an assistant professor
of surgery at UTHSCSA and director of
the UTHSCSA Minimally Invasive Surgery
Fellowship. She leads a research team investigating
the physiologic effects and the
infectious risk of Natural Orifice Surgery.
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