Natural Orifice Transluminal Endoscopic Surgery: The Future of Gastrointestinal Surgery

Lee L Swanström, MD, FACS; Yashodan Khajanchee, MD; Maher A Abbas, MD, FACS, FASCRS

Spring 2008 - Volume 12 Number 2



Considering the continued evolution of flexible endoscopy into more of a therapeutic tool and, at the same time, the growing awareness that the degree of invasiveness of surgery has a large impact on patient outcomes, it was perhaps inevitable that endoscopy and surgery would eventually work together (Figure 1). Accelerating technologic developments mean that this theoretic point of fusion has a potential clinical application. It is conceivable that the current generation of surgical endoscopists is on the verge of witnessing a true paradigm shift, which is being referred to as Natural Orifice Transluminal Endoscopic Surgery (NOTES). The potential of flexible endoscopy to perform therapeutic procedures beyond the wall of the gastrointestinal tract was recognized as early as 1980 when the first transluminal feeding gastrostomy was described by Gauderer et al.1 Kozarek et al2 published the first report of successful endoscopic drainage of pseudocyst in 1985. On the surgical side, the established benefits of laparoscopic procedures over conventional laparotomy in terms of patient recovery and perioperative morbidity, the increasing skill set of advanced laparoscopists, and the comfort of practitioners in performing complex surgeries using video imaging and pneumoperitoneum raised the possibility of replicating such operations endoscopically. The first report of oral peritoneoscopy done in animals was published by Kalloo et al3 in 2004. Since then, multiple investigators have used transluminal flexible endoscopy in animal models to perform various intraperitoneal procedures, ranging from tubal ligation to splenectomy3–8 (Table 1). There have been additional reports of clinical cases, but no publications about them have appeared. On the basis of these initial reports exploring both the scope and feasibility of NOTES, the transluminal approach appears to have tremendous potential. However, several important issues, including the safety of this approach and whether it will provide significant patient benefit in terms of postoperative recovery compared with laparoscopy, must be resolved before the new technique is widely introduced into clinical use. Additionally, it is recognized that early use of this approach by surgeons or gastroenterologists who might be relatively inexperienced in the particular skill sets required might lead to serious complications, which should definitely be avoided during the infancy of this concept. To head off such errors and to develop NOTES in a responsible and safe manner, a working group of 14 leading laparoscopic surgeons and endoscopists from the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) and the American Society for Gastrointestinal Endoscopy (ASGE) met in July 2005. The working group was named Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR). The prime goal of the meeting was to produce a document that would serve as a guide for responsible development of NOTES. In the white paper that the group subsequently published, NOSCAR discussed in detail the potential challenges to safe use of NOTES in clinical practice and outlined guidelines for investigators working on NOTES and criteria for expanding participation in NOSCAR.9



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