Taking NOTES: translumenal flexible endoscopy and endoscopic surgery

Natural orifice specimen extraction in laparoscopic colorectal cancer surgery: A case series study

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Now that laparoscopic surgery is widespread, minimally invasive surgery is desired.

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Natural orifice specimen extraction is minimally invasive surgery.

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Transanal specimen extraction and transvaginal specimen extraction.

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Natural orifice specimen extraction appears to be feasible and safe.

Introduction

In recent years, natural orifice specimen extraction (NOSE) has been attracting attention as a further minimally invasive operation for colorectal cancer, and not only improvement of appearance, but also reduction of pain and wound-related complications due to abdominal wall destruction has been reported. However, NOSE is technically complicated and difficult, and it has not yet been widely used. The aim of this study was to confirm the feasibility, safety, and short-term outcomes of total laparoscopic colon cancer surgery with NOSE.

Case presentation

From May 2018 to October 2019, eight patients with stage 0 or I colon cancer underwent NOSE surgery in our hospital. Transanal specimen extraction was performed in six cases, and transvaginal specimen extraction was performed in two cases. All operations were successfully accomplished without conversion to open surgery. The anastomosis method was double stapling technique in three cases and overlap method in five cases. The median operative time was 224 min. The median blood loss was 10 mL. The median time to first flatus was 1 day, and the median time to first stool was 2 days. The median postoperative observation period was 18 months, but there was no recurrence. There were no postoperative complications in these cases.

Conclusion

Total laparoscopic colon cancer surgery with NOSE appears to be feasible, safe, and show promising efficacy for selected patients.

Safety and Oncological Outcomes of Laparoscopic NOSE Surgery Compared With Conventional Laparoscopic Surgery for Colorectal Diseases: A Meta-Analysis

Objective: To evaluate the safety and oncological outcomes of laparoscopic colorectal surgery using natural orifice specimen extraction (NOSE) compared with conventional laparoscopic (CL) colorectal surgery in patients with colorectal diseases.

Methods: We conducted a systematic search of PubMed, EMBASE, and Cochrane databases for randomized controlled trials (RCTs), prospective non-randomized trials and retrospective trials up to September 1, 2018, and used 5-year disease-free survival (DFS), lymph node harvest, surgical site infection (SSI), anastomotic leakage, and intra-abdominal abscess as the main endpoints. Subgroup analyses were conducted according to the different study types [RCT and NRCT (non-randomized controlled trial)]. A sensitivity analysis was carried out to evaluate the reliability of the outcomes. RevMan5.3 software was used for statistical analysis.

Results: Fourteen studies were included (two RCTs, seven retrospective trials and five prospective non-randomized trials) involving a total of 1,435 patients. Compared with CL surgery, the NOSE technique resulted in a shorter hospital stay, shorter time to first flatus, less post-operative pain, and fewer SSIs and total perioperative complications. Anastomotic leakage, blood loss, and intra-abdominal abscess did not differ between the two groups, while operation time was longer in the NOSE group. Oncological outcomes such as proximal margin [weighted mean difference [WMD] = 0.47; 95% confidence interval [CI] −0.49 to 1.42; P = 0.34], distal margin (WMD= −0.11; 95% CI −0.66 to 0.45; P = 0.70), lymph node harvest (WMD = −0.97; 95% CI −1.97 to 0.03; P = 0.06) and 5-year DFS (hazard ratio = 0.84; 95% CI 0.54–1.31; P = 0.45) were not different between the NOSE and CL surgery groups.

Conclusions: Compared with CL surgery, NOSE may be a safe procedure, and can achieve similar oncological outcomes. Large multicenter RCTs are needed to provide high-level, evidence-based results in NOSE-treated patients and to determine the risk of local recurrence.

Prospective randomized trial of hybrid NOTES colectomy versus conventional laparoscopic colectomy for left-sided colonic tumors

BACKGROUND

We conducted a randomized study of a laparoscopic technique for removing left-sided colon tumors that can reduce postoperative pain and other wound-related complications compared to the conventional technique. It is a novel technique of hybrid natural orifice translumenal endoscopic surgery (NOTES) colectomy (HNC) whereby laparoscopic colonic mobilization, transection, and anastomosis are performed intracorporeally. The specimen is then delivered through the anus using the transanal endoscopic operation (TEO) device, precluding the need for mini-laparotomy. We compared the short-term outcomes of patients who underwent HNC with those who underwent conventional laparoscopic colectomy (CL).

METHODS

Patients suffering left-sided colonic tumor were recruited and were randomized into two groups: HNC and CL. Operative data and complications were prospectively recorded and analyzed.

RESULTS

During a 3-year period, we recruited 70 patients (35 per group). No significant difference was observed between the two groups with respect to operating time (105 vs. 100 min, p = 0.851), blood loss (30 vs. 30 ml, p = 0.954), or length of hospital stay (5 vs. 5 days, p = 0.990). The maximum pain score during the first week was significantly lower in the HNC group (1 vs. 2, p = 0.017). No patients in the HNC group developed wound infection, whereas four patients in the CL group did so (p = 0.005).

CONCLUSIONS

With this hybrid NOTES technique, selected patients with left-sided colonic tumors can enjoy the full benefits of minimally invasive surgery with significantly less wound pain and a lower wound infection rate than are observed with CL.

Natural orifice translumenal endoscopic surgery in humans: a review

Natural orifice translumenal endoscopic surgery (NOTES) had its origins in numerous small animal studies primarily examining safety and feasibility. In human trials, safety and feasibility remain at the forefront; however, additional logistic, practical, and regulatory requirements must be addressed. The purpose of this paper is to evaluate and summarize published studies to date of NOTES in humans. The literature review was performed using PUBMED and MEDLINE databases. Articles published in human populations between 2007 and 2011 were evaluated. A review of this time period resulted in 48 studies describing procedures in 916 patients. Transcolonic and transvesicular procedures were excluded. The most common procedure was cholecystectomy (682, 75%). The most common approach was transvaginal (721, 79%). 424 procedures (46%) were pure NOTES and 491 (54%) were hybrid NOTES cases. 127 (14%) were performed in the United States of America and 789 (86%) were performed internationally. Since 2007, there has been major development in NOTES in human populations. A preponderance of published NOTES procedures were performed internationally. With further development, NOTES may make less invasive surgery available to a larger human population.

Obese women's perception of bariatric trans-vaginal NOTES

Much of the discussion pertaining to natural orifice transluminal endoscopic surgery (NOTES) focuses on technical issues, with little attention to women's perception and to their willingness to consent to this surgery, especially in the field of obesity. Aim of this study was to evaluate obese women's perception of NOTES and trans-vaginal access. Sixty two obese patients undergoing bariatric surgery were given a written description of NOTES with an anonymous questionnaire exploring their concerns and opinions regarding this technique. The risk of complications was the most important aspect with regard to surgical procedures for 87.1% of patients, while the aesthetic result counted only for 16.1%; none of the patients would accept an increased risk of surgical complications for a better aesthetic result, and 74.2% of them would prefer a standardized traditional surgical approach. Nulliparous women were more concerned about the potentially negative effects of NOTES on fertility than multiparous women and younger women were more worried about the effects on sexual function than older women. 83.9% of patients refusing NOTES stated that the main reason for their refusal was the lack of definitive data on the beneficial effects. Bariatric NOTES potentially offers obese women a scarless intervention, but only a few obese women expressed worries about the cosmetic/aesthetic effects of surgery, while most of them were worried about effects on future fertility and sexual life. Our study highlights a strong need for early reporting of outcome data to enlighten patients about this new approach to bariatric surgery.

Natural Orifice Surgery (NOS)-the next step in the evolution of minimally invasive surgery

Endoscopy, which was introduced in the 20(th) century, changed the outcome of surgery by reducing the need for analgesia and shortening hospital stay. Any new surgical method should improve safety and outcome. At the beginning of the 21(st) century, the use of natural orifice surgery is a promising progress. The transgastric and transdouglas approaches are currently being investigated and evaluated. The transgastric approach still has a long way to go due to objective problems such as infections, stomach acidity, and the optimal way to ensure the safe closure of gastrotomy. The transdouglas approach, however, is already starting to establish itself and it seems that with the construction of designated instruments it will prevail in the 21(st) century.

Delayed assessment and eager adoption of laparoscopic cholecystectomy: Implications for developing surgical technologies

Despite the prevailing emphasis in the medical literature on establishing evidence, many changes in the practice of surgery have not been achieved using proper evidence-based assessment. This paper examines the adoption of laparoscopic cholecystectomy (LC) into regular use for the treatment of cholecystitis and the process of its acceptance, focusing on the limited role of technology assessment in its appraisal. A review of the published medical literature concerning LC was performed. Approximately 3000 studies of LC have been conducted since 1985, and there have been nearly 8500 publications to date. As LC was adopted enthusiastically into practice, the results of outcome studies generally showed that it compared favorably with the traditional, open cholecystectomy with regard to mortality, complications, and length of hospital stay. However, despite the rapid general agreement on surgical technique, efficacy, and appropriateness, there remained lingering doubts about safety, outcomes, and cost of the procedure that suggested that essential research questions were ignored even as the procedure became standard. Using LC as a case study, there are important lessons to be learned about the need for important guidelines for surgical innovation and the adoption of minimally invasive surgical techniques into current clinical and surgical practice. We highlight one recent example, natural orifice transluminal endoscopic surgery and how necessary it is to properly evaluate this new technology before it is accepted as a safe and effective surgical option.

Transvaginal natural orifice translumenal endoscopic surgery (NOTES): a survey of women's views on a new technique

BACKGROUND

Laparoscopic and minimally invasive surgery has changed the surgical landscape irrevocably. Natural orifice translumenal endoscopic surgery (NOTES) offers the possibility of surgery without visible scars. Transvaginal entry offers potential benefits because it gains access to the peritoneal cavity without the need to open an abdominal viscus. Much of the discussion pertaining to NOTES focuses on technical and training issues, with little attention to date paid to the opinions of women. The perceptions of female health care workers and patients were sought in relation to their views on transvaginal NOTES.

METHODS

This study surveyed 300 women using a 12-point questionnaire devised by a multidisciplinary group of surgeons interested in minimally invasive surgery. The questionnaire was designed to establish the opinions of women with respect to NOTES surgery versus standard laparoscopic procedures. Responses were de-identified.

RESULTS

Three-fourths of the women surveyed were neutral or unhappy about the prospect of a NOTES procedure, and this remained constant even when it was stipulated that laparoscopic cholecystectomy and NOTES had equivalent safety and efficacy. Younger nulliparous women were most concerned about the potential negative effect of NOTES on sexual function. A minority were concerned about the cosmetic effect of surgery, although surgical scars were perceived as more important to younger respondents.

CONCLUSIONS

Potentially, NOTES surgery offers women a scarless operation with the possibility of less pain than experienced in standard laparoscopic surgery. Few women, however, were troubled about the cosmetic effect of surgery. The effect of NOTES on sexual function was expressed as a particular concern by younger women. In all groups and across all ages, peritoneal access using the transvaginal route was met by significant scepticism. In Australia, women remain to be convinced about the potential advantages of the emerging NOTES technology.

NOTES: new dimension of minimally invasive surgery

Natural orifice transluminal endoscopic surgery (NOTES) is an emerging experimental alternative to conventional surgery. NOTES eliminates abdominal incisions and incision-related complications by combining endoscopic and laparoscopic techniques to diagnose and treat abdominal pathology. Since the first NOTES was reported by Kalloo et al. in 2004, significant achievements in the laboratory have occurred. Clinical use in humans has been limited, but several cases and one small clinical trial were published recently. As a further technical revolution in minimally invasive surgery, NOTES has the promising potential to be safer, less invasive, provide better cosmesis and possibly be more cost-effective. The purpose of the present article was to review the development and current status of NOTES and highlight important advances associated with this innovative approach.

Natural orifice versus conventional laparoscopic distal pancreatectomy in a porcine model: a randomized, controlled trial

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) research has primarily involved case series reports of low-risk procedures. Distal pancreatectomy has significant postoperative morbidity and would permit rigorous examination in a controlled trial setting.

OBJECTIVE

To compare endoscopic transgastric distal pancreatectomy (ETDP) and laparoscopic distal pancreatectomy (LDP).

DESIGN

Prospective, randomized, controlled trial.

SETTING

Academic hospital.

SUBJECTS

Forty-one swine, 28 block randomized.

INTERVENTIONS

LDP was performed with 3 trocars and stapled transection of the pancreas. ETDP was performed via a gastrotomy, with 1 trocar for visualization, by using endoloop placement, snare transection, and purse-string gastrotomy closure.

MAIN OUTCOME MEASUREMENTS

Clinical examination, CT, serum chemistries, necropsy, peritoneal fluid analysis, and histologic examination.

RESULTS

Swine were survived for 8 days. The procedure time for ETDP was significantly greater than for LDP (1:52 vs 0:33 [hours:minutes]; P = .00). Pancreatic specimen weight was similar (4.1 g vs 5.5 g; P = .108). Postoperatively, 26 of 28 animals thrived. In the LDP group, 1 death caused by pancreatic leak and renal failure occurred on day 1. In the ETDP group, 1 death caused by pneumothorax occurred intraoperatively. The necropsy, CT, and histologic examinations revealed focal resection-margin necrosis in 3 to 7 swine in the ETDP group with no proximal necrosis or pancreatitis. The groups were equivalent clinically, by survival, and by serum and peritoneal fluid analysis. The gastrotomy closure was associated with small serosal adhesions, but no gross abscess or necrosis.

LIMITATION

Animal study.

CONCLUSIONS

In the largest controlled trial of NOTES orifice surgery to date, there was no clinical or survival difference between NOTES and laparoscopic approaches.

Endoscopic interventions for weight loss surgery

In this paper we review the state-of-the-art in endoscopic interventions for obesity treatment and make best practice recommendations for weight loss surgery (WLS). We performed a systematic search of English-language literature published between April 2004 and June 2008 in MEDLINE and the Cochrane Library on WLS and endoscopic interventions, endoscopically placed devices, minimally invasive surgery, image-guided surgery, endoluminal surgery, endoscopic instrumentation, interventional gastroenterology, transluminal surgery, and natural orifice transluminal surgery. We also searched the literature on endoscopic interventions and WLS and patient safety. We identified 36 pertinent articles, all of which were reviewed in detail; assessed the current science in endoscopic interventions for WLS; and made best practice recommendations based on the latest available evidence. Our findings indicate that endoscopic interventions and endoscopically placed devices may provide valuable approaches to the management of WLS complications and the primary management of obesity. Given the rapid changes in endoscopic technologies and techniques, systematic literature review is required to address issues related to the emerging role of endoluminal surgery in the treatment of obesity. These interventions should be a high priority for development and investigation.

Novel technologies for natural orifice surgery: an overview

Natural Orifice Surgery (NOS) is now being elaborated with the aim to make abdominal surgery simpler and safer. The existing natural openings of the body are used for introduction of surgical instruments and thus to perform surgical procedures while avoiding to penetrate the abdominal wall. Actually, the transvaginal and transgastric approaches are the common routes used for NOS applications in humans. The transvaginal approach does not necessitate any sophisticated devices for opening and closure of the posterior colpotomy, thus being easy for the surgeon and safe for the patient. In contrast, the problem of transluminal access and closure represents significant obstacles in the transgastric approach and is still unsolved. In order to achieve this goal, various surgical prototype devices have been developed. This article aims to give an overview on the current status of techniques and technologies that are being developed and applied in conjunction with NOS procedures.

Technical feasibility of totally natural orifice cholecystectomy in a swine model

The goal of this study was to evaluate the feasibility of totally NOTES performing a cholecystectomy without laparoscopic assistance. A gastroscope was used through a transvaginal access in five acute female pigs. An incision of 2 cm was created in the vagina and pneumoperitoneum was obtained with a Veress needle. The gallbladder was located in the abdominal cavity using endoscopic transillumination for spatial orientation. After the abdominal suspension of the gallbladder the cholecystectomy was completed with the NOTES technique in four animals without complications. In one animal we had technical problems and the procedure was stopped. The mean operative time was 110 minutes. The transvaginal approach provides complete abdominal exploration and both the cystic duct and artery were identified, clipped, and transected. After dissection the gallbladder was removed through the vagina. Our results showed that completely transvaginal NOTES cholecystectomy is a feasible technique performed only with a flexible endoscope.

Endoscopic transcolonic catheter-free pelvic abscess drainage

Natural orifice transluminal endoscopic surgery is a novel therapeutic method in development that uses different routes of surgical approach. The use of various methods, instruments and accessories during this procedure are currently being investigated. A case of appendicitis-related intra-abdominal abscess that was resolved by a transcolonic endoscopic approach using a wide-channel colonoscope with the help of precut and standard sphincterotome without radiological percutaneous drainage is presented.

Natural orifice translumenal endoscopic surgery (NOTES) applied totally to sigmoidectomy: an original technique with survival in a porcine model

BACKGROUND

Natural orifice translumenal endoscopic surgery (NOTES) continues to evolve. This study investigated the feasibility and outcome of performing localized sigmoidectomy in its entirety via NOTES.

METHODS

A survival study of five male minipigs (mean weight, 30 kg) was conducted. After anesthesia, a gastrotomy was created by a per os double-channel endoscope, and full peritoneoscopy was performed. A Berci needle then was inserted transparietally to allow maintenance and monitoring of the pneumoperitoneum. Using a transanal probe to facilitate intestinal retraction, the mesentery was dissected with instruments worked through the channels of the transgastric endoscope. The anvil of a circular stapler then was passed per anum into the colon above the point of intended transection. A penetrating transrectal trocar was placed to allow entry of a linear stapler into the peritoneum through a colotomy, and the sigmoid was cross-stapled proximally. The strut of the anvil then was snugged into a colotomy made at this staple line. The specimen was delivered via the anus by a "pull-through" technique. The distal sigmoidal margin was cross-stapled extracorporeally, ensuring that the colotomy was included within the specimen. Retrograde passage of the circular stapler head per anus allowed colocolonic reanastomosis by its mating with the anvil already in situ. The gastrotomy was closed with a previously validated prosthesis. Postoperatively, all the animals were recovered and monitored for well-being during convalescence. Endoscopy (gastroscopy and sigmoidoscopy), laparoscopy, and laparotomy were performed on postoperative day 14 as follow-up measures.

RESULTS

Each operation was satisfactorily completed. The mean operative time was 76 min (range, 44-95 min). All the animals prospered postoperatively. Follow-up examination showed full healing of all anastomoses and gastrotomy sites. There was no evidence of luminal stricturing, peritonitis, or intraabdominal sepsis in any animal.

CONCLUSIONS

Using this experimental model, colonic resection and reanastomosis can be performed safely within the NOTES format.

Devices for the treatment of obesity: will understanding the physiology of satiety unravel new targets for intervention?

The rise in the prevalence of obesity in the last few decades and its growing impact on health has driven the scientific community to investigate the physiological basis of energy homeostasis and mechanisms of satiety, and seek targets for intervention against this burgeoning epidemic. Recent findings highlight the role of gut-derived, hormonal signals in the regulation of satiety. These hormones act together with the dense and intricate enteric nervous system to coordinate and regulate gastrointestinal satiety signals, motility, and digestive processes. Bariatric surgical approaches attempt to take advantage of these mechanisms to facilitate early satiety and weight loss. Some of these procedures, by altering the anatomical structure of the upper gastrointestinal tract, also modify the hormonal response to food. Similarly, devices such as volume-occupying elements and nerve stimulators attempt to alter the gastrointestinal milieu in a manner that will ultimately lead to long-term weight loss. Novel surgical, endoscopic, and device-oriented methodologies seem to be promising approaches to treat obesity, yet further research is needed to appreciate their long-term effect.

NOTES--case report of a unidirectional flexible appendectomy

BACKGROUND

Natural orifice transluminal endoscopic surgery (NOTES) refers to a new surgical procedure using flexible endoscopes in the abdominal cavity. With this procedure, access is gained by way of organs which are reached through a natural, already-existing external orifice. The hoped-for advantages associated with this method include the reduction of post-operative wound pain, shorter convalescence, avoidance of wound infection and abdominal-wall hernias as well as the absence of scars. We performed a trans-vaginal appendectomy on a human subject.

MATERIALS AND METHODS

In experimental operations on animals, we first evaluated the trans-vaginal access site. After them, we started first operation in human. The procedure was carried out under preventive administration of antibiotics. We used a therapeutic single-canal gastroscope. The appendix was located after exploration of the abdomen. After preparation of the mesenteriolum, ligature of the appendix base was performed by means of endoloop, followed by transsection with scissors. Recovery of the specimen was achieved by pulling it out with the instrument.

RESULTS

On the evening of the day on which surgery had taken place, administration of nourishment was begun. After the procedure, the patient reported slight soreness in the muscles of the abdominal wall; she felt otherwise perfectly well.

INTERPRETATION

In the space of a year, the first operations have been performed on human subjects by a few select work groups. NOTES procedures are still in the initial stages of clinical development. Until they can be introduced into surgical daily routine, further improvements are required as to equipment, technology and operative procedure.

Treatment options for esophageal strictures

Esophageal strictures are a problem commonly encountered in gastroenterological practice and can be caused by malignant or benign lesions. Dysphagia is the symptom experienced by all patients, regardless of whether their strictures are caused by malignant or benign lesions. The methods most frequently used for palliation of malignant esophageal strictures are stent placement (particularly in patients with an expected survival of 3 months or less) and brachytherapy (in patients with a life expectancy of more than 3 months). Brachytherapy has been shown to be beneficial in patients with an expected survival of longer than 3 months with regard to (prolonged) dysphagia improvement, complications and quality of life. The mainstay of benign esophageal stricture treatment is dilation. Although dilation usually results in symptomatic relief, recurrent strictures do occur. In order to predict which types of strictures are most likely to recur, it is important to differentiate between esophageal strictures that are simple (i.e. focal, straight strictures with a diameter that allows endoscope passage) and those that are more complex (i.e. long (>2 cm), tortuous strictures with a narrow diameter). These complex strictures are considered refractory when they cannot be dilated to an adequate diameter. Novel treatment modalities for refractory strictures include temporary stent placement and incisional therapy.

[Natural orifice transluminal endoscopic surgery]

In Natural Orifice Transluminal Endoscopic Surgery (NOTES) a flexible endoscope is passed through a natural orifice of the body and intra-abdominal procedures can be performed through a transvisceral (transgastric, -colonic, -vaginal or -vesical) incision. Principally, this state-of-the-art technology decreases invasiveness and postoperative pain, prevents postoperative hernia formation and improves cosmetic results. However, numerous questions regarding the technique are unanswered yet. Further research is necessary to extend the armamentarium of minimally invasive surgery. This article reviews the current state of experimental results and clinical approaches of NOTES.