Surgery News - August 2008 - (Page 12) OPINION GUEST EDITORIAL SURGERY NEWS • A U G U S T 2 0 0 8 NOTES: The New Art of Surgery? atural orifice transluminal endo- (NOSCAR) to outline the fundamental scopic surgery (NOTES) is a novel principles and techniques for using method of accessing the abdomen NOTES in humans. Among the recomthrough the stomach, vagina, or rectum. mendations NOSCAR published in a 2005 Transgastric peritoneoscopy was first de- white paper were safe access, safe closure, scribed by Kalloo and colleagues (Gastro- infection prevention, and management of intest. Endosc. 2004;60:114-17), whose in- complications. Over the past year, worldnovative approach led to a wide reports have supported multitude of animal studies exthe feasibility of NOTES in huploring the feasibility, physiolmans. The list of human ogy, and limits of a burgeoning NOTES procedures includes paradigm shift. peritoneoscopy, transgastric NOTES promises minimal and transvaginal cholecystecor no pain and improved tomies, transgastric tubal ligacosmesis (no abdominal wall tion, percutaneous endoscopic incisions), coupled with signifgastrostomy rescue, and transicantly shorter recovery time vaginal appendectomies. and faster return to normal BY KURT E. Thus far, all of the NOTES activity. ROBERTS, M.D. procedures reported in the litMotivated by the enthusiasm surrounding NOTES, the Society of erature are either case reports or case seAmerican Gastrointestinal and Endoscop- ries with anywhere from 1 to 20 patients. ic Surgeons (SAGES) and the American So- Therefore, no reliable or comparable data ciety for Gastrointestinal Endoscopy exist regarding patient safety, postopera(ASGE) formed a Natural Orifice Surgery tive pain assessment, or complications. Consortium for Assessment and Research Only anecdotal evidence of minimal pain N and grateful patients following NOTES procedures underpins the literature. Additionally, almost all of the reported procedures have been performed using a hybrid technique in which one or two additional small (3-5 mm) abdominal wall incisions for retraction have been made to optimize patient safety. Despite the promising initial results of NOTES, questions about operator credentialing, skills maintenance, procedure location, and reimbursement remain unanswered. For instance, it is unclear whether NOTES procedures should be performed by surgeons or provided by gastroenterologists. Larger studies—including prospective, randomized, and controlled series—are needed, and NOTES procedures must be performed with appropriate informed consent and Institutional Review Board approval. Going forward, the surgical community has a unique opportunity to establish a robust database and registry of NOTES procedures and patients. Such information will make it possible to rigor- ously evaluate outcomes and establish appropriate guidelines and recommendations. Regardless of the ultimate outcome of NOTES, our goal as physicians and surgeons should be to honor the paramount principle of “primum non nocere.” ■ DR. ROBERTS is a surgeon at Yale University, New Haven, Conn. Clarification The study discussed in “4-D CT Pinpoints Parathyroid Gland Preoperatively” (SURGERY NEWS, June 2008, p. 11) was presented at the annual meeting of the Southern Surgical Association by Dr. Kelly K. Hunt on behalf of Dr. Melinda Mortenson and her colleagues at the University of Texas M.D. Anderson Cancer Center, Houston. Dr. Hunt, who is also with M.D. Anderson, was not involved in conducting the study. POINT/COUNTERPOINT Is it worthwhile to pursue NOTES? The risks outweigh the potential benefits. orifice transluminal endoscopic surgery Naturalhave(NOTES) investigators and surgeons suggested that this approach 15,000 perforations. This means that even if the leak rate was a very low 0.01% (one per 10,000 cases), it would be 50% higher. NOTES is intrinsically less safe because is superior because it is less invasive, causes less trauma and pain, shortens postop- exposure, visualization, and hemostasis are erative recovery, provides better cosmetic inferior to laparoscopy during the intraresults, and can be performed on an out- peritoneal portion of the operation. NOTES lacks proven systemic, patient basis. Some NOTES adhemodynamic, or immunologvocates have said that public ic benefits; it requires general demand for such procedures anesthesia and a pneumoperitowill follow, along with technoneum; and it puts another hole logical advances heretofore unin the viscera and might still reseen and opportunities for surquire laparoscopy. Finally, it is geons to expand their skills. more difficult and tedious than But NOTES is intrinsically other surgical approaches. less safe than laparoscopic Technological advances also surgery because it perforates a will occur without NOTES, as normal organ, thereby increasDANIEL J. DEZIEL, indicated by an expert panel ing the risk of microbial contaM.D., FACS that ranked it 22nd on a list of mination. A study of experimental NOTES procedures performed on questions asking which research is likely to pigs with a percutaneous endoscopic gas- have an important impact on clinical care trotomy tube closure reported that 75% of (Surg. Endosc. 2007;21:1518-25). A survey found that 56% of patients the pigs had intra-abdominal abscesses or positive peritoneal cultures at 14 days (Surg. would choose NOTES cholecystectomy over laparoscopy if it involved less risk, Endosc. 2007;21[suppl. 1]:S462). In another study of 50 patients receiving pain, and cost, but they also regarded the a gastrostomy during laparoscopic Roux- risk of complications as more important en-Y gastric bypass, the peritoneal cavity than cosmesis (Surg. Endosc. 2007;21[supwas routinely contaminated with an aver- pl. 1]:S349). In another survey, potential age of 1,102 colony-forming units/mL, bariatric surgery patients ranked NOTES with a range of up to nearly 1 million third behind laparoscopy and open surgery CFU/mL (Surg. Endosc. 2008;22:605-11). as their preference for organ removal, with NOTES also carries the risk of leaking most stating that they would accept no inbecause it is impossible to guarantee closure creased risk even if the benefit increased of viscerotomies. In a review of 77,604 la- (Surg. Endosc. 2007;21[suppl. 1]:S473). ■ paroscopic cholecystectomies, five gastric perforations occurred, or nearly one per- DR. DEZIEL is a professor of surgery at foration in every 15,000 cases (Am. J. Surg. Rush Medical College and a senior attending 1993;165:9-14). But if you perform 15,000 surgeon at Rush Presbyterian St. Luke’s transgastric cholecystectomies, there will be Medical Center, Chicago. Today’s rudimentary tools may be superseded. reason that NOTES is investigational and is not yet ready for prime time. But the pace of change since publication of the rent residents will be performing proce- first NOTES case report has been extraordures 25 years from now that do not exist dinary and is a testimony to the investigatoday. They will be using new paradigms to tors and their ability to take the field formanage disease. These will involve proce- ward in a measured fashion. Procedures that commonly dures that use image guidance cause greater postoperative to perform precise ablation and pain might have more to gain replace damaged organs rather through the use of NOTES. than repair them. NOTES techniques are being NOTES has proved feasible in developed to perform a gastrohuman transvaginal and transjejunal anastomosis. If you had gastric cholecystectomy as well pancreatic cancer and an obas appendectomy, and many Instructed duodenum, would you stitutional Review Board–aprather have a laparotomy or an proved studies are underway. endoscopic procedure and be Every NOTES study so far DAVID W. RATTNER, able to eat the next day? has reported that patients exM.D., FACS My own research group is inperience less pain after NOTES procedures, even though they are not ide- vestigating totally incisionless transanal al NOTES procedures. NOTES also un- and transgastric sigmoid colectomy with splenic flexure mobilization. We also have questionably leaves fewer scars. Data are not yet available on whether demonstrated the survival of animals NOTES causes fewer complications than without infectious complications after a other surgical approaches. We may spec- transesophageal mediastinoscopy and thoulate about the risks of viscerotomy leaks racoscopy. Currently, no one has a thoraand peritoneal contamination during coscopy and goes home pain-free the next NOTES, but at the same time we ignore day. Many thoracoscopy patients have inwound infections, pulmonary complica- tercostal neuralgias that last 6-12 months. Even if NOTES is a failure, the frenzy of tions, and other problems that occur with device development will at minimum allaparoscopic and open approaches. Cholecystectomy and appendectomy low surgeons to perform endoluminal, might not be ideal applications for NOTES, full-thickness bowel resections. Other benbut these serve as waypoints that prove its eficial findings are likely to follow. ■ feasibility. They do not represent end points for NOTES. The tools being used to DR. RATTNER is a professor of surgery at perform NOTES procedures are much Harvard Medical School, Boston, and chief more rudimentary than the equivalent of the division of gastrointestinal and tools that were used to perform initial la- general surgery at Massachusetts General paroscopic cholecystectomies. This is the Hospital, Boston. of the performed by today’s surgeons did Many us wereproceduresnot exist when many of residents. I think that cur-
Table of Contents Feed for the Digital Edition of Surgery News - August 2008 Surgery News - August 2008 Contents The 20/20 Vision: Making Amends News From the College: Dedicated Effort Opinion: NOTESworthy? Pediatric Surgery: Burn Remedy Surgery News - August 2008 Surgery News - August 2008 - Contents (Page 1) Surgery News - August 2008 - Contents (Page 2) Surgery News - August 2008 - Contents (Page 3) Surgery News - August 2008 - Contents (Page 4) Surgery News - August 2008 - Contents (Page 5) Surgery News - August 2008 - The 20/20 Vision: Making Amends (Page 6) Surgery News - August 2008 - The 20/20 Vision: Making Amends (Page 7) Surgery News - August 2008 - News From the College: Dedicated Effort (Page 8) Surgery News - August 2008 - News From the College: Dedicated Effort (Page 9) Surgery News - August 2008 - News From the College: Dedicated Effort (Page 10) Surgery News - August 2008 - News From the College: Dedicated Effort (Page 11) Surgery News - August 2008 - Opinion: NOTESworthy? (Page 12) Surgery News - August 2008 - Pediatric Surgery: Burn Remedy (Page 13) Surgery News - August 2008 - Pediatric Surgery: Burn Remedy (Page 14) Surgery News - August 2008 - Pediatric Surgery: Burn Remedy (Page 15) Surgery News - August 2008 - Pediatric Surgery: Burn Remedy (Page 16)
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