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Broad clinical utilization of NOTES: is it safe?

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Abstract

Background

Natural orifice transluminal endoscopic surgery (NOTES) has been the focus of several studies as a less invasive alternative to conventional laparoscopy to access and treat intracavitary organs. For the last 5 years, much has been accomplished with animal studies, yet the clinical utilization of this novel technique is still modest. After 2 years of experience in the laboratory, we started our clinical experience. We report our experience with clinical utilization of NOTES procedures from 2007 to 2010.

Methods

Under UCSD institutional review board–approved trials, 104 patients were enrolled under seven different NOTES protocols from 2007 to 2010, where a NOTES procedure was offered as an alternative to conventional treatments. The treated pathologies were cholelithiasis, biliary dyskinesia, acute and chronic appendicitis, ventral hernias, morbid obesity, and achalasia. The access routes included transgastric (TG), transvaginal (TV), transesophageal (TE), and perirectal (PR).

Results

Among the 104 patients enrolled, 103 underwent a surgical procedure starting with diagnostic laparoscopy, and 94 cases were deemed appropriate to proceed via a NOTES approach. There were 9 aborted NOTES procedures at the time of the initial peritoneoscopy before creating a NOTES access route. The reasons to not proceed with a NOTES procedure in the TV cholecystectomy group (n = 5) were a large amount of pelvic adhesions in 4 patients and a severe inflammation of the gallbladder in 1 patient. In the TG cholecystectomy group (n = 1), it was severe inflammation of the gallbladder. In the TG appendectomy group (n = 1), it was the presence of localized peritonitis. In the TE endoscopic myotomy group (n = 2), it was the presence of megaesophagus with an inability to clean the esophagus of food debris. The NOTES procedures performed were 48 TV cholecystectomies, 4 TV appendectomies, 8 TG cholecystectomies, 2 PR peritoneoscopies, 3 TG appendectomies, 3 TV ventral hernia repairs, 5 TE endoscopic myotomies, 3 TV sleeve gastrectomies, and 18 TG sleeve gastrectomies. The average body mass indexes for those in the sleeve gastrectomy group was 42.1 kg/m2 (TG route) and 40.6 kg/m2 (TV route). There were no intraoperative complication and no conversions to standard laparoscopy during these procedures. The average hospital stay was 1–2 days. One patient who underwent TV cholecystectomy required an emergency department visit for nausea and vomiting. To date, 3 patients who underwent TV cholecystectomy have become pregnant and delivered normally.

Conclusions

NOTES is safe, feasible, and reproducible with previous training in the laboratory and a consistent team at a high-volume center. Prospective randomized studies of a large patient population are necessary to assess long-term results.

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References

  1. Pellegrini C, Wetter LA, Patti M, Leichter R, Mussan G, Mori T, Bernstein G, Way L (1992) Thoracoscopic esophagomyotomy. Initial experience with a new approach for the treatment of achalasia. Ann Surg 216(3):291–296

    Article  PubMed  CAS  Google Scholar 

  2. Kalloo AN, Singh VK, Jagannath SB, Niiyama H, Hill SL, Vaughn CA, Magee CA, Kantsevoy SV (2004) Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc 60(1):114–117

    Article  PubMed  Google Scholar 

  3. Jagannath SB, Kantsevoy SV, Vaughn CA, Chung SS, Cotton PB, Gostout CJ, Hawes RH, Pasricha PJ, Scorpio DG, Magee CA, Pipitone LJ, Kalloo AN (2005) Peroral transgastric endoscopic ligation of fallopian tubes with long-term survival in a porcine model. Gastrointest Endosc 61(3):449–453

    Article  PubMed  Google Scholar 

  4. Park PO, Bergstrom M, Ikeda K, Fritscher-Ravens A, Swain P (2005) Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis. Gastrointest Endosc 61(4):601–606

    Article  PubMed  Google Scholar 

  5. Pai RD, Fong DG, Bundga ME, Odze RD, Rattner DW, Thompson CC (2006) Transcolonic endoscopic cholecystectomy: a NOTES survival study in a porcine model. Gastrointest Endosc 64(3):428–434

    Article  PubMed  Google Scholar 

  6. Palanivelu C, Rajan PS, Rangarajan M, Parthasarathi R, Senthilnathan P, Prasad M (2008) Transvaginal endoscopic appendectomy in humans: a unique approach to NOTES—world’s first report. Surg Endosc 22(5):1343–1347

    Article  PubMed  Google Scholar 

  7. Bessler M, Stevens PD, Milone L, Parikh M, Fowler D (2007) Transvaginal laparoscopically assisted endoscopic cholecystectomy: a hybrid approach to natural orifice surgery. Gastrointest Endosc 66(6):1243–1245

    Article  PubMed  Google Scholar 

  8. Zorron R, Maggioni LC, Pombo L, Oliveira AL, Carvalho GL, Filgueiras M (2008) NOTES transvaginal cholecystectomy: preliminary clinical application. Surg Endosc 22(2):22–27

    Article  Google Scholar 

  9. Zornig C, Mofid H, Siemssen L, Emmermann A, Alm M, von Waldenfels HA, Felixmüller C (2009) Transvaginal NOTES hybrid cholecystectomy: feasibility results in 68 cases with mid-term follow-up. Endoscopy 41(5):391–394

    Article  PubMed  CAS  Google Scholar 

  10. Mintz Y, Cullen J, Stuart D, Falor E, Talamini MA (2007) NOTES: technical problems and solutions. Surg Endosc (21):S334

  11. Mintz Y, Horgan S, Cullen J, Stuart D, Falor E, Talamini MA (2008) NOTES: a review of the technical problems encountered and their solutions. J Laparoendosc Adv Surg Tech A 18(4):583–587

    Article  PubMed  Google Scholar 

  12. Mintz Y, Horgan S, Cullen J, Ramamoorthy S, Chock A, Savu MK, Easter DW, Talamini MA (2007) NOTES: the hybrid technique. J Laparoendosc Adv Surg Tech A 17(4):402–406

    Article  PubMed  Google Scholar 

  13. Horgan S, Cullen JP, Talamini MA, Mintz Y, Ferreres A, Jacobsen GR, Sandler B, Bosia J, Savides T, Easter DW, Savu MK, Ramamoorthy SL, Whitcomb E, Agarwal S, Lukacz E, Dominguez G, Ferraina P (2009) Natural orifice surgery: initial clinical experience. Surg Endosc 23(7):1512–1518

    Article  PubMed  Google Scholar 

  14. Jacobsen GR, Thompson K, Spivack A, Fischer L, Wong B, Cullen J, Bosia J, Whitcomb E, Lucas E, Talamini M, Horgan S (2010) Initial experience with transvaginal incisional hernia repair. Hernia 14(1):89–91

    Article  PubMed  CAS  Google Scholar 

  15. Fischer LJ, Jacobsen G, Wong B, Thompson K, Bosia J, Talamini M, Horgan S (2009) NOTES laparoscopic-assisted transvaginal sleeve gastrectomy in humans—description of preliminary experience in the United States. Surg Obes Relat Dis 5(5):633–636

    Article  PubMed  Google Scholar 

  16. Meireles O, Kantsevoy SV, Kalloo AN, Jagannath SB, Giday SA, Magno P, Shih SP, Hanly EJ, Ko CW, Beitler DM, Marohn MR (2007) Comparison of intraabdominal pressures using the gastroscope and laparoscope for transgastric surgery. Surg Endosc 21(6):998–1001

    Article  PubMed  CAS  Google Scholar 

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Disclosures

Drs. Santiago Horgan, Ozanan R. Meireles, Garth R. Jacobsen, Bryan J. Sandler, Alberto Ferreres, Sonia Ramamoorthy, Thomas Savides, Toshio Katagiri, Takayuki Dotai, Michael Sedrak, Saniea F. Majid, Sheetal Nijhawan, and Mark A. Talamini have no conflicts of interest or financial ties to disclose.

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Authors and Affiliations

  1. Division of Minimally Invasive Surgery, Department of Surgery, University of California San Diego, San Diego, CA, USA

    Santiago Horgan, Garth R. Jacobsen, Bryan J. Sandler, Alberto Ferreres, Sonia Ramamoorthy, Thomas Savides, Toshio Katagiri, Takayuki Dotai, Michael Sedrak, Saniea F. Majid, Sheetal Nijhawan & Mark A. Talamini

  2. Division of Minimally Invasive Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA

    Ozanan R. Meireles

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  1. Santiago Horgan
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  2. Ozanan R. Meireles
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  9. Takayuki Dotai
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  11. Saniea F. Majid
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  13. Mark A. Talamini
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Correspondence to Ozanan R. Meireles.

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Horgan, S., Meireles, O.R., Jacobsen, G.R. et al. Broad clinical utilization of NOTES: is it safe?. Surg Endosc 27, 1872–1880 (2013). https://doi.org/10.1007/s00464-012-2736-z

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  • DOI: https://doi.org/10.1007/s00464-012-2736-z

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