Natural orifice transluminal endoscopic surgery (NOTES)
- Pankaj J Pasricha, MD
Pankaj J Pasricha, MD
- Professor of Medicine and Neuroscience
- Johns Hopkins University School of Medicine
- Director, Johns Hopkins Center for Neurogastroenterology
- Homero Rivas, MD, MBA, FACS
Homero Rivas, MD, MBA, FACS
- Assistant Professor
- Section, Minimally Invasive Surgery
- Director of Innovative Surgery
- Stanford School of Medicine
- Section Editor
- Douglas A Howell, MD, FASGE, FACG
Douglas A Howell, MD, FASGE, FACG
- Section Editor — EUS/ERCP
- Assistant Clinical Professor of Medicine, Tufts Medical School Director,
- Pancreaticobiliary Center Director, Advanced Interventional Endoscopy Fellowship, Maine Medical Center
Natural orifice transluminal endoscopic surgery (NOTES) is an emerging field within gastrointestinal surgery and interventional gastroenterology in which the surgeon accesses the peritoneal cavity via a hollow viscus and performs diagnostic and therapeutic procedures. NOTES is evolving rapidly, presenting seemingly limitless possibilities for innovation, technique, and device development.
EXPERIMENTAL EVOLUTION AND DEVELOPMENT
The concept of flexible transluminal endoscopy, a term used before NOTES was coined, was first developed by a multicenter team of investigators (the Apollo Group) in the late 1990s . The publication of the initial animal studies generated a wave of enthusiasm, and many centers began experiments of their own, using the NOTES approach for a variety of operations . These have ranged from diagnostic explorations of the peritoneal cavity to complex organ resections including pancreatectomy, splenectomy, and nephrectomy [3-5].
The initial approach was transgastric, but more recently NOTES has been performed through several other orifices, resulting in transcolonic, transvaginal, and transurethral/transcystic approaches. The approach has also been extended from the peritoneum to other compartments in the body, such as transesophageal approaches to the mediastinum and heart, transgastric intrauterine interventions in pregnant animals, and novel approaches to the vertebral column [6-9].
Given this flurry of activity and mounting enthusiasm, in 2005 the American Society of Gastrointestinal Endoscopy and the Society of Gastrointestinal Endoscopic Surgeons came together in a consortium (the Natural Orifice Surgery Consortium for Assessment and Research) to provide consensus and guidelines on how best to bring this procedure to the clinical mainstream. In the last few years, an increasing number of NOTES procedures in humans have been performed. However, technological limitations of the current flexible platforms have been a major challenge, limiting the adoption of this approach (to date) to a few major medical centers. Nevertheless, while it is still too early to predict its ultimate role and value, it is clear that NOTES has dramatically altered our perceptions of how to approach gastrointestinal surgery.
A strong argument can be made that NOTES has been instrumental in the resurgence of lesser invasive surgical techniques such as single-incision laparoscopic surgery, which for some may represent a bridge to NOTES [10-14]. Furthermore, developmental efforts in NOTES have resulted in numerous advanced surgical and endoscopic technologies that are now being applied in conventional laparoscopic and endoscopic techniques.
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- Marks JM, Ponsky JL, Pearl JP, McGee MF. PEG "Rescue": a practical NOTES technique. Surg Endosc 2007; 21:816.
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- Jay Pasricha P, Krummel TM. NOTES and other emerging trends in gastrointestinal endoscopy and surgery: the change that we need and the change that is real. Am J Gastroenterol 2009; 104:2384.
- EXPERIMENTAL EVOLUTION AND DEVELOPMENT
- PREMISE AND PROMISE OF NOTES
- TECHNICAL CONSIDERATIONS
- Bacterial contamination, peritonitis, and abscess formation
- Effects on the immune system and other physiological effects
- Inability to deal with major complications
- Training and credentialing
- Economic limitations
- HUMAN EXPERIENCE
- Transvaginal NOTES
- Transgastric NOTES
- Miscellaneous approaches
- IMPLICATIONS BEYOND THE PROCEDURE ITSELF
- SUMMARY AND RECOMMENDATIONS