Natural orifice translumenal endoscopic surgery applications in clinical practice

To review natural orifice translumenal endoscopic surgery (NOTES) applications in clinical practice and assess the evidence base for each application as reported in the literature.An electronic literature search was performed.Inclusion criteria were publications relating to NOTES applications in humans.For each type of operation the highest level of evidence available for clinical NOTES publications was evaluated.Morbidity and short-term operative outcomes were compared with gold standard published evidence where available.Finally,registered trials recruiting patients for NOTES applications were identified.Human NOTES publications with the highest level of evidence in each application are identified.There were no RCTs in the literature to date.The strongest evidence came in the form of large,multi-centre trials with 300-500 patients.The results are encouraging,comparable with gold standard techniques on morbidity and mortality.While short-term operative outcomes were also simi-lar when compared to the gold standard techniques,other than improved cosmesis little else can definitely be concluded as a clear benefit of a NOTES procedure.The most common procedures are cholecystectomy,appendicectomy and peritoneoscopy mainly performed via transvaginal access.It is evident that morbidity appears to be higher when the transgastric route is used.The safety profile of hybrid NOTES transvaginal procedures is beginning to be confirmed as is evident from the large number of procedures presented in this review.A number of authors have presented work on pure NOTES procedures but the results are inconsistent and thus the vast majority of NOTES procedures worldwide are performed in a hybrid fashion with a variable amount of laparoscopy.This review of the clinical applications of NOTES summarises the growing evidence behind this surgical discipline and highlights NOTES procedures with an acceptable safety profile.

Meta-analysis comparing differing methods of endoscopic therapy for colorectal lesions

AIM： To compare the outcomes of endoscopic mucosal resection （EMR） and endoscopic submucosal dissection （ESD） of colorectal lesions.METHODS： An electronic systematic literature search of four computerized databases was performed in July 2014 identifying studies reporting the outcomes of colorectal ESD and EMR. The primary outcome measures were en-bloc resection rate, endoscopic clearance rate and lesion recurrence rate of the patients followed up. The secondary outcome was the complication rate （including bleeding, perforation and surgery post EMR or ESD rate）. Statistical pooling and random effects modelling of the studies calculating risk difference, heterogeneity and assessment of bias and quality were performed.RESULTS： Six observational studies reporting the outcomes of 1324 procedures were included. The en-bloc resection rate was 50% higher in the ESD group than in the EMR group （95%CI： 0.17-0.83, P 〈 0.0001, I2 = 99.7%）. Endoscopic clearance rates were also signifcantly higher in the ESD group （95%CI： -0.06-0.02, P 〈 0.0001, I2 = 92.5%）. The perforation rate was 7% higher in the ESD group than the EMR group （95%CI： 0.05-0.09, P 〉 0.05, I2 = 41.1%） and the rate of recurrence was 50% higher in the EMR group than in the ESD group （95%CI： 0.20-0.79, P 〈 0.001, I2 = 99.5%）. Heterogeneity remained consistent when subgroup analysis of high quality studies was performed （with the exception of piecemeal resection rate）, and overall effect sizes remained unchanged for all outcomes.CONCLUSION： ESD demonstrates higher en-bloc resection rates and lower recurrence rates compared to colorectal EMR. Differences in outcomes may beneft from increased assessment through well-designed comparative studies.