Removal of a guide-wire sliding into abdominal cavity via transgastric natural orifice transluminal endoscopic surgery: A case report

BACKGROUND Guidewire slippage into the peritoneal cavity during clinical operations is extremely rare.Therefore,this paper aims to report a successful case of guidewire removal using transgastric natural orifice transluminal endoscopic surgery(NOTES).The goal is to enhance physicians'understanding of the management plan for this unique scenario and provide a valuable reference for clinical practice.CASE SUMMARY A 64-year-old man presented with abdominal distension and was diagnosed with cirrhosis combined with massive ascites.To proceed with treatment,the patient underwent ultrasound-guided peritoneal puncture and underwent catheterization and drainage.Unfortunately,a 0.035-inch guidewire slipped into the abdominal cavity during the procedure.Following a comprehensive evaluation and consultation by a multidisciplinary team,the guidewire was successfully removed using NOTES.CONCLUSION This case highlights the potential consideration of transgastric NOTES removal when encountering a foreign body,such as a guidewire,within the abdominal cavity.

Analysis of quality of life in patients after transgastric natural orifice transluminal endoscopic gallbladder-preserving surgery

BACKGROUND At present,laparoscopic cholecystectomy(LC)is the main surgical treatment for gallstones.But,after gallbladder removal,there are many complications.Therefore,it is hoped to remove stones while preserving the function of the gallbladder,and with the development of endoscopic technology,natural orifice transluminal endoscopic surgery came into being.AIM To compare the quality of life,perioperative indicators,adverse events after LC and transgastric natural orifice transluminal endoscopic gallbladder-preserving surgery(EGPS)in patients with gallstones.METHODS Patients who were admitted to The First Affiliated Hospital of Xinjiang Medical University from 2020 to 2022 were retrospectively collected.We adopted propen-sity score matching(1:1)to compare EGPS and LC patients.RESULTS A total of 662 cases were collected,of which 589 cases underwent LC,and 73 cases underwent EGPS.Propensity score matching was performed,and 40 patients were included in each of the groups.In the EGPS group,except the gastr-ointestinal defecation(P=0.603),the total score,physical well-being,mental well-being,and gastrointestinal digestion were statistically significant compared with the preoperative score after surgery(P<0.05).In the LC group,except the mental well-being,the total score,physical well-being,gastrointestinal digestion,the gastrointestinal defecation was statistically significant compared with the preoperative score after surgery(P<0.05).When comparing between groups,gastrointestinal defecation had significantly difference(P=0.002)between the two groups,there was no statistically significant difference in the total postoperative score and the other three subscales.In the surgery duration,hospital stay and cost,LC group were lower than EGPS group.The recurrence factors of gallstones after EGPS were analyzed:and recurrence was not correlated with gender,age,body mass index,number of stones,and preoperative score.CONCLUSION Whether EGPS or LC,it can improve the patient’s symptoms,and the EGPS has less impact on the patient’s defecation.It needed to,prospective,multicenter,long-term follow-up,large-sample related studies to prove.

Natural orifice transluminal endoscopic surgery:Where are we going?

The foundation for natural orifice transluminal endoscopic surgery(NOTES) is to access the peritoneal and other body cavities through the wall of the alimentary tract via natural orifices,with the goal of performing procedures within the peritoneum and other cavities,without the need to make incisions in the abdominal wall.We have made great progress in the field of NOTES since the publication of the White Paper in 2006.There are still major fundamental goals as outlined by the Society of American Gastrointestinal and Endoscopic Surgeons/American Society for Gastrointestinal Endoscopy joint committee that need to be evaluated and answered before NOTES is ready for widespread clinical use.These include prevention of infection,instrument development,creation of a multitasking platform,and the ability to recognize and treat intraperitoneal complications such as hemorrhage and other physiological adverse events.In response to this need,recent abstracts and papers have focused on the management of intraoperative complications.The next phase is to focus on controlled prospective multicenter clinical trials that compare defined NOTES procedure to standard laparoscopy.The goal is to produce reliable and convincing data for the United States Food and Drug Administration,insurance companies,the physician community and the general public.At the present time,we still have many important milestones that still need to be met.Most investigators agree that a hybrid technique and not a pure NOTES practice should be advocated until devices can meet the current and new challenges in this f ield.

Current developments in natural orifices transluminal endoscopic surgery:An evidence-based review

Tremendous advances have been made in recent years addressing the key obstacles to safe performance and introduction of human natural orifice transluminal endoscopic surgery (NOTES). Animal studies have focused on identifying optimal solutions to these obstacles, in particular methods of creating transluminal access,safe closure of the point of access, and development of a multitasking platform with dedicated instruments. Whether the performance data generated from these animal studies can be reproduced in humans has yet to be determined. Reports of human NOTES procedures are emerging, and the possibility of accomplishing human NOTES based on existing technology has been demonstrated. However, dedicated platforms and devices are still lacking to allow for pure NOTES procedures, and whether NOTES can deliver the postulated benef its of earlier recovery and improved cosmesis remains uncertain.

Natural orifice transluminal endoscopic surgery in urology: The Chinese experience

Objective:To describe the Chinese experience of natural orifice transluminal endoscopic surgery(NOTES)in urology.Methods:From December 2008 to May 2017,35 animal experiments and 305 clinical surgeries of NOTES or natural orifices specimen extractions(NOSE)were performed in China.The animal experiments included five kidney biopsies,24 nephrectomies and six partial nephrectomies.The clinical surgeries included 12 transvaginal NOSE(TV-NOSE),266 hybrid transvaginal NOTES(TV-NOTES)and 27 pure TV-NOTES.The TV-NOSE procedure was performed in five transumbilical laparoendoscopic single-site(U-LESS)nephrectomies,four suprapubic-assisted laparoendoscopic single-site surgery(SA-LESS)nephroureterectomies,and three laparoscopic radical cystectomies.The hybrid TV-NOTES procedure included 210 nephrectomies,31 adrenalectomies,eight nephroureterectomies,13 partial nephrectomies,and four heminephrectomies.The pure TV-NOTES procedure included five renal cyst decortications and 22 nephrectomies.Results:A total of 29 animal experiments were successfully performed.One partial nephrectomy was converted to standard laparoscopic surgery.Two kidney biopsies and two nephrectomies were unsuccessful.A total of 297 clinical surgeries were successfully performed.Six patients who underwent hybrid TV-NOTES were converted to open surgery.Two patients who underwent pure TV-NOTES were converted to SA-LESS.There were 22 major complications,16 occurred intraoperatively and six postoperatively.The mean visual analog score(VAS)of 48 h after the operation was 2.5 points in TV-NOSE,2.3 points in hybrid TV-NOTES and 1.7 points in pure TV-NOTES.The mean follow-up of 50.6(3.0-87.0)months showed that all patients were in good condition.The umbilicus scars were nearly invisible in TV-NOSE and hybrid TV-NOTES.The vaginal incision healed well.Conclusions:TV-NOSE and TV-NOTES are feasible,safe,and effective with little injury,low pain,fast recovery,and good cosmetic outcomes in properly selected patients.They are worth consideration for urological clinical practice.

Embryonic natural orifice transluminal endoscopic surgery in the treatment of severe acute pancreatitis complicated by abdominal compartment syndrome

BACKGROUND: The study aimed to estimate the value of embryonal natural orifice transluminal endoscopic surgery(ENOTES) in treating severe acute pancreatitis(SAP) complicated with abdominal compartment syndrome(ACS).METHODS: The patients, who were randomized into an ENOTES group and an operative group, underwent ENOTES and laparotomy, respectively. The results and complications of the two groups were compared.RESULTS: Enterocinesia was observed earlier in the ENOTES group than in the operative group. Acute Physiology and Chronic Health Evaluation II(APACHE II) score of patients in the ENOTES group was lower than that of the operative group on the 1st, 3rd and 5th post-operative day(P<0.05). The cure rate was 96.87% in the ENOTES group, which was statistically different from 78.12% in the operative group(P<0.05). There were significant differences in complications and mortality between the two groups(P<0.01).CONCLUSION: Compared with surgical decompression, ENOTES associated with flexible endoscope therapy is an effective and minimal invasive procedure with less complications.

Pure transvaginal natural orifice transluminal endoscopic surgery right hemicolectomy for colon cancer:A case report

BACKGROUND Pure natural orifice transluminal endoscopic surgery(NOTES)for colorectal cancer is a complex procedure and rarely used in clinical practice because of the ethical concerns and technical challenges,including loss of triangulation,in-line orientation,and instrument collision.Transvaginal(v)NOTES,however,can overcome these technical challenges.We report a case of pure vNOTES right hemicolectomy for colon cancer,attached with surgical video.CASE SUMMARY A 65-year-old woman with a 2-year history of intermittent diarrhea was diagnosed with ascending colon adenocarcinoma by colonoscopy and biopsy.Pure vNOTES right hemicolectomy was performed with complete mesocolic excision by well-experienced surgeons.The operative time was 200 min and the estimated blood loss was 30 mL.No intraoperative or postoperative complications occurred within 30 d after the surgery.The visual analog scale pain score on postoperative day 1 was 1 and dropped to 0 on postoperative days 2 and 3.The patient was discharged at postoperative day 6.The pathologic specimen had sufficient clear resection margins and 14 negative harvested lymph nodes.CONCLUSION vNOTES right hemicolectomy,performed by well-experienced surgeons,overcomes the technical challenges of pure NOTES and may be feasible for colon cancer.

Are laparoscopic cholecystectomy and natural orifice transluminal endoscopic surgery gallbladder preserving cholecystolithotomy truly comparable?A propensity matched study

BACKGROUND Cholecystectomy is the preferred treatment option for symptomatic gallstones.However,another option is gallbladder-preserving cholecystolithotomy which preserves the normal physiological functions of the gallbladder in patients desiring to avoid surgical resection.AIM To compare the feasibility,safety and effectiveness of pure natural orifice transluminal endoscopic surgery(NOTES)gallbladder-preserving cholecystolithotomy vs laparoscopic cholecystectomy(LC)for symptomatic gallstones.METHODS We adopted propensity score matching(1:1)to compare trans-rectal NOTES cholecystolithotomy and LC patients with symptomatic gallstones.We reviewed 2511 patients with symptomatic gallstones from December 2017 to December 2020;517 patients met the matching criteria(NOTES,110;LC,407),yielding 86 pairs.RESULTS The technical success rate for the NOTES group was 98.9%vs 100%for the LC group.The median procedure time was 119 min[interquartile ranges(IQRs),95-175]with NOTES vs 60 min(IQRs,48-90)with LC(P<0.001).The frequency of post-operative pain was similar between NOTES and LC:4.7%(4/85)vs 5.8%(5/95)(P=0.740).The median duration of post-procedure fasting with NOTES was 1 d(IQRs,1-2)vs 2 d with LC(IQRs,1-3)(P<0.001).The median post-operative hospital stay for NOTES was 4 d(IQRs,3-6)vs 4 d for LC(IQRs,3-5),(P=0.092).During follow-up,diarrhea was significantly less with NOTES(5.8%)compared to LC(18.6%)(P=0.011).Gallstones and cholecystitis recurrence within a median of 12 mo(range:6-40 mo)following NOTES was 10.5%and 3.5%,respectively.Concerns regarding the presence of abdominal wall scars were present in 17.4%(n=15/86)of patients following LC(mainly women).CONCLUSION NOTES provides a feasible new alternative scar-free treatment for patients who are unwilling or unable to undergo cholecystectomy.This minimally invasive organ-sparing procedure both removes the gallstones and preserves the physiological function of the gallbladder.Reducing gallstone recurrence is essential to achieving widespread clinical adoption of NOTES.

Natural orifice transluminal endoscopic surgery in pancreatic diseases

Natural orifice transluminal endoscopic surgery (NOTES) is a surgical technique that has received considerable interest in recent years. Although minimal access surgery has increasingly replaced traditional open abdominal surgical approaches for a wide spectrum of indications, in pancreatic diseases its widespread use is limited to few indications because of the challenging and demanding nature of major pancreatic operations. Nonetheless, there have been attempts in animal models as well as in the clinical setting to perform diag- nostic and resectional NOTES for pancreatic diseases. Here, we review and comment upon the available data regarding currently analyzed and performed pancreatic NOTES procedures. Potential indications for NOTES include peritoneoscopy, cyst drainage, and necrosectomy, palliative procedures such as gastroenterostomy, as well as resections such as distal pancreatectomy or enucleation. These procedures have already been shown to be technically feasible in several studies in animal models and a few clinical trials. In conclusion, NOTES is a rapidly developing concept/technique that could potentially become an integral part of the armamentarium dealing with surgical approaches to pancreatic diseases.

Snare-assisted flexible endoscope in trans-gastric endoscopic gallbladder-preserving surgery:A pilot animal study

BACKGROUND Natural orifice transluminal endoscopic surgery(NOTES)gallbladder-preserving surgery by flexible endoscopy is an emerging technology.However,the gallbladder fails to obtain traction and positioning functions during the operation.AIM To evaluate the feasibility and safety of a new surgical method,“snare-assisted pure NOTES gallbladder-preserving surgery”.METHODS Eight miniature pigs were randomly divided into the experimental group[NOTES gallbladder-preserving surgery using the snare device,snare assisted(SA)]and the control group(NOTES gallbladder-preserving surgery without using the snare device,NC),with four cases in each group.The differences between the two groups of animals in operating time,operating workload,complications,adverse events,white blood cells,and liver function were determined.RESULTS No differences were found in the surgical success rate,gallbladder incision closure,white blood cell count,or liver function between the two groups.The total operating time,gallbladder incision blood loss,gallbladder disorientation time,gallbladder incision closure time,and workload scores on the National Aeronautics and Space Administration-Task Load Index were significantly reduced in the SA group(P<0.05).CONCLUSION These results indicated that snare-assisted pure NOTES gallbladder-preservation surgery using standard endoscopic instruments reduced the difficulty of operation,shortened operation time,and did not increase complications in pigs.A new method for pure NOTES gallbladder-preservation surgery was provided.

Infection during transgastric and transvaginal natural orifice transluminal endoscopic surgery in a live porcine model

Background The infection risk of natural orifice transluminal endoscopic surgery （NOTES） is of concern. The aim of this study was to assess the safety of NOTES by investigating the intraperitoneal bacterial load during transgastric and transvaginal procedures with antiseptic or controling perioperative preparation.Methods Forty-five female pigs were randomly assigned to five equal groups： the transgastric （TG） control group （group A）, the TG middle volume gastric lavage group （group B）, the TG high volume lavage group （group C）, the transvaginal （TV） control group （group D） and the TV study group （group E）. The study groups received gastric or vaginal lavage and abdominal antimicrobial irrigation, while the control groups received neither. All animals were administered intravenous antibiotics, underwent NOTES peritoneoscopy and transumbilical laparoscopic cholecystectomy under NOTES view with sterile instruments. The viscerotomy was closed by laparoscopic suture. The animals were observed until necropsy was performed 14 days postoperatively. Quantitative bacteriologic cultures were taken from the gastric or vaginal aspirate before and after lavage; peritoneal fluid was collected before and after peritoneal irrigation and at necropsy. Results The surgical procedures were completed for all the pigs and all of them survived. The mean operative time of the TG group and the TV group was （81±27） minutes and （66±12） minutes, respectively. All animals survived for 14 days.At necropsy, significantly more peritoneal infections were noted in group A than in group D （5：9 vs. 0：9; P 〈0.05）. Nogross evidence of intra-peritoneal infection was found in groups B, C, D and E. Bacteriological evidence was seen in all pigs in group A, 7 pigs in group B, 6 pigs in group D, and none in groups C and E.Conclusions Without gastric or vaginal lavage and antibiotic peritoneal irrigation, the TG procedure has a higher infection rate than the TV access. After antiseptic preparation, the bacterial load significantly decreased in the TG group,which seems as safe as the sterile TV approach.

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.

Closure techniques in exposed endoscopic full-thickness resection:Overview and future perspectives in the endoscopic suturing era

Exposed endoscopic full-thickness resection(EFTR)without laparoscopic assistance is a minimally invasive natural orifice transluminal endoscopic surgery technique that is emerging as a promising effective and safe alternative to surgery for the treatment of muscularis propria-originating gastric submucosal tumors.To date,various techniques have been used for the closure of the transmural postEFTR defect,mainly consisting in clip-and endoloop-assisted closure methods.However,the recent advent of dedicated tools capable of providing full-thickness defect suture could further improve the efficacy and safety of the exposed EFTR procedure.The aim of our review was to evaluate the efficacy and safety of the different closure methods adopted in gastric-exposed EFTR without laparoscopic assistance,also considering the recent advent of flexible endoscopic suturing.

Current progress on natural orifice transluminal endoscopic surgery(NOTES)

Natural orifice transluminal endoscopic surgery(NOTES)has received considerable interest in recent years as a novel surgical technique.Here,we aim to review the current progress on NOTES,particularly focusing on the advantages and complications related to NOTES,the recent advances of surgical approaches,new instruments for closure of the natural orifice incision,and the newly developed platform for NOTES.Finally,we make a prediction of the conceivable applications of NOTES on human subjects.

Exposed endoscopic full-thickness resection for duodenal submucosal tumors: Current status and future perspectives

Exposed endoscopic full-thickness resection(EFTR),with or without laparoscopic assistance,is an emergent natural orifice transluminal endoscopic surgery technique with promising safety and efficacy for the management of gastrointestinal submucosal tumors(SMTs)arising from the muscularis propria(MP),especially of the gastric wall.To date,evidence concerning duodenal exposed EFTR is lacking,mainly due to both the technical difficulty involved because of the special duodenal anatomy and concerns about safety and effectiveness of transmural wall defect closure.However,given the non-negligible morbidity and mortality associated with duodenal surgery,the recent availability of dedicated endoscopic tools for tissue-approximation capable to realize full-thickness defect closure could help in promoting the adoption of this endosurgical technique among referral centers.The aim of our study was to review the current evidence concerning exposed EFTR with or without laparoscopic assistance for the treatment of MP-arising duodenal SMTs.

经自然腔道取标本手术(NOSES)治疗结直肠癌的国际共识

近年来,经自然腔道取标本手术(NOSES)治疗结直肠癌已引起了广泛关注。NOSES应用于结直肠手术的潜在优势包括减轻术后疼痛,减少伤口并发症,减少对术后镇痛的需求,加快肠道功能的恢复,缩短住院时间,更好的美容效果,以及给患者带来了更佳的心理状态。尽管NOSES的手术创伤显著减轻,然而该技术也存在一些潜在问题。尤其随着这项新技术的兴起,人们对其无菌的把控、肿瘤学结果和病例选择等问题表示出关切。因此,迫切需要一部操作指南来规范NOSES手术在结直肠癌中的开展。经过国际NOSES联盟全体成员的三轮讨论,最终形成了该部共识。这一共识有助于NOSES在全球范围内的长远发展。