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 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.

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.

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.

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.

Gastrointestinal tract access for urological natural orifice transluminal endoscopic surgery

We conducted a literature review of natural orifice transluminal endoscopic surgery(NOTES),focusing on urologic procedures with gastrointestinal tract access,to update on the development of this novel surgical approach.As part of the methods,a comprehensive electronic literature search for NOTES was conducted using Pub Med and Cochrane Library from March 2002 to February 2016 for papers reporting urologic procedures performed utilizing gastrointestinal tract access.A total of 11 peer-reviewed studies examining utility of gastrointestinal access for NOTES urologic procedures were noted,with the first report in 2007.The procedures reported in the studies were total/radical nephrectomy,partial nephrectomy,adrenalectomy,and prostatectomy.The transgastric approach was identified in five studies examining total/radical nephrectomy(n = 2),partial nephrectomy(n = 1),partial cystectomy(n = 1),and adrenalectomy(n = 1).Six studies evaluated transrectal approach for NOTES,describing total/radical nephrectomy(n = 3),partial nephrectomy(n = 1),robotic nephrectomy with adrenalectomy(n = 1) and prostatectomy(n = 1).Feasibility was reported in all studies.Most studies were preclinical and acute,and limited by concerns regarding restricted instrumentation and infection risk.We concluded that gastrointestinal access for urologic NOTES demonstrates promise as described by outlined feasibility studies in preclinical models.Nonetheless,clinical application awaits further advancements in surgical technology and concerns regarding infectious potential.

Natural orifice transluminal endoscopic wedge hepatic resection with a water-jet hybrid knife in a non-survival porcine model

AIM: To explore the feasibility of a water-jet hybrid knife to facilitate wedge hepatic resection using a natural orifice transluminal endoscopic surgery (NOTES) approach in a non-survival porcine model. METHODS: The Erbe Jet2 water-jet system allows a needleless, tissue-selective hydro-dissection with a pre-selected pressure. Using this system, wedge hepatic resection was performed through three natural routes (trans-anal, trans-vaginal and trans-umbilical) in three female pigs weighing 35 kg under general anesthesia. Entry into the peritoneal cavity was via a 15-mm incision using a hook knife. The targeted liver segment was marked by an APC probe, followed by wedge hepatic resection performed using a water-jet hybrid knife with the aid of a 4-mm transparent distance soft cap mounted onto the tip of the endoscope for holding up the desired plane. The exposed vascular and ductal structures were clipped with Endoclips. Hemostasis was applied to the bleeding cut edges of the liver parenchyma by electrocautery. After the procedure, the incision site was left open, and the animal was euthanized followed by necropsy. RESULTS: Using the Erbe Jet2 water-jet system, trans-anal and trans-vaginal wedge hepatic resection was successfully performed in two pigs without laparoscopic assistance. Trans-umbilical attempt failed due to an unstable operating platform. The incision for peritoneal entry took 1 min, and about 2 h was spent on excision of the liver tissue. The intra-operative blood loss ranged from 100 to 250 mL. Microscopically, the hydro-dissections were relatively precise and gentle, preserving most vessels. CONCLUSION: The Erbe Jet2 water-jet system can safely accomplish non-anatomic wedge hepatic resection in NOTES, which deserves further studies to shorten the dissection time.

Patient and physician perception of natural orifice transluminal endoscopic appendectomy

AIM:To investigate perception of natural orifice transluminal endoscopic surgery(NOTES)as a potential technique for appendectomy.METHODS:One hundred patients undergoing endoscopy and 100 physicians were given a questionnaire describing in detail the techniques of NOTES and laparoscopic appendectomy.They were asked about the reasons for their preference,choice of orifice,and extent of complication risk they were willing to accept.RESULTS:Fifty patients(50%)and only 21 physicians(21%)preferred NOTES(P<0.001).Patients had previously heard of NOTES less frequently(7%vs73%,P<0.001)and had undergone endoscopy more frequently(88%vs 36%,P<0.001)than physicians.Absence of hernia was the most common reason for NOTES preference in physicians(80%vs 44%,P= 0.003),whereas reduced pain was the most common reason in patients(66%vs 52%).Physicians were more likely to refuse NOTES as a novel and unsure technique(P<0.001)and having an increased risk of infection(P<0.001).The preferred access site in both groups was colon followed by stomach,with vagina being rarely preferred.In multivariable modeling,those with high-school education[odds ratio(OR):2.68,95% confidence interval(CI):1.23-5.83]and prior colonoscopy(OR:2.10,95%CI:1.05-4.19)were more likely to prefer NOTES over laparoscopic appendectomy.There was a steep decline in NOTES preference with increased rate of procedural complications.Male patients were more likely to consent to their wives vaginal NOTES appendectomy than male physicians(P=0.02).CONCLUSION:The preference of NOTES for appendectomy was greater in patients than physicians and was related to reduced pain and absence of hernia rather than lack of scarring.

Per-oral endoscopic myotomy:Major advance in achalasia treatment and in endoscopic surgery

Per-oral endoscopic myotomy(POEM)represents a natural orifice endoscopic surgery(NOTES)approach to laparoscopy Heller myotomy(LHM).POEM is arguably the most successful clinical application of NOTES.The growth of POEM from a single center in 2008 to approximately 60 centers worldwide in 2014 with several thousand procedures having been performed attests to the success of POEM.Initial efficacy,safety and acid reflux data suggest at least equivalence of POEM to LHM,the previous gold standard for achalasia therapy.Adjunctive techniques used in the West include impedance planimetry for real-time intraprocedural luminal assessment and endoscopic suturing for challenging mucosal defect closures during POEM.The impact of POEM extends beyond the realm of esophageal motility disorders as it is rapidly popularizing endoscopic submucosal dissection in the West and spawning offshoots that use the submucosal tunnel technique for a host of new indications ranging from resection of tumors to pyloromyotomy for gastroparesis.

New trends in colorectal surgery: Single port and natural orifice techniques

Single-incision laparoscopic surgery (SILS) and natural orifice transluminal endoscopic surgery (NOTES) have rapidly gained pace worldwide, potentially replacing conventional laparoscopic surgery (CLS) as the preferred colorectal surgery technique. Currently available data mainly consist of retrospective series analyzed in four meta-analyses. Despite conflicting results and lack of an objective comparison, SILS appears to offer cosmetic advantages over CLS. However, due to conflicting results and marked heterogeneity, present data fail to show significant differences in terms of operative time, postoperative morbidity profiles, port-site complications rates, oncological appropriateness, duration of hospitalization or cost when comparing SILS with conventional laparoscopy for colorectal procedures. The application of &#x0201c;pure&#x0201d; NOTES in humans remains limited to case reports because of unresolved issues concerning the ideal access site, distant organ reach, spatial orientation and viscera closure. Alternatively, minilaparoscopy-assisted natural orifice surgery techniques are being developed. The transanal &#x0201c;down-to-up&#x0201d; total mesorectum excision has been derived for transanal endoscopic microsurgery (TEM) and represents the most encouraging NOTES-derived technique. Preliminary experiences demonstrate good oncological and functional short-term outcomes. Large-scale randomized controlled trials are now mandatory to confirm the long-term SILS results and validate transanal TEM for the application of NOTES in humans.

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.

Ever-changing endoscopic treatment for early gastric cancer:Yesterday-today-tomorrow

Endoscopic resection has been an optimal treatment for selected patients with early gastric cancer(EGC) based on advances in endoscopic instruments and techniques. As endoscopic submucosal dissection(ESD) has been widely used for treatment of EGC along with expanding ESD indication, concerns have been asked to achieve curative resection for EGC while guaranteeing precise prediction of lymph node metastasis(LNM). Recently, new techniques including ESD or endoscopic full-thickness resection combined with sentinel node navigation enable minimal tumor resection and a laparoscopic lymphadenectomy in cases of EGC with high risk of LNM. This review covers the development and challenges of endoscopic treatment for EGC. Moreover, a new microscopic imaging and endoscopic techniques for precise endoscopic diagnosis and minimally invasive treatment of EGC are introduced.

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.

Per-oral endoscopic myotomy for achalasia: An American perspective

Achalasia is an uncommon esophageal motility disorder characterized by the selective loss of enteric neurons leading to absence of peristalsis and impaired relaxation of the lower esophageal sphincter.Per-oral endoscopic myotomy(POEM) is a novel modality for the treatment of achalasia performed by gastroenterologists and surgeons.It represents a natural orifice transluminal endoscopic surgery(NOTES) approach to Heller myotomy.POEM has the minimal invasiveness of an endoscopic procedure that can duplicate results of the surgical Heller myotomy.POEM is conceptually similar to a surgical myotomy without the inherent external incisions and post-operative care associated with surgery.Initial high success and low complications rates promise a great future for this technique.In fact,POEM has been successfully performed on patients with end-stage achalasia as an initial treatment reserving esophagectomy for those without good response.The volume of POEMs performed worldwide has grown exponentially.In fact,surgeons who have performed Heller myotomy have embraced POEM as the preferred intervention for achalasia.However,the niche of POEM remains to be defined and long term results are awaited.We describe our experience with POEM having performed the first POEM outside of Japan in 2009,the evolution of our technique,and give our perspective on its future.

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.

International consensus on natural orifice specimen extraction surgery(NOSES)for colorectal cancer

In recent years,natural orifice specimen extraction surgery(NOSES)in the treatment of colorectal cancer has attracted widespread attention.The potential benefits of NOSES including reduction in postoperative pain and wound complications,less use of postoperative analgesic,faster recovery of bowel function,shorter length of hospital stay,better cosmetic and psychological effect have been described in colorectal surgery.Despite significant decrease in surgical trauma of NOSES have been observed,the potential pitfalls of this technique have been demonstrated.Particularly,several issues including bacteriological concerns,oncological outcomes and patient selection are raised with this new technique.Therefore,it is urgent and necessary to reach a consensus as an industry guideline to standardize the implementation of NOSES in colorectal surgery.After three rounds of discussion by all members of the International Alliance of NOSES,the consensus is finally completed,which is also of great significance to the long-term progress of NOSES worldwide.

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.