Establishment of a pure NOTES procedure using a conventional flexible endoscope

Mori et al. [1] discuss the possibility of using a conventional flexible endoscope during pure natural orifice transluminal endoscopic surgery (NOTES) in patients with gastric gastrointestinal stromal tumors (GISTs), which is a really amazing idea. They use several novel techniques during full-thickness resection of GISTs, which may lay the foundation for the realization of pure NOTES using only conventional flexible endoscopes. First, a nasal endoscope was introduced to either create a perforation or assist in pulling up the collapsed gastric wall to prevent the operative view from being obscured. Second, a duodenal balloon was used to prevent gas from flowing beyond the outlet of the stomach and causing uncomfortable distention of the intestine. Third, unlike previous studies, perforation was made at 10-mm intervals instead of a continuous incision, a process that can also provide landmarks for resection of GISTs.

However, although the authors state that the endoscopes were sterilized with ethylene oxide, they do not specify how to prevent post-NOTES infection, which as previously reported [2] is crucial to the success of the whole operation. It is well known that several risk factors for infection, such as intraoperative spillage, contamination of the sterile endoscope when passing through the natural orifice, or inadequate closure of the transmural incision, are inherent to the NOTES procedure. The authors report that all patients were discharged without any complications, and it would therefore be interesting to know how they achieved such good outcomes without infection. Furthermore, three endoscopes, each with its own working channels, were used during the procedures, and therefore it would be useful to know how the authors minimized the interference between the endoscopes.

References

• 1 Mori H, Kobara H, Kobayashi M et al. Establishment of pure NOTES procedure using a conventional flexible endoscope: review of six cases of gastric gastrointestinal stromal tumors.  Endoscopy. 2011;  43 631-634
• 2 Yang Q Y, Zhang G Y, Wang L et al. Infection during transgastric and transvaginal natural orifice transluminal endoscopic surgery in a live porcine model.  Chin Med J. 2011;  124 556-561