ESGE Newsletter

”EURO-NOTES”: Advanced Interventional Endoscopic Procedures and NOTES

Natural orifice transluminal endoscopic surgery (NOTES) is becoming increasingly attractive for the surgeon – but what about the gastroenterologist? Various surgical procedures such as hybrid NOTES cholecystectomy, single-incision laparoscopic surgery (SILS), transvaginal surgery with rigid endoscopes, and transumbilical surgery with flexible endoscopes (E-NOTES), all of them adopting the concept of scarless surgery, have recently been integrated into clinical routine medicine, at least in highly specialized centers. The term ”NOTES” has become a trademark for innovative, minimally invasive surgery. However, as gastroenterologists never perform such procedures, you may well ask why they should be interested in scarless surgical interventions such as NOTES cholecystectomies or appendectomies. The initial hype is over; is it now time for the gastrointestinal endoscopist to quietly retreat? The answer is: No, it is not!

Moreover, the European Society of Gastrointestinal Endoscopy (ESGE), together with the European Association for Endoscopic Surgery (EAES), is organizing and conducting a joint workshop on NOTES and interventional endoscopy each year. The 4th EURO-NOTES workshop this year will take place in Rome, Sept 9th to 11th. There are three good reasons why the trip to Rome could well be worth it, even for a GI endoscopist!

1. Flexible endoscopic procedures performed via natural orifices are most familiar to gastroenterological endoscopists. And transluminal endoscopy is part of the evermore complex interventional procedures endoscopists perform. Such a ”transluminal approach” is closely related to management of complications (closure of perforations) or can be performed on purpose for access to peri-esophageal and peri-gastric abscesses and necrosis. Since the key to successful NOTES procedures is a safe closure of the entry point, NOTES-associated procedures therefore help in our daily routine practice. Hence, GI endoscopists should participate and stay interested in NOTES research to maintain their competence in management of complications and perhaps also ”transluminal endoscopic therapy”.

2. Endoluminal endoscopy is certainly not perfect and even highly skilled endoscopists may struggle with several limitations in their everyday practice. Furthermore, the more complex the endoscopic procedure becomes, the more obvious are these limitations. Endoscopic submucosal dissection (ESD) is a good example. Performing an ESD demands a high level of training and even in an expert's hands, the time needed and rate of complications are considerable. On the other hand, successful ”surgical” NOTES procedures can only be achieved with two independently working instruments used for traction and counter-traction, precise dissection, and tissue approximation; hence, use of a single standard endoscope makes a procedure cumbersome if not impossible. Many innovations related to NOTES have therefore been aimed to overcome these limitations either by developing new devices or by designing new multifunctional platforms. Since the technical challenges of NOTES-associated procedures are strongly linked to those of interventional endoluminal endoscopy (i.e. the need for two independent working instruments), GI endoscopists should take advantage of innovations in the era of NOTES.

3. NOTES as performed today (by surgeons) is still experimental, clumsy and in some ways cumbersome. There is a strong demand for further ongoing research. However, research in NOTES has been most successful where teams have been formed. Many open questions remain, on infection and immunity, access and closure, indications for NOTES-related procedures and on training and education. There is a need for consensus guidelines on how to handle these issues. Since GI endoscopists have a (traditionally) high competence in interventional flexible endoscopy and are therefore familiar with these topics, they should actively participate in solving these problems.

Dear colleagues, in summary, we would like to encourage you to stay on track and actively participate in NOTES-related research since it is similar to research related to interventional endoscopy. EURO-NOTES 2010 (www.euro-notes.eu) offers a good opportunity to do so.

We hope to see you in Rome.

Guido Costamagna
ESGE President
Paul Fockens
ESGE Secretary General
Alexander Meining
EURO-NOTES Committee Chairman