Lee L Swanstrom MD, FACS

Division of GI and Minimally Invasive SurgeryLegacy Health System

Portland, OR

The Future of Foregut Surgery: NOTES and Esophageal

Surgery: What could be more Natural?

0

200000

400000

600000

800000

1000000

1200000

1970 1980 1990 2000

laparoscopy

diagnosticendoscopy

therapeuticendoscopy

• [another DeMeester legacy!]

Currently endoscopic applications in the foregut

• Pancreatic pseudocyst debridement

• Partial/Full thickness gastric excision

• Barretts stripping/ablation

• Perforation closure

• Transesophageal mediastinal drainage

• Perigastric node removal

Advanced endoluminal esophageal surgeries:

• Mucosal ablation

• Partial thickness resection

• Full thickness resection

• Perforation repair/treatments

• Stenting

• Antireflux surgery

• Bariatric surgery

Surgery Endoscopy

• Open Zenkers excision

• Transthoracic repair esophageal perforation

• Esophageal exclusions

• Palliative esophagectomy

• Esophagectomy for HGD Barretts

X

Evolution of GI Surgery

Open surgery

DiagnosticFlex endoscopy

Laparoscopic Surgery

TherapeuticEndoscopy

stents

ablations

EUSFNA

Mucosectomy/Mucosal resection

invasiveness TransluminalEndoscopic

surgery

SURGERYSURGERY

Flexible EndoscopyFlexible Endoscopy

ASGE/SAGES Working group on Natural Orifice Translumenal

Endoscopic Surgery WHITE PAPER

• N natural

• O orifice

• Ttranslumenal

• E endoscopic

• S surgery

Why NOTES?

• Less invasive– Less pain– Less tissue trauma

• Outpatient procedures• Cosmesis• “Surgery, gaining much from

the general advancement of knowledge will be rendered both knifeless and bloodless…”

John Hunter, London 1762

The dream….

• That a person could present with a surgical problem, see the surgeon, be taken to an outpatient facility, change into a gown, receive conscious sedation, have an endoscopic surgery with no incisions or scars, wake up and go home an hour later and be back to normal life the next day….

Patient survey on attitudes towards NOTES

• 192 patients• Question posed = lap chole vs NOTES• 56% chose NOTES / 44% lap chole• Summary:

– NOTES would have “less pain, risk, cost and recovery time”

– It would require more skill– 80% would still prefer if slightly higher

complication rate• Desirability of NOTES decreased as risk,

cost, distance to obtain increased and surgeon experience decreased

Abstract SAGES, 2007

But surely not the esophagus!

Endoluminal esophageal surgery

mucosectomy

Extended mucosectomy

Full thickness excisions

Fitscher-Ravens

Perforation repair/treatment

Mediastinal perforation / abscesses

2000 n=1 Mediastinal perforation, EUS

drainage

2000 n=6 Mediastinal abscesses,

bedside drainage on ITU

2003 n=8 Acute mediastinitis, urgent bedside

EUS diagnosis and drainage

Fritscher-R et al: Endoscopy 2000, Crit Care Med 2003

Closure options

• Clips

• Sutures

• Others

Stents for perforations

Perforation closureTreatment of esophageal perforations

1999–2006: N=29

Operative = 8• Debride and drain = 2• Primary closure = 2• Exclusion = 3• Esophagectomy = 1• Subsequent surgery 2• Hospital stay = 19

Non-operative = 21• Clips = 4• Stent = 7• Clip + stent= 10

• Subsequent surgery 2• Hospital stay = 8.5

Extraluminal endoscopic dissection

Why?

• Direct access to the mediastinum for cardiac, mediastinal, thoracic interventions

• Full thickness excisions of esophageal lesions

• Node harvest for staging

• Myotomy

• Diverticulectomy

• Esophageal mobilization for resection

timeline

1998

ESD Barretts

BSC FTRD

Flex endo FTRD/TEM

Endoluminal GERD

Endoluminal Bariatric

NOTES

TGperitneoscopy

Shapelockendoscopy

Generation IIIScope design

Tissue approximation

2003 2007TG hiatal

hernia repair

TGcholecystectomy

DDS

HumanNOTES

Trans rectalsurgeries

TG/TRBowel resect

Barretts striping

2008

Transesophagealdissection

Enabling technologies

Swing control

knob

Swing knife

Elevator control

lever

Elevate forceps

2nd angulations control knob

Multi-bending section

14.3mm12.8mm

Lifting

ResectingWater Jet

R-Scope

Olympus

DDES, Boston Scientific

EndoSamuraiOlympus

Transesophageal selective lymphadnectomy

Fritscher-R GIE 2006

Transcervical esophageal mobilization

Transcervical esophageal myotomy

Transoral thoracic surgery

Thanks to Fritscher-Ravens and Perretta

Conclusions:

• More of GI “surgery” is doable endoluminally, and fewer surgeries are the result.

• Enthusiasm for “NOTES” is pushing technology evolution for endoluminal and extraluminal surgery

• The esophageal wall is no longer the unreachable barrier that it was.