title: Natural orifice translumenal thoracoscopic surgery: does the slow progress and the associated risks affect feasibility and potential clinical applications?
abstract: BACKGROUND
  Natural orifice translumenal endoscopic surgery (NOTES) is an emerging new technique but with much of the focus for the clinical applications of this technique centered on the abdomen. Consequently, its adaptation to the chest has been overlooked. The evidence for safe access, periprocedural complications and potential thoracic applications needs to be evaluated.
  
  
  OBJECTIVE
  This study systematically reviews the evidence for the feasibility and potential clinical applications of natural orifice translumenal thoracoscopic surgery.
  
  
  METHODS
  MEDLINE and the Cochrane central database of controlled trials, from the earliest available date to July 2008.
  
  
  METHODS
  All studies evaluating the use of NOTES involving the thoracic cavity or structures therein were identified. The minimum inclusion criterion for each study was the extraction of discernible trial data. No restrictions were placed on language.
  
  
  RESULTS
  The literature search identified 197 citations. Review of abstracts led to 10 full-text articles for assessment; 7 articles were considered for this review, reporting on a total of 37 cases. All cases used the porcine model in both survival (7 to 42 days; mean 16; n = 5) and nonsurvival studies (n = 2). Mortality was 5% (n = 2) and morbidity 19% (n = 7); histopathological leak was detected on autopsy in 1 case.
  
  
  CONCLUSIONS
  No human trials have currently been performed using NOTES within the thoracic cavity. There is a wide diversity of clinical applications from which cardiothoracic surgery could potentially benefit. There is a great deal of technical improvement that is still required before the technique is viable as an alternative surgical approach in humans.
authors.affiliation: Department of Biosurgery and Surgical Technology, Imperial College, London, United Kingdom. j.clark@imperial.ac.uk
authors.forename: James
authors.initials: J
authors.lastname: Clark
authors.forename: Mikael
authors.initials: M
authors.lastname: Sodergren
authors.forename: Jorge
authors.initials: J
authors.lastname: Correia-Pinto
authors.forename: Emmanouil
authors.initials: E
authors.lastname: Zacharakis
authors.forename: Julian
authors.initials: J
authors.lastname: Teare
authors.forename: Guang-Zhong
authors.initials: GZ
authors.lastname: Yang
authors.forename: Ara
authors.initials: A
authors.lastname: Darzi
authors.forename: Thanos
authors.initials: T
authors.lastname: Athanasiou
mesh_terms: D006801:Humans; D023421:Models, Animal; D035703:Therapies, Investigational; D035423:Thoracic Cavity / Q000601:surgery; D013906:Thoracoscopy / Q000009:adverse effects / Q000379:methods*