title: Broad clinical utilization of NOTES: is it safe?
abstract: BACKGROUND
  Natural orifice transluminal endoscopic surgery (NOTES) has been the focus of several studies as a less invasive alternative to conventional laparoscopy to access and treat intracavitary organs. For the last 5 years, much has been accomplished with animal studies, yet the clinical utilization of this novel technique is still modest. After 2 years of experience in the laboratory, we started our clinical experience. We report our experience with clinical utilization of NOTES procedures from 2007 to 2010.
  
  
  METHODS
  Under UCSD institutional review board-approved trials, 104 patients were enrolled under seven different NOTES protocols from 2007 to 2010, where a NOTES procedure was offered as an alternative to conventional treatments. The treated pathologies were cholelithiasis, biliary dyskinesia, acute and chronic appendicitis, ventral hernias, morbid obesity, and achalasia. The access routes included transgastric (TG), transvaginal (TV), transesophageal (TE), and perirectal (PR).
  
  
  RESULTS
  Among the 104 patients enrolled, 103 underwent a surgical procedure starting with diagnostic laparoscopy, and 94 cases were deemed appropriate to proceed via a NOTES approach. There were 9 aborted NOTES procedures at the time of the initial peritoneoscopy before creating a NOTES access route. The reasons to not proceed with a NOTES procedure in the TV cholecystectomy group (n = 5) were a large amount of pelvic adhesions in 4 patients and a severe inflammation of the gallbladder in 1 patient. In the TG cholecystectomy group (n = 1), it was severe inflammation of the gallbladder. In the TG appendectomy group (n = 1), it was the presence of localized peritonitis. In the TE endoscopic myotomy group (n = 2), it was the presence of megaesophagus with an inability to clean the esophagus of food debris. The NOTES procedures performed were 48 TV cholecystectomies, 4 TV appendectomies, 8 TG cholecystectomies, 2 PR peritoneoscopies, 3 TG appendectomies, 3 TV ventral hernia repairs, 5 TE endoscopic myotomies, 3 TV sleeve gastrectomies, and 18 TG sleeve gastrectomies. The average body mass indexes for those in the sleeve gastrectomy group was 42.1 kg/m(2) (TG route) and 40.6 kg/m(2) (TV route). There were no intraoperative complication and no conversions to standard laparoscopy during these procedures. The average hospital stay was 1-2 days. One patient who underwent TV cholecystectomy required an emergency department visit for nausea and vomiting. To date, 3 patients who underwent TV cholecystectomy have become pregnant and delivered normally.
  
  
  CONCLUSIONS
  NOTES is safe, feasible, and reproducible with previous training in the laboratory and a consistent team at a high-volume center. Prospective randomized studies of a large patient population are necessary to assess long-term results.
authors.affiliation: Division of Minimally Invasive Surgery, Department of Surgery, University of California San Diego, San Diego, CA, USA. shorgan@ucsd.edu
authors.forename: Santiago
authors.initials: S
authors.lastname: Horgan
authors.forename: Ozanan R
authors.initials: OR
authors.lastname: Meireles
authors.forename: Garth R
authors.initials: GR
authors.lastname: Jacobsen
authors.forename: Bryan J
authors.initials: BJ
authors.lastname: Sandler
authors.forename: Alberto
authors.initials: A
authors.lastname: Ferreres
authors.forename: Sonia
authors.initials: S
authors.lastname: Ramamoorthy
authors.forename: Thomas
authors.initials: T
authors.lastname: Savides
authors.forename: Toshio
authors.initials: T
authors.lastname: Katagiri
authors.forename: Takayuki
authors.initials: T
authors.lastname: Dotai
authors.forename: Michael
authors.initials: M
authors.lastname: Sedrak
authors.forename: Saniea F
authors.initials: SF
authors.lastname: Majid
authors.forename: Sheetal
authors.initials: S
authors.lastname: Nijhawan
authors.forename: Mark A
authors.initials: MA
authors.lastname: Talamini
mesh_terms: D000328:Adult; D001062:Appendectomy / Q000379:methods / Q000706:statistics & numerical data; D017081:Cholecystectomy, Laparoscopic / Q000379:methods / Q000706:statistics & numerical data; D005240:Feasibility Studies; D005260:Female; D005743:Gastrectomy / Q000379:methods / Q000706:statistics & numerical data; D059685:Herniorrhaphy / Q000379:methods / Q000706:statistics & numerical data; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D057605:Natural Orifice Endoscopic Surgery / Q000706:statistics & numerical data*; D061646:Operative Time; D061214:Patient Safety; D011446:Prospective Studies; D016896:Treatment Outcome; D055815:Young Adult