The risk of spreading infection into the abdominal
cavity is a major concern of NOTES proponents as well. Learning to control
that risk is a chief focus of animal studies, they say. Yet they also
point out that infection is an issue with any surgery.
To Kalloo and Ponsky, many of the objections to natural
orifice surgery bear striking resemblance to those presented decades ago
against laparoscopy. Gallbladder removals and appendectomies had long
ago become routine, and many doctors wondered why anyone would risk a
radically new approach. Only in hindsight have the advantages come to
be universally recognized. “Laparoscopy is a marvel,” Ponsky
says. “Now we have to investigate what kinds of benefits, including
unexpected ones, natural orifice surgery may offer.”
David W. Rattner, chief of the division of gastrointestinal
general surgery at the Massachusetts General Hospital, has collaborated
with Thompson on experiments funded by the Center for the Integration
of Medicine and Innovative Technology, a Cambridge-based consortium linking
several Harvard-affiliated hospitals, the Massachusetts Institute of Technology
and Draper Laboratories. “The dream with natural orifice surgery
is that you could have a procedure done and be back at work in a day or
two, instead of the one or two weeks it takes after laparoscopic procedures
or the month to recover from open surgery,” Rattner says.
To gastroenterologist Christopher J. Gostout of the
Mayo Clinic, a chief advantage of natural orifice surgery is that it could
reduce the need for general anesthesia, which is required to counteract
the pain of open or laparoscopic surgery. Instead, patients could be deeply
sedated, placed into a state of drug-induced relaxation that allows for
quicker revival than anesthesia. Another possible advantage involves the
body’s immune system. Open surgery depresses natural defense mechanisms,
making the patient more vulnerable to infection and disease. Laparoscopy
offered a significant improvement, and NOTES could further reduce stress
on the immune system.
The NOTES approach might work particularly well for
certain procedures, Gostout explains, including gastrojejunostomies, in
which surgeons attach a section of the small intestine directly to the
stomach to create a new passageway when a tumor has blocked the existing
passage. These surgeries carry a significant post-operative morbidity
rate, Gostout says, requiring a lengthy recuperation for pancreatic cancer
patients; NOTES could potentially get such patients out of the hospital
sooner. NOTES could also be useful for operating on obese patients because
it eliminates the need to slice large amounts of fat between the skin
and the abdominal cavity.
hen 14 surgeons and gastroenterologists met in New
York City last July, they all “agreed that translumenal endoscopic
surgery could offer such benefits to patients as less pain, faster recovery
and better cosmesis than current laparoscopic techniques,” according
to a white paper released in February. Still, the paper is laced with
words of caution. “Bad outcomes by inadequately trained physicians
could lead to regulatory intervention preventing development of a technology
that would ultimately benefit many patients,” they wrote. Even proponents
say that, in the early stages, NOTES procedures will have to be done in
conjunction with laparoscopy and under general anesthesia. Moreover, says
Rattner, co-chair of the group that wrote the white paper, early NOTES
procedures would need to be monitored by institutional review boards.
Even if the procedures prove to be medically viable
and offer clinical advantages, adoption may be slow. “Initially,
there’s going to be a lot of risk involved and very little reimbursement,” predicts
Rattner. “Most gastroenterologists aren’t going to want to
have anything to do with this.”
Whether NOTES overcomes such resistance and takes
its place as the next laparoscopy—or becomes a medical footnote,
one among thousands of bright ideas that never panned out—may not
be clear for years. Says Rattner, “For this new kind of surgery,
you either have the religion or you don’t—I’ve got it.” He
adds, “But I could be wrong.” 
 Dossier
1. “ASGE/SAGES Working Group on Natural
Orifice Translumenal Endoscopic Surgery,” Surgical Endoscopy,
February 2006. This white paper by 14 gastroenterologists and surgeons
offers a detailed description of the challenges facing NOTES.
2. “Flexible Transgastric Peritoneoscopy:
A Novel Approach to Diagnostic and Therapeutic Interventions,” by Anthony N. Kalloo
et al., Gastrointestinal Endoscopy, July 2004. Groundbreaking study
by a NOTES pioneer and his Johns Hopkins team.
3. “Transgastric Surgery Panel.” Panel discussion to be
held at the annual meeting of the Society of American Gastrointestinal
and Endoscopic Surgeons, Dallas, April 28, moderated by David W. Rattner.
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