devuelta al lumen · the notes concept . abdominal surgery in perspective open surgery . ... cios,...
TRANSCRIPT
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Devuelta al Lumen: Cirugía endoscópica transluminal a través
de orificios naturales 2012 Curso Internacional Retos Clinicos en la Gastroenterologia de
Urgencias Asociacion Colombiana de Gastroenterologia
1 de Septiembre, 2012 Pereira, Risaralda • Hotel Movich
John A. Martin, MD
Associate Professor of Medicine and Surgery Director of Endoscopy
Northwestern University Feinberg School of Medicine • Chicago, Illinois
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In the beginning…
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In the beginning…
Rao GV, Reddy N., 2005 Transgastric Appendectomy in Humans. Unpublished; presentation at World Congress of Gastroenterology, Montreal, Quebec, Canada, September 2005.
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• Enter body through natural orifice with standard flexible endoscope
• Open wall of viscus • Replicate traditionally surgical intra-
abdominal procedure • Withdraw into viscus and close visceral
wall securely • Remove endoscope from orifice
The NOTES Concept
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Abdominal Surgery in Perspective Open Surgery
Laparoscopic Surgery (same operations, smaller incisions)
Percutaneous + Endoscopic Excision, Ablation, Debridement, Drainage
(Interventional radiology & endoscopy)
Natural Orifice Transluminal Endoscopic Surgery (NOTES)
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Why NOTES? • Less invasive (?)
– Less pain
– Less tissue trauma
• Lower anesthesia requirement (?)
• Better postop pulmonary function (?)
• Decreased hernia formation
• Decreased wound infection
• Decreased immunomodulation (?)
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Why NOTES? • Faster recovery times
• Shorter hospital stays
• Outpatient procedures (?)
• Improved cosmesis
• Anticipated public demand for
“incisionless” surgery
• Potential positive impact on endoluminal
procedures
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NOTES would • Change laparoscopic surgery • Expand the horizon of the
gastroenterologist • Lead to rapid development of
instrumentation specific to NOTES • Evolve new breed of GI
interventionalist—neither surgeon nor gastroenterologist
The NOTES Concept: Chapter 1
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NOTES would • Change laparoscopic surgery • Expand the horizon of the
gastroenterologist • Lead to rapid development of
instrumentation specific to NOTES • Evolve new breed of GI
interventionalist—neither surgeon nor gastroenterologist— really?
The NOTES Concept: Chapter 1
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What actually happened? • Gastroenterologists and surgeons
teamed up and started to work together
• Industry teamed up with clinical teams of clinical investigators
• Conceptualization and development of new technology accelerated rapidly
• NOSCAR formed
The NOTES Concept: Chapter 1
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NOSCAR
• Natural Orifice Surgery Consortium for Assessment and Research
• Joint initiative supported by both ASGE & SAGES
• White papers published 2006
• Industry grants $2 million
• 3rd annual conference held in San Francisco, July 10-12, 2008 (www.noscar.org)
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The NOTES Concept: Chapter 1
Early animal work • Liver biopsy
• Oophrectomy
• Tubal ligation
• Cholecystectomy
• Splenectomy
• Gastrojejunostomy
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Closure devices: clips + clamps
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Closure devices: T-tags
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Closure devices: suturing
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Closure devices: suturing
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Closure devices: plugs
Cios, et al., Surg Endosc 2007
100% successful closure of standardized 1cm gastrotomy in large animal survival model
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Closure devices: atrial septal occluder
Perretta, et al., Gastrointest Endosc 2007;66: 809-813.
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Closure devices: flexible stapler
Kaehler, et al., Surg Endosc 2007;20:519-521.
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New Generation Endoscopes
“Endoscopic paradigm”
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Multitasking platforms
“Surgical paradigm”
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Multitasking platforms
“Combining endoscopic & surgical paradigms”
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Proprietary platform
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Dedicated instrumentation
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Human NOTES Procedures Appendectomy Cholecystectomy PEG “rescue” Proposed Staging for cancer Diagnosis / treatment of pain
syndromes Tubal ligation / Oophrectomy Adhesiolysis Diaphragm pacing Gastric pacing
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Technical limitations to current platform • Flexible endoscopes
• Too flexible for counter-forces • Small instrument channels • Weak suction / insufflation • Parallel (instrument and visual) access
• Endoscopic Instrumentation • Weak graspers • Small end-effectors • No (or limited) independent steering • Inadequate tissue approximators & hemostasis
The NOTES Concept: Chapter 1 What did we learn?
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NOTES Hybrid Human Chole (not the full Monty)
Auyang E, Vaziri K, Martin J, Hungness E, Soper N. Human NOTES Hybrid Transgastric Cholecystectomy. DDW 2008, San Diego, CA
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Issues: Technological & Technical
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Issues: Efficiency & Ergonomics
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• Technical limitations to current platform
• Conceptualization and development of new technology takes time
• Laparoscopy is a very good technology
• Fundamental differences between gastroenterologist and surgeon
The NOTES Concept: Chapter 1 What did we learn?
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• “Hybrid NOTES” instead of “pure NOTES” • Single laparoscopic port • Other abdominally-inserted end-
effectors • The understanding that there must be
more to NOTES than simply replicating what laparoscopy already does well
The NOTES Concept: Chapter 1 What did this lead to?
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• Gastroenterologists are not surgeons, and surgeons are not gastroenterologists • Different knowledge base • Distinct skill-sets • Working together in NOTES yields
different rewards to each • What are NOTES’s rewards for the
gastroenterologist?
The NOTES Concept: Chapter 1 What was realized?
(post NOSCAR 2008)
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Pasricha P, Hawari R, Ahmed I , Chen J, Cotton P, Hawes R, Kalloo A, Kantsevoy S, Gostout CJ. Endoscopic Submucosal Esophageal Myotomy. Endoscopy
2007;39:761-764, and DDW 2007, Washington, DC
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Auyang E, Vaziri K, Volckmann E, Martin J, Soper N, Hungness E. Cadaveric Rendezvous Hybrid Small Bowel Resection. Surg Endosc 2008 & SAGES 2008.
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Desilets D, Romanelli J, Earle D. Endoscopic Stapled Cystgastrostomy. DDW 2008, San Diego, CA, May, 2008
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From Kim HB, Fauza D, Garza J, Oh JT, Nurko N, Jaksic T. Serial Transverse Enteroplasty (STEP): A Novel Bowel Lengthening Procedure. J Ped Surg 2003.
What else is possible?
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*
Cy5.5 monofunctional dye
Fluorescence Probe Endoscopy The cathepsin probe: are molecular probes the future of diagnostic endoscopy? Gounaris and Khazaie, PLoS ONE 2008; 3: e2916.
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Molecular imaging in endoscopy: Cathepsin probe endoscopy in a mouse model Gounaris and Khazaie
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The Wish List Endoscopic stapler
Better knives
Improved mucosal undermining
Robust retractors, approximators, & hemostatic apparatus
More secure closure
Agile, versatile multitasking platforms
•endoscopic directional control •flexible •robust
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Fly-by-Wire?
From Ho, KY, et al. Endoscopic Submucosal Dissection Using a Computer-controlled Master-Slave Robot. DDW 2009
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