lee l swanstrom md, facs division of gi and minimally invasive surgery legacy health system...
TRANSCRIPT
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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?
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0
200000
400000
600000
800000
1000000
1200000
1970 1980 1990 2000
laparoscopy
diagnosticendoscopy
therapeuticendoscopy
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• [another DeMeester legacy!]
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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
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Advanced endoluminal esophageal surgeries:
• Mucosal ablation
• Partial thickness resection
• Full thickness resection
• Perforation repair/treatments
• Stenting
• Antireflux surgery
• Bariatric surgery
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Surgery Endoscopy
• Open Zenkers excision
• Transthoracic repair esophageal perforation
• Esophageal exclusions
• Palliative esophagectomy
• Esophagectomy for HGD Barretts
X
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Evolution of GI Surgery
Open surgery
DiagnosticFlex endoscopy
Laparoscopic Surgery
TherapeuticEndoscopy
stents
ablations
EUSFNA
Mucosectomy/Mucosal resection
invasiveness TransluminalEndoscopic
surgery
SURGERYSURGERY
Flexible EndoscopyFlexible Endoscopy
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ASGE/SAGES Working group on Natural Orifice Translumenal
Endoscopic Surgery WHITE PAPER
• N natural
• O orifice
• Ttranslumenal
• E endoscopic
• S surgery
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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
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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….
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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
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But surely not the esophagus!
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Endoluminal esophageal surgery
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mucosectomy
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Extended mucosectomy
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Full thickness excisions
Fitscher-Ravens
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Perforation repair/treatment
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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
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Closure options
• Clips
• Sutures
• Others
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Stents for perforations
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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
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Extraluminal endoscopic dissection
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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
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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
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Enabling technologies
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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
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DDES, Boston Scientific
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EndoSamuraiOlympus
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Transesophageal selective lymphadnectomy
Fritscher-R GIE 2006
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Transcervical esophageal mobilization
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Transcervical esophageal myotomy
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Transoral thoracic surgery
Thanks to Fritscher-Ravens and Perretta
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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.