The Future of Foregut Surgery: NOTES and Esophageal Surgery: What could be more Natural ?

1. Lee L Swanstrom MD, FACSDivision of GI and Minimally Invasive SurgeryLegacy Health SystemPortland, OR The Future of Foregut Surgery: NOTES and Esophageal Surgery: What could be more Natural?

3. [another DeMeester legacy!]

4. 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

5. Advanced endoluminal esophageal surgeries: • Mucosal ablation • Partial thickness resection • Full thickness resection • Perforation repair/treatments • Stenting • Antireflux surgery • Bariatric surgery

6. X Surgery Endoscopy • Open Zenkers excision • Transthoracic repair esophageal perforation • Esophageal exclusions • Palliative esophagectomy • Esophagectomy for HGD Barretts

7. Evolution of GI Surgery SURGERY Open surgery Laparoscopic Surgery Transluminal Endoscopic surgery invasiveness Mucosectomy/ Mucosal resection Therapeutic Endoscopy EUS FNA ablations stents Diagnostic Flex endoscopy Flexible Endoscopy

8. ASGE/SAGES Working group on Natural Orifice Translumenal Endoscopic Surgery WHITE PAPER • N natural • O orifice • T translumenal • E endoscopic • S surgery

9. 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

10. 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….

11. 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

12. But surely not the esophagus!

13. Endoluminal esophageal surgery

14. mucosectomy

15. Extended mucosectomy

16. Full thickness excisions Fitscher-Ravens

17. Perforation repair/treatment

18. Mediastinal perforation / abscesses • n=1 Mediastinal perforation, EUS • drainage • n=6 Mediastinal abscesses, • bedside drainage on ITU • n=8 Acute mediastinitis, urgent bedside • EUS diagnosis and drainage Fritscher-R et al: Endoscopy 2000, Crit Care Med 2003

20. Closure options • Clips • Sutures • Others

21. Stents for perforations

22. 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 Perforation closureTreatment of esophageal perforations 1999–2006: N=29

23. Extraluminal endoscopic dissection

24. 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

25. timeline Transesophageal dissection TG cholecystectomy NOTES Flex endo FTRD/TEM Generation III Scope design Barretts striping ESD Barretts TG/TR Bowel resect 1998 2003 Endoluminal Bariatric 2007 2008 TG hiatal hernia repair BSC FTRD Shapelock endoscopy Human NOTES Endoluminal GERD TG peritneoscopy Tissue approximation DDS Trans rectal surgeries

26. Enabling technologies

27. Elevator control lever Lifting Swing control knob Multi-bending section Water Jet Elevate forceps Resecting Swing knife R-Scope 2nd angulations control knob Olympus 12.8mm 14.3mm

29. DDES, Boston Scientific

30. EndoSamurai Olympus

31. Transesophageal selective lymphadnectomy Fritscher-R GIE 2006

32. Transcervical esophageal mobilization

33. Transcervical esophageal myotomy

34. Transoral thoracic surgery Thanks to Fritscher-Ravens and Perretta

35. 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.