EDITORIAL ANZJSurg.com
Comments on the current status and future development of natural orifice transluminal endoscopic surgery Natural orifice transluminal endoscopic surgery (NOTES) has emerged in the early 2000 as a logical development of ideas originating from interventional endoscopists. The process was supported by gastrointestinal surgeons with the motivation to expand the possibilities of minimal access surgery. The US-based NOSCAR group, followed by the EuroNOTES group, established yearly summit workshops to exchange knowledge and promote research. After the initial hype of ideas and fantasies of performing intra-abdominal surgery via flexible endoscopes, followed by a more critical phase of reflection and after years of intensive work in many dedicated centres, the concept of NOTES has become a clinical reality. This has happened, despite the early disappointment of many, due to the complex problems and the technical limitations of NOTES procedures. The principle of minimal access surgery is the reduction of access size and access trauma aiming for a shorter patient recovery; improved post-operative well-being; better cosmesis; less postoperative restriction allowing the patient to return quickly back to full physical and psychological abilities, and possibly an improved long-term outcome. The latter is achieved by reduction in wound infections and less incisional hernias over time. The advantages of the concept of minimal access surgery over conventional open surgery have been clearly shown in the past decades. It is best to consider that NOTES is not a technique, but a concept. The concept being that NOTES can cause further reduction of access trauma by using a natural orifice as an access route to the intraabdominal cavity. Further minimizing access trauma at the abdominal or thoracic wall could possibly lead to less post-operative pain, improved and quicker recovery from surgery, less post-operative complications, less wound infection and less long-term problems such as hernias. Some authors comment that NOTES is ‘dead’ because the hype has not created a revolution as seen with laparoscopic surgery in the 1990s. This argument is premature considering laparoscopy has been around since the 1930s and operative laparoscopy did not start until the early 1980s, with the final breakthrough occurring in the early 1990s, with a remarkable rise in complications. Thus, it has been appropriate that there has been a careful assessment of the new ideas and techniques related to NOTES and even more careful introduction into clinical practice. After 5 years of experimental and clinical practice, clinical evaluation and evidence assessment reveals the infection issue is not a major concern and the frequency of infectious NOTES complications is low.1,2 The principle of hybrid techniques has overcome some of the limitations that inhibited the clinical breakthrough of NOTES techniques. In hybrid procedures, trans-abdominal trocars are used in © 2015 Royal Australasian College of Surgeons
limited numbers and limited size to facilitate, assist and/or enable the manoeuvres through the natural orifice via graspers for better retraction, exposure and/or delivery of rigid energy devices. Despite the fact that trans-abdominal instruments will limit the possible positive effects of NOTES, hybrid procedures usually increase patient safety by facilitating the use of experienced and safe laparoscopic techniques. The first comparative trials have been published demonstrating the possible advantage of NOTES-hybrid procedures over classic laparoscopic cholecystectomy specifically assessing the cosmetic result. Randomized trials are on the way. Using the trans-oesophageal route, one of the current and most promising NOTES procedures is Per-Oral Endoscopic Myotomy (POEM). Several clinical indications are being evaluated for the use of the POEM techniques such as achalasia, diffuse esophageal spasm, other spastic motility disorders and mediastinal exploration. With respect to achalasia, POEM is becoming an established therapeutic option compared with alternatives such as endoscopic dilation and laparoscopic oesophageal myotomy. The trans-anal/trans-colonic approaches were considered to be a problem because of the bacterial load of the colon and the potential for infection. Presently, trans-anal and trans-colonic hybrid-NOTES procedures are increasingly performed in Europe. Based on the long-term clinical experiences of trans-anal endoscopic mucosectomy and based on the conceptual modifications that were made in the past years for using the anastomotic site as a natural orifice into the abdominal cavity, trans-anal hybrid colon resections and trans-anal hybrid rectal resections are now the most promising development in NOTES today. In the past 24 months, there have been hundreds of trans-anal colon resections and trans-anal TME procedures performed in Europe. The safe performance of these NOTES procedures requires increased experience and mental work load compared with traditional minimal invasive surgery. As well, interventional endoscopy and advanced laparoscopy must be well established prior to involving NOTES techniques. In summary, NOTES and more frequently hybrid-NOTES techniques have emerged for all natural orifices. Interesting enough, different indications are used for different natural orifices. Each technique has been optimized for the purpose of finding a safe and realistic solution to perform the procedure according to the specific indication. Each approach has been established clinically with a good safety record so far. The most important result is the low complication rate that could be realized during the introduction of NOTES and associated techniques in clinical practice in contrast to the introduction of operative laparoscopy. ANZ J Surg 85 (2015) 201–203
202
A major impediment to the progression of NOTES techniques during the first years was the worldwide economic crisis, which limited the technical development by industry. Despite these hurdles, NOTES associated techniques have progressively increased in their clinical application around the world, especially in Europe. NOTES techniques will stay in the clinical arena and will hopefully help to advance endoscopy and minimal access surgery for the benefit of patients.
Editorial
2. Fuchs KH, Meining A, von Renteln D et al. The EuroNOTES status paper – NOTES from the concept to clinical practice. Surg. Endosc. 2013; 27: 1456–67.
Karl-Hermann Fuchs, MD AGAPLESION Markus Krankenhaus, Frankfurt, Germany doi: 10.1111/ans.12984
References 1. Rattner D, Hawes R, Schwaitzberg S, Kochman M, Swanstrom L. The second SAGES/ASGE white paper on natural orifice translumenal endoscopic surgery: 5 years of progress. Surg. Endosc. 2011; 25: 2441–8.
Low-energy falls Trauma in the elderly, a physiologically fragile population, is an increasing challenge in an ageing population.1 Low-energy falls account for an expanding proportion of geriatric hospital admissions, with head injury and hip fracture as the two most common injuries.2 In the current issue of the journal,3 an inner city trauma centre has analysed its prospective trauma registry over 11 years for patients over 65 who sustained a fall less than 1 m. It has found that the burden of geriatric hip fracture has steadily decreased (n = 127 in 2000, n = 60 in 2011), an increase in severe head injuries (Abbreviated Injury Scale (AIS) ≥ 3, including intracranial haemorrhage and skull fracture; n = 35 in 2000, n = 108 in 2011) and a 25% need for inpatient rehabilitation. Unfortunately, most of the causative effects on these changes are only speculative as they have not been measured in this study. The halving of hip fracture numbers is significant. The authors attribute this 6% per annum decrease to better falls prevention and pharmacological therapy of osteoporosis. Falls prevention decreasing injury contradicts the introductory statement of falls being an increasing cause of hospitalization. A trend for falls in their institution is not provided, only an absolute number of admission over 11 years (n = 4964) and the figures for 2000 (n = 354) and 2011 (n = 361), which makes it difficult to interpret whether falls prevention is responsible. It is difficult to interpret what proportion received osteoporosis pharmacotherapy, as trauma registries are generally not designed to this detail. Nationally, incidence of geriatric hip fracture is decreasing, despite an increasing number of cases because of an ageing population.4 If the population in the hospital’s catchment has not expanded, or not aged at the same rate as other areas, this may contribute to their finding. An increase in severe head injuries of 5.9% per annum is reported by the authors, who hypothesize that this may result from increased utilization of antiplatelet or anticoagulant agents. Once again, this is not clarified whether patients sustain a head injury, and what proportion of patients sustaining falls were taking blood-thinning medication. The trauma registry cannot answer this possible justification, and this finding warrants scientific explanation.
The burden elderly patients place on rehabilitation facilities is an important finding in this study. As much focus is being justifiably placed on the need for acute orthogeriatric services to improve patient outcomes,5 the unavailability of prompt referral of trauma patients to rehabilitation after acute care can be frustrating for the clinician, and place strain on trauma resources. A trauma service cannot solve this problem; it needs a State or National health-level solution. The John Hunter Hospital in Newcastle, NSW, has reported an increased incidence of geriatric hip fracture over a decade (n = 413 in 2002, n = 431 in 2011; mean of 427 ± 20), with a significant increase in length of stay over this time (2.5% increase per annum between 2002 (median 11 (12) ) and 2011 (median 11 (14), P < 0.05).6 This may be due to a greater demand for rehabilitation services, but was not explored through limitation of our own databases. We have reported an inpatient mortality of 4.6% per annum in our study of management errors and impact on mortality,7 which is similar to the authors’ 5%. Recent minimum data set collection in accordance with the Agency for Clinical Innovation’s hip fracture guidelines indicate a rehab discharge rate of 51.2% for our institution. This needs to be extrapolated over a longer period. Examining our prospectively collected trauma database (consisting of patients meeting trauma call criteria and all trauma patients with Injury Severity Score (ISS) > 15 since 2009), 294 patients over the age of 65 sustained a head injury with AIS ≥ 3 from a fall less than 1 m (Fig. 1). This was a median of 62 patients per annum (interquartile range (IQR) 50,63), with a mean age of 77.3 (±8.0 standard deviation), median ISS of 16 (IQR 9,25), inpatient mortality of 16.3% and rehabilitation discharge destination of 26.5%. The authors report a mortality of 10% and rehab referral of 33%, which is similar to our potentially sicker data set (ISS is not mentioned for head injury group alone). This paper highlights all the limitations of the registry-based studies; they are reasonable for hypothesis generation and monitoring long-term trends of limited data at best. An exciting development is the inception of the Australia New Zealand Hip Fracture Registry. It will form a tool to assess desired standards in hip fracture care, and © 2015 Royal Australasian College of Surgeons
Copyright of ANZ Journal of Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
Comments on the current status and future development of natural orifice transluminal endoscopic surgery Natural orifice transluminal endoscopic surgery (NOTES) has emerged in the early 2000 as a logical development of ideas originating from interventional endoscopists. The process was supported by gastrointestinal surgeons with the motivation to expand the possibilities of minimal access surgery. The US-based NOSCAR group, followed by the EuroNOTES group, established yearly summit workshops to exchange knowledge and promote research. After the initial hype of ideas and fantasies of performing intra-abdominal surgery via flexible endoscopes, followed by a more critical phase of reflection and after years of intensive work in many dedicated centres, the concept of NOTES has become a clinical reality. This has happened, despite the early disappointment of many, due to the complex problems and the technical limitations of NOTES procedures. The principle of minimal access surgery is the reduction of access size and access trauma aiming for a shorter patient recovery; improved post-operative well-being; better cosmesis; less postoperative restriction allowing the patient to return quickly back to full physical and psychological abilities, and possibly an improved long-term outcome. The latter is achieved by reduction in wound infections and less incisional hernias over time. The advantages of the concept of minimal access surgery over conventional open surgery have been clearly shown in the past decades. It is best to consider that NOTES is not a technique, but a concept. The concept being that NOTES can cause further reduction of access trauma by using a natural orifice as an access route to the intraabdominal cavity. Further minimizing access trauma at the abdominal or thoracic wall could possibly lead to less post-operative pain, improved and quicker recovery from surgery, less post-operative complications, less wound infection and less long-term problems such as hernias. Some authors comment that NOTES is ‘dead’ because the hype has not created a revolution as seen with laparoscopic surgery in the 1990s. This argument is premature considering laparoscopy has been around since the 1930s and operative laparoscopy did not start until the early 1980s, with the final breakthrough occurring in the early 1990s, with a remarkable rise in complications. Thus, it has been appropriate that there has been a careful assessment of the new ideas and techniques related to NOTES and even more careful introduction into clinical practice. After 5 years of experimental and clinical practice, clinical evaluation and evidence assessment reveals the infection issue is not a major concern and the frequency of infectious NOTES complications is low.1,2 The principle of hybrid techniques has overcome some of the limitations that inhibited the clinical breakthrough of NOTES techniques. In hybrid procedures, trans-abdominal trocars are used in © 2015 Royal Australasian College of Surgeons
limited numbers and limited size to facilitate, assist and/or enable the manoeuvres through the natural orifice via graspers for better retraction, exposure and/or delivery of rigid energy devices. Despite the fact that trans-abdominal instruments will limit the possible positive effects of NOTES, hybrid procedures usually increase patient safety by facilitating the use of experienced and safe laparoscopic techniques. The first comparative trials have been published demonstrating the possible advantage of NOTES-hybrid procedures over classic laparoscopic cholecystectomy specifically assessing the cosmetic result. Randomized trials are on the way. Using the trans-oesophageal route, one of the current and most promising NOTES procedures is Per-Oral Endoscopic Myotomy (POEM). Several clinical indications are being evaluated for the use of the POEM techniques such as achalasia, diffuse esophageal spasm, other spastic motility disorders and mediastinal exploration. With respect to achalasia, POEM is becoming an established therapeutic option compared with alternatives such as endoscopic dilation and laparoscopic oesophageal myotomy. The trans-anal/trans-colonic approaches were considered to be a problem because of the bacterial load of the colon and the potential for infection. Presently, trans-anal and trans-colonic hybrid-NOTES procedures are increasingly performed in Europe. Based on the long-term clinical experiences of trans-anal endoscopic mucosectomy and based on the conceptual modifications that were made in the past years for using the anastomotic site as a natural orifice into the abdominal cavity, trans-anal hybrid colon resections and trans-anal hybrid rectal resections are now the most promising development in NOTES today. In the past 24 months, there have been hundreds of trans-anal colon resections and trans-anal TME procedures performed in Europe. The safe performance of these NOTES procedures requires increased experience and mental work load compared with traditional minimal invasive surgery. As well, interventional endoscopy and advanced laparoscopy must be well established prior to involving NOTES techniques. In summary, NOTES and more frequently hybrid-NOTES techniques have emerged for all natural orifices. Interesting enough, different indications are used for different natural orifices. Each technique has been optimized for the purpose of finding a safe and realistic solution to perform the procedure according to the specific indication. Each approach has been established clinically with a good safety record so far. The most important result is the low complication rate that could be realized during the introduction of NOTES and associated techniques in clinical practice in contrast to the introduction of operative laparoscopy. ANZ J Surg 85 (2015) 201–203
202
A major impediment to the progression of NOTES techniques during the first years was the worldwide economic crisis, which limited the technical development by industry. Despite these hurdles, NOTES associated techniques have progressively increased in their clinical application around the world, especially in Europe. NOTES techniques will stay in the clinical arena and will hopefully help to advance endoscopy and minimal access surgery for the benefit of patients.
Editorial
2. Fuchs KH, Meining A, von Renteln D et al. The EuroNOTES status paper – NOTES from the concept to clinical practice. Surg. Endosc. 2013; 27: 1456–67.
Karl-Hermann Fuchs, MD AGAPLESION Markus Krankenhaus, Frankfurt, Germany doi: 10.1111/ans.12984
References 1. Rattner D, Hawes R, Schwaitzberg S, Kochman M, Swanstrom L. The second SAGES/ASGE white paper on natural orifice translumenal endoscopic surgery: 5 years of progress. Surg. Endosc. 2011; 25: 2441–8.
Low-energy falls Trauma in the elderly, a physiologically fragile population, is an increasing challenge in an ageing population.1 Low-energy falls account for an expanding proportion of geriatric hospital admissions, with head injury and hip fracture as the two most common injuries.2 In the current issue of the journal,3 an inner city trauma centre has analysed its prospective trauma registry over 11 years for patients over 65 who sustained a fall less than 1 m. It has found that the burden of geriatric hip fracture has steadily decreased (n = 127 in 2000, n = 60 in 2011), an increase in severe head injuries (Abbreviated Injury Scale (AIS) ≥ 3, including intracranial haemorrhage and skull fracture; n = 35 in 2000, n = 108 in 2011) and a 25% need for inpatient rehabilitation. Unfortunately, most of the causative effects on these changes are only speculative as they have not been measured in this study. The halving of hip fracture numbers is significant. The authors attribute this 6% per annum decrease to better falls prevention and pharmacological therapy of osteoporosis. Falls prevention decreasing injury contradicts the introductory statement of falls being an increasing cause of hospitalization. A trend for falls in their institution is not provided, only an absolute number of admission over 11 years (n = 4964) and the figures for 2000 (n = 354) and 2011 (n = 361), which makes it difficult to interpret whether falls prevention is responsible. It is difficult to interpret what proportion received osteoporosis pharmacotherapy, as trauma registries are generally not designed to this detail. Nationally, incidence of geriatric hip fracture is decreasing, despite an increasing number of cases because of an ageing population.4 If the population in the hospital’s catchment has not expanded, or not aged at the same rate as other areas, this may contribute to their finding. An increase in severe head injuries of 5.9% per annum is reported by the authors, who hypothesize that this may result from increased utilization of antiplatelet or anticoagulant agents. Once again, this is not clarified whether patients sustain a head injury, and what proportion of patients sustaining falls were taking blood-thinning medication. The trauma registry cannot answer this possible justification, and this finding warrants scientific explanation.
The burden elderly patients place on rehabilitation facilities is an important finding in this study. As much focus is being justifiably placed on the need for acute orthogeriatric services to improve patient outcomes,5 the unavailability of prompt referral of trauma patients to rehabilitation after acute care can be frustrating for the clinician, and place strain on trauma resources. A trauma service cannot solve this problem; it needs a State or National health-level solution. The John Hunter Hospital in Newcastle, NSW, has reported an increased incidence of geriatric hip fracture over a decade (n = 413 in 2002, n = 431 in 2011; mean of 427 ± 20), with a significant increase in length of stay over this time (2.5% increase per annum between 2002 (median 11 (12) ) and 2011 (median 11 (14), P < 0.05).6 This may be due to a greater demand for rehabilitation services, but was not explored through limitation of our own databases. We have reported an inpatient mortality of 4.6% per annum in our study of management errors and impact on mortality,7 which is similar to the authors’ 5%. Recent minimum data set collection in accordance with the Agency for Clinical Innovation’s hip fracture guidelines indicate a rehab discharge rate of 51.2% for our institution. This needs to be extrapolated over a longer period. Examining our prospectively collected trauma database (consisting of patients meeting trauma call criteria and all trauma patients with Injury Severity Score (ISS) > 15 since 2009), 294 patients over the age of 65 sustained a head injury with AIS ≥ 3 from a fall less than 1 m (Fig. 1). This was a median of 62 patients per annum (interquartile range (IQR) 50,63), with a mean age of 77.3 (±8.0 standard deviation), median ISS of 16 (IQR 9,25), inpatient mortality of 16.3% and rehabilitation discharge destination of 26.5%. The authors report a mortality of 10% and rehab referral of 33%, which is similar to our potentially sicker data set (ISS is not mentioned for head injury group alone). This paper highlights all the limitations of the registry-based studies; they are reasonable for hypothesis generation and monitoring long-term trends of limited data at best. An exciting development is the inception of the Australia New Zealand Hip Fracture Registry. It will form a tool to assess desired standards in hip fracture care, and © 2015 Royal Australasian College of Surgeons
Copyright of ANZ Journal of Surgery is the property of Wiley-Blackwell and its content may not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's express written permission. However, users may print, download, or email articles for individual use.
