Natural Orifice Translumenal Endoscopic Surgery (NOTES)® might represent the next major advancement in minimally invasive therapy. To address this emerging technology, a working group consisting of expert laparoscopic surgeons from SAGES and a group of expert interventional endoscopists representing ASGE have joined together as the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) Working Group on (NOTES)®.
The growing capabilities of therapeutic flexible endoscopy have ushered in a new era in treatment of gastrointestinal conditions. Refinements in laparoscopic surgery have progressed to the point that complex surgical procedures, such as gastric bypass, can now be performed in a minimally invasive fashion. These trends have set the stage for the development of even less invasive methods to treat conditions in both the gut lumen and in the peritoneal cavity. It seems feasible that major intraperitoneal surgery may one day be performed without skin incisions. The natural orifices may provide the entry point for surgical interventions in the peritoneal cavity thereby avoiding abdominal wall incisions.
The NOSCAR group identified a number of baseline issues. For NOTES® to mature into a viable technology, both procedure and device development must continue. At this stage, NOTES® must be performed by a team that has the skills of an advanced therapeutic endoscopist and a laparoscopic surgeon who in many instances will bring unique but complementary skills. There are a number of other fundamental issues, many of which are identified in the white papers which may be accessed via www.NOSCAR.org – the group’s official web site. These issues must be understood prior to the safe introduction of NOTES®. These are best addressed in laboratory settings. Having supportive laboratory data is an essential step prior to approval from regulatory agencies like the FDA or Institutional Review Board for performing initial NOTES. The most important areas for initial study are: safe peritoneal access and secure gastric closure, intraperitoneal contamination, image display and maintenance of spatial orientation, development of stable working platforms, physiologic perturbations, and tissue approximation methods (suturing and others).
The Society of American Gastrointestinal and Endoscopic Surgeons (SAGES) was founded in 1981 to foster, promote, support and encourage academic, clinical and research achievement in gastrointestinal endoscopic surgery. Our members are general and colorectal surgeons who perform endoscopy and laparoscopy as part of their practice as well as surgical resident, fellows, and other allied health personnel. The Society has grown from fewer than 50 original members to more than 6,500 from every state and over 80 countries. Visit www.sages.org for more information.
The American Society for Gastrointestinal Endoscopy (ASGE), founded in 1941, is the preeminent professional organization dedicated to advancing the practice of endoscopy. ASGE, with more than 14,000 physician members worldwide, promotes the highest standards for endoscopic training and practice, fosters endoscopic research, recognizes distinguished contributions to endoscopy, and is the foremost resource for endoscopic education. Visit www.asge.org and www.screen4coloncancer.org for more information.
About Ethicon Endo-Surgery
Ethicon Endo-Surgery, Inc. develops and markets advanced medical devices for minimally invasive and open surgical procedures. The company focuses on procedure-enabling devices for the interventional diagnosis and treatment of conditions in general and bariatric surgery, as well as gastrointestinal health, gynecology and surgical oncology. More information on the company can be found at www.ethiconendo.com.
Looking back …
Since its inception in July 2005, ASGE and SAGES have worked collaboratively to further the development of the NOSCAR/NOTES initiative. To date, working groups were established, a NOTES® conference was conducted and summaries were constructed to help identify the next steps. Above all, we’ve promised ongoing communication regarding the NOTES/NOSCAR initiative.
Through working group activities and the March 2006 NOTES® Conference in Scottsdale, Ariz., critical areas for further NOTES® development have been identified as well as the need for continued research. Two white papers have been published, a web site has been developed (www.noscar.org) and a joint committee has been appointed to further the work already begun.
The ASGE/SAGES NOSCAR Joint Committee (see sidebar) has begun its work and additional goals and outcomes will be identified this fall. Further information on research initiatives as well as state-of-the-science updates will be developed as part of the committee’s charge.
The Joint Committee conducted its first meeting via conference call in early August. We identified the purpose of the committee (see sidebar below) and discussed short-term and long-term goals. One of the short-term goals was to identify three subcommittees that will address critical issues including 1) outlining research grant guidelines and requests, 2) program content for the next NOTES® Conference, and 3) development of a registry of NOTES® research. Each of these areas will be assessed, explored and developed by their respective subcommittees and outcomes established. The subcommittees will be meeting this fall to take action in each of these areas.
The group discussed conducting the next NOTES® Conference and determined that the best time to hold this event will be summer 2007. By that time, additional research will take place and new developments in the device and technique arenas will occur. There will be a great deal of new information to share and absorb. As soon as we have identified a date and location, we’ll make an announcement.
Another component the Joint Committee addressed was the use of the NOSCAR web site to communicate information, collect research grant requests and maintain a registry of research to date. More details on how this site will expand in the coming months will be forwarded to you as developments occur.
Stay tuned …
The NOSCAR initiative and the Joint Committee are moving at a rapid pace; we want to share accurate, timely information as quickly as we’re able. Please visit www.noscar.org regularly to be sure you’re getting the most current updates. Of course, if you have specific inquiries or would like to be removed from future communications, please contact us at [email protected].
Thank you for being a part of this important movement.
Purpose of Joint Committee…
Overall charge: Nurture NOTES® in a responsible manner
1. Set standards
– human application
2. Promote/guide research
– raise/distribute money
3. Organize NOTES® practitioners
– annual meeting
– maintain website
4. Record development results
– create repository for research
– create database for patient