1. Lee L Swanstrom MD, FACS Division of GI and Minimally Invasive Surgery Legacy Health System Portland, 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. Surgery Endoscopy Open Zenkers excision Transthoracic repair esophageal perforation Esophageal exclusions Palliative esophagectomy Esophagectomy for HGD Barretts X

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

8. ASGE/SAGES Working group on Natural Orifice Translumenal Endoscopic Surgery WHITE PAPER Nnatural Oorifice Ttranslumenal Eendoscopic Ssurgery

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 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

20. Closure options Clips Sutures Others

21. Stents for perforations

22. Perforation closure Treatment 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

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

26. Enabling technologies

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

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.