NOTES has the potential to revolutionize the way some operations are conducted.
Surgeons from Boston and Barcelona teamed up to perform the first-ever rectal cancer surgery on a human using natural orifice surgery. During the procedure, virtually all the surgical instruments were passed through the anus minimizing painful abdominal incisions. The technique, which is called NOTES or natural orifice translumenal endoscopic surgery, involves passing a flexible endoscope as well as surgical instruments through a natural orifice, such as the anus, mouth or vagina, to the surgical site.
NOTES has been developed to reduce pain and speed up recovery time. The procedure was performed November 9 at the Hospital Clinic of Barcelona. The patient was a 76-year-old woman with rectal cancer who had received preoperative chemotherapy and radiation. The team successfully removed her tumor via her anus and she was able to return home on the fifth post-operative day with minimal pain.
“NOTES has the potential to revolutionize the way some operations are conducted,” said surgeon, David Rattner, MD, chief of Mass General’s Division of Gastrointestinal and General Surgery and a Professor of Surgery at Mass General and Harvard Medical School. “By using a natural orifice as the entry point for surgical tools and the route for removing organs that are resected, pain is avoided, potentially resulting in a faster recovery.”
The transanal (through the anus) route presents many advantages. It can be used in both men and women, unlike the transvaginal route (through the vagina). “This approach could have wide use for patients with colorectal cancer, diverticulitis, and other diseases of the colon and rectum,” said Dr. Sylla. “This pioneering intervention is just the beginning.”
An international collaboration
The surgical team consisted of Antonio de Lacy, MD, Professor of Surgery, Chief of Gastrointestinal Surgery Hospital Clinic (University of Barcelona) and Patricia Sylla, MD, Instructor of Surgery at Mass General and Harvard Medical School. Lacy and Sylla are both colorectal surgeons specializing in minimally invasive approaches to diseases of the colon and rectum. Dr. Lacy has played a pivotal role in proving the benefits of laparoscopic surgery, done through small incisions in the abdomen for the treatment of colon cancer. Since 2007, Dr. Sylla has been working to develop techniques for incisionless colorectal surgery with Dr. David Rattner at Mass General. Rattner, a leader in NOTES, is also co-founder of NOSCAR (Natural Orifice Surgery Consortium for Assessment and Research).
“We are convinced that this type of surgery will bring additional advantages to those already shown by laparoscopic surgery, reducing surgical invasiveness by eliminating abdominal incisions, and resulting in fewer postoperative complications and a speedier recovery,” explained Dr. Lacy.
During the past year, Dr. Rattner has removed several womens’ gallbladders through their vaginas. These procedures were part of a clinical trial to test the safety and effectiveness of natural orifice surgery. Their recovery was quicker than many of his patients who underwent conventional surgery.
CIMIT support of NOTES innovation
Dr. Sylla and Dr. Rattner, as part of an initiative supported by CIMIT (Center for Integration of Medicine and Innovative Technology), have been working on developing techniques for removing portions of the colon and rectum transanally in an animal model. After showing the procedure was safe and effective in swine, they next studied the technique in human cadavers. Unlike many other NOTES procedures, which make holes in healthy tissues to access the surgical site, the transanal approach is unique in that the tissue being perforated to access the area of disease is part of the organ that will ultimately be removed. CIMIT was an early supporter of this revolutionary approach to minimally invasive surgery.
The next step
NOTES represents an innovative approach to surgery. The success of this first-ever rectal cancer surgery paves the way for a new protocol. Dr. Sylla at Mass General and Dr. Lacy at The Hospital Clinic are working to establish a cross-institutional clinical trial that will focus on refining this procedure for both benign and malignant tumors of the rectum. Dr. Rattner and Dr. Syllas’ group at Mass General is also examining other potential applications of the NOTES approach.
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