I was reading about Natural Orifice Transgastric Endoscopic Surgery, aka NOTES, and I'm wondering what kind of effect this will have on general surgery and gastroenterology, once it gets fully developed. While it was a gastroenterologist (and IMG! Dr Anthony Kalloo at Hopkins) who developed the concept, general surgeons obviously have much interest in this.

I have read several case reports of pancreatic necrosectomy being done this way, usually because percutaneous drainage was not effective or tolerated by the patient, and the patient either refused or was a poor risk for open or laparoscopic debridement. You can watch cool videos of it here: Transgastric Endoscopic Necrosectomy for Walled-Off Pancreatic Necrosis « DAVE Project – Gastroenterology

The two groups who are instrumental in making NOTES progress from clinical experiments to a daily reality, gastroenterologists and general surgeons both have complementary skills.

Gastroenterologists have much more skill with flexible diagnostic and therapeutic endoscopy than do general surgeons, as GIs do hundreds in their fellowship and make a career out of it, while general surgeons don't even break 100 cases (and appear to dread it, and use that rotation for vacation and interviews) during residency, and usually never do them again.

General surgeons have an impressive understanding of anatomy and experience in laparoscopy which will be quite useful in performing NOTES. They also have more critical care experience, as the patient population for NOTES would seem to include a) those who don't want scars, and b) those who are poor surgical risks for whatever reason. Some also do endoscopy fellowships to bring themselves to the level of the gastroenterologists in endoscopy skill.

Now, the issue of complications. While general surgeons will rightly be concerned about peritonitis, bowel perforation, ileus, etc., the complications can be managed by the endoscopist in conjunction with the interventional radiologist. For example, lets say a patient develops an intra-abdominal abscess and peritonitis post-NOTES due to accidental perforation of the bowel. The interventional radiologist can perform serial percutaneous lavage with chlorhexidine gluconate to remove the pus and enteral contents, and the endoscopist can repair the bowel perforation with an omental patch or covered stent.

Now there will be some complications that can't be managed by the endoscopist, and certain general surgeons will say that gastroenterologists shouldn't be doing the procedure because of that. I have never bought this, because no-one can do everything in medicine. We're all here to help out; medicine is not a ****-swinging contest. Should they also stop doing routine screening colonoscopies because they might perforate the colon so badly that a general surgeon needs to perform a colectomy?

(As a note aside, general surgeons aren't immune to needing help, they just need it less often. And I appreciate that. As someone who hopes to go into IM or one of its subspecialties, I'm happy that the general surgeons don't need me to manage their patient's medical issues, I need to concentrate on mine)

Personally, I don't care if the doctor performing a NOTES procedure came from a general surgery background or a gastroenterology background, as long as they have a high enough volume to keep their skills up, no-one should complain. Complaining about who does what procedure based on someones background and "you can't handle every single complication that might arise," is a sign of insecurity. As long as they don't do something wildly outside of their specialty, like a urologist doing breast implants.

Since you are intentionally causing a temporary gastric perforation to perform the procedure, aseptic technique by administering preoperative IV antibiotics and lavaging the stomach with chlorhexidine gluconate to sterilize it is a must.

An advantage of NOTES is that the sterile operating field is now the GI tract, which means you no longer need a sterile OR, which means that you can now do intra-abdominal surgery anywhere, like in the office endoscopy suite or at the hospital bedside.

Another advantage is that you could do the surgery under conscious sedation, since the stomach has very few pain fibers, so intra- and postoperative pain is lessened considerably. This eliminates the risk of general anesthesia.

Maybe NOTES will become like interventional neuroradiology in that either a diagnostic neuroradiologist, vascular neurologist, or neurosurgeon can be trained in it, and each provide quality care and have their own perspective, advantages and disadvantages.

What your opinion on the subject?