A Note on NOTES

I write this from the Case Medical Center in Cleveland, Ohio. I write at the conclusion of the first day of the 1st International Summit on … um … er …

Some of it is clear. For example, we are talking about NOTES: Natural Orifice Translumenal Encoscopic Surgery. You know, the kind in which the surgeon removes your kidney through your vagina. You perhaps did not know that the vagina opened naturally to the kidney. Happily there are surgeons who do.

Some of the terminology of the day was a bit muddier. That part had to do with SAS, which has nothing to do with Her Majesty’s Special Air Services. Rather, this form of slicing and dicing has to do with Single Access Surgery. Also known as SPA: Single Port Access. And many other things to be partly sorted out in the upcoming symposium of NO SCAR: Natural Orifice Surgery Consortium for Assessment and Research. Yep, this brand new field of surgery has a brand new symposium. And new types of proposed advertising, as perhaps a Nascar NOSCAR car. This is one inventive bunch!

I have not ever been to a symposium attended by gynecologists, general surgeons, pediatric surgeons, and urologists. In this there was some excitement, especially when, as a prostate cancer surgeon unaccustomed to such a medley of specialists, I was unceremoniously advised to remember that “the vagina is your friend.” Yeah, right! Try doing a prostatectomy through a vagina and surely you’ll get on the evening news.

Giggles aside, what we saw was that we surgical specialists have a lot in common. Sure there is some rivalry: urologists claim the first endoscopy (cystoscopy) and gynecologists claim the first laparoscopy and surgeons get credit for brilliant clinical synthesis (“never let skin get between you and diagnosis”). But overall we’re cut from the same cloth.

There was a lot of energy. Young Turks showed off new gadgets and inventiveness. There was a particularly strange video of a surgeon removing a stomach through a mouth. That aside, nobody could answer some key questions:

(1) What is all the hoopla about?
(2) What are the benefits to patients?
(3) How will we generate data to substantiate integration at the bedside?
(4) How much would development cost?
(5) Will anybody pay for application?

Rumors swirled of NOTES cholecystectomy (gall bladder removal through the mouth) cases who bled to death. Jeff Ponsky, a senior surgeon, suggested that some colleagues had learned from laparoscopic cholecystectomy and improved open cholecystectomy to a point at which the clinical differences are less distinct (a similar trend is referenced with prostate cancer surgery, by the way). Michel Gagner, a general surgeon who was involved in Operation Lindbergh, the first trans-Atlantic laparoscopic cholecystectomy, said that the original randomized trials showed that lap and open cholecystectomy showed no difference to patient outcome. Slowly some doses of moderation were voiced.

A gynecologist appealed to learn from urologists, who she believes have more recent experience in the integration of minimally invasive technology. On that point, there are perhaps two items of interest:

A paper at this year’s AUA meeting presents a systematic literature review that found that a lot of the minimally invasive surgery literature is of “poor methodological quality”; as an example, it cites the paucity of randomized comparisons of techniques and devices. Another group presented evidence that in some cases new techonology can be associated with patients who are more regretful and less satisfied with treatment decisions. It is not a given that our hopes as patients and scientists will be realized. Proving that technology is good for patients is thus an ongoing and inescapable inventor’s burden.

As we watch the inevitable evolution of technology, we might want to remember that the cost of being wrong is exacted in patient life and limb. No matter the gadgeteer’s excitement, there will be no substitute for standardized jargon and properly designed prospective clinical trials to demonstrate that all the effort is actually worth something to patients.

For men and women exposed to the new energy and jargon, there is no easy way to know what is good and what is best. The key, as always, is to find a surgeon (or indeed any physician) who knows what he’s doing and who cares about YOU!

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