I recently
participated in the NOSCAR workshop in Chicago. NOSCAR is funded by an industry-sponsored
consortium. This is "by
invitation" annual event designed to confirm the status and elucidate key
issues and possible solutions in implementing Natural Orifice Translumenal
Endoscopic Surgery (NOTES). NOSCAR is
run by leaders from the Surgery (SAGES) and Gastroenterology (ASGE) societies,
and the participants included leaders from Europe, South America, and India,
where most clinical tests have been conducted. CIMIT is strongly represented in
NOSCAR leadership by David Rattner, MD, (MGH); Richard Rothstein, MD, (Dartmouth); and Chris
Thompson, MD, (BWH).
There was
general agreement on the overall progression of NOTES, which will move from
today's laparoscopy and endoscopy practices, with some procedures converting to
a single port laparoscopy, and then gradual adoption of NOTES. Almost all human procedures today are not
purely "natural orifice access," rather a small laparoscope is
inserted conventionally through the peritoneal wall to ensure safety. By far the most popular approach is
trans-vaginal. Now in Germany, where
they have performed hundreds of cases with minimal complications, this is
considered a viable option in the standard of care, and routinely presented as
an option to women who are candidates for gallbladder removal. Almost all of these use rigid
instruments. Much less work has been
done with flexible scopes, something we wish to support with improved
instrument tracking and guidance.
Procedures which use transgastric or transcolonic access (our MGH
colleague Pat Sylla’s work was featured during the conference) are more
challenging, but will develop over time. Trans-esophageal approaches, which offer excellent access to the mediastinum,
will lag because it is even more difficult to ensure a safe aperture and good
closure.
There was
considerable discussion of bariatric surgery (where image guidance will likely
be less important); with consensus that the only treatment that works long term
is Roux-en-Y gastric bypass. This
implies that intermediate steps, such as gastric plication, should be done so
that eventual bypass is possible.
In the working
sessions, I described the work of my group (and some others) work in the use of
pre-procedure volumetric models to support navigation and targeting of
endoscopic and laparoscopic instruments.
Assuming the summary slides aren't too tightly edited when this gets to
publication, these concepts should make it into the next series of White
Papers, which have been established as the foundations for research in the
field over the past five years.
Kirby Vosburgh, PhD
Assistant Professor, Radiology
at
Brigham and Women's Hospital
CIMIT Image Guidance Laboratory
