Integración del endoscopio flexible en cirugía digestiva / Incorporation of the flexible endoscope in gastrointestinal surgery

El endoscopio flexible no ha figurado tradicionalmente entre el conjunto de dispositivos manejados por el cirujano digestivo. La endoscopia flexible intraoperatoria puede ser una de las técnicas que en un futuro no lejano estén disponibles en el quirófano de manera habitual. Al analizar el desarrollo de la cirugía mínimamente invasiva y de la endoscopia flexible, nos damos cuenta de cómo estamos convergiendo y de cómo podemos ir cediendo terreno a la endoscopia digestiva por un lado y ganándolo, con el endoscopio flexible, por otro. El desarrollo de las técnicas «híbridas» NOTES nos ha enseñado a mirar como potencialmente útiles en el quirófano equipos que no son habituales en nuestro entorno. La endoscopia flexible es probablemente la técnica que ofrece mayor rentabilidad al incorporarse al área quirúrgica. Es necesaria la colaboración estrecha con los digestólogos endoscopistas, a la vez que vamos formando a los cirujanos en este tipo de técnicas para un futuro de especialistas «híbridos» (AU)

The flexible endoscope has not traditionally figured among the tools used by the surgeon. Intra-operative flexible endoscopy may be one of the techniques available in the operating room in the near future. On analysing the development of minimally invasive surgery and flexible endoscopy, it can be seen that they are converging and losing ground to gastrointestinal endoscopy on the one hand, and gaining it with the flexible endoscope, on the other. The technical development of «hybrid» NOTES has shown how some tools not usually available in theatre may bevery useful. Flexible endoscopy is probably the technique to enter into the surgical area that offers improved performance. Surgeons need to work closely with the gastroenterologists, while they are trained in these techniques for future «hybrid» specialists (AU)

Prospective randomized clinical trial comparing laparoscopic cholecystectomy and hybrid natural orifice transluminal endoscopic surgery (NOTES) (NCT00835250).

BACKGROUND AND STUDY AIMS: Natural orifice transluminal endoscopic surgery (NOTES) is a technique still in experimental development whose safety and effectiveness call for assessment through clinical trials. In this paper we present a three-arm, noninferiority, prospective randomized clinical trial of 1 year duration comparing the vaginal and transumbilical approaches for transluminal endoscopic surgery with the conventional laparoscopic approach for elective cholecystectomy. PATIENTS AND METHODS: Sixty female patients between the ages of 18 and 65 years who were eligible for elective cholecystectomy were randomized in a ratio of 1:1:1 to receive hybrid transvaginal NOTES (TV group), hybrid transumbilical NOTES (TU group) or conventional laparoscopy (CL group). The main study variable was parietal complications (wound infection, bleeding, and eventration). The analysis was by intention to treat, and losses were not replaced. RESULTS: Cholecystectomy was successfully performed on 94% of the patients. One patient in the TU group was reconverted to CL owing to difficulty in maneuvering the endoscope. After a minimum follow-up period of 1 year, no differences were noted in the rate of parietal complications. Postoperative pain, length of hospital stay, and time off from work were similar in the three groups. No patient developed dyspareunia. Surgical time was longer among cases in which a flexible endoscope was used (CL, 47.04 min; TV, 64.85 min; TU, 59.80 min). CONCLUSIONS: NOTES approaches using the flexible endoscope are not inferior in safety or effectiveness to conventional laparoscopy. The transumbilical approach with flexible endoscope is as effective and safe as the transvaginal approach and is a promising, single-incision approach.

[Incorporation of the flexible endoscope in gastrointestinal surgery]. / Integración del endoscopio flexible en cirugía digestiva.

The flexible endoscope has not traditionally figured among the tools used by the surgeon. Intra-operative flexible endoscopy may be one of the techniques available in the operating room in the near future. On analysing the development of minimally invasive surgery and flexible endoscopy, it can be seen that they are converging and losing ground to gastrointestinal endoscopy on the one hand, and gaining it with the flexible endoscope, on the other. The technical development of «hybrid¼ NOTES has shown how some tools not usually available in theatre may be very useful. Flexible endoscopy is probably the technique to enter into the surgical area that offers improved performance. Surgeons need to work closely with the gastroenterologists, while they are trained in these techniques for future «hybrid¼ specialists.

Estudio comparativo, prospectivo y no aleatorizado de la colecistectomía endoscópica transvaginal frente a la colecistectomía laparoscópica transparietal / Non-randomised, comparative, prospective study of transvaginal endoscopic cholecystectomy versus transparietal laparoscopic cholecystectomy

Introducción: Presentamos un estudio comparativo no aleatorizado de dos series seguidas de manera prospectiva en las que se compara la colecistectomía laparoscópica convencional con la colecistectomía transvaginal, procedimiento endoscópico transluminal híbrido, con el objetivo de valorar la seguridad clínica del procedimiento y su eficacia en la resolución de la colelitiasis. Pacientes y método: Serie clínica prospectiva no aleatorizada de 40 mujeres intervenidas por colelitiasis mediante cirugía endoscópica, 20 con abordaje laparoscópico convencional y 20 mediante abordaje endoscópico transvaginal. Se analizaron como variables la infección de herida quirúrgica, la infección urinaria, la evisceración, la eventración, la mortalidad y otras complicaciones. Resultados: Se realizó la intervención prevista en las 40 pacientes a quienes se indicó. No hubo complicaciones intraoperatorias. No hubo ningún caso de mortalidad relacionada con los procedimientos y sólo se produjo una complicación postoperatoria, infección del tracto urinario, en una paciente operada por vía transvaginal. El seguimiento medio ha sido el mismo en ambos grupos (9 meses). La estancia media fue en ambos grupos<0,8 días. La duración de la cirugía fue mayor en el grupo con abordaje transvaginal, con 69,5min de media frente a 46,2min en el grupo laparoscópico. Conclusiones: Si bien la ventaja estética es patente, en esta serie no se han encontrado diferencias en relación con problemas parietales. La duración de la cirugía transvaginal es mayor que la de la transparietal, pero los tiempos medios de ambas son aceptables. En este estudio se puede valorar la no inferioridad en eficacia y seguridad del abordaje transvaginal(AU)

Introduction: We present a non-randomised comparative study of two patients series followed up prospectively, in which convention laparoscopic cholecystectomy is compared with transvaginal cholecystectomy, a hybrid transluminal endoscopic procedure, with the objective of assessing the clinical safety of the procedures and its efficacy in the resolution of cholelithiasis. Patients and method: A non-randomised prospective clinical series of 40 female patients, operated on for cholelithiasis using endoscopic surgery, 20 with a conventional laparoscopic approach and 20 using a transvaginal endoscopic approach. Surgical wound infection, urinary infection, evisceration, eventration, mortality and other complications. Results: Scheduled operations were performed on the 40 patients as indicated. There were no complications during the operations. There was no mortality associated with the procedures and there was only one post-surgical complication, a urinary tract infection in one patient operated on by the transvaginal approach. The mean follow up was the same in both groups (9 months). The mean hospital stay was less than 0.8 days in both groups. The duration of the surgery was longer in the transvaginal approach group, with a mean of 69.5min, compared to 46.2min in the laparoscopy group. Conclusions: Although the cosmetic benefit is obvious, no differences were found as regards parietal problems in this series. The duration of the transvaginal surgery is higher than that of the transparietal, but the times of both are acceptable. In this study, the non-inferiority in the safety and efficacy of the transvaginal approach is able to be assessed(AU)

[Non-randomised, comparative, prospective study of transvaginal endoscopic cholecystectomy versus transparietal laparoscopic cholecystectomy]. / Estudio comparativo, prospectivo y no aleatorizado de la colecistectomía endoscópica transvaginal frente a la colecistectomía laparoscópica transparietal.

INTRODUCTION: We present a non-randomised comparative study of two patients series followed up prospectively, in which convention laparoscopic cholecystectomy is compared with transvaginal cholecystectomy, a hybrid transluminal endoscopic procedure, with the objective of assessing the clinical safety of the procedures and its efficacy in the resolution of cholelithiasis. PATIENTS AND METHOD: A non-randomised prospective clinical series of 40 female patients, operated on for cholelithiasis using endoscopic surgery, 20 with a conventional laparoscopic approach and 20 using a transvaginal endoscopic approach. Surgical wound infection, urinary infection, evisceration, eventration, mortality and other complications. RESULTS: Scheduled operations were performed on the 40 patients as indicated. There were no complications during the operations. There was no mortality associated with the procedures and there was only one post-surgical complication, a urinary tract infection in one patient operated on by the transvaginal approach. The mean follow up was the same in both groups (9 months). The mean hospital stay was less than 0.8 days in both groups. The duration of the surgery was longer in the transvaginal approach group, with a mean of 69.5 min, compared to 46.2 min in the laparoscopy group. CONCLUSIONS: Although the cosmetic benefit is obvious, no differences were found as regards parietal problems in this series. The duration of the transvaginal surgery is higher than that of the transparietal, but the times of both are acceptable. In this study, the non-inferiority in the safety and efficacy of the transvaginal approach is able to be assessed.