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Natural orifice translumenal endoscopic surgery - NOTES in Japan

NOTES (Natural orifice transluminal endoscopy, or Natural orifice translumenal endoscopy) is a central focus of the recent clinical researches. Using the endoscope passing through the natural orifice (mouth, urethra, anus, etc), NOTES eliminates the external incisions to treat cancers or diseases in stomach, esophagus, vagina, bladder, or colon, etc. Thus, NOTES achives a set of goals deemed a paradigm shift:

  • Scarless abdominal operations
  • Faster recovery
  • Shorter Hospital Stays
  • Avoidance of transabodominal wound infections

Clinical Application

Recently, NOTES is reported to have various applications such as: 

  • Abdominal Cavity Screening
  • Liver Biopsy (Screening)
  • Appendectomy (Digestive system surgical procedure)
  • Cholecystectomy (Biliary Tract)
  • Tubal Ligation (Gynecologic surgical procedure)
  • Ovariectomy (Endocrine, Urogential, Gynecologic surgical procedure)
  • Cholecystoenterostomy

The first clinical application is reportedly operated by N. Reddy in India, but the cases were never documented as the research paper. In 2007, transvaginal NOTES were, at the first time, formally operated by M. Bessler (US team), LL. Swan (US team), and J. Marescaux (French team).

NOTES Pathway

  1. Transesophageal
  2. Transgastric
  3. Transcolonic / Transrectal
  4. Transvaginal
  5. Transvesical

Categories of pathways are listed above. Researchers figure out that colon or vagina routes are more appropriate than others.

Japan NOTES research group

Along with SAGES (Society of American Gastrointestinal and Endscopic Surgeons), ASGE (American Society of Gastrointestinal Endoscopy), and NOSCAR (Natural Orifice Surgery Confortium for Assessment and Research), Japan launched the JWNOTES (Japan Working group for NOTES) in 2007. Since then, several clinical applications are reported in research papers and clinical cases are increasing.

Further Reading

1) 池田圭一・他：NOTES(Natural Orifice Translumenal Endoscopic Surgery)の最前線．臨牀消化器内科,22:1521-1525,2007

2) 安田一弘・他：世界におけるNOTES (Natural Orifice Translumenal Endoscopic Surgery)研究の現況．日本内視鏡外科学会雑誌,12:473-479,2007
3) Kalloo AN, Singh VK, Jagannath SB, et al.: Flexible transgastric peritoneoscopy: a novel approach to diagnostic and therapeutic interventions in the peritoneal cavity. Gastrointest Endosc. 60:114-7, 2004.
4) Park PO, Bergstrom M, Ikeda K, Fritscher-Ravens A, Swain P. Experimental studies of transgastric gallbladder surgery: cholecystectomy and cholecystogastric anastomosis (videos). Gastrointest Endosc. 61: 601-6, 2005.
5) Bergstrom M, Ikeda K, Swain P, Park PO. Transgastric anastomosis by using flexible endoscopy in a porcine model (with video). Gastrointest Endosc. 63: 307-12, 2006.
6) Ikeda K, et al.: Endoscopic full-thickness resection with sutured closure in a porcine model. Gastrointest Endosc ,62: 122-129, 2005.
7) Sumiyama K, et al.: Transgastric cholecystectomy: transgastric accessibility to the gallbladder improved with the SEMF method and a novel multibending therapeutic endoscope. Gastrointes Endosc ,65: 1028-1034, 2007.
8) Sumiyama K, et al.: Transeshophageal mediastinoscopy by submucosal endoscopy with mucosal flap safety valve technique. Gastrointest Endosc, 65: 679-683, 2007.
9) M. H. Whiteford, et al. Feasibility of radical sigmoid colectomy performed as natural orifice translumenal endoscopic surgery (NOTES) using transanal endoscopic microsurgery. Surg Endosc. 21:1870-4, 2007
10) Y. Mintz, et al.: Dual-lumen natural orifice translumenal endoscopic surgery (NOTES): a new method for performing a safe anastomosis. Surg Endosc. 22:348-51, 2008
11) Jeffrey W. Hazey, et al.: Natural-orifice transgastric endoscopic peritoneoscopy in humans: Initial clinical trial. Surgical Endoscopy. 22;16-20, 2008
12) Jeffrey M. Marks, et al.: PEG “Rescue” a practical NOTES technique. Surg Endosc. 21:816-9, 2007
13) Marescaux J, et al.: Surgery without scars: report of transluminal cholecystectomy in a human being. Arch Surg. 142: 823-6, 2007.
14) R.Zorron, et al.: NOTES transvaginal cholecystectomy: preliminary clinical application. Surgical Endosocpy. 22:542-7, 2008
15) Buess G, Frimberger E. The dirty way to the gallbladder. Endoscopy, 39: 893-4. 2007.
16) Ikeda K, et al.: Endoscopic full-thickness resection: circumferential cutting method. Gastrointest Endosc, 64: 82-89, 2006.
17) ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery White Paper October 2005. Gastrointest Endosc. 63: 199-203, 2006.
18) ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery White Paper October 2005. Surg Endosc. 20:329-33, 2006


 

International Hospital Ranking

Cancer Adoptive Cell Immunotherapy in Japan

Cell based Immunotherapy (Autologous immune enhancement therapy) has been more frequently practised in Japan.Techniques to harvest the cells are extremely intricate and delicate processes. For the treatments to be rountinely available to the cancer patients apart from the clinical trials, advanced engineering cell reprocessing center must be available with good corroboration with the hospitals.

Since Japan made the Immuno-Cell Therapy to be a part of health care systems, the cell processing centers (CPCs) rapidly increased in the past decades. For the therapy of high complexity such as dendritic cell / autologous enhancement immunotherapy to be regularly practiced in the hospital, those CPCs were essential, and this explains why much of innovations in cell based cancer immunotherapy took place in Japan. 

Endoscopic Submucosal Dissection (ESD) \ Endoscopic Mucosal Resection (EMR) in Japan

Both EMR and ESD was originally developed in Japan. EMR / ESD (endoscopic biopsy or polyp resection procedure on gastrointestinal tract) is the area that Japanese surgeons are leading the research at forefront. It is the minimally invasive endoscopic procedure that conserves organs / tissues, and patients can be discharged from the hospital in the same day or a week after the operations. It is usually applicable to early stage cancer / tumor, and improves the post-surgical health conditions such as loss of appetite, fever, chills, pains and life-long medication.

Proton Beam Therapy

Currently there are about 31 proton (or carbon ion) therapy facilities in the world, 8 of which is built in Japan. Proton Beam Therapy is much less invasive than other radiotherapy treatments, and can treat the cancer without incision of the body, and with much less side effects than X-ray treatments. Japan has invested in Proton beam therapy (PBT) / Carbon Ion Therapy infrastructure for a long time, and clinical level studies are numerous and thus well experienced with all kinds of localized tumors.

Radiofrequency Ablation (RFA) on Liver cancer (Hepatocellular carcinoma)

Japan has been leading the RFA intervention technology for a long time, and the yearly number of RFA interventions in Japan currently exceeds that of United States and China. (See the Table below.) Survival rates for the patients undergoing the RFA are not different from those of surgery. But the surgery is harder to be operated multiple times, whereas the RFA is not restricted by the number of interventions or by the presence of Hepatitis.  For this reason, RFA becomes a standard treatment in Japan.

Yearly volume of RFA on Liver Cancer
Japan 34,000
US 14,000
China 9,500

Table: Yearly number of Radiofrequency ablation of Liver or hepatic tumors by country.

Regenerative Medicine on Dilated Cardiomyopathy, or Myocardial Infarction

Recent technological advances in cell sheets engineering extended to the pre-clinical trial of the treatment of heart disease patients often in need for the heart transplant.

Micro-Catheter treatments on varicose veins (including the veins below the knee)

In japan, complex operations towards varicose veins below the knee are established with safey and high response rates. Various catheter and micro-catheter devices are extensively used, and some of them are only available in Japan.

Cancer and Heart Disease Treatment in Japan  

Medical technology in Japan for cancer screening and gastrointestinal diseases are known to be very strong, supported by good clinical statistics, i.e., high five year survival rate after the surgery (or radiology / chemotherapy) among the colon, rectal, stomach, and esophageal cancer patients as well as liver, lung, and larynx cancer (See Table below). 

Since Japanese health agency is notoriously slow and counter-productive when it comes to the approval of new drugs, Japan's hospitals and patients suffered for so long by the technology lag from the rest of the world. Ironically, these regulatory problems lead physicians to the innovations in the fields other than drug discoveries, i.e., in the surgical / laparoscopic, endoscopic, micro-catheter procedures, cell based immunotherapy / vaccinations, radiation (carbon ion and proton beam), and regenerative medicine (iPS cells, cell sheets).

Since the Japanese physicians had less options in chemotherapy, they had more opportunities in experiencing difficult surgeries, and tried the new treatments due to the low availability of new drugs. Thus, many exotic and unique medical technologies emerged out of the isolations casued by the incompetence of Japanese health agency.

Site (Survival Rate:  %)

7 Cancer Registrates in Japan

 US SEER Program Eurocare-3
Esophagus 25 14 10
Stomach 58 22 23
Colon 66 62 51
Rectum 63 63 48
Liver 17 7 7
Gallbladder 18 16 12
Pancreas 6 4 4
Larynx 77 65 62
Lung, bronchus 20 15 11