A study in the British
Journal of Surgery says that removing an inflamed appendix via the stomach is
feasible and "promising." This is what is known as NOTES or natural orifice transluminal endoscopic
surgery.
The paper (full text
plus videos under "Supporting Information" tab) describes the first 15 cases done at the University of
Heidelberg in Germany.
There is so much wrong
with this paper and the concept in general that it is hard to know where to
start.
During the year from
April 2010 to April 2011, 111 patients were offered the chance to have this
procedure done and only 15 agreed to do so. It appears that patients have a lot
more common sense than some physicians think. The patients were carefully
selected. Those with BMIs > 30 and with perforated appendicitis were
excluded
The procedure was done
by inserting an endoscope through the mouth and then through the stomach wall, but if you read only the abstract, you would
miss the fact that a separate trocar was inserted via the umbilicus to
facilitate the operation. Therefore, it is not a pure NOTES procedure. The NOTES crowd would call this a "hybrid" procedure.
Several complications
occurred. The first case had to be converted to an open appendectomy because of
"severe inflammation." This was not explained in the paper but was
revealed in the typically uncritical MedPage Today article about it.
Two patients developed
postoperative pelvic abscesses requiring what they called "laparoscopic
revision" which is their euphemism for second operations. A second operation is very
uncommon in patients without perforated appendicitis.
In one patient, a technical
problem necessitated ligation of the stump of the appendix through the
umbilical port. Another patient had bleeding which had to be controlled by
clips. For an obese patient (curious, as only patients with BMIs < 30 were said
to have been included), the appendix had to be cut into two pieces because it
would not fit through the opening in the gastric wall.
The median duration of
the NOTES cases was 105 minutes with a range of 59 to 150 minutes. The
average time for a standard three-port laparoscopic appendectomy is about 25 to
35 minutes which means that the NOTES takes three times as long.
The median hospital stay was 3 days with a range on
1 to 8 days. The usual length of stay for a standard laparoscopic appendectomy
in the United States is < 24 hours.
The heavily edited videos are worth a look,
especially the fourth one, which shows that it takes at least 10 snips of the
tiny endoscopic scissors before the appendix is completely divided.
Because of the two patients in the series who
developed abscesses, the authors advise caution for those with purulent
appendicitis and suggest doing a standard laparoscopic appendectomy instead.
The problem is that the surgeon would not know that a patient has purulent
appendicitis until she has looked and made what would then have been an
unnecessary hole in the stomach.
Most standard laparoscopic appendectomy scars are
invisible anyway. If just one patient suffered a leak of the stomach wall
closure which would cause sepsis and other major complications, that would strongly
negate the minimal cosmetic gain from the trans-gastric operation.
The study ended two years ago but was just
published. I always wonder about that. What took so long? Was it rejected by
other journals? You would think the authors would want this sort of breakthrough
brought to light as soon as possible. Have they done more cases since then?
What were the outcomes?
After reading the paper and seeing the videos, is
there a surgeon in the world who would want a trans-gastric appendectomy
performed on herself or a loved one? An unscientific Twitter poll indicated
they would decline. One surgeon said, "Not sure
if I'd answer 'No' or 'Hell No,' and I do NOTES research."
Here's the bottom
line. Unless you have promised your patient trouble, only the most ardent
proponent of NOTES could call these results "promising".
