Is stapling of the stomach a technique in an evolutionary dead-end? Will new endoluminal devices lower the treatment risk for obese patients? Is NOTES the treatment answer for morbidly obese patients?
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Natural orifice transluminal endoscopic surgery (NOTES) avoids the need for abdominal incisions. The technique holds promise for many common surgical procedures, including cholecystectomy, splenectomy, tubal ligation, gastric treatment for obesity and abdominal hernia repair. Access to intra-abdominal structures via the transluminal endoscopic route for surgery has the potential to eliminate complications associated with traditional surgery such as postoperative abdominal wall pain, wound infections, hernias, adhesions, and possibly impaired immune function and promises to revolutionize traditional flexible endoscopy.
This transluminal approach is particularly important for morbidly obese patients and others at high risk for standard surgery; however improved endoscopic devices are needed before NOTES becomes the prefered approach. A start-up company develops such devices for the treatment of morbid obesity using minimally invasive techniques for effectively reducing stomach volume, bypassing a portion of the stomach and small intestines and reducing nutrient absorption in the stomach and small intestines.
The devices consist of a system of components such as an artificial stoma device applied in the stomach or lower esophagus. When located in the stomach, the device reduces the flow of food into the stomach or when located in the esophagus or at the gastroesophageal junction, the device reduces the flow back from the stomach into the esophagus. The stoma is introduced transesophageally and implanted under visualization with a flexible endoscope, using sutures, staples or clips for anchoring the device to the esophageal or stomach wall. In order to create a narrow passage for installation of the stoma and for reducing the gastric volume, the stoma may be applied with gastric suturing or banding using a hybrid laparoscopic endoluminal technique. The stoma has an adjustable opening that can be changed at the time of implantation or remotely after implantation without reintervention.
The second component of the device system consists of an internal gastric sleeve. The funnel-shaped gastric sleeve works in conjunction with the artificial stoma component and has an anchoring segment for attachment to the stomach wall or close to the gastroesophageal junction. In the stomach, the lumen of the funnel reduces the volume of the stomach and the flow of solid food and in combination with the stoma, the funnel acts like a pouch in a gastric bypass or vertical banded gastroplasty.
The sleeve is designed to be porous in order to permit the flow of nutrients out through the wall of the gastric sleeve. The sleeve is flexible to allow the peristaltic motions of the stomach for the movement of food through it, while preventing duodenal mixing of Chyme with biliary secretion. A gastric balloon is another possible component of the device system for providing a feeling of satiety and for reducing nutrient intake.
By reducing the technical challenge of operating through the thick abdominal wall, the new devices and the hybrid technique have the potential to change the treatment of obese and morbidly obese patients.