Transrectal GERD treatment – just what we need?

On the face of it, the study by Wilhelm et al. on the transrectal insertion and flexible endoscopic placement of a plastic band around the gastroesophageal junction for GERD (”NOTES for the cardia: antireflux therapy via transluminal access”) [1] would seem like the essence of a very bad idea. After all, it violates many established surgical precepts: deliberate perforation of the colon with risk of fecal contamination of the peritoneum, introduction of a permanent implant through a contaminated field, placement of a fixed plastic band around the distal esophagus, etc. None the less, even though the study itself seemed to indicate that this was not a great idea, (one animal died of infectious complications, one of gastric herniation; i. e., a 25 % mortality rate) there is much to be learned from it.

In 2006 the Natural Orifice Surgery Consortium for Assessment and Research (NOSCAR) group published an outline of research questions that needed to be answered before natural orifice transluminal surgery (NOTES) could be regarded as a viable clinical modality [2]. The current study touches on several of the questions raised by NOSCAR. First, it demonstrates that the upper abdomen can be accessed from the pelvis using a flexible endoscope and that fairly sophisticated surgical maneuvers can be performed, although with presently available endoscopes laparoscopic or percutaneous assistance is required. It also demonstrated that careful abdominal access through the colon without clinical infection may be possible. Contamination of the peritoneal cavity was a major concern of the first NOSCAR white paper: it was expected that extraordinary measures would be needed to prevent clinical infections when accessing through the mouth, rectum, or vagina. This has subsequently been refuted, mainly because of the natural defense mechanism of the peritoneal cavity [3]. Clinically, infectious complications have been very rare in natural orifice surgeries no matter what approach is used [4].

Whether placement of an indwelling foreign prosthesis through the rectum (or vagina or mouth for that matter) would ever be a clinical reality though, is somewhat dubious. Surgical procedures have three classifications as to their sterility: clean, clean/contaminated, and contaminated. A NOTES case is by definition a contaminated case and surgeons do everything in their power to avoid contamination during placement of a permanent plastic prosthesis. Such infections if they do occur are major problems, frequently requiring multiple surgeries for correction. In fact, surgeons are concerned enough about contamination that trainees are educated to abort any case using plastic mesh immediately if there is even the smallest enterotomy encountered: which is certainly the case with this model.

Finally, while not the main thrust of the paper by Wilhelm and co-workers, there is the issue of using a plastic band around the gastroesophageal junction as an antireflux procedure. There is no doubt that a durable and reliable prosthetic lower esophageal sphincter (LES) would be a desirable entity – being quick, easy, and reproducible – and it has certainly been an aim in an ongoing quest by this group for many years. On the other hand, as the authors mention, the track record for such prosthetic augmentation isn’t great, as documented by the experience with the Angelchik prosthesis [5]. Related procedures with the same theme – namely the lap band and the type used in vertical banded gastroplasty – certainly have their problems and complications with stricturing, migration, and erosion that have contributed to their falling out of favor. I look forward to seeing further data regarding the outcomes of the authors’ current band variation, but would wonder whether, at least for the NOTES approach, an idea described by the senior author in 1992 of using an absorbable mesh around the gastroesophageal junction might be more suitable [6].

In the end, one has to commend the authors" pioneering spirit in exploring this improbable combination of minimally invasive procedures. They have added to the growing body of knowledge about natural orifice surgery and show the capacity of human ingenuity to create solutions ”outside the box.”

Competing interests: None

References

• 1 Wilhelm D, Meining A, Schneider A. et al . NOTES for the cardia: antireflux therapy via transluminal access.  Endoscopy. 2010;  42 1085-1091
• 2 ASGE/SAGES Working Group on Natural Orifice Translumenal Endoscopic Surgery White Paper October 2005.  Gastrointest Endosc. 2006;  63 199-203
• 3 Giday S A, Dray X, Magno P. et al . Infection during natural orifice transluminal endoscopic surgery: a randomized, controlled study in a live porcine model.  Gastrointest Endosc. 2010;  71 812-816
• 4 Narula V K, Happel L C, Volt K. et al . Transgastric endoscopic peritoneoscopy does not require decontamination of the stomach in humans.  Surg Endosc. 2009;  23 1331-1336
• 5 Stuart R C, Dawson K, Keeling P. et al . A prospective randomized trial of Angelchik prosthesis versus Nissen fundoplication.  Br J Surg. 1989;  76 86-89
• 6 Feussner H, Horvath O P, Siewert J R. Vicryl-scarf-induced scarring around esophagogastric junction as treatment of esophageal reflux disease. An experimental study in the dog.  Dig Dis Sci. 1992;  37 875-881