Advances in Pediatric Minimal Access Therapy: A Cautious Journey From Therapeutic Endoscopy to Transluminal Surgery Based on the Adult Experience

摘要

Since the introduction of laparoscopic surgery by Kelling in 1901, minimal access surgery has developed into a safe and clinically comparable alternative to open surgery of the abdomen. It brings substantial benefits to patients, both adult and pediatric, including less pain, reduced risk of local and systemic complications (eg, ventral herniation, wound infection, adhesion formation), faster recovery, and superior cosmesis (1). In recent years, therapeutic endoscopy has entered the realm of minimal access surgery, motivated by the goal of further minimizing the invasiveness of abdominal access. With the focus mainly on gastroesophageal reflux disease (GERD), several innovative endoscopic tools have been developed in the attempt to replicate 1 or more of the features of a surgical fundoplication. The Wilson-Cook Endoscopic Sew-Right suturing device, the Bard EndoCinch, and the NDO full-thickness plicator are examples of devices now in clinical use. Alternatively, procedures such as the Stretta exploit the use of energy sources, in this case radiofrequency ablation, to bolster the lower esophageal valve mechanism. Blurring the lines between endoscopy and minimal access surgery, a new surgical technique has emerged that uses the natural orifices of the body, such as the mouth, anus, and vagina, to access the peritoneal cavity and pelvis. This new paradigm, natural orifice transluminal endoscopic surgery (NOTES), is expected to further reduce the pain, scarring, and recovery time associated with intraperitoneal surgery. For any of these procedures to be adopted into mainstream clinical practice, efficacy and safety equal to that of existing surgical approaches (ie, open and laparoscopic surgery) must be demonstrated to realize the benefits of the endoscopic approach. Literature to support this is limited for the adult population and nearly absent for the pediatric population. There is a danger that conceptually exciting therapies such as NOTES may be prematurely adopted and applied to pediatric populations before sufficient experimental evidence accumulates to demonstrate their safety and efficacy. Perhaps a greater danger, however, is to prematurely discredit these therapies or ignore their existence. It is likely that future therapies will incorporate elements of minimal access endoscopic approaches, and it behooves the pediatric medical community to play an active role in their development and ethical application. This article explores the confluence of pediatric minimal access surgery and therapeutic endoscopy in a novel modality called transluminal surgery, or NOTES. The limitations of conventional pediatric minimal access surgery are briefly discussed, and existing therapeutic endoscopic procedures are reviewed. The concept of transluminal surgery, with its future directions and challenges, is introduced, and the emergence of a new type of minimal access surgical specialist is proposed. The goal is to raise awareness of these “fringe” technologies so that practitioners can understand better what the future may hold for pediatric minimal access therapy. PEDIATRICS AND MINIMAL ACCESS SURGERY Laparoscopy has gained firm ground in the adult population since the first laparoscopic cholecystectomy in 1985, and a large majority of abdominal and thoracic procedures are now routinely performed by the use of minimal access methods. Pediatric surgeons have taken a more cautious approach. They first applied laparoscopic techniques already developed in adults, such as cholecystectomy, fundoplication, and appendectomy, before proceeding to conditions unique to pediatrics such as imperforate anus, biliary atresia, and tracheoesophageal fistula. This careful approach is attributed to a reluctance to “test” novel procedures on children and to the recognition that children are in many ways unique from adults. The most obvious hurdle is that infants and children are not merely small adults to whom adult techniques can be applied. Contained wi