Asian-Chinese patient perceptions of natural orifice transluminal endoscopic surgery cholecystectomy

Women's Perception of Transgastric and Transvaginal Natural Orifice Transluminal Endoscopic Surgery (NOTES) - Impact of Medical Education, Stage of Life and Cross-Cultural Aspects

Introduction

Despite that NOTES produces at least matchable clinical long-term results when compared to laparoscopy, still a restraint within the medical community and among patients is evident. Consequently, it might be meaningful to evaluate factors of patient's NOTES perception to promote its acceptance. NOTES is still quite novel and questionnaires regarding its perception by the public is still lacking even so in the Middle East. Aim of our survey is to investigate the viewpoint of female healthcare staff on NOTES.

Materials and Methods

A total of 350 questionnaires along with written information about Minimally Invasive Surgery and NOTES were distributed among the female staff in a Tertiary-care Hospital in Abu Dhabi, 257 were returned completely anonymously and voluntarily and entered into a database with a response rate of 73%. We surveyed factors like religion, medical background, age as well as history of previous laparoscopy, endoscopy, birth and other aspects that may impact a woman's perception of both transgastric and transvaginal NOTES for cholecystectomy and ovariectomy, respectively.

Results

Univariate analyses revealed the majority of Muslim women to be more receptive to NOTES as a choice of surgical technique for cholecystectomy and for ovariectomy, respectively, when compared to Christians and Hindus. However, when compared to Muslims, Christian and Hindu groups had a larger share of medical professions. Women with a medical background would opt significantly less for NOTES. Among younger women, NOTES cholecystectomy was refused due to anxiety concerning future pregnancies and sexual dysfunction. Multinomial logistic regression analysis determined medical background and with independent predictive value for the overall choice of interventional technique (p<0.001). Marital status played a significant role only in the comparison of laparoscopy vs transgastric NOTES when performing cholecystectomy and ovariectomy (p<0.01).

Conclusion

In this first study emanating from the Middle East, medical education and partly life stage rather than cross-cultural differences seem to influence NOTES perception in women.

Which Cholecystectomy do Medical Students Prefer?

Introduction:

This study was undertaken to identify which minimally invasive technique medical students prefer for cholecystectomy and what factors determine their decision.

Methods:

Brazilian medical students watched a video reviewing the advantages and disadvantages of six different surgical approaches to cholecystectomy: open surgery, conventional laparoscopy, mini-laparoscopy (MINI), single-incision laparoscopic surgery, natural-orifice transluminal endoscopic surgery, and robotic surgery. Respondents then answered questions about hypothetical situations in which the participants would be submitted to elective cholecystectomy.

Results:

One hundred eleven medical students completed the survey, 60 females (54%) and 51 males (46%). Most students were 19–26 years old. When asked whether they would consider an open cholecystectomy if minimally invasive surgery (MIS) techniques were available, only 9% answered yes. Senior medical students were the least willing to consider open surgery (P = .036). When asked if they would prefer conventional laparoscopy, MINI, or robotic surgery for their cholecystectomy, 85% of the women and 63% of the men chose MINI (P = .025). When asked if they would consider a single-incision laparoscopic surgery or natural-orifice transluminal endoscopic surgery approach, 94 respondents (84%) answered no. When asked to rank which factors they consider the most important when choosing a surgical technique, they ranked safety of the procedure first (58%) and surgeon experience second (30%).

Conclusion:

When Brazilian medical students were asked to select a surgical approach for cholecystectomy, most chose MINI. The preference for MINI was strongest amongst female medical students. Both female and male medical students ranked safety as the most important factor.

Women’s Perception of Transvaginal Natural Orifice Transluminal Endoscopic Surgery (NOTES)

Objective. Over the past 8 years, natural orifice transluminal endoscopic surgery (NOTES) has developed from preclinical to routine clinical practice. However, there are still concerns regarding the transvaginal approach. In our survey, we were interested in females with a professional medical background, thus having at least a basic medical understanding, which might discriminate between objective and subjective concerns. Material and Methods. A questionnaire with 14 items was distributed among 1895 female physicians and nursing and administration staff of the University Medical Center Hamburg-Eppendorf. In addition, a qualitative literature review was performed. Data analysis was carried out using statistical package R version 2.15.0. Results. The questionnaire was answered anonymously by 553 employees (29%). Fifty-seven percent were nurses, 18.6% belonged to administration, and 17% were physicians. A total of 63.1% of our respondents would choose the transvaginal NOTES technique for an assumed ovariectomy, while only 30.4% would choose this access for cholecystectomy. Doubts regarding transvaginal NOTES were related to sexual dysfunction (44.8%), its experimental nature (43.8%), future pregnancies (36.8%), and ethical reasons (30.3%). The literature review showed that women’s perception of the transvaginal access is documented very heterogeneously and therefore difficult to compare. Conclusions. Despite the good reported results of NOTES and the medical background of the surveyed female employees, our study and the literature review clearly shows that there are  fears regarding the transvaginal access, which might be a result of limited information. More accurate explanation of the available methods by the attending surgeon can lead to a better choice of the patient’s preferred method.

Natural-orifice transluminal endoscopic surgery

BACKGROUND

Natural-orifice transluminal endoscopic surgery (NOTES) represents one of the most significant innovations in surgery to emerge since the advent of laparoscopy. A decade of progress with this approach has now been catalogued, and yet its clinical application remains controversial.

METHODS

A PubMed search was carried out for articles describing NOTES in both the preclinical and the clinical setting. Public perceptions and expert opinion regarding NOTES in the published literature were analysed carefully.

RESULTS

Two hundred relevant articles on NOTES were studied and the outcomes reviewed. A division between direct- and indirect-target NOTES was established. The areas with the most promising clinical application included direct-target NOTES, such as transanal total mesorectal excision and peroral endoscopic myotomy. The clinical experience with distant-target NOTES, such as for appendicectomy and cholecystectomy, showed feasibility; however, NOTES-specific morbidity was introduced and this represents an important limitation.

CONCLUSION

NOTES experimentation in the preclinical setting has increased substantially. There has also been a significant increase in the application of NOTES in humans in the past decade. Enthusiasm for NOTES should be tempered by the risk of incurring NOTES-specific morbidity. Surgeons should carefully consider patient preferences regarding this new minimally invasive option, as opinions are not unanimously supportive of NOTES. As technical limitations are overcome, the clinical application of NOTES is predicted to increase. It is paramount that, when this complex technique is performed on humans, it is applied judiciously by appropriately trained experts with outcomes recorded in a registry.

Consumer demand for surgical innovation: a systematic review of public perception of NOTES

BACKGROUND

The full scope of benefits offered by NOTES over traditional laparoscopy, if any, is not yet fully clear. Perceived patient demand for truly "scarless surgery" is often referenced one of the driving factors in the continued development of this relatively new technique. The true scale of patient preference and demand for NOTES as a surgical technique is unknown. This review aims to summarise currently available literature on the topic of patient perceptions of NOTES to guide future development of the technique.

METHODS

A comprehensive search of PubMed and Web of Science electronic databases was performed on 1st Jan 2014. To be considered for inclusion, articles were required to assess and report the perception of NOTES in a sample of laypersons (patients or general public). The primary endpoint assessed was acceptance or preference rates expressed by patients for NOTES procedures. Reasons given for preference or rejection of NOTES were recorded, as well as preferred access routes and any predicting factors of NOTES acceptance.

RESULTS

Initial search returned 1,334 results, resulting in 15 articles included in final data synthesis. These polled a total of 4,420 subjects. Acceptance of NOTES ranged between 41 and 84 %. Compared to a laparoscopic approach, preference rates for NOTES ranged from 0 to 78 %. Reasons for preferring NOTES were largely centred on potentially reduced recovery time, complications (particularly with reference to hernias) and postoperative pain. Improved cosmesis also played a role, but was secondary to the above issues. Overall, study quality was poor.

CONCLUSIONS

This review suggests significant public interest in NOTES and scarless surgery in general. Further research and consideration of differences in public perceptions across regions, countries and cultures are required.