The New NOTES: More “E” and Less “S” Leads to Success!

In this issue, renowned natural orifice translumenal endoscopic surgery (NOTES) pioneers offer several cogent reasons for the perceived demise of “traditional NOTES” procedures, such as transvaginal cholecystectomy. We would like to add to these reasons the lack of a critical mass of operators who, while skilled in endoscopic techniques such as endoscopic submucosal dissection (ESD), also had a firm grasp of surgical anatomy and principles. NOTES flourished with the advent of per-oral endoscopic myotomy (POEM) and its offshoots, precisely because, while still requiring superior flexible endoscopic resection skills, these “New NOTES” procedures eschewed the requirement for extensive surgical expertise and the formidable surgical instrumentation demands (eg, triangulation/retraction, illumination and wide-range visualization, robust hemostasis) imposed by the ambitious surgical procedures, including organ resections envisioned by “traditional NOTES.” In this “post mortem” of traditional NOTES however, we should remember and appreciate that it is largely the vision and pioneering work of the luminaries of “traditional NOTES” that led to novel techniques (most prominently submucosal endoscopy) and devices (most prominently endoscopic suturing) that are fueling the “New NOTES” revolution. This issue focuses on this exciting rebirth of NOTES in the form of “short-range” endoscopic interventions that breech the gastrointestinal tract wall but stay close to it: interventions such as POEM, submucosal tunnel endoscopic resection (STER), endoscopic full-thickness resection (EFTR), and per-oral pyloromyotomy (POP). Whereas traditional NOTES, with its grand vision of deep incursions into the abdominal and chest cavities and major organ resections, failed to gain wide adoption, it planted the seeds for the “New NOTES” procedures, which are thriving and enjoying rapid growth. These “New NOTES” interventions are finally delivering on the great promise of NOTES, replacing traditional surgical procedures with minimally invasive, scarless ones. This issue brings together a “dream team” of New NOTES masters from Asia, Europe and the US. It features the “first-in-humans” pioneers of POEM, EFTR, STER, POP and device-assisted FTR and internationally recognized gurus of laparoendoscopic resection and ESD (the “parent techniques” of New NOTES) and endoscopic suturing (a critical enabling technology for New NOTES procedures). We hope that this issue will not only educate readers but also excite them about the great potential of this nimble and versatile NOTES that capitalizes on the strengths of the flexible endoscope to challenge laparoscopic surgery via a highly successful “target of opportunity” approach rather than the unsuccessful brute-force “frontal assault” attempted in the past by traditional NOTES.

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