NOTES spin-off for the therapeutic gastroenterologist: natural orifice surgery.

Natural orifice transluminal endoscopic surgery (NOTES) has ushered in a new era in flexible endoscopy. Over the past decade, modest advances have been made in addressing the fundamental challenges of NOTES surgery including transluminal access and closure techniques, and advancement of NOTES-specific technology. Despite these encouraging initial efforts significant obstacles to widespread acceptance of NOTES as a surgical option persist. Moreover, due to the well-documented safety and efficacy of laparoscopic techniques, the question remains as to the best candidate NOTES procedure. Presently, interest has shifted from true NOTES to hybrid procedures and single incision laparoscopic surgery, due to the lure of more immediate success. Additionally, there is also a growing awareness of the potential applications of natural orifice surgery techniques to the present field of therapeutic endoscopy. Research into transluminal access and closure has born several techniques and devices that are now being explored in endoscopic procedures such as full-thickness resection, endoscopic myotomy, direct endoscopic pancreatic necrosectomy and bariatric endoscopy. Such NOTES "spin-off" procedures are expanding the armamentarium of today's therapeutic endoscopists, and a growing body of literature suggests that they will play a significant role in the evolution of therapeutic endoscopy in the future.