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Patient attitudes and expectations regarding natural orifice translumenal endoscopic surgery

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Abstract

Background

Natural orifice translumenal endoscopic surgery (NOTES) has theoretical patient advantages. Because public attitude toward NOTES will influence its adoption, this study aimed to assess patients’ opinions regarding the NOTES procedure.

Methods

For this study, 192 patients were surveyed. Both NOTES and laparoscopic surgery (LS) are described together with an example case. Presurgical patients rated the importance of various aspects of surgical procedures and their preference for cholecystectomy via NOTES or LS.

Results

Complication risks, recovery time, and postoperative pain were considered more important than cosmesis, cost, length of hospital stay, or anesthesia type (p < 0.001). In the self-reports, 56% of the respondents preferred NOTES for their cholecystectomy and 44% chose LS. The patients perceived NOTES as having less pain, cost, risk of complications, and recovery time but requiring more surgical skill than open surgery or LS (p < 0.04). College-educated patients were more likely to choose NOTES, whereas patients 70 years of age or older and those who had undergone previous flexible endoscopy were less likely to select NOTES (p < 0.04). Although 80% of the patients choosing NOTES still preferred it even if it carried a slightly greater risk than LS, their willingness to choose NOTES decreased as complications, cost, and hospital distance increased and as surgeon experience decreased (p < 0.001). This study had a limitation in that the survey population was from surgery clinics.

Conclusion

A majority of the patients surveyed (56%) would choose NOTES for their cholecystectomy. The deciding characteristics of the patients were more education, youth, and no previous flexible endoscopy. Procedure-related risks, pain, and recovery time were more important than cosmesis, cost, length of hospital stay, and anesthesia type in the choice of a surgical approach. Patients were less willing to accept NOTES as risks and costs increased and as surgeon experience and availability decreased.

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Correspondence to Lee L. Swanstrom.

Appendix 1: the survey tool

Appendix 1: the survey tool

Background

Age:

Sex:

Education:

Employment:

Have you had surgery before?

Flexible endoscopy (e.g., colonoscopy or upper endoscopy):

Outpatient minor surgery (e.g., tonsils, plastic surgery):

Open surgery (e.g., appendectomy, lung surgery, heart surgery, abdominal surgery):

Laparoscopic surgery (e.g., tubal ligation, gallbladder surgery):

Had you heard about laparoscopic surgery before this study?

Had you heard about natural orifice translumenal endoscopic surgery (NOTES) type surgeries?

General attitudes:

When having a surgery what aspects of the procedure approach are most important?

  • Cost of the procedure

  • Complication risk

  • Length of hospital stay

  • Type of anesthesia (sedation vs general)

  • Cosmetic result

  • Amount of pain after surgery

  • Time required for return to full activity levels

Based on the preceding description or on your own knowledge and understanding of the surgical options mentioned in the preceding scenario, please grade each option compared with an old-fashioned “open” surgery using 0 (no, none, nothing) to 5 (severe, maximum, high)

 

Open (traditional) surgery

Laparoscopic (“keyhole”) surgery

NOTES (flexible endoscopic surgery)

Amount of pain after surgery

   

Cost of the procedure

   

Risk of having a complication (e.g., infection, organ injury, blood clot)

   

Length of recovery (time until return to work or normal activities)

   

Degree of skill needed by your surgeon to perform the procedure

   

If your surgeon was very experienced in one of the procedures but new to the other (yet well trained and fully credentialed in it), would that influence your choice?

NOTES vs. Laparoscopy:

Who do you think NOTES surgeries might be best for infants? children? working adults? the elderly? everyone?

If you were the one who needed the gallbladder surgery and your surgeon was fully qualified to perform either procedure, which would you prefer?

Laparoscopic surgery

NOTES surgery

If you choose laparoscopic surgery as your preferred approach:

Why did you choose laparoscopy?

  • NOTES is too new.

  • NOTES sounds more risky.

  • I see no advantage to NOTES over laparoscopic surgery.

  • It sounds more painful than laparosopy.

  • I don’t like the thought of something being removed from my mouth or rectum.

  • Other ____

Would you still choose NOTES as your preferred surgical approach if:

The complication rate was slightly higher (2% vs 1%)? Significantly higher (10% vs 1%)?

If you had to pay slightly more (<$100)? Significantly more ($100–$1,0000)? Had to pay out of pocket ($12,000)?

If your surgeon was fully trained but you were his first patient for the procedure? 10th?, 100th?

If you had to go to another hospital in your town? To a hospital 25 miles away? To a hospital 100 miles away? To a hospital 500 miles away?

Other reasons why you chose NOTES? ______________

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Swanstrom, L.L., Volckmann, E., Hungness, E. et al. Patient attitudes and expectations regarding natural orifice translumenal endoscopic surgery. Surg Endosc 23, 1519–1525 (2009). https://doi.org/10.1007/s00464-009-0431-5

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  • DOI: https://doi.org/10.1007/s00464-009-0431-5

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