4. Conclusion Natural mean orifice translumenal endoscopic surgery has progressed to human populations and is evolving for certain indications. Due to practical concerns, much of the initial work has focused on elective procedures. Many NOTES surgeries have redemonstrated laparoscopic procedures which have a high degree of safety and little morbidity. More recent studies have raised the possibility that NOTES may come to offer more substantial improvements over the current standard, going beyond cosmesis and reduced pain medication usage [22]. The studies reviewed here suggest a high degree of safety and feasibility with low rates of infection. As the field progresses, rigorous, prospective, controlled studies will become more important in defining the exact benefits versus a traditional approach [73].

With greater experience in redemonstrating standard procedures, it is hoped that the field will continue to evolve, enabling novel approaches that distinguish the potential for more unique contributions. Acknowledgment This work supported by departmental funding.
Natural orifice transluminal endoscopic surgery (NOTES) has gained a great deal of attention from gastroenterologists and surgeons all over the world since its introduction in 2000 [1]. Interest in NOTES procedures within the thoracic cavity is gaining momentum [2�C7]. Transesophageal approach into the mediastinum has been successfully performed in animal and cadaveric models via endoscopic full thickness incision of the esophageal wall, submucosal endoscopy techniques or assisted by endoscopic ultrasound (EUS) [7, 8].

Transesophageal NOTES enables access into the posterior mediastinum with visualization of the descending thoracic aorta, esophagus, trachea, pleura, lung, vagus nerves, and hilar lymph nodes [9]. The excellent visualization of Carfilzomib these structures has allowed for a variety of transesophageal mediastinal NOTES interventions including mediastinal lymph node resection, vagotomy, thoracic duct ligation, thymectomy, biopsy of the lung and pleura, epicardial coagulation, saline injection into the myocardium, and pericardial fenestration [4, 5, 7]. Transesophageal NOTES is still in its infancy. However, its potential clinical applications deserve commitment from NOTES researchers to further investigate potential novel applications for transesophageal NOTES. The proximity of the esophagus to the vertebral column provides a closer and direct access to the thoracic spine and opens a new ground for multilevel anterior spine procedures using NOTES techniques. Furthermore, a NOTES approach to the spine could potentially avoid complications of conventional surgical techniques such as postsurgical neuralgia, rib resections, muscular atrophy, and trauma [10].