NOTES Pancreatic Pseudocystgastrostomy: a Human NOTES Anastomosis

Introduction: Natural orifice transluminal endoscopic surgery (NOTES) is a technique where an operation is performed across the lumen of a hollow viscus without the aid of an abdominal incision. Much of the early work in NOTES has utilized a transgastric approach due to ease of endoscope passage through the mouth. Pancreatic pseudocysts have long been treated surgically with drainage into the stomach. Open and laparoscopic approaches have been employed, and endoscopic transgastric pseudocyst drainage is well-described. We report a case where we passed a computer-mediated, flexible stapler perorally under fluoroscopic and endoscopic guidance, and performed a pancreatic pseudocystgastrostomy without the aid of an abdominal incision.
Methods: The patient was a 71-year-old man who suffered from acute gallstone pancreatitis and developed a large pancreatic pseudocyst measuring greater than 30 cm in diameter. This was initially treated with percutaneous drainage. The pseudocyst was reduced to 16 cm in size, but it became infected. After unsuccessful trials of intravenous antibiotics, drainage became necessary. Using standard endoscopic technique including ultrasound, the pseudocyst was punctured and two transgastric 10-Fr stents were placed after drainage of 800cc of purulent material. Two more stents were added two weeks later for additional drainage. Ultimately, endoscopic debridement and drainage failed, leading to consideration of surgical drainage. Given the location of the cystgastrostomy near the gastroesophageal junction, the cyst was anatomically amenable to a transoral approach.
After obtaining IRB approval and informed consent, the patient was taken to the operating room. The tract between the stomach and pseudocyst was again dilated with a balloon catheter. The stents were removed, and the Power Medical® stapler was introduced into the stomach via an overtube. An endoscope was passed alongside of the stapler into the stomach. The anvil of the stapler was snared endoscopically and positioned inside the cystgastrostomy. The stapler was then closed and fired successfully. A second firing completed an 8-cm opening into the pseudocyst.
Results: The patient recovered well from the procedure and suffered no complications. He reported no postoperative pain or discomfort. His infection resolved and he was discharged to rehab 14 days after the procedure. Repeat endoscopic examination at six days showed that the cystgastrostomy was still widely patent with lysis of most necrotic debris. Repeat endoscopy at 6 weeks showed that the cyst had reduced to 2 cm in size with an opening less than 10 mm.
Conclusion: NOTES pancreatic pseudocystgastrostomy is a new approach to a well-accepted surgical procedure than can be successful in appropriate candidates. The flexible computer-mediated stapler should be considered for use in this setting.

Session: Podium Presentation

Program Number: V027

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