NOTES® Stapled Cystgastrostomy -a Novel Approach for Surgical Management of Pancreatic Pesudocysts

Background:
Traditional approach for surgical management of mature pancreatic pseudocysts is by internal drainage by cystgastrostomy or cystjejunostomy via open or laparoscopic approaches. Endoscopic drainage procedures have been described; however, they require multiple interventions and are sometimes not definitive. We describe NOTES® (Natural Orifice Translumenal Endoscopic Surgery) stapled cystgastrostomy as a less invasive surgical procedure for mature pseudocysts.

Study Design: Case series.

Methods:
NOTES cystgastrostomy was performed in 6 patients with mature pseudocysts from June 2007 to July 2009 under IRB protocol. The size of the pseudocysts varied from 8cm- 23cm.The team included two general surgeons and a gastroenterologist. The procedure included endoscopic ultrasound-guided puncture of the stomach just below the GE junction to gain access to the pseudocyst, placement of a guide wire, and then dilatation with a balloon to 18-20mm. Endoscopic necrosectomy and debridement were performed, followed by transoral surgical anastomosis under endoscopic visualization with an endoscopic stapling device – SurgAssist™ SLC 55 (Power Medical Interventions, Langhorne, PA) green load stapler. Length of anastomosis varied from 5.5- 8cm. In one patient, diagnostic laparoscopy was performed at the time of NOTES® procedure due to inadvertent pneumoperitoneum; however, no leak or perforation was identified

Results:
Length of hospital stay was 2-3 days postoperatively for five outpatients done electively.
One patient was in ICU when the cystgastrostomy was performed and was discharged
2 weeks after the procedure. All patients had a routine EGD as per protocol at one week and six weeks after the procedure to evaluate the patency of the anastomosis, and a follow up CT scan in 2-3 months postoperatively to demonstrate the healing of the pseudocyst. All 6 patients had significant decrease in the size of the pseudocyst with a patent anastomosis in the post op EGD. One patient had a persistently large pseudocyst and required endoscopic dilatation of the cystgastrostomy due to continued symptoms six weeks after the operation.

Two patients presented back months later with recurrent pancreatitis without recurrence of the pseudocysts – one of them was found to have pancreas divisum on ERCP, for which minor papillotomy with stenting was done. He developed pancreatic ascites but was managed conservatively. The second patient had idiopathic, self-limited pancreatitis, and MRCP was negative.

Conclusion:
NOTES cystgastrostomy is comparable to endoscopic drainage procedures previously described for the management of pseudocysts. It is less invasive than laparoscopic or open cystgastrostomy, yet provides definitive treatment. However, the procedure demands significant endoscopic expertise, and long term data will be needed to postulate NOTES cystgastrostomy as the procedure of choice for the management of pancreatic pseudocysts. In addition, further refinements to the endoscopic stapler will enable the procedure to be performed in a more widespread fashion.

Session: Poster

Program Number: P236