NOTES(®) stapled cystgastrostomy: a novel approach for surgical management of pancreatic pseudocysts
BACKGROUND: Traditional approach for surgical management of mature pancreatic pseudocysts is by internal surgical drainage. Endoscopic drainage procedures have also been described. We describe Natural Orifice Translumenal Endoscopic Surgery (NOTES(Â®)) stapled cystgastrostomy as a less invasive surgical procedure. STUDY DESIGN: Case series. METHODS: NOTES(Â®) cystgastrostomy was performed in six patients with mature pseudocysts from June 2007 to July 2009 under institutional review board (IRB) protocol. The size of the pseudocysts varied from 8 to 23Â cm, and all of the pseudocysts were considered complex pseudocysts. The operative team included two general surgeons and a gastroenterologist. The procedure included endoscopic ultrasound (EUS)-guided puncture of the stomach just below the gastroesophageal (GE) junction to gain access to the pseudocyst, guidewire placement, and then dilatation with a balloon to 18-20Â mm. Endoscopic necrosectomy and debridement were performed when possible, followed by transoral surgical anastomosis under endoscopic visualization with the SurgAssistâ„¢ SLC 55 (Power Medical Interventions, Langhorne, PA) 4.8-mm stapler. Anastomotic length varied from 5.5 to 8Â cm. In one patient, diagnostic laparoscopy was performed after the procedure due to inadvertent pneumoperitoneum; no leak or perforation was identified. RESULTS: Length of stay varied between 2 and 14Â days. All patients had routine esophagogastroduodenoscopy (EGD) at 1 and 6Â weeks postoperatively to evaluate patency; computed tomography (CT) scan was done at 2-3Â months to demonstrate resolution of the pseudocyst. All patients had significant decrease in pseudocyst size with patent anastomosis on postoperative EGD, although one patient required endoscopic anastomotic dilatation due to continued symptoms 6Â weeks after the operation. Her pseudocyst completely resolved 4Â months postoperatively. An additional patient required subsequent distal pancreatectomy due to recurrent symptoms of chronic pancreatitis. CONCLUSION: NOTES(Â®) cystgastrostomy is comparable to previously described surgical approaches, yet is as minimally invasive as endoscopic drainage procedures previously described for management of pseudocysts. It is less invasive than laparoscopic or open cystgastrostomy, yet provides definitive treatment.
Pallapothu R, Earle DB, Desilets DJ, Romanelli JR. NOTES(®) stapled cystgastrostomy: a novel approach for surgical management of pancreatic pseudocysts Surg Endosc 2011 Mar;25(3):883-9.