On the Non-cutting Edge Baystate Surgeons Achieve Breakthrough with Incisionless Procedure

Necessity is the mother of invention, the adage goes, and Eugene LaFlam was a man in need.

Thanks to what Dr. John Romanelli, director of Bariatric Surgery at Baystate Medical Center, calls “a confluence of new ideas and a taxing clinical problem,” LaFlam is feeling a lot better these days. That’s because doctors at the hospital were able to recently perform the first-ever incisionless cyst gastrostomy on a man who was deemed too weak to undergo conventional surgery.

In performing the procedure, Romanelli and Dr. David Desilets, chief of Gastroenterology, shed some light on the possibilities afforded by natural orifice translumenal endoscopic surgery, NOTES for short, a cutting-edge surgical and gastroenterological approach that involves passing flexible surgical tools and a camera through the patient’s natural orifices, such as the mouth, nose, anus, or vagina. By eliminating incisions, the technique offers the hope of surgery with less pain, less infection, and quicker recovery time.

Just ask LaFlam.

“Since they have done this procedure, boy, do I feel good,” the Vermont resident said soon after the cyst was successfully removed earlier this summer. “There are always risks when you go through an operation, but my wife and I didn’t care — we said, ‘go for it!’ I was sick of going through what I was going through. So they did the operation, and I feel great now.”

This month, The Healthcare News examines how surgeons successfully treated LaFlam — and what that might mean for countless other patients in the years to come.

Last Chance

LaFlam, 72, had been hospitalized since February with an infected pancreatic pseudocyst, likely brought about by a gallstone. He was transferred from a Vermont hospital to Baystate Medical Center, where small stents were placed through an endoscope, connecting the stomach to the cyst in order to drain it. At its peak size, Romanelli said, the cyst measured 30 centimeters in diameter. Draining it allowed physicians to collapse it to the size of a softball, but no smaller. Surgery was necessary.

Romanelli explained that a surgical procedure using abdominal incisions is typically performed in such a case, creating a large, stapled ‘link’ between the pancreatic cyst and stomach. However, in LaFlam’s case, the location of the cyst made a traditional surgical approach difficult. Meanwhile, his weakened immune system and decreased ability to heal made even laparoscopic surgery, which uses small incisions and a tiny camera, risky.

“Mr. LaFlam was a very sick guy, and he was not going to tolerate the usual surgical approach; he probably wouldn’t have survived it,” said Delilets. And doctors were up front about that bleak outlook — until they started to consider another option.

“We were told he wasn’t going to make it, and to get our family together, which we did,” said Diane LaFlam, the patient’s wife. “Then they came up with this procedure, which we wanted to do. He wasn’t well enough, so we had to wait until he was well enough, and we went ahead and did it. It saved his life.”

During the NOTES procedure, a computer-powered surgical stapler, manufactured by Pennsylvania-based Power Medical Interventions, was passed through LaFlam’s mouth and into his stomach alongside a small endoscopic camera. Using a remote-control unit, the stapler was positioned and fired, forging a connection between the cyst and the stomach and in the process creating a large pathway through which fluid could drain harmlessly from the cyst into the stomach in order to clear the infection.

LaFlam recovered quickly and had no pain or other complications, said Romanelli. In fact, after being fed intravenously for several months prior to the procedure, he began drinking clear liquids two days after the surgery. Meanwhile, his white blood count, a sign of infection, dropped significantly for the first time in more than a month, a sign that he was recovering quickly.

Romanelli recalled that LaFlam felt no different — in particular, no weaker — upon waking up from the surgery, and visibly improved from there. “He was still recovering from the illness, but in terms of recovery from the actual surgery, there was none,” he said.

Quantum Leap

Doctors have long touted the benefits of minimally invasive laparoscopic surgery. Traditional open surgery, which relies on the creation of an incision large enough to allow a direct view of the operating field and insertion of surgical instruments, was for years the most common form of surgery. However, over the past 30 years, advanced technology has led to improved visualization, access, and diagnostic capability with the use of smaller incisions.

Natural-orifice surgery, say Romanelli and Desilets, may turn out to be just as dramatic a shift, which they realized when they first encountered it at a conference two years ago. There, they saw a video of such a technique, produced by doctors in India.

“We came back from this conference eager to explore new ways of using existing surgical tools to make minimally invasive surgery even less invasive,” said Romanelli.

After seeing its first application at Baystate, he suggested that natural-orifice surgery could eventually prove as widespread as laparoscopic surgery, unheard of a generation ago, is today.

“Around the world, a few cases have been reported of procedures done through the orifices, but this is the first union of the stomach with a cyst of the pancreas,” said Dr. Richard Wait, chairman of Baystate’s Department of Surgery, adding that the procedure reflects a closer collaboration between different specialties — surgery and gastroenterology, in this case — emerging alongside advances in care and technology.

“This patient was sick for many weeks, and we had a great result,” said Wait. “It’s a good example of how people from different hospital services who are used to working independently can come together to revolutionize the care of patients.”

“In the next three to five years, the appendix might be removed through the colon or the stomach, or the gall bladder through the stomach,” Romanelli said. “Investigations are going on in labs throughout the U.S. to determine scientifically the best way to do these things.”

“The driving factor is no scars and no pain, and that’s where we’re going, in my opinion,” Desilets said. “We have no long-term data, but this kind of work needs to be done.”

At the same time, Romanelli stressed, the procedure chosen for this experimental technique was deemed to be a safe one with minimal risk. “This is a tried and true operation, only done with a different technique,” he said, conceding that the application of NOTES to more complex surgeries will require far more investigation.

Still, Baystate surgeons believe natural-orifice surgery will be the dominant mode someday.

“Fifteen years ago, surgeons would chastise you” for such a notion, said Dr. David Earle, director of Minimally Invasive Surgery at Baystate. “But we’re moving toward all of it being natural-orifice, with no incisions. People may say that’s impossible, or it may take a lot of time before other procedures will be done that way, but if we never do anything, we’ll never get there.”

And that wouldn’t be in the best interest of Eugene LaFlam.

“Initially things weren’t going so well,” Diane LaFlam said, “but when Dr. Romanelli came up with this procedure, we wanted to try. And it was the best thing that ever happened. I’m very thankful.”