A novel technique at Rambam Health Care Campus (RHCC) enables patients to undergo a brief and elegant outpatient procedure for draining large pancreatic cysts.  This short, minimally-invasive operation (with a long name), replaces the traditional surgical approach, saving time and costs.  Above all, it shields patients from risk and discomfort. Faster, simpler and safer than conventional methods, endoscopic-ultrasound-guided cystogastrostomy is part of the new movement to maximize patient care by using Natural Orifices for Trans-Endoscopic Surgical (NOTES) procedures.
 
Thirty minutes. That’s the amount of time needed to perform an operation to drain large pancreatic cysts using an innovative method carried out for the first time last week at Rambam Healthcare Campus. For two years, a 55-year old woman from Northern Israel suffered from severe upper abdominal pains due a pancreatic cyst which pressed against her stomach and other adjacent organs. The cysts, with a diameter of over 8 cm (the size of an orange) caused pain, and resulted in difficulty eating by causing a sense of early satiety, all this and additional discomforts.

Until now, the treatment for this problem involved a highly invasive operation to get to the rear part of the abdomen. While doctors at Rambam possess great experience in performing procedures of this sort, the operation involves at least a week of hospitalization, four to six more weeks for recovery, and a number of major risks.  The new procedure, “endoscopic-ultra-sound (EUS)-guided cystogastrostomy” is shorter and has many advantages.

While the patient is under moderate sedation, the doctor passes the EUS tube through the mouth and into the stomach. The EUS allows imaging of the cyst through the stomach. Most significantly, it allows the physician to choose an operation site through which no blood vessels pass, thus minimizing bleeding. After choosing the site, the doctor creates a small hole in the stomach, through which he places a miniature device (stent). This stent drains liquid contents from the pancreatic cyst and into the stomach. Liquid draining from the cyst harmlessly spills into the stomach and is eliminated from the body naturally. The procedure takes about half an hour and the patient is released from the hospital the same day. Within three months, the cyst disappears altogether.

This procedure has been performed in select centers around the world for two years. It was first conducted in Israel at the international endoscopy workshop held every two years at Rambam. The Institute of Gastroenterology at Rambam, led by Prof. Rami Eliakim, is the only place in Northern Israel, and one of the few places worldwide, where this operation is performed.

According to Senior Physician at the Institute of Gastroenterology, Dr. Jesse (Yishai) Lachter, who performed the operation, pancreatic cysts are a common phenomenon.  For the more typical small cysts that do not require surgical stents, Dr. Lachter has published his experience of using EUS to guide puncturing and draining of over one hundred small pancreatic cysts of varying origins. “There are different reasons why very large cysts may develop; most commonly they are the result of pancreatitis caused by gallstones. In many cases, the body does not heal itself completely and does not re-absorb the cyst, which develops until an operation is needed,” said Dr. Lachter.

“The medical community is witnessing a trend of technological advancement that enables operations that do not require the use of scalpels on the abdominal wall,” said Dr Lachter. “This innovative operation is one example of how the body’s natural openings can be used in a way that leaves no scars, and is accompanied by reduced pain and faster recovery.  The medical equipment needed for this operation already existed at Rambam, and now we have the expertise as well. I hope in the coming years this procedure will enter more and more hospitals in Israel.”

During the operation, Dr Lachter, who serves as head of the EUS service at Rambam, was accompanied by  Dr Alain Suissa, director of the invasive gastroenterology unit; Hannah Rauchfleisch, nurse at the Institute of Gastroenterology; and Aviva Valenci, x-ray technician.  The operation was conducted with great success, and after the procedure, the patient felt well, and suffered no pain.  In light of this initial success, Rambam will continue to employ this innovative technique in procedures for draining pancreatic cysts.