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Surgery with No Incision: Baystate Was a Pioneer

March 31, 2017

In 2005, surgeons from Hyderabad, India shocked the world with their video of an appendix being removed from a patient’s mouth. They performed the operation using a standard endoscope to enter the abdominal cavity via the stomach. Thus was born a new type of surgery called NOTES—natural orifice translumenal endoscopic surgery.

Less than three years later, Baystate doctors performed their own groundbreaking NOTES surgery, and they are still on the cutting edge of incisionless surgery.

Baystate Becomes a Leader in the New NOTES Field

In 2008, Drs. John Romanelli and David Desilets were confronted with a clinically unstable ICU patient who was not improving despite having an endoscopic procedure to drain his infected pancreatic pseudocyst.

The patient needed an operation called a cystogastrostomy to drain the cyst into the stomach where gastric acid helps to digest the infected debris. Previously, this had only been performed open or laparoscopically, but this patient was too sick for either of these procedures.

Romanelli and Desilets successfully performed the procedure through the patient's mouth—the first surgery of its type performed anywhere in the world.

From the Laboratory Bench to the Patient’s Bedside

Romanelli, from the Department of Surgery, and Desilets, from the Division of Gastroenterology, were ready for the challenge because they and their team had been collaborating since 2006 to research surgical techniques using an endoscope via natural orifices.

The lessons they learned from their early experiments on how to overcome the limitations of only one “incision” and using basic endoscopic tools to perform surgical maneuvers allowed them to develop a technique to perform a cystogastrostomy orally.

They were able to apply lessons learned in the research lab to benefit this critically ill patient—who was discharged within 14 days and recovered completely.

Still on the Cutting Edge of Incisionless Surgery

When reports emerged of a technique to remove a gallbladder through the vagina, the Baystate team again turned to the lab to hone their technique. They have now performed 20 transvaginal cholecystectomies with no major complications.

Some of these procedures were part of the first multicenter trial comparing the technique to standard laparoscopic cholecystectomy. The trial, which will be published later this year, showed that transvaginal cholecystectomy was not inferior to laparoscopic cholecystectomy.

More recently, Baystate's expertise in a new operation called POEM (peroral endoscopic myotomy) has made it a regional referral center for the treatment of achalasia, a disease of the smooth muscle of the esophagus that prevents contractions and makes it difficult to swallow food or liquids.

After learning the POEM technique directly from its creator in Yokohama, Japan, the Baystate team has performed 61 POEM procedures—the largest series in New England.

Collaboration Leads to Patient Care Breakthroughs

This collaborative work reinforces the importance of research in improving patient care. Further, it demonstrates that physicians from different disciplines can work most effectively when they collaborate to deliver disease-focused care in novel ways.

“To us, this represents the future of healthcare delivery,” said Dr. Romanelli.