title: Laparoscopic-assisted transgastric endoscopy: current indications and future implications.
abstract: BACKGROUND
  Endoscopic access to the proximal gastrointestinal tract may prove difficult for a variety of anatomic reasons. Under laparoscopic visualization, trocars can be placed into the stomach with the subsequent introduction of a flexible endoscope directly into the body of the stomach. The purpose of this study was to describe this technique and demonstrate that it is safe, effective, and feasible.
  
  
  METHODS
  Six patients with altered proximal foregut anatomy were examined. Five patients had previously undergone laparoscopic Roux-Y gastric bypass, and one patient had severe distal esophageal stenosis precluding distal passage of an endoscope. All patients required endoscopic retrograde cholangiopancreatography (ERCP), and one patient underwent closure of a symptomatic gastrogastric fistula. In each patient, two 5-mm ports were inserted and tacking sutures placed between the gastric body and the anterior abdominal wall. Subsequently, a flexible endoscope was inserted into the stomach through a gastrotomy under direct visualization. Picture-in-picture technology enabled simultaneous monitoring of the laparoscopic and endoscopic field.
  
  
  RESULTS
  The operative time ranged from 64 minutes to 93 minutes. All therapeutic endoscopic procedures were successful. The anterior gastrotomies were either closed primarily or a feeding tube was placed. Patients reported minimal postoperative pain. No complications resulted from the procedures.
  
  
  CONCLUSIONS
  In an age where surgeons and gastroenterologists are focusing on the stomach as an access point for transgastric endoscopic surgery, we view the stomach as a portal into the gastrointestinal tract. In patients with limited access for traditional endoluminal therapy, laparoscopic-assisted transgastric endoscopy can be performed safely and efficiently.
authors.affiliation: Yale University School of Medicine, Department of Surgery, New Haven, Connecticut 06510, USA.
authors.forename: Kurt E
authors.initials: KE
authors.lastname: Roberts
authors.forename: Lucian
authors.initials: L
authors.lastname: Panait
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Duffy
authors.forename: Priya A
authors.initials: PA
authors.lastname: Jamidar
authors.forename: Robert L
authors.initials: RL
authors.lastname: Bell
mesh_terms: D002760:Cholangiopancreatography, Endoscopic Retrograde; D019723:Endoscopes; D016099:Endoscopy, Gastrointestinal / Q000379:methods*; D004867:Equipment Design; D005260:Female; D006801:Humans; D010535:Laparoscopy / Q000379:methods*; D008875:Middle Aged; D016717:Sphincterotomy, Endoscopic; D013536:Suture Techniques