title: A pilot study of laparoscopic gastric pull-up by using the natural orifice translumenal endoscopic surgery technique: a novel procedure for treating long-gap esophageal atresia (type a).
abstract: OBJECTIVE
  This study aimed to develop a novel procedure for treating long-gap pure esophageal atresia. This procedure, which entails the combined use of laparoscopy and natural orifice translumenal endoscopic surgery (NOTES), would enable primary repair without cervical and thoracic incisions and prevent postoperative gastroesophageal reflux disease (GERD).
  
  
  METHODS
  Nonsurvival experiments were conducted in 9 pigs to study the technical feasibility. The procedure comprised the following: (1) creation of the disease model by laparoscopic resection of the lower esophagus; (2) laparoscopic fundoplication, complete mobilization of the stomach, and enlargement of the esophageal hiatus; (3) formation of a peroral transesophageal entry site into either the postmediastinum or the right thoracic cavity followed by fashioning a tunnel to the peritoneal cavity; (4) gastric pull-up by using both laparoscopy and NOTES; (5) esophagoesophageal anastomosis using BraceBar™, a prototype of the double T-bar suturing device (Olympus Medical Systems Co., Tokyo, Japan).
  
  
  RESULTS
  Laparoscopic procedures were performed without complications. The postmediastinal tunnel was successfully created three times with a complication of pleural injury. However, gastric pull-up via this route could not be completed due to porcine anatomical reasons. Gastric pull-up through the right thoracic route was achieved five times in six attempts. Two disorientations and a hemorrhagic death occurred during the procedures.
  
  
  CONCLUSIONS
  This study showed that combined use of laparoscopy and NOTES enabled gastric pull-up without cervical and thoracic incisions. Our method has the potential of lowering the incidence of GERD and enabling primary repair of this disease.
authors.affiliation: Department of Pediatric Surgery, The University of Tokyo Hospital, Tokyo, Japan. i-tetsuya@umin.ac.jp
authors.forename: Tetsuya
authors.initials: T
authors.lastname: Ishimaru
authors.forename: Tadashi
authors.initials: T
authors.lastname: Iwanaka
authors.forename: Hiroshi
authors.initials: H
authors.lastname: Kawashima
authors.forename: Kan
authors.initials: K
authors.lastname: Terawaki
authors.forename: Tetsuro
authors.initials: T
authors.lastname: Kodaka
authors.forename: Kan
authors.initials: K
authors.lastname: Suzuki
authors.forename: Masataka
authors.initials: M
authors.lastname: Takahashi
mesh_terms: D000818:Animals; D004933:Esophageal Atresia / Q000601:surgery*; D004947:Esophagus / Q000601:surgery; D005240:Feasibility Studies; D018662:Fundoplication; D005764:Gastroesophageal Reflux / Q000517:prevention & control; D010535:Laparoscopy / Q000379:methods*; D057605:Natural Orifice Endoscopic Surgery / Q000379:methods*; D010865:Pilot Projects; D011183:Postoperative Complications / Q000517:prevention & control; D013270:Stomach / Q000601:surgery*; D013552:Swine