Laparoscopic-Assisted Transgastric Endoscopy: Current Indications and Future Implications

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. CONCLUSION: 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.