subsequent modifications in instrumentation by elsner , schindler , and hirschovitz led to the creation of modern - day endoscopes .
almost all advanced diagnostic and therapeutic modalities of today , including variceal banding , management of peptic ulcer disease , biliary tract manipulation , and even transgastric exploration via natural orifice transluminal endoscopic surgery ( notes ) , require normal anatomy and unobstructed access through the transoral route .
however , access difficulties emerge when patients have altered anatomy of the upper gastrointestinal tract due to esophageal obstruction or altered anatomy following roux - en - y gastric bypass or billroth ii surgery .
methods of alternate access routes with variable degrees of success in resolving the patients ' medical condition have been described in the literature .
percutaneous , ultrasound , and ct - guided transcatheter access to the gastric remnant , performed with injection of contrast , have been completed in patients after gastric bypass . however , these are only diagnostic techniques that offer no concomitant opportunity for therapeutic intervention .
the duodenum or stomach remnant can be visualized with a long endoscope passed via the gastric pouch into the roux limb or the afferent billroth ii limb .
this procedure is technically difficult , especially in patients with a long limb of excluded small bowel . with altered foregut anatomy ,
the success rate of endoscopic retrograde cholangiopancreatography ( ercp ) is well below 70% . until recently ,
open surgery was the only available method for access to the biliary tree or stomach in this select group of patients .
not surprisingly , the associated morbidity , cost , and length of hospitalization make this an unattractive alternative .
minimally invasive access to the stomach with a laparoscopic - assisted gastrostomy was first performed in 1991 for feeding purposes .
similarly , the stomach remnant can be accessed in patients who underwent gastric bypass and require ercp .
table 1 lists current published efforts with regards to laparoscopic - assisted , transgastric endoscopy . using this approach , ercp was first described in 2002 for management of a benign biliary stricture in a patient with roux - en - y gastric bypass .
the authors accessed the stomach remnant through a 15-mm port in the left upper quadrant .
a gastrotomy was performed with ultrasonic shears and a purse - string suture placed around it for traction .
subsequently , ceppa et al performed successful transgastric endoscopy , or ercp , or both , in 9 of 10 patients studied , and nguyen et al have described a similar technique .
martinez et al initially placed a gastrostomy tube utilizing ct - scan guidance and fluoroscopy .
the authors subsequently dilated the gastrostomy tract to allow passage of the endoscope a few weeks after the original procedure . using this technique , successful endoscopy or ercp
laparoscopic gastrostomy has also been described . in this technique , the edges of the gastrostomy are sutured to the anterior abdominal wall fascia , which allows for immediate passage of an endoscope . after completion of the ercp ,
a gastrostomy tube is left in place for future access to the stomach remnant should that be necessary .
finally , we have previously described the transgastric approach for closure of a gastrogastric fistula after roux - en - y gastric bypass . in this scenario ,
the gastrogastric fistula was then closed primarily with several figure - of - eight sutures placed with the aid of an endo stitch ( autosuture , norwalk , ct ) .
literature reports on the use of laparoscopic assisted transgastric endoscopy ercp = endoscopic retrograde cholangiopancreatography ; luq = left upper quadrant ; gi = gastrointestinal ; sma = superior mesenteric artery .
this study is a retrospective review of the patients who required laparoscopic - assisted , transgastric endoscopy at a single institution .
six such patients were identified , and the indications for the procedure are summarized in table 2 .
characteristics of patients who underwent laparoscopic - assisted , transgastric endoscopy ercp = endoscopic retrograde cholangiopancreatography , loa = lysis of adhesions , luq = left upper quadrant .
although subtle variations existed from case to case , the following steps are highlighted : ( 1 ) port placement : carbon dioxide pneumoperitoneum is induced with a veress needle to achieve a peritoneal pressure of 15 mm hg .
additional trocars are placed at the umbilical level ( 12 mm ) , left lower quadrant ( 5 mm ) , and left upper quadrant ( 12 mm ) ( figure 1 ) .
( 2 ) gastrotomy : after visualization of the gastric remnant , a site is chosen on the greater curvature for the gastrotomy .
four # 0 ticron sutures ( autosuture , norwalk , ct ) are placed in a diamond - shaped configuration on the gastric corpus , with the center of the diamond being the future site of the gastrotomy ( figure 2 ) . a veress needle and versastep sleeve ( autosuture , norwalk , ct )
are introduced through the left - upper quadrant-12-mm incision into the gastric corpus , in the center of the 4 previously placed sutures .
adequate traction and countertraction are placed on the 4 sutures to allow accurate insertion of the veress needle into the stomach
. the veress needle is subsequently withdrawn , and a 12-mm port is inserted through the previously placed sleeve to dilate the subcutaneous tract and the gastrotomy .
( 3 ) ercp : a sterile side viewing endoscope is inserted manually through the left - upper - quadrant-12-mm port site into the gastric fundus under direct laparoscopic visualization ( figure 3 ) .
two other patients underwent sphincter of oddi manometry , which confirmed the preoperative diagnosis of sphincter of oddi dysfunction .
( 4 ) closure of gastrotomy : upon completion of the ercp , the gastrotomy is usually closed in 2 layers : the first layer is a running stitch of # 0 polysorb ( autosuture , norwalk , ct ) ( figure 4 ) .
this layer is then imbricated using interrupted # 0 ticron sutures placed in a horizontal mattress fashion .
, a pancreaticoduodenal drain was passed through the gastrotomy wound outside of the abdominal cavity .
this patient had the gastrotomy closed in a single layer with a figure - of - eight # 0 silk ( autosuture , norwalk , ct ) .
another patient had 2 gastrotomies in the gastric remnant for closure of a gastrogastric fistula .
all patients required endoscopic evaluation of the biliary tree , but had altered gastrointestinal anatomy , which precluded performance of esogastroduodenoscopy via the standard route .
five patients had previously undergone roux - en - y gastric bypass , and one patient had a distal esophageal stricture secondary to tumor , which did not allow passage of the endoscope .
she had a past medical history significant for a bone marrow transplant for non - hodgkin 's lymphoma ( 5 years earlier ) .
her alkaline phosphatase level was elevated ( 1300 ) , and abdominal ultrasound and ct scan revealed multiple gallstones .
laparoscopic cholecystectomy was performed , and the intraoperative cholangiogram showed impacted stone at the ampulla of vater .
intraoperative ercp was attempted but was not possible due to previously undiagnosed esophageal stricture from graft versus host disease .
laparoscopic - assisted transgastric endoscopy was subsequently performed with successful ercp , sphincterotomy , and extraction of stone .
a feeding gastrostomy tube was placed through the gastrotomy wound at the end of the procedure .
patient 2 was a 35-year - old female who was evaluated for intermittent episodes of right upper quadrant abdominal pain .
the patient had undergone cholecystectomy and roux - en - y gastric bypass 3 years earlier and had a documented gastrogastric fistula .
abdominal ultrasound and ct scan as well as magnetic resonance cholangiopancreatography ( mrcp ) revealed a dilated common bile duct ( 12 mm ) .
patient 3 was a 39-year - old female who presented with right upper quadrant abdominal pain .
she had a past surgical history significant for cholecystectomy and rouxen - y gastric bypass ( 2 years prior ) .
abdominal ultrasound and mrcp revealed common bile duct dilatation ( 12 mm ) and likely periampullary stricture .
ercp and sphincterotomy were performed , after which the gastrotomy was closed in 2 layers .
patient 4 was a 44-year - old female with a history of laparoscopic roux - en - y gastric bypass and laparoscopic cholecystectomy who was admitted with chronic right upper quadrant abdominal pain .
sphincter of oddi dysfunction was suspected , and the patient underwent laparoscopic lysis of adhesions , transgastric ercp , sphincterotomy , and sphincter of oddi manometry .
a pancreaticoduodenal drain was passed through the gastrotomy site and connected extracorporeally for gravity drainage .
the gastrotomy was closed with a figure - of - eight suture around the drain and the stomach was anchored to the anterior abdominal wound .
patient 5 was a 60-year - old female with a history of rouxen - y gastric bypass and laparoscopic cholecystectomy who was admitted for ascending cholangitis secondary to choledocholithiasis .
the patient underwent laparoscopic lysis of adhesions , transgastric ercp , sphincterotomy , and extraction of the retained stone .
patient 6 was a 45-year - old female who was evaluated for chronic right upper quadrant pain .
the patient had a history of open cholecystectomy and roux - en - y gastric bypass .
with the suspected diagnosis of sphincter of oddi sphincter dysfunction , the patient underwent laparoscopic lysis of adhesions , transgastric endoscopy , sphincterotomy , and sphincter of oddi manometry .
laparoscopic - assisted , transgastric endoscopy was successfully performed in 6 patients with altered upper gastrointestinal tract anatomy .
this technique was originally described in 2002 , but it was not until recently that it was adopted in clinical practice . in most of the case reports , the technique was used in patients who had previously undergone roux - en - y gastric bypass for morbid obesity . to our knowledge , this is the first description of the procedure in a patient with malignant esophageal stricture . performing an upper endoscopy via the gastrostomy feeding tube site has been previously described in patients with benign esophageal strictures .
several variations in the described technique are possible : the number of ports may be as few as 2 , although we found 3 to be optimal .
the placement of ports may also vary depending on the patient 's anatomy and previous operations . in most cases
, we attempted to place the ports through the previous healed laparoscopic incisions from the laparoscopic roux - en - y gastric bypass or laparoscopic cholecystectomy .
nevertheless , one large port ( 12 mm or 15 mm ) needs to be placed in the left upper quadrant to allow easy mobilization of the gastric remnant and the creation of the future gastrotomy .
the chosen site of the gastrotomy on the anterior gastric remnant wall is circumscribed by the placement of 3 sutures or 4 sutures in a triangular or diamond - shape configuration , which will aid in providing adequate retraction and exposure . in our series , variations also existed in the type of gastrotomy closure
: the authors ' preferred method is the double - layer technique , although single - layer and stapled closure were used in special circumstances , ie , when a pancreaticoduodenal drain was passed through the gastrotomy site and when 2 gastrotomies were performed in the gastric remnant , respectively .
additionally , a gastrostomy tube can be left in place should the patient need a tube for enteral feeds or if subsequent access to the gastric remnant is envisioned .
the described technique could easily be used to treat a dieulafoy 's lesion or bleeding peptic ulcer , resect a proximal lesser curve gastric tumor , or resect a benign duodenal tumor .
in addition , transgastric surgery may be an adjunct to capsule endoscopy in the localization and treatment of occult gastrointestinal bleeding .
finally , this surgical technique could also be applicable as an immediate bridge to natural orifice surgery .
in an age where surgeons and gastroenterologists are focusing on the stomach as an access point out of the gastrointestinal tract and into the peritoneal cavity , we also view the stomach as a portal into the gastrointestinal tract . in the patient with limited access for traditional endoluminal therapy ,
 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 . 
INTRODUCTION
METHODS
RESULTS
DISCUSSION
CONCLUSION