Surgical technique

The procedure started with the patient in the French position. After performing pneumoperitoneum using Veress needle, a 10-mm optical trocar (Opti-View Trocar®) was placed above the umbilicus. Then, two balloon-tipped trocars, 5 mm and 12 mm in diameter, were introduced through the midclavicular line below the right and left costal margins for the surgeon’s left-and right-hand working ports, respectively. A subxiphoid incision was made for introducing the Nathanson^® liver retractor. Both balloon-tipped trocars were introduced into the stomach under direct endoscopic view through a small incision made with a monopolar scalpel in the anterior wall of the greater curvature at the level of the gastric body. The stomach was inflated with CO₂ through the 12-mm intragastric port at a pressure of 8 mm Hg.

Under endoscopic guidance and retroflexed view, the lesion was gently tractioned with a 5-mm Endo Clinch grasper held with the surgeon’s left hand, and the resection was performed using one fire of mechanical stapler with a 60 mm load through the 12- mm port held in the surgeon’s right hand. The surgical specimen was placed in an endoscopic retrieval bag and an endoscopic grasper was then used to retrieve the specimen through the mouth. Finally, the small gastrotomies used for introducing the intragastric ports were closed with two loads of mechanical stapler (see online video).

The patient evolved without postoperative complications and was discharged 24 hours later tolerating solid food. The pathological examination of the surgical specimen reported complete surgical resection of a GIST with clear margins. One year after surgery the patient remains asymptomatic for dysphagia or gastroesophageal reflux.

The stomach is the most common location of GIST⁶. In 2008, Privette et al.⁷ described an easy classification based on submucosal gastric tumor location to manage the appropriate operative approach. GIST type I correspond to tumors located in the grater curvature and funds, type II are tumors of the prepyloric region and antrum and type III are tumors located in the lesser curvature or cardia, as the one described in this case report that was treated with the combined intragastric approach.

Several publications of case reports or case series have demonstrated that this approach is safe and valid⁸. A recent study by Barajas-Gamboa et al.⁹ demonstrated that laparo-endoscopic transgastric resection of gastric submucosal tumors was safe and efficient for GIST with optimal oncologic results.

The minimally invasive concept of these procedures has been emphasized by single incision laparoscopic surgery using single port devices for combined resections, with favorable outcomes¹⁰.

A possible limitation for this combined approach is the need for a group of professionals with both surgical and endoscopic skills. This association is essential for the treatment of many gastroesophageal conditions, which requires continuous training of surgeons endoscopists.

This technique has already been described and validated in the bibliography but is still innovative in our environment. Our experience is limited to few cases as the prevalence of these tumors in the GEJ is rare.

We have reported a case of a subcardial GIST resected using a combined laparoscopic and endoscopic approach. The procedure is safe, reproducible and relatively simple performed by trained professionals, representing a minimally invasive therapeutic option for patients with this condition.