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The esophagogastric junction (EGJ) is a rare location for gastrointestinal stromal tumors (GIST) and resection remains challenging in posterior/fundic lesions [1]. Laparoscopic and endoscopic cooperative surgery (LECS) is a new combined minimally invasive method [2–4]. Recently, a large series of 126 patients who underwent LECS for gastric submucosal tumors (86 GISTs) was published showing a high rate of feasibility and less than 5% morbidity [5]. We report our experience in difficult gastric GIST resections. Three patients underwent the procedure for posterior EGJ GISTs with various symptomatology. The absence of metastasis and the location of the GIST were confirmed by esophagogastroscopy and computed tomography scan (▶Fig. 1). All procedures were performed under general anesthesia and with orotracheal intubation. The LECS steps were (▶Fig. 2, (▶Video1): 1) exposing the esophagus and liberating the angle of His by laparoscopy; 2) full-thickness incision around the tumor by endoscopy (Hook knife; Olympus, Tokyo, Japan); 3) exposure of the tumor pedicle to the surgeon (forceps); 4) laparoscopic resection with linear stapler; 5) gastrotomy suturing. All LECS procedures were performed successfully in a mean time of 107 minutes (range 90–120 minutes). The blood loss was very low and did not require any blood transfusion. There were no immediate perioperative complications such as spleen wound, pneumothorax, vagus nerve injury, or any other adverse event. The mean tumor size was 5.3 cm, with the largest diameter measuring 5.5 cm, 4.5 cm, and 6cm, respectively, and with Miettinen grade considered as low or very low risk of recurrence. The mean fasting duration, including nasogastric tube time, was 5 days (range 2–8 days), and the median hospital stay was 9.3 days (range 5–14 days). No rehospitalization or latest complications were reported during a mean follow-up of 14 months. There was no recurrence of the tumors. LECS following a rigorous surgical protocol is safe, and offers easiest accessibility and lower morbidity for complicated gastric GIST resection.

Laparoscopic and endoscopic cooperative surgery for difficult resection of posterior esophagogastric junction gastrointestinal stromal tumors