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Page 6 of 7 Priego et al. Mini-invasive Surg 2018;2:6 I http://dx.doi.org/10.20517/2574-1225.2018.01

EGJ or posterior wall. These approaches include tumor enucleation, exogastric wedge resection, transgastric
tumor-everting resection, intragastric tumor everting resection, laparoscopic and endoscopic cooperative
surgery and esophagogastrectomy [8-11] .

[12]
Laparoscopic transgastric resection of GST was first described by Geis et al. . Several publications of this
technique have shown the procedure to be feasible and safe with good outcomes in the resection of GISTs
[1-5]
located near EGJ, posterior wall and the antropyloric region . However, certain principles need to be
practiced when performing this intervention.

First, this procedure requires greater expertise and laparoscopic skills, so whether you want to follow
strict oncological outcomes, this surgery should be only performed in hands of experienced surgeons with
advanced laparoscopic skills.

In our experience, we advise the use of ballon trocars in order to minimize the leakage of pneumogastrum
during the resection of the tumor. Moreover, we consider trocar placement as the key of a successfully
resection. In fact, before introducing any trocar, when the upper part of stomach is covered by bulky
liver,we first introduce a Nathanson liver retractor in order to define the anatomy. It is important to put
the trocars as high as possible, and to introduce the left balloon trocar in the midline of the epigastrium in
order to reduce the distance between the abdominal and gastric wall.

We have not used any system of occlusion of duodenum to maintain air-inflated stomach, and we have not
had any problem during resection of the tumors.

Another important step is avoiding EGJ stenosis, especially when an endoscopic linear stapler is used to
remove the specimen. In addition, one needs to confirm if the EGJ is intact prior to firing, either with the
position of a nasogastric tube or a gastroscope.

Most authors utilized the technique of transgastric stapled resection as it allows simultaneous resection
and closure of the defect in the stomach. In our series, we have preferred the use of ultrasonic device to
remove the tumor because it is feasible to manipulate and to avoid bleeding. With the stapling, overall
operating time would be shortened, because it was not require closing the gastric wall with suture. Finally,
we have only had one intraoperative complication using this technique. In one patient, a methylene blue
leakage was observed when the suture line was checked, requiring reinforced.

Caution need to be taken to minimize tumor handling in order to prevent tumor rupture or spillage. It is
advisable to avoid grasping the center of the tumor, but instead to grasp the normal mucosal surrounding
it. For this reason and also to facilitate the resection, sometimes we use a suture into the tumor for
retraction.

Moreover, it is important to achieve good haemostasis during the surgery, avoiding using suction and
irrigation in order to maintain air-inflated in the stomach.

In conclusion, and if these principles are followed, laparoscopic transgastric resection seems to be a safe
and effective procedure for gastric submucosal tumors located near the esophagogastric junction. However,
advancedtraining in laparoscopic surgery is advised.

DECLARATIONS
Authors’ contributions
Study conception and design, drafting of manuscript: Priego P
Data collection: Cuadrado M, García-Moreno F
Analysis and interpretation of results, critical revision: Carda P, Galindo J