Abstract Background The rising global prevalence of morbid obesity has led to increased metabolic and bariatric surgeries (MBS), including Roux-en-Y gastric bypass (LRYGB) and sleeve gastrectomy (SG). Greater intraoperative access to the stomach during these procedures has resulted in more incidental findings of submucosal gastric lesions such as gastrointestinal stromal tumours (GISTs), leiomyomas, lipomas, and carcinoids. These lesions are often asymptomatic and may be overlooked during routine endoscopy due to their subepithelial location and intact mucosa. Differentiating benign, premalignant, and malignant gastric lesions preoperatively remains a clinical challenge, especially considering the unpredictable malignant potential of even small submucosal tumours. This complexity is amplified when lesions are near the esophagogastric junction (EGJ), where achieving complete resection without compromising function is technically demanding. Additionally, altered anatomy following bariatric procedures complicates follow-up. In LRYGB, the excluded stomach is inaccessible via standard endoscopy, limiting surveillance. While SG preserves endoscopic access, lesions near the EGJ or lesser curvature may be difficult to resect without risking sleeve deformity or stenosis, which could negatively impact both metabolic and oncologic outcomes. Laparoscopic intragastric surgery (LIGS) offers a minimally invasive solution for resecting tumours in anatomically challenging areas such as the EGJ. By placing balloon trocars directly into the gastric lumen via anterior gastrotomies, LIGS allows precise tumour excision while preserving gastric anatomy. When combined with bariatric procedures, it enables a single-stage intervention that meets both oncologic and metabolic (oncometabolic) goals, avoiding unnecessary tissue loss or delayed treatment. This video case report demonstrates the use of LIGS to safely and effectively resect a suspected GIST near the EGJ, where conventional imaging and endoscopy were inconclusive. Case presentation A 55-year-old male presented with recurrent epigastric pain and vomiting. Endoscopy revealed a subepithelial mass just below the EGJ. CT confirmed a 37 mm lesion along the lesser curvature. Endoscopic ultrasound showed a mucosa-covered nodular mass in the cardia, suggestive of GIST. Fine needle aspiration was inconclusive, showing smooth muscle features without atypia (CD10-, DOG-1-, desmin+). Given the tumour’s location and inconclusive findings, LIGS was selected. Three balloon trocars (12 mm, 10 mm, 5 mm) were inserted via anterior gastrotomies, with intragastric insufflation maintained at 8 mmHg. A calibration tube was placed in the oesophagus to prevent stenosis. The ∼4 cm lesion, 1 cm from the cardia, was resected with a Harmonic Scalpel and retrieved in an Endo bag. Histopathology confirmed a gastric leiomyoma with R0 margins. The patient recovered uneventfully and was discharged without complications. Conclusion This case highlights LIGS as a safe and effective method for resecting submucosal gastric tumours, particularly near the EGJ. It also supports its potential as a bridging strategy in patients undergoing MBS, offering a one-stage, function-preserving approach aligned with both oncologic and metabolic goals.
Cruz et al. (Thu,) studied this question.