Radiomics analysis for prediction and classification of submucosal tumors based on gastrointestinal endoscopic ultrasonography.

Objectives: To identify and classify submucosal tumors by building and validating a radiomics model with gastrointestinal endoscopic ultrasonography (EUS) images. Methods: A total of 144 patients diagnosed with submucosal tumors through gastrointestinal EUS were collected between January 2019 and October 2020. There are 1952 radiomic features extracted from each patient's EUS images. The statistical test and the customized least absolute shrinkage and selection operator regression were used for feature selection. Subsequently, an extremely randomized trees algorithm was utilized to construct a robust radiomics classification model specifically tailored for gastrointestinal EUS images. The performance of the model was measured by evaluating the area under the receiver operating characteristic curve. Results: The radiomics model comprised 30 selected features that showed good discrimination performance in the validation cohorts. During validation, the area under the receiver operating characteristic curve was calculated as 0.9203 and the mean value after 10-fold cross-validation was 0.9260, indicating excellent stability and calibration. These results confirm the clinical utility of the model. Conclusions: Utilizing the dataset provided curated from gastrointestinal EUS examinations at our collaborating hospital, we have developed a well-performing radiomics model. It can be used for personalized and non-invasive prediction of the type of submucosal tumors, providing physicians with aid for early treatment and management of tumor progression.

Extraction of terminal ileal lipomas to cecum can facilitate endoscopic resection: A case series with video.

Large ileal lipomas over 2 cm can cause symptoms, that may require a resection. Due to the narrow lumen and thin walls of the ileum, endoscopic treatments can have a high risk of adverse events and require technical expertise, thus surgical resection is currently the mainstay of treatment. To overcome the technical challenges, we developed a novel method to endoscopically resect terminal ileal lipomas. The technique involves extracting the lesion into the cecum, which creates sufficient space to maneuver, and a better field of view. The lipoma is resected with endoscopic mucosal resection or endoscopic submucosal dissection. The appearance of the lipoma protruding out of the ileocecal valve resembles that of a tongue sticking out of the mouth, thus we named this the "tongue out technique". To assess the technical feasibility of this method, we retrospectively analyzed seven cases of terminal ileal lipoma that were endoscopically resected using the "tongue out technique" at NTT Medical Center Tokyo between January 2017 and October 2023. Technical success was 100% and en bloc resection was achieved in all cases. The median size was 31 (14-55) mm. Three cases were resected with endoscopic mucosal resection while endoscopic submucosal dissection was performed on the other four cases. There was one case of delayed post-endoscopic mucosal resection bleeding, which was caused by clip dislodgement. There were no perforations. No recurrence of the lipoma or associated symptoms have been observed. This new technique can allow more ileal lipomas to be treated with minimally invasive and organ-preserving endoscopic procedures.

Successful modified CLEAN-NET with semicircular seromuscular layer incision for a gastric GIST near the cardia: a case report and video demonstration.

BACKGROUND: The combination of laparoscopic and endoscopic approaches to neoplasia with a non-exposure technique (CLEAN-NET) is a laparoscopic and endoscopic cooperative surgery (LECS). It combines laparoscopic gastric resection and endoscopic techniques for local resection of gastric tumors, such as gastrointestinal stromal tumors (GIST), with minimal surgical margins. A conventional CLEAN-NET surgical procedure is complex, requiring careful techniques to preserve the cardia, particularly in case of nearby lesions. We describe the case of a patient who underwent a modified CLEAN-NET approach with a semi-circular seromuscular layer incision surrounding the base of the tumor, different from a circular shape seromuscular layer in the conventional CLEAN-NET: around the tumor to preserve mucosal continuity, which acts as a barrier to avoid intraoperative tumor dissemination. CASE PRESENTATION: A 43-year-old woman was referred to our hospital because of a gastric submucosal tumor near the cardia, detected on medical examination. The patient was diagnosed with gastric GIST based on the results of endoscopic ultrasound-guided fine-needle aspiration. Modified CLEAN-NET was performed with a semicircular incision of the seromuscular layer on the opposite side of the cardia, making the surgical procedure simple and minimizing partial resection of the gastric wall, including the tumor, while preserving the cardia. The operative time was 147 min, preoperative blood loss volume was 3 mL, and postoperative hospital stay was 9 days. The resected specimen revealed a minimal resection of the gastric wall, including the tumor. The cardia and gastric nerves were preserved, and the postoperative food intake was good. CONCLUSIONS: The modified CLEAN-NET with semicircular seromuscular layer dissection is a simple and reliable surgical procedure for GIST near the cardia.

Outcomes of laparoscopic and endoscopic cooperative surgery for gastric submucosal tumors: A retrospective multicenter study at 21 Japanese institutions.

Aim: We conducted a multicenter study on classical laparoscopic and endoscopic cooperative surgery (LECS) and LECS-related procedures to retrospectively clarify the safety, problems, and mid-term outcomes of these methods after their coverage by the national health insurance. Methods: A total of 201 patients who underwent classical LECS/LECS-related procedures for gastric submucosal tumors (G-SMTs) in 21 institutions affiliated with the Laparoscopy Endoscopy Cooperative Surgery Study Group from April 2014 to March 2016 were included. Data was retrospectively obtained from the patients' charts. Results: The most common surgical procedure was classical LECS (155 patients, 77.1%), non-exposed endoscopic wall inversion surgery (22 patients, 11.4%), a combination of laparoscopic and endoscopic approaches to neoplasia with non-exposure technique (16 patients, 8%), and closed LECS (two patients, 1%). Only six (3%) patients underwent LECS with gastrostomy. The mean operative time and blood loss were 188.4 (70-462) minutes and 23.3 (0-793) g, respectively. Ten (5%) patients developed postoperative complications (Clavien-Dindo classification grade II or higher). Two patients needed reoperation due to postoperative bleeding or anastomotic leakage. All tumors were resected with negative margins. A total of 127 (63.2%) patients underwent follow-up observations for over 36 months, one of whom had a recurrence of peritoneal dissemination and one had poor oral intake. Conclusion: Classical LECS and LECS-related procedures for G-SMTs have favorable short/mid-term outcomes.

Misdiagnosis of hemangioma of left triangular ligament of the liver as gastric submucosal stromal tumor: Two case reports.

BACKGROUND: Extragastric lesions are typically not misdiagnosed as gastric submucosal tumor (SMT). However, we encountered two rare cases where extrinsic lesions were misdiagnosed as gastric SMTs. CASE SUMMARY: We describe two cases of gastric SMT-like protrusions initially misdiagnosed as gastric SMTs by the abdominal contrast-enhanced computed tomography (CT) and endoscopic ultrasound (EUS). Based on the CT and EUS findings, the patients underwent gastroscopy; however, no tumor was identified after incising the gastric wall. Subsequent surgical exploration revealed no gastric lesions in both patients, but a mass was found in the left triangular ligament of the liver. The patients underwent laparoscopic tumor resection, and the postoperative diagnosis was hepatic hemangiomas. CONCLUSION: During EUS procedures, scanning across different layers and at varying degrees of gastric cavity distension, coupled with meticulous image analysis, has the potential to mitigate the likelihood of such misdiagnoses.

Case report: A large gastric calcifying fibrous tumor treated with endoscopic submucosal excavation.

Gastric calcifying fibrous tumor (CFT) is a rare benign mesenchymal tumor. Several previous studies have reported surgical resection for gastric CFT larger than 20mm for the difficulty in preoperative diagnosis. Here, we report a rare case of large gastric CFT treated with endoscopic submucosal excavation (ESE). A 70-year-old woman presented with recurrent epigastric pain and underwent endoscopy, which revealed a 35mm-sized submucosal tumor in the gastric body. ESE was performed after imaging examination and endoscopic ultrasonography. En bloc resection was achieved, but due to the specimen's substantial size and difficulty in mincing, it posed challenges for removal through the mouth. Finally, the specimen was temporarily placed in the stomach and was completely removed two days later. The diagnosis was confirmed based on pathological and immunohistochemical findings. There was no recurrence during the patient's 11-month follow-up. We provided a case report related to the diagnosis and endoscopic treatment for large gastric CFT. In addition, our experience of temporarily leaving a large postoperative specimen, considered a benign lesion, in the stomach for later removal was successful but requires appropriate timing to avoid blockage of the gastrointestinal tract.

Safety and efficacy of a modified endoscopic full-thickness resection technique for gastric submucosal tumors: a case series.

Objectives: Endoscopic full-thickness resection (EFTR) has proven effective and economical for patients with gastric submucosal tumors (SMTs). However, the poor operative field of view, the risk of massive hemorrhage, and the difficulties in defect closure have limited its widespread application. Herein, we described a modified EFTR technique developed to simplify the dissection and defect closure procedures using common and economical endoscopic accessories. Methods: Forty-two patients who underwent the modified EFTR for gastric SMTs in the Shenzhen Guangming District People's Hospital were enrolled in the case series. Following a cross incision to expose the intraluminal surface the tumors were captured by suction through a transparent cap and the roots were ligated using a loop. The tumors and part of the suction tissue were removed along the ligated root. A tension-relieving closure was performed by clipping the raised plica in four quadrants outside the ligated root. Patient demographics, tumor characteristics, and therapeutic outcomes were evaluated retrospectively. Results: All tumors had an R0 resection. The median procedure time was 51.8 min (IQR 34.25 min). No severe perioperative adverse events occurred. No residual lesion or recurrence was reported during the follow-up period of 9.84 months (IQR 5.0 months). Conclusion: The safety and practicability of Modified-EFTR could allow for wide clinical application in patients with micro-gastric SMTs.

Gastric Adenocarcinoma Presenting as a Submucosal Tumor: A Case Report.

Gastric adenocarcinoma presenting as a submucosal tumor (SMT) accounts to only 0.1% to 0.63%. A 56-year-old Filipino male presenting with new onset melena underwent magnifying endoscopy, narrow-band imaging, endoscopic ultrasound, and computed tomography revealing a 2.5 cm x 2.0 cm polypoid SMT-like lesion at the fundus. Total gastrectomy with lymph node dissection and esophagojejunostomy was performed with histopathology showing adenocarcinoma. This suggests the need for different modalities to ensure the accuracy of diagnosis and the need for subsequent invasive treatments.

Implantation cyst appearing more than 30 years after gastrectomy.

Implantation cyst is often reported to be a delayed complication after colorectal surgery. This report presents a 70-year-old man undergoing gastrectomy 33 years earlier for an acute gastric ulcer. His endoscopic finding showed a submucosal tumor about 20 mm in diameter at the gastro-jejunal anastomosis. Endoscopic ultrasonography showed that the tumor was a cystic mass that was continuous from the third layer, but there were no existences of internal substantial nodules, indicating that the tumor was diagnosed as implantation cyst. This is the first report showing that implantation cyst can occur at gastro-jejunal anastomosis. We should take into account the occurrence of implantation cyst, when we encounter a submucosal tumor at gastro-jejunal anastomosis after surgery even if a long period has passed.

The Outcome of Snare-Assisted Traction Endoscopic Full-Thickness Resection for the Gastric Fundus Submucosal Tumors Originating from the Muscularis Propria.

Aim: To explore the feasibility and effectiveness of snare-assisted traction endoscopic full thickness resection (EFTR) on gastric fundus submucosal tumors (SMTs). Methods: The clinical and pathological data of patients with gastric SMTs who underwent EFTR treatment at the Endoscopy Center of Kaifeng Central Hospital from January 2018 to June 2023 were collected. Among them, 36 patients underwent snare-assisted traction EFTR (SAT-EFTR) and 46 patients underwent standard EFTR (S-EFTR). The clinical baseline data, operative data, adverse events, and follow-up results of the two groups were collected and compared. Results: All patients successfully completed EFTR technique. There were 34 male and 48 female patients, with an average age of (56.62 ± 11.31) years. The average operation time was shorter in the snare-assisted EFTR group than the S-EFTR group (73.39 ± 31.33 minutes versus 92.89 ± 37.57 minutes, P = .014). In addition, the resection speed of the snare-assisted EFTR group was also significantly faster than that of the S-EFTR group (4.04 ± 2.23 versus 2.48 ± 0.93 mm2/min, P < .001). There was no statistically significant difference in the age, gender, lesion size, postoperative fasting duration, and postoperative hospitalization stay between the two groups (P > .05). One patient in the SAT-EFTR group developed delayed postoperative perforation which was close with purse­string suture technique. All patients were discharged successfully, and there was no recurrence or metastasis during the follow-up period. Conclusion: Snare-assisted traction of EFTR could shorten the operation time, reduce the difficulty of the operation, and improve the efficiency of the operation. At the same time, this method is simple and easy to learn, more suitable for beginners, and worthy of clinical promotion and application.

Effect of endoscopic full-thickness resection assisted by distal serosal turnover with floss traction for gastric submucosal masses.

BACKGROUND: Complex and high-risk surgical complications pose pressing challenges in the clinical implementation and advancement of endoscopic full-thickness resection (EFTR). Successful perforation repair under endoscopy, thereby avoiding surgical intervention and postoperative complications such as peritonitis, are pivotal for effective EFTR. AIM: To investigate the effectiveness and safety of EFTR assisted by distal serosal inversion under floss traction in gastric submucosal tumors. METHODS: A retrospective analysis of patients with gastric and duodenal submucosal tumors treated with EFTR assisted by the distal serosa inversion under dental floss traction from January 2023 to January 2024 was conducted. The total operation time, tumor dissection time, wound closure time, intraoperative bleeding volume, length of hospital stay and incidence of complications were analyzed. RESULTS: There were 93 patients, aged 55.1 ± 12.1 years. Complete tumor resection was achieved in all cases, resulting in a 100% success rate. The average total operation time was 67.4 ± 27.0 min, with tumor dissection taking 43.6 ± 20.4 min. Wound closure times varied, with gastric body closure time of 24.5 ± 14.1 min and gastric fundus closure time of 16.6 ± 8.7 min, showing a significant difference (P < 0.05). Intraoperative blood loss was 2.3 ± 4.0 mL, and average length of hospital stay was 5.7 ± 1.9 d. There was no secondary perforation after suturing in all cases. The incidence of delayed bleeding was 2.2%, and the incidence of abdominal infection was 3.2%. No patient required other surgical intervention during and after the operation. CONCLUSION: Distal serosal inversion under dental-floss-assisted EFTR significantly reduced wound closure time and intraoperative blood loss, making it a viable approach for gastric submucosal tumors.

Gastric lipoma: An unusual cause of the upper gastrointestinal bleeding.

INTRODUCTION: Gastric lipomas, though rare, are noteworthy for their potential to cause upper gastrointestinal bleeding. This case report highlights the diagnostic and management challenges associated with this uncommon entity. CASE PRESENTATION: We present a case of a 39-year-old male with epigastric pain and hematemesis, ultimately diagnosed with a gastric lipoma in the antrum. Endoscopy revealed a submucosal lesion with mucosal ulceration, confirmed by imaging studies. Surgical resection was performed, leading to a favorable outcome. CLINICAL DISCUSSION: Gastric lipomas are benign tumors that can present with gastrointestinal bleeding, abdominal pain, or obstruction. Diagnosis relies on imaging and endoscopic findings, with biopsy often inconclusive due to the submucosal location. Surgical resection is the preferred treatment for symptomatic or large lipomas, while observation may suffice for asymptomatic lesions. CONCLUSION: Gastric lipomas, although infrequent, pose a challenge for diagnosis, especially when associated with bleeding. Surgical resection remains the cornerstone of management for symptomatic or large lipomas, with observation being an option for asymptomatic lesions.

Retrospective observational cohort study of laparoscopic surgical strategies for gastrointestinal stromal tumors.

Laparoscopic surgery has been used to treat gastric submucosal tumors (SMTs). Laparoscopic and endoscopic cooperative surgery (LECS) has been used when subtotal resection has been difficult, which enabled resection of these tumors. In this study, we reviewed the medical records of patients with gastric SMTs who underwent laparoscopic surgery in our hospital with the aim of reporting the surgical indications, procedures (especially for LECS), and outcomes of surgery. This study involved 55 patients who underwent laparoscopic surgery between April 2014 and March 2021. We classified the patients into two groups: laparoscopy-assisted surgery group (non-LECS group, n = 30) and LECS group (n = 25). LECS was performed in the upper stomach, in the greater curvature of the lower stomach, and in both intraluminal and intramural locations in the middle stomach. Non-LECS was selected for extraluminal and intramural tumors in the greater curvature of the upper stomach. There were no severe complications associated with the operation. There was one postoperative complication in the LECS group. The length of postoperative hospital stay did not significantly differ between the LECS and non-LECS groups. We reported the surgical procedures for gastric SMTs in our hospital. It is essential to make full use of the multiple techniques reported in this article and examine the location of the tumor to avoid excess or insufficient resection. Our review of the present case series allowed us to select the appropriate surgical approach for gastric SMTs based on the lesion location and type of development.

A case of needle tract seeding with endoscopic findings of progression over time.

An 83-year-old male underwent three transgastric punctures with endoscopic ultrasound-guided fine-needle aspiration for the examination of a pancreatic body tumor. After a diagnosis of resectable pancreatic cancer and undergoing distal pancreatectomy, the patient was administered postoperative adjuvant chemotherapy with oral S-1 for 6 months, and carcinoembryonic antigen and carbohydrate antigen 19-9 levels were bimonthly evaluated. Carbohydrate antigen 19-9 levels continually increased to 4638.1 U/mL at 45 months post-fine-needle aspiration. Endoscopic ultrasound-guided showed a 25 mm low-echoic, irregularly shaped, and heterogeneous tumor with clear margins protruding from the mucosa outside the gastric wall, and biopsy confirmed adenocarcinoma. Since the immunostaining findings of the specimen matched those of the previously resected specimen, needle tract seeding (NTS) due to puncture of the pancreatic cancer was identified as the cause. After a pylorus-preserving gastrectomy at 46 months post-fine-needle aspiration, postoperative chemotherapy initiation, comprising gemcitabine and nab-paclitaxel, was initiated; however, the patient died despite these interventions as he developed multiple peritoneal dissemination. Although rare, the incidence of NTS will increase in the future owing to the expected extended survival in post-pancreatic cancer resection cases. We suggest regular upper gastrointestinal endoscopy and endoscopic ultrasound-guided evaluations for patients who are at risk for NTS can facilitate early detection. Furthermore, it is extremely relevant to share experiences of encountered NTS cases in practice and extend knowledge of its varying endoscopic appearances.

Intussusception of Heterotopic Gastric Mucosa in the Transverse Colon: A Rare Cause of Perforation and Bleeding.

Heterotopic gastric mucosa in the colorectal region is a rare condition and can be found throughout the gastrointestinal tract. Intussusception in adults is mostly associated with adenocarcinoma and requires prompt surgical intervention, especially in cases of intestinal perforation. Our case report demonstrates a cecal perforation caused by the intussusception of heterotopic gastric mucosa within the transverse colon. The patient presented with substantial hematochezia. Despite the challenges of diagnosing this condition preoperatively and in the ICU, accurate pathologic evaluation is important. The consideration of a heterotopic gastric mucosa is crucial in cases of persistent hematochezia, especially in cases of intussusception. The postoperative course of the patient was characterized by hematochezia, which improved with proton pump inhibitors. The consideration of the possibility of heterotopic gastric mucosa may be a guide to appropriate surgical management and optimization of patient outcomes.

Clinical course of small gastric subepithelial lesion less than 20 mm diagnosed by endoscopic ultrasound-guided fine-needle aspiration.

BACKGROUND AND AIM: Gastrointestinal stromal tumors (GISTs) are treated as malignant gastric subepithelial lesions (SELs), and resection is recommended. However, small gastric SELs < 20 mm with no malignant features are monitored without histopathological examination, and the frequency of malignancy is unknown. This study aimed to clarify the clinicopathological findings and clinical course of gastric SELs < 20 mm measured by endoscopic ultrasound (EUS). METHODS: This retrospective cohort study included consecutive patients with small gastric SELs < 20 mm diagnosed using EUS at a tertiary referral center between 2009 and 2021. The clinical course after diagnosis using EUS-guided fine-needle aspiration (EUS-FNA) was reviewed. RESULTS: Among 333 patients with small gastric SELs, 104 patients with 105 lesions underwent EUS-FNA. The pathological diagnosis was confirmed in 87 patients. GISTs were the most common pathology (47%). Among the 87 patients, 43 underwent therapeutic interventions, including tumor resection and chemotherapy. In groups of tumor resection, the pathological tumor size on the resected specimen was significantly larger than the size measured by EUS (19.5 mm vs 15.0 mm, P < 0.001), and 37% of resected SELs were 20 mm or over. No recurrence was observed after tumor resection during a mean follow-up period of 40 months. CONCLUSIONS: Approximately 40% of small gastric SELs were malignant tumors, such as GIST, with most of them requiring treatment. Additionally, considering that the EUS measurement is 5 mm smaller than the pathological tumor diameter, further examinations, such as systematic EUS-FNA, may be required for SEL, including those smaller than 20 mm.

Gastric inflammatory myofibroblastic tumor: a case report.

BACKGROUND: Inflammatory myofibroblastic tumor (IMT) of the stomach is an uncommon mesenchymal neoplasm. We present a case of gastric submucosal tumor (SMT) where the final diagnosis was IMT. CASE PRESENTATION: A 69-year-old man presented with a 24-mm SMT on the posterior wall of the middle third of the stomach that was detected by screening upper gastrointestinal endoscopy. Abdominal contrast-enhanced computed tomography showed that the tumor was well-enhanced. Although endoscopic ultrasonography-guided biopsy was performed, the histological diagnosis was not confirmed preoperatively. Since the tumor was clinically suspected to be a gastrointestinal stromal tumor, we performed gastric wedge resection by laparoscopic-endoscopic cooperative surgery. Pathologically, proliferative spindle cells with a positive reaction for smooth muscle actin, negativity for c-kit, desmin, s-100, CD34, STAT-6, ß-catenin and anaplastic lymphoma kinase 1 were identified. Hence, the tumor was finally diagnosed as an IMT originating from the stomach. CONCLUSIONS: When an SMT of the stomach is identified, the possibility of gastric IMT should be considered.

Gastric Schwannoma-Two Unusual Cases with Usual Presentation and Review of Literature.

Schwannomas, also known as neurilemmomas, are characteristically benign, slow growing neoplasms originating from Schwann cell sheath. Gastrointestinal schwannomas are very rare with stomach being the most affected organ representing approximately 0.2% of all gastric tumours. Malignant transformation is rarely reported in these tumors and complete surgical resection with negative margins is the recommended treatment. Herein, we report our experience of 2 cases of gastric submucosal spindle cell tumour (SMT), which were preoperatively assumed to be as gastrointestinal stromal tumor (GIST), however postoperatively confirmed as schwannoma on immunohistochemical examination.

Analysis of Thoracoscopic Enucleation Combined with Esophagoscopy in the Prone Position for Esophageal Submucosal Tumor.

Background: Esophageal submucosal tumors (SMTs) are rare, occurring in less than 1% of esophageal neoplasms. For surgical treatment of esophageal SMTs, enucleation is usually the procedure of choice for benign tumors. This study aimed at evaluating the surgical technique and outcomes of thoracoscopic enucleation with esophagoscopy for esophageal SMTs. Methods: Patients with esophageal SMTs who underwent thoracoscopic enucleation between 2015 and 2022 were retrospectively investigated. Surgery was performed with the patient in the prone position. First, an esophagoscope was inserted, and a sodium hyaluronate solution with indigo carmine dye was injected into the submucosal layer just below the tumor. Next, under thoracoscopy, the tumor was exposed through a thoracoscopic incision and dissection of the muscularis propria and adventitia was performed at the tumor site. The colored layer resulting from the previously injected dye was identified, and tumor enucleation was performed under guidance of the dye so as not to damage the mucosa or pseudocapsule. Results: In total, 5 surgeries were performed. The mean operative time was 122.6 minutes (range 84-168 minutes), mean blood loss was 21.1 mL (range 0-80 mL), and mean postoperative hospital stay was 8 days (range 7-10 days). There were no postoperative complications. Pathological diagnosis revealed 2 cases of gastrointestinal stromal tumors, 2 cases of schwannoma, and 1 case of leiomyoma. Conclusions: We believe that this technique is a useful and safe method of performing thoracoscopic enucleation of esophageal SMTs because the injected dye provides an indicator of the resection line during enucleation.

Surgical tips and tricks for laparoscopic intragastric surgery for submucosal tumors relative to the esophagogastric junction.

Recent reports have described the practicality of laparoscopic intragastric surgery (l-IGS) as an alternative for resecting submucosal tumors (SMTs) near the esophagogastric junction (EGJ), where excision using an exogastric approach would be difficult. However, even using IGS to perform a full-thickness resection of SMTs that are in or extremely close to the EGJ is very difficult to do safely and avoid disrupting or causing stenosis of the EGJ, without advanced experience. This study retrospectively examined the usefulness of l-IGS for gastric SMTs located in or extremely close to the EGJ. Fourteen patients with gastric SMTs < 2 cm of the EGJ and underwent l-IGS were eligible for this study. We examined the tumor location, operative time, intraoperative hemorrhage, degree of deformation, gastroesophageal reflux disease, perioperative complications, and recurrence. Furthermore, we compared patients with tumors in the EGJ with those with tumors near the EGJ and patients in whom three-port l-IGS was performed with those who underwent single-incision laparoscopic surgery. The average tumor size, operative time, intraoperative hemorrhage, and postoperative hospitalization of the 14 patients were 30.9 ± 21.3 mm, 125.2 ± 31.1 min, 30.7 ± 103.3 mL, and 9.2 ± 3.1 d, respectively. No differences in these parameters according to the type of l-IGS or tumor location were observed. All patients underwent l-IGS without complications and were free from EGJ deformation or esophagitis. We believe that l-IGS is useful for gastric SMTs located < 2 cm of the EGJ as it can be safely performed for difficult tumor locations and does not cause deformation of the EGJ.