Reflux esophagitis with hypotonic LES was demonstrated with 24-hours esophageal pH-manometry. Bortezomib structure The patient was then scheduled for excision of the intramural gastric tumor and laparoscopic antireflux surgery. Figure 1 Ultrasound appearance of iuxta-cardial gastrict GIST. Through an Hasson trocar inserted in the epigastric area and other two 5-mm trocars positioned in the subcostal regions, the mobilization of the esophago-gastric junction was accomplished. Then, two 5-mm radially expandable trocars were inserted through the abdominal and gastric walls and a 5 mm 30�� scope was introduced into the gastric lumen. Through insufflations of the gastric cavity, an endoscopic polipectomy snare introduced per mouth, was maneuvered by an endoscopist who grasped and tractioned the gastric iuxta-cardial lesion (Figure 2).

Figure 2 Position of the two 5-mm expandable trocars and exposure of the dissection plane through the traction of the GIST with the endoscopic grasping. An harmonic scalpel device inserted through the other 5 mm laparoscopic trocar was used to remove the gastric tumor with a sub-mucosal resection. The resection of the lesion was accomplished thanks to the traction made by the endoscopist through the polipectomy snare which allowed an excellent exposure of the site of dissection. This laparoscopic-endoscopic rendez-vous technique made possible a complete resection of the submucosal GIST, which otherwise could have been more challenging and with intraoperative risks of complications (such as perforation), considering the iuxta-cardial location of the tumor.

The specimen was then pulled away from the mouth after its introduction in a small plastic bag. After withdrawal of the expandable trocars and closure of the gastric holes with monofilament non-absorbable sutures, an antireflux floppy Nissen-Rossetti procedure was performed. Performing a ��floppy�� Nissen allowed us not to use a dilator to calibrate the wrap, which could have led to a threatening risk of perforation of the iuxta-cardial region, in the site of the previous surgical dissection. The naso- gastric tube was left in place. Post-operative phase was uneventful. The patient passed gas in day one p.o. and started feeding in the same day, after gastrografin X-ray examination and removal of the nasogastric tube. He was discharged from the hospital in day 4 p.o.

In a 5 years follow-up with clinical observation, endoscopic and CT scan examinations performed every six months for two years and then yearly, neither complaints nor disease recurrence were observed. Pathologic examination confirmed the diagnosis of gastric GIST. The tumor was limited to the submucosa and the resection margins were disease-free. GSK-3 Immunohistochemical analysis revealed the CD117 positivity. Discussion The incidence of GISTs is estimated to be 1,5-2 cases per 100.