Gastric cancer in the excluded stomach after Roux-en-Y gastric bypass is a rare finding and most reported diagnoses are made via surgery. Endoscopic access to the excluded stomach is difficult, even with balloon-assisted enteroscopy. We present the case of a 74-year-old woman with malignant gastric outlet obstruction of the excluded stomach, 41 years after Roux-en-Y gastric bypass. Minimally invasive access to the excluded stomach was obtained by placement of a percutaneous gastrostomy tube, followed by insertion of a pediatric gastroscope through the gastrostomy tube tract. This novel approach provides minimally invasive access to the excluded stomach in patients with high suspicion of pathology in the excluded stomach, when balloon-assisted enteroscopy is not technically feasible or available.