Thoracoscopic enucleation of leiomyoma of the oesophagus

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.

Video-assisted thoracoscopic surgery (VATS) enucleation of large gastroesophageal junction leiomyoma: A case report

Introduction and importance

Esophageal leiomyomas are the most common benign esophageal tumors. They are typically smaller than 3 cm, but larger tumors can impede local structures to cause symptoms, including dysphagia and epigastric pain. Surgical treatment of esophageal leiomyomas has historically involved open thoracotomy, but this approach is being replaced by minimally invasive approaches, including video-assisted thoracoscopic surgery (VATS).

Case presentation

A 46-year-old female patient presented with upper abdominal pain. Computerized tomography (CT) scanning of the abdomen and chest revealed a large (6.0 × 4.0 × 3.0 cm) gastroesophageal junction (GEJ) mass. An endoscopic ultrasound (EUS) with fine needle aspiration confirmed diagnosis of esophageal leiomyoma. A right VATS esophageal mass resection was performed to enucleate the mass. An intraoperative EGD was performed to check mucosal integrity, ensure adequate lumen patency, and visualization and insufflation was negative for a mucosal leak. The post-operative course was unremarkable.

Clinical discussion

This case report adds to the emerging evidence that VATS can be utilized for enucleation of larger leiomyomas (>5 cm in largest dimension). Additionally, the use of direct intraoperative endoscopic evaluation via esophagoscopy suggests that larger esophageal masses could potentially be enucleated with a combined VATS and endoscopic approach.

Conclusion

The purpose of this report is to add to the limited literature on minimally invasive surgical treatment of a relatively large GEJ leiomyoma. This case highlights that VATS, in addition to simultaneous endoscopic visualization, is an efficacious and safe option for treatment of larger leiomyomas (>5 cm) and can be associated with minimal risk.

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VATS can be utilized for enucleation of larger gastroesophageal leiomyomas (>5 cm)

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Direct endoscopic evaluation can be used during VATS to examine mucosa integrity

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VATS may be associated with fewer intraoperative and post-operative complications

Surgical Treatment for Esophageal Leiomyoma: 13 Years of Experience in a High-Volume Tertiary Hospital

Background

Esophageal leiomyoma is the most common benign tumor in the esophagus. Thoracotomy and thoracoscopy are both elective for esophageal leiomyoma enucleation. This study aimed at presenting surgical experience in our center and exploring more suitable surgical methods for different situations.

Methods

We conducted this retrospective study by collecting data from patients who underwent esophageal leiomyoma enucleation through thoracotomy or thoracoscopy from January 2009 to November 2021 at West China Hospital Sichuan University.

Results

A total of 34 patients were enrolled for analysis. All patients were diagnosed with a single esophageal leiomyoma. There were 25 men and 9 women. The mean age was 44.41 years (range, 18–72 years), the mean longest diameter was 4.99 cm (range, 1.4–10 cm), and the esophagus was thoroughly circled with leiomyoma in 10 patients, 10 patients underwent thoracotomy to enucleate leiomyoma, while others underwent thoracoscopic enucleation. No perioperative deaths occurred. Between the thoracotomy group and thoracoscopy group, baseline characteristics were comparable except for gastric tube status (p = 0.034). Patients were inclined to undergo the left lateral surgery approach (p = 0.001) and suffered esophagus completely encircled by leiomyoma (p = 0.002). Multivariable logistic regression analysis demonstrated that the left lateral surgery approach (p = 0.014) and esophagus completely encircled by leiomyoma (p = 0.042) were risk factors for thoracotomy of leiomyoma enucleation, while a larger tumor size demonstrated no risk. The median follow-up time was 63.5 months, and no deaths or recurrence occurred during the follow-up period.

Conclusion

Thoracotomy enucleation of the leiomyoma was recommended when the esophagus was thoroughly encircled by the leiomyoma and the left lateral surgery approach was needed. However, tumor size demonstrated less value for selecting a surgical approach.

Robotic-assisted surgery for esophageal submucosal tumors: a single-center case series

Esophageal submucosal tumors (SMTs) are rare heterogenous clinical entities. The surgical resection can be performed in different surgical approaches. However, the robotic surgical strategy is poorly documented in the treatment of SMTs. We present our series of operated esophageal SMTs approached via robotic-assisted surgery. Six patients with symptomatic esophageal submucosal tumors underwent robotic surgery within a 3-year period. The performed procedures were robotic-assisted enucleation, robotic esophagectomy (RAMIE) and reverse hybrid robotic esophagectomy. Patients’ clinical data, intra/postoperative outcomes, and histopathological features were retrieved from the institution’s prospective database. Five of six patients were scheduled for upfront surgery: four underwent robotic enucleation (three leiomyoma and one suspected GIST) and one underwent reverse hybrid robotic esophagectomy (suspected GIST). One patient, diagnosed with GIST, was treated with neoadjuvant Imatinib therapy, before undergoing a RAMIE. No major intra-operative complications were recorded. Median length of stay was 7 days (6–50), with a longer post-operative course in patients who underwent esophagectomy. Clavien–Dindo > 3a complications occurred in two patients, aspiration pneumonia and delayed gastric emptying. The final histopathological and immuno-histochemical diagnosis were leiomyoma, well-differentiated GIST, low-grade fibromyxoid sarcoma and Schwannoma. Robotic-assisted surgery seems to be a promising option for surgical treatment strategies of benign or borderline esophageal submucosal tumors.

Video assisted thoracoscopy or laparoscopy for enucleation of esophageal leiomyoma: A seven-year single center experience of 75 cases

OBJECTIVE

Leiomyoma is the most common benign tumor of the esophagus. Extra mucosal enucleation is the standard treatment. Herein we evaluated the feasibility and the outcomes of Minimally Invasive Surgery (MIS) using video-assisted thoracoscopic (VATS) or laparoscopic surgery (VALS) for esophageal leiomyoma enucleation.

SUBJECTS AND METHODS

Retrospective study of patients who were treated via VATS or VALS for esophageal leiomyoma enucleation in "Hanoi Viet Duc Hospital" from 2010 to 2017 by the same operator. The operative approach, tumor size, complications and outcomes after surgery were recorded.

RESULTS

Seventy-five patients were included. Mean age was 41.9 (range 20-68) years. The male/female sex ratio was 2.1:1. Fifty-five patients had clinical symptoms (73.3%). Tumors were identified in the upper third (12%), middle third (51%), and lower third (37%) of the esophagus. Mean tumor size was 3.7 (range 2-11) cm. VALS enucleation was performed in 23 patients who had leiomyoma located near the cardia (gastroesophageal junction or abdominal esophagus). The remaining 52 patients underwent right (n=42) or left VATS (n=10). Five patients (6.7%) sustained esophageal mucosa injury during dissection, repaired by MIS without late morbidity. A mini-incision (2 mini-laparotomies and 1 thoracotomy) was required in three patients (4%) due to large tumor size or mucosal injury. The mean operative time was 105min in VATS and 174min in VALS. No major perioperative surgical or medical complications were reported. The mean duration of hospital stay was 7.2 (range 5-12) days.

CONCLUSIONS

MIS enucleation of esophageal leiomyoma is technically safe and associated with a high therapeutic success rate with low medico-surgical morbidity. VATS could be applied for almost all esophageal leiomyoma tumors; however, the VALS approach was preferred for tumors located near the gastroesophageal junction in order to create an anti-reflux valve after enucleation.

Giant circumferential esophageal leiomyoma successfully treated by thoracoscopic enucleation with the patient in a prone position: A case report

Esophageal leiomyomas are common benign tumors. Although surgical resection is warranted in symptomatic patients, the procedure used to enucleate a giant, circumferential tumor is complicated. A 38-year-old man was referred to our institution with a diagnosis of submucosal esophageal tumor. An endoscopic examination revealed a protruding submucosal mass in the lower third of the esophagus. Computed tomography scans demonstrated a circumferential mass measuring 90 × 40 mm. Examination of the biopsy specimens resulted in a diagnosis of leiomyoma of the esophagus, and thoracoscopic enucleation of the tumor via the right thorax with the patient in the prone position was planned. Histopathological and immunohistochemical staining of the surgical specimen confirmed the preoperative diagnosis of benign leiomyoma. The patient was discharged on postoperative day 7 without any complications.

Endoscopic submucosal dissection of coexisting early esophageal carcinoma and leiomyoma: a case report and review of the literature

The occurrence of early esophageal cancer located within an area of leiomyoma is extremely rare, and its clinical features and treatment methods have not been well described. We herein report the clinical characteristics, diagnosis, and treatment methods of early esophageal cancer that developed on top of a leiomyoma in the upper third of the esophagus in a 78-year-old woman. All tumor marker concentrations were normal. The leiomyoma was correctly diagnosed as a submucosal tumor by endoscopy and endoscopic ultrasonography. Endoscopic biopsy revealed esophageal squamous cell carcinoma. Both lesions were successfully treated by endoscopic submucosal dissection. The patient was followed up for 6 months without recurrence. Endoscopic submucosal dissection was a successful initial treatment method for esophageal carcinoma coexisting with esophageal leiomyoma in this case.

Clinical Outcomes of Minimally Invasive Enucleation of Leiomyoma of the Esophagus and Esophagogastric Junction

OBJECTIVE

Minimally invasive enucleation is the treatment of choice in symptomatic patients with esophageal leiomyoma. Comprehensive long-term follow-up data are lacking. Aim of this study was to review the clinical outcomes of three procedures for enucleation of leiomyoma of the esophagus and esophagogastric junction.

METHODS

A single institution retrospective review was performed using a prospectively collected research database and individual medical records. Demographics, presenting symptoms, use of proton-pump inhibitors (PPI), tumor location and size, treatment modalities, and subjective and objective clinical outcomes were recorded. Barium swallow and upper gastrointestinal endoscopy were routinely performed during the follow-up. Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) and Short-Form 36 questionnaires were used to compare quality of life before and after treatment.

RESULTS

Between 2002 and 2017, 35 patients underwent minimally invasive leiomyoma enucleation through thoracoscopy (n = 15), laparoscopy (n = 15), and endoscopy (n = 5). The overall morbidity rate was 14.3% and there was no mortality. All patients had a minimum of 1-year follow-up. The median follow-up was 49 (IQR 54) months, and there were no recurrences of leiomyoma. At the latest follow-up, the SF-36 scores were unchanged compared to baseline. However, there was a higher incidence of reflux symptoms (p < 0.050) and PPI use (p < 0.050) after endoscopic treatment.

CONCLUSIONS

Minimally invasive enucleation is safe and effective and can be performed by a variety of approaches according to leiomyoma location and morphology. Overall, health-related quality of life outcomes of each procedure appear satisfactory, but PPI dependence was greater in the endoscopic group.

[Leiomyoma of the esophagus : A further indication for robotic surgery?]

BACKGROUND

Leiomyomas of the esophagus are rare tumors but the most common benign lesion of the esophagus originating from smooth muscle cells. The symptoms are mainly determined by the size of the tumor and are caused by dysphagia and/or retrosternal pain. The majority of patients are however asymptomatic. The diagnostics include esophagoscopy, endosonography and chest computed tomography. Surgery is considered the treatment of choice and ideally involves enucleation of the tumor but may lead to esophagectomy. In addition to the classical open procedures, minimally invasive procedures are also used. Regardless of the selected procedure, a lesion of the mucosa should be avoided.

OBJECTIVE

A review of the literature on thoracoscopic and robotic resections in the treatment of leiomyomas was carried out and an illustration of a clinical case is presented.

MATERIAL AND METHODS

A review of minimally invasive surgical treatment of esophageal leiomyomas is presented. The literature search was carried out in PubMed for publications of thoracoscopic and robotic-assisted thoracic enucleation of leiomyomas of the esophagus. In addition, the robotic-assisted thoracic enucleation of a horseshoe-shaped leiomyoma in the middle third of the esophagus is described.

RESULTS

The enucleation of the esophageal leiomyoma was carried out through a right-sided robotic-assisted operation with one lung ventilation. The surgery time was 143 min. There were no intraoperative or postoperative complications. On the 3rd postoperative day a light diet was started and the thorax drainage was removed. Histopathology confirmed a leiomyoma. The patient was discharged on the 5th postoperative day and free of complaints.

CONCLUSION

Robotic-assisted surgery for leiomyomas of the esophagus is a safe procedure. Taking the available data into account, robotic-assisted thoracic enucleation of leiomyomas was characterized by less mucosal lesions, general complications and a lower conversion rate as well as a shorter hospital stay compared to classical thoracoscopic enucleation. Thus, robotic-assisted surgery can be the method of choice for leiomyomas of the esophagus.

Video-Assisted Thoracoscopic Surgery for Esophageal Leiomyoma: A Ten-Year Single-Institution Experience

OBJECTIVE

This study was a 10-year single-institution experience with surgery for esophageal leiomyomas comparing a minimally invasive approach to thoracotomy.

MATERIALS AND METHODS

A retrospective review of patients who underwent resection of esophageal leiomyomas between 2008 and 2017 was conducted. Information on demographic features, symptoms, the operative approach, and complications was recorded.

RESULTS

Fifty-six patients were enrolled. Forty patients underwent an open surgical approach, and 16 patients were treated using thoracoscopy. There was no postoperative mortality or esophageal leakage. Five patients required the repair of a mucosal injury during resection. There were no statistically significant differences in operative time, blood loss, chest tube duration, or the length of postoperative stay between the video-assisted thoracoscopic surgery (VATS) group and the thoracotomy group. The mean tumor size in the thoracotomy group was larger than that in the VATS group (3.63 ± 2.15 versus 2.23 ± 1.30, P = .01).

CONCLUSIONS

Thoracoscopic enucleation is a safe and effective treatment for esophageal leiomyoma.

Comparison of endoscopic submucosal tunneling dissection and thoracoscopic enucleation for the treatment of esophageal submucosal tumors

BACKGROUND AND AIMS

Endoscopic submucosal tunneling dissection (ESTD) has been proved to be safe and effective for removal of esophageal submucosal tumors (SMTs) and can maintain the mucosal integrity compared with other endoscopic methods. The aim of the study was to estimate the safety and efficacy of ESTD as well as compare its efficacy with thoracoscopic enucleation for esophageal SMTs, which is used increasingly as a minimally invasive approach.

METHODS

We retrospectively collected the clinical data of patients with esophageal SMTs <40 mm who underwent ESTD or thoracoscopic enucleation at Nanfang Hospital between January 2008 and August 2016. Epidemiologic data (sex, age), tumor location, tumor size, en bloc resection rate, adverse events, pathologic results, length of postoperative hospital stay, and cost were compared between ESTD and thoracoscopic enucleation.

RESULTS

A total of 126 patients were included. A total of 74 patients underwent ESTD, and the other 52 underwent thoracoscopic enucleation. There was no significant difference between the 2 groups in sex, age, tumor size, hospitalization expense, infection, adverse events, and en bloc resection rate (P < .05). However, patients in the ESTD group had a shorter operating time, less estimated blood loss, shorter length of postoperative hospital stay, and lower chest pain level (P < .05). Kaplan-Meier curves for disease-free survival also showed no statistically significant difference between ESTD and thoracoscopic enucleation groups during the median follow-up of 19.5 and 42 months, respectively.

CONCLUSIONS

The treatment efficacy was comparable between the ESTD and thoracoscopic enucleation for esophageal SMTs <40 mm. However, there was a significant advantage in the ESTD group for a shorter operating time, reduced postoperative chest pain, and shorter hospitalization.

Comparative study between open and minimally invasive approach in the surgical management of esophageal leiomyoma

INTRODUCTION

Leiomyomas are the most common benign tumors of the esophagus. Although classically surgical enucleation through thoracotomy or laparotomy has been widely accepted as treatment of choice, development of endoscopic and minimally invasive procedures has completely changed the surgical management of these tumors.

MATERIAL AND METHODS

We performed a retrospective review of all esophageal leiomyoma operated at Hospital Universitario Ramón y Cajal (Madrid, Spain) between January 1986 and December 2014, analyzing patients' demographic data, symptomatology, tumor size and location, diagnostic tests, surgical data, complications and postoperative stay.

RESULTS

Thirteen patients were found within that period, 8 men and 5 women, with a mean age of 53.62 years (range 35-70 years). Surgical enucleation was achieved in all patients. In 8 cases (61.54%) a thoracic approach was performed (4 thoracotomies and 4 thoracoscopies), and in 5 cases (38.56%) an abdominal approach was performed (3 laparotomies and 2 laparoscopies); enucleation was carried out through a minimally invasive approach in 6 patients (46.15%). There were no cases of endoscopic resection alone. Surgery mean length was 174.38 minutes (range 70-270 minutes) and median postoperative stay was 6.5 days (range 2-27 days). There was neither mortality nor cases of intraoperative complications were described. No postoperative major complications were reported; however one patient presented important pain in his right hemithorax that required management and long term follow-up by the Pain Management Unit. With a mean follow-up of 165.57 months (median 170; range 29-336 months) no recurrences were reported.

CONCLUSION

Enucleation is the treatment of choice for the majority of esophageal leiomyomas. In our experience, duration of the surgical procedure through minimally invasive approach was longer than surgery through open approach; however, postoperative stay was shorter in the first group. Paradoxically, incision pain after surgery (thoracic neuralgia) was found to be higher in the minimally invasive approach group. Nevertheless, none of the results obtained in the study reached statistical significance, probably due to the small simple size.

Novel methylene blue staining technique for localizing small esophageal leiomyomas during thoracoscopic enucleation

The treatment of choice for leiomyoma, the most common benign esophageal tumor, is thoracoscopic enucleation. One of the most difficult aspects of thoracoscopic enucleation is the precise localization of small tumors (≤1.5 cm) and tumors without external protrusion. No simple, feasible solutions to this problem are available. We developed a novel methylene blue staining technique to localize small esophageal leiomyomas and evaluated the feasibility of our technique. Between January 2013 and July 2014, eight patients with small esophageal leiomyomas (≤1.5 cm) underwent thoracoscopic enucleation in Tongji Hospital. Preoperative endoscopic ultrasonography was performed in all patients. The leiomyomas were located in the middle (n = 5) and lower (n = 3) thirds of the esophagus. We preoperatively injected 0.5-1.0 mL methylene blue in the submucosa adjacent to the tumors under standard gastroscope guidance. The entire staining process took about 10 minutes. Staining was successful in all patients. The unstained tumor was exposed after the blue-stained mediastinal pleura, and overlying muscle were incised longitudinally. All procedures were successfully completed without conversion to open surgery. No abnormalities were detected in the esophageal mucosa. The median operating time was 60 minutes (range, 40-90 minutes). Postoperative histopathology confirmed leiomyoma in all patients. The median postoperative hospital stay was 6 days (range, 5-7 days). No major complications, such as esophageal leakage or esophageal diverticulum, occurred. Endoscopic methylene blue staining is safe and feasible for localizing small esophageal leiomyomas during thoracoscopic enucleation. This method will enable precise and easy enucleation.

Intraoperative esophagoscopy provides accuracy and safety in video-assisted thoracoscopic enucleation of benign esophageal submucosal tumors

Benign esophageal tumors are rare; complete surgical resection is essential for the management of the submucosal tumors. Larger, symptomatic, or non-diagnostic lesions should be resected for both diagnostic and therapeutic indications. Video-assisted thoracic surgery has become a popular treatment in the field of thoracic surgery; however, thoracoscopic esophageal surgery may lead to an increase in operative complications. The effect and safety of thoracoscopic surgery for esophageal submucosal lesions were evaluated. A retrospective study evaluated patients undergoing thoracoscopic treatment of benign submucosal tumors. Between March 2011 and December 2013, 17 patients underwent thoracoscopic resection of benign submucocal tumors. Intraoperative esophagoscopy was performed for tumor localization by transillumination and confirmation of mucosal integrity after enucleation in every patient. Median patient age was 47 years (range 30-65). The median surgery time was 170 minutes (range 80-429). The median tumor size was 3.8 cm (range 1.3-9). The median hospital stay was 4 days (range 2-12). There were 16 leiomyoma and 1 neurogenic tumor. There was one case of conversion to thoracotomy because of residual tumor after enucleation. Mucosal injuries occurred in three patients, two accidentally and one intentionally; each patient was treated with primary repair and confirmed integrity with flexible esophagoscopy at operating room. The small sized tumor with intraoperative esophagoscopy could be localized. Esophagoscopic assistance was necessary in eight patients to have better idea where to make myotomy. There were no major morbidities such as postoperative leakage or mortality. Esophageal submucosal tumors can be treated safely with thoracoscopic surgery. However, intraoperative esophagoscopy allows accurate tumor localization, direction of esophageal access incision, and decreases complications during VATS enucleation of esophageal submucosal tumors.

Retrospective analysis of thoracoscopic surgery for esophageal submucosal tumors

Background

Surgical enucleation is the treatment of choice for esophageal submucosal tumors (SMTs) with symptomatic, larger, or ill-defined lesions. The enucleation of SMTs has traditionally been performed via thoracotomy. However, minimally invasive approaches have recently been introduced and successfully applied. In this study, we present our experiences with the thoracotomic and thoracoscopic approaches to treating SMTs.

Methods

We retrospectively reviewed 53 patients with SMTs who underwent surgical enucleation between August 1996 and July 2013. Demographic and clinical features, tumor-related factors, the surgical approach, and outcomes were analyzed.

Results

There were 36 males (67.9%) and 17 females (32.1%); the mean age was 49.2±11.8 years (range, 16 to 79 years). Histology revealed leiomyoma in 51 patients, a gastrointestinal stromal tumor in one patient, and schwannoma in one patient. Eighteen patients (34.0%) were symptomatic. Fourteen patients underwent a planned thoracotomic enucleation. Of the 39 patients for whom a thoracoscopic approach was planned, six patients required conversion to thoracotomy because of overly small tumors or poor visualization in five patients and accidental mucosal injury in one patient. No mortality or major postoperative complications occurred. Compared to thoracotomy, the thoracoscopic approach had a slightly shorter operation time, but this difference was not statistically significant (120.0±45.6 minutes vs. 161.5±71.1 minutes, p=0.08). A significant difference was found in the length of the hospital stay (9.0±3.2 days vs. 16.5±5.4 days, p<0.001).

Conclusion

The thoracoscopic enucleation of submucosal esophageal tumors is safe and is associated with a shorter length of hospital stay compared to thoracotomic approaches.

Enucleation of esophageal submucosal tumors: a single institution's experience

BACKGROUND

Esophageal submucosal tumors (SMTs) are usually benign, and surgical enucleation is widely accepted as the treatment of choice. The goals of this study were to investigate the surgical outcomes after enucleation of esophageal SMTs and to establish the feasibility of video-assisted thoracoscopic enucleation.

METHODS

We performed a retrospective review of 87 patients who underwent enucleation of esophageal SMTs between 1995 and 2011 at Samsung Medical Center.

RESULTS

There were 59 men and 28 women in the study group, with a mean age of 43.3 years (range, 20-73 years). Fifty-eight (67%) patients were asymptomatic. Among the remaining patients, the most common symptom was dysphagia (n=12). Transthoracic approaches were used in 79 patients, including 63 patients who underwent video-assisted thoracoscopic enucleation. Transabdominal approaches were performed in 8 patients. Pathologic diagnosis included leiomyoma (n=78 [89.7%]), gastrointestinal stromal tumors (GISTs) (n=5 [5.7%]), schwannoma (n=3 [3.4%]), and hemangioma (n=1 [1.1%]). The thoracoscopic enucleation group had a significantly shorter median hospital stay compared with the thoracotomy groups (5 versus 6 days; p=0.013). Overall, there were 2 postoperative leaks, including in 1 patient who underwent reoperation after enucleation. With the exception of 2 patients, there was no other major complications. One patient underwent esophagectomy for tumor recurrence after enucleation of GISTs.

CONCLUSIONS

Overall, surgical outcomes were excellent after enucleation. The thoracoscopic approach was feasible for most patients and was correlated with a shorter hospital stay. However, careful management is warranted after enucleation of GISTs considering the recurrence risk.

Videoendoscopic surgery for the treatment of esophagus' leiomyoma

INTRODUCTION

Leiomyomas are the commonest benign esophageal neoplasms. Surgical treatment is the therapy of choice for such tumors. Open enucleation via thoracotomy has long been the standard procedure. With the emergence of thoracoscopic and laparoscopic approaches, minimally invasive surgery represent interesting alternatives to open surgical procedures.

AIM

To propose endoscopic technique for the treatment of these myomas avoiding thoracotomy.

TECHNIQUE

Enucleation of leiomyoma by: A) thoracoscopy, for thoracic esophageal tumors, or B) laparoscopy to the ones located in abdominal esophagus. A) The operations are performed under general anesthesia with selective intubation of the left lung. Patients are placed in the left lateral decubitus position and mild dorsiflexion. Four work trocars are used, two of 11 mm and two of 5 mm. One of the 11 mm is put in the 6(th) intercostal space in the posterior axillary line to use the 30° endoscope; another, at the same hemi-clavicular line, to take the lung away off surgical site. Other two trocars of 5 mm are installed for working tools of the surgeon, one in the 4(th) space in the posterior axillary line, and another in the 7(th), also in the posterior axillary line. Operations are always initiated by opening the mediastinal pleura, dissection of the tumor with opening the muscle of the esophageal wall, simple enucleation of the tumor and closure of esophageal parietal muscular layer. B) The interventions are done with patients undergoing general anesthesia and placed in the French position. The approach is the same performed to correct the hiatal hernia, and enucleation is done without difficulty.

CONCLUSION

Videosurgery for leiomyomas resection is safe and feasible and provides results similar to open procedure, but with a significant reduction in morbidity.

Thoracoscopic enucleation of a giant leiomyoma of the esophagus

Minimally invasive surgery has gained a rapid development and popularity in the recent years. With these developments in minimally invasive surgery, video-thoracoscopic approaches has become more frequently preferred interventions for benign esophageal lesions. Herein, we report a case of a giant esophageal leiomyoma which was successfully enucleated by video-thoracoscopic approach without any peroperative or postoperative complications.

Successful enucleation of a fluorine-18-fluorodeoxyglucose positron emission tomography positive esophageal leiomyoma in the prone position using sponge spacer and intra-esophageal balloon compression

Recently, prone position esophagectomy for esophageal cancer is thought to be an easier and safer procedure. Here, we introduced prone position for enucleation of the fluorine-18-fluorodeoxyglucose positron emission tomography (FDG-PET) positive esophageal leiomyoma. The patient was a 47-year-old man with a 4 cm mid-thoracic esophageal submucosal tumor. The tumor was enucleated safely without injury of the esophageal mucosa under the gravity effect of the prone position with use of a sponge spacer and Sengstaken-Blakemore balloon. Postoperative examination revealed that the tumor was a leiomyoma that was positive for smooth muscle actin and negative for CD117. Postoperative course was uneventful and the patient was discharged on day 7 after the operation. The prone position with use of a sponge spacer and Sengstaken-Blakemore balloon was a safer and easier procedure for the enucleation of the esophageal submucosal tumor.

Video-thoracoscopic enucleation of esophageal leiomyoma

BACKGROUND

Leiomyoma is the most common benign tumor of the esophagus. Surgical enucleation is indicated in case of symptoms or an unclear diagnosis, and open thoracotomy has long been the standard approach for this procedure. However, enucleation through video assisted thoracoscopic surgery (VATS) has been developed as a preferred approach for most lesions in recent years.

METHOD

Herein we report our twelve patients (seven men and five women, with median age of 42 years) from 2001 to 2009, who underwent enucleation through VATS for esophageal leiomyomas, with a size from 1 to 8 cm in diameter (median: 5), and at different locations, from the thoracic outlet to near the diaphragmatic level of the thoracic esophagus. Intraoperative fiberoptic esophagoscopy was performed in two patients for localization by illumination. A right-sided approach was performed in eight cases (upper two thirds of esophagus) and the left-sided in another four cases (lower third of esophagus).

RESULT

The median operative time was 95 minutes (70 to 230 minutes). Four of them required small utility incisions (4-6 cm) for better exploration and manipulation. There were no major complications, such as death or empyema due to leaks from mucosal tears, and the presenting symptoms were improved during the follow-up period, from 12 to 98 months.

CONCLUSION

VATS can be considered as an initial approach for most patients with esophageal leiomyomas, even large in size, irregular in shape, or at unfavorable location. It is a safe, minimally invasive, and effective treatment. However, conversion to open thoracotomy should be required for the sake of clinical or technical concern.

Thoracoscopic enucleation of esophageal leiomyoma in patient with MEN I syndrome

Minimal invasive thoracic surgery is growing rapidly and may become the standard of care for certain diseases. Its benefits over traditional surgery, including reduced morbidities and hospital stay, have been well established in several reports. We herein report a case of midesophageal leiomyoma in a patient with MEN I syndrome successfully enucleated by thoracoscopy highlighting the technical details of the procedure.

Surgical management of the esophageal leiomyoma: lessons from a retrospective review

Esophageal leiomyoma is the most common benign tumor of the esophagus. Although enucleation via thoracotomy has been considered standard treatment, minimally invasive surgery is increasingly used for the treatment of this disease. We analyzed our surgical outcomes by comparing thoracotomy and the thoracoscopic approach. A retrospective review was performed of patients who underwent surgical resection of esophageal leiomyomas at the Seoul National University Hospital. Between 1982 and 2005, 63 patients were identified (male, n= 39; female, n= 24) at a mean age of 44.5 years. Thirty-two patients (51%) were symptomatic. Forty-five patients underwent thoracotomy, and 18 patients were resected using thoracoscopy. There was no mortality. The mean length of hospital stay was 10.3 days in the open group and 8.0 days in thoracoscopy group. Intraoperative mucosal repair was required in eight patients. Preoperative endoscopic mucosal biopsy within 1 month was identified as a risk factor for mucosal injury. Among the 11 patients with tumors less than 1.5 cm in size, thoracoscopic resection was attempted on four patients, and three out of the four cases required conversions to thoracotomy. Minimally invasive surgery for esophageal leiomyoma can be performed with good results. Our results suggest that the thoracoscopic approach should be considered as a standard surgical method for the treatment of esophageal leiomyoma. However, in cases of small tumors less than 1.5 cm in size, localization of the tumor may be difficult, and if asymptomatic, a regular monitoring should be considered as an alternative approach in such small tumors.

Thoracoscopic enucleation of a gastrointestinal stromal tumor of the esophagus

Since the introduction of thoracoscopy in surgery, many thoracic interventions have been considered feasible and safe via the thoracoscopic route. We report the case of a 42-year-old man with a 7.5-cm esophageal gastrointestinal stromal tumor. Thoracoscopic enucleation of the tumor was performed and the patient was discharged on the third postoperative day after tolerating a full oral diet. Given the well-known advantages of minimally invasive surgery, we believe that removal of esophageal submucosal tumors can be attempted using a thoracoscopic approach, even if the tumor is large.

Minimally invasive surgical enucleation for esophageal leiomyoma: report of seven cases

Benign esophageal tumor is a rare entity, with leiomyoma being the most common lesion. We present our experience with enucleation of esophageal leiomyomas using a minimally invasive approach. Between March 1998 and June 2008, seven patients with esophageal leiomyoma underwent right thoracosopic enucleation (n=4) or laparoscopic transhiatal enucleation (n=3). A Dor (n=2) or Toupet fundoplication (n=1) were added for laparoscopic procedure. The mean tumor size was 3.9 cm (range, 1.5-5.5 cm). Tumor locations were upper (n=2), middle (n=1), and lower (n=4) thirds of the esophagus. No major morbidities including postoperative leakage or mortalities occurred. At a mean follow-up period of 60.1 months (range, 14-260 months), no evidence of recurrences were observed. Thoracoscopic and laparoscopic transhiatal enucleation for esophageal leiomyomas is a safe and feasible procedure. The optimal approaches should be tailored based on the location and size of the tumor.

Enucleation of a leiomyoma of the mid-esophagus through a right thoracoscopy with the patient in prone position

BACKGROUND

Leiomyoma is the most common benign esophageal neoplasm. Different open and minimally invasive approaches have been described. We describe a right thoracoscopic enucleation with the patient in the prone position.

METHOD

A 49-year-old woman consulted us about solid-diet dysphagia without other symptoms. Preoperative work-up showed the presence of 50 x 28-mm leiomyoma of the middle esophagus, without satellite lymph nodes. The patient underwent general anesthesia with a double-lumen endotracheal tube, and subsequently was placed in the prone position. A 30 degrees scope was introduced in the right 7th intercostal space on the posterior axillary line. Perioperative gastroscopy permitted localization of the lesion, which appeared to be situated at the level of the azygos vein. Two 5-mm trocars were inserted in the right 5th and 9th intercostal spaces on one line with the first one. The azygos vein was ligated. The muscular layer of the mid-esophagus was opened by coagulating hook. Due to a 2-mm trocarless Cadière's forceps (Microfrance, France), introduced into the right 7th intercostal space, the operative field was well exposed and the lesion was enucleated without mucosal perforation. The muscular layer was closed by interrupted silk 2/0 stitches. A drain was left in the chest cavity.

RESULTS

Total operative time was 85 min and blood loss was less than 20 ml. The gastrograffin swallow on postoperative day 2 showed good clearance of the esophagus and absence of leak, hence the patient was allowed a liquid diet. The patient was discharged on postoperative day 3. Benign pathology was confirmed.

CONCLUSION

Thoracoscopy in the prone position permits the surgeon to reach the esophagus under excellent working conditions, despite an only partially deflated lung. Gravity displaces blood loss eventually, which allows good visualization, and the surgeon can operate in an ergonomic position. This approach allows for fewer trocars which favorably influences the patient's comfort and reduces the length of hospital stay.

Thoracoscopic enucleation of esophageal leiomyoma: a retrospective study on 40 cases

Esophageal leiomyoma is the most common benign esophageal tumor. Thoracoscopic enucleation is currently a preferred approach to most of these lesions. We present our experiences of enucleation of these tumors using thoracoscopic approach. A retrospective review of 40 patients who underwent enucleation of esophageal leiomyoma from 1997 to 2007 in our institute was conducted. Presenting symptoms, operative approach, tumor size, tumor shape, outcomes, and indication for this approach were analyzed. Forty patients were identified. Postoperative histopathology confirmed the leiomyoma in all patients. The thoracoscopic enucleation was completed in 34 cases, and the operation was converted to open procedure in six cases. Reasons for conversion included too small tumors to be visualized in two cases, thoracic cavity adhesion in one case, and the too large tumors in three cases. The median operating time was 70 min (50 to 210 min). Mean tumor size was 3.7 cm (0.5-10 cm). There were no major postoperative complications. Symptoms especially dysphasia were relieved postoperatively. Short- and long-term follow-up was satisfactory with none of the patients having tumor recurrences or other problems. Thoracoscopic enucleation of esophageal leiomyoma is technically safe and effective. It is currently the best choice for management of esophageal leiomyoma 1 to 5 cm in diameter. It can also be tried on a tumor larger than 5 cm, although the possibility of conversion to thoracotomy increases along with tumor growing and surrounding the esophagus.

Minimally invasive surgical enucleation or esophagogastrectomy for benign tumor of the esophagus

Experience in surgical resection of benign tumor of the esophagus is limited. Authors performed a chart review of 5 patients who underwent minimally invasive surgical resection of benign esophageal tumor. Main outcome measures included operative approaches, tumor's location and size, and outcomes. Tumor location were middle esophagus (n = 1), distal esophagus (n = 2), and gastroesophageal junction (n = 2). There were 4 females with a mean age of 55 years. Surgical approaches included thoracoscopic enucleation (n = 1), laparoscopic enucleation (n = 1), and laparoscopic and thoracoscopic Ivor Lewis esophagogastrectomy (n = 3). There were no open conversions. Mean operative time for enucleation was 127 minutes and 240 minutes for Ivor Lewis esophagectomy. Mean hospital stay was 5.8 days. There were no major or minor complications. Three patients developed stomal stenosis. The 30-day mortality was zero. Surgical pathology showed leiomyoma in 3 patients and gastrointestinal stromal tumor in 2 patients. Tumor size ranged from 1.1 to 10.5 cm. There has been no tumor recurrence at a mean follow-up of 14 months. Minimally invasive surgical enucleation or esophagogastrectomy for benign esophageal tumor is feasible and safe. The optimal approaches should be tailored based on the location and size of the tumor.

Minimally invasive therapy for benign tumors of the distal third of the esophagus--a single institute's experience

INTRODUCTION

Traditionally, the treatment of benign esophageal tumors is enucleation achieved via a thoracotomy. Since 1992, many reports of thoracoscopic and laparoscopic approaches have been published. In this paper, we present a retrospective study of 18 patients with benign distal esophageal tumors who underwent minimally invasive procedures.

MATERIALS AND METHODS

A total of 18 patients were treated in our institute form 1994 to 2006. Tumors of the middle third were approached thoracoscopically, and laparoscopic transhiatal enucleation was performed for tumors of the lower third. One patient had associated achalasia cardia, for which a cardiomyotomy with Toupet fundoplication was also performed, and another patient underwent an esophagectomy for a large tumor.

RESULTS

There were 12 males and 6 females and the average age was 59 years. The majority of the tumors were in the lower third, and the most common type of tumor was leiomyoma. Postoperative complications were recorded.

DISCUSSION

Leiomyomas are the most common benign tumors and are located frequently in the middle and lower third. Based on our experience, we feel that lower esophageal tumors are best approached by a laparoscopic transhiatal route and midesophageal tumors by a right thoracoscopic approach.

CONCLUSIONS

Minimally invasive surgery for benign esophageal tumors is ideal, reducing the morbidity of conventional methods.

Minimally invasive enucleation of esophageal leiomyoma

BACKGROUND

Leiomyoma accounts for 70% of all benign tumors of the esophagus. Open enucleation via thoracotomy has long been the standard procedure, but thoracoscopic and laparoscopic approaches have recently emerged as interesting alternatives. To date, only case reports or very small series of such techniques have been reported. The authors report their experience over the past decade.

METHODS

Between January 1999 and August 2005, 11 patients (6 men and 5 women; median age, 44 years) underwent surgery after presenting with dysphagia, chest pain, or heartburn. The surgical approaches included right video-assisted thoracoscopy (n = 7) for tumors of the middle lower third of the esophagus and laparoscopy (n = 4) for tumors within 4 to 5 cm of the lower esophageal sphincter or located at the gastroesophageal junction (GEJ). Intraoperative endoscopy with air insufflation during enucleation was used to confirm mucosal integrity and safeguard against esophageal perforation. Reapproximation of the muscle layers was performed after tumor enucleation to prevent the development of a pseudodiverticulum. A Nissen or Toupet fundoplication was added for patients undergoing laparoscopic enucleation of the leiomyoma.

RESULTS

The median operative time was 150 min. All tumors were benign leiomyomas (median size, 4.5 cm). One leiomyoma located at the gastroesophageal junction required intraoperative mucosal repair with three stitches for an esophageal perforation (preoperative biopsies had been taken). There were no major morbidities, including deaths or postoperative leaks. The median postoperative hospital stay was 6 days. All the patients were free of dysphagia during a median followup period of 27 months. One patient had a small (< 2 cm) asymptomatic pseudodiverticulum at the 6-month follow-up endoscopy.

CONCLUSIONS

Video-assisted enucleation of esophageal leiomyoma can be performed effectively and safely with no mortality and low morbidity. Thoracoscopic and laparoscopic techniques for the removal of esophageal leiomyomas may be recommended as the treatment of choice in centers experienced with minimally invasive surgery.

Thoracoscopic management of benign tumors of the mid-esophagus: a retrospective study

Benign esophageal tumors are rare conditions. Traditionally, thoracotomy was the preferred route to approach these lesions. Now, increasingly more surgeons are using minimally invasive techniques to treat these benign mid-esophageal lesions. We present our experiences from a specialised minimally invasive surgery unit. We have managed 12 patients with benign tumors of the mid-esophagus from 1995 to 2007 in our institute. The enucleation was achieved with the patient placed in the prone position and approached via a right thoracoscopy in all cases. Hospital stay was 3-5 days and there were minor postoperative complications in 2 patients. Mortality was nil. There were 10 patients with leiomyoma and 2 with GISTs, as proved by immunohistochemistry. Short and long-term follow up was satisfactory, with none of the patients having recurrences or other problems. Leiomyomas and GISTs, respectively, are the commonest benign tumors of the esophagus. Tumors more than 5 cm have to be enucleated, and thoracotomy has been the traditional approach to these lesions. Thoracoscopy has definite benefits regarding reduced morbidity. The combined modality of peroperative endoscopy is useful in locating the lesion as well as confirming its complete removal. Based on our experience, a right thorax approach and the prone patient position is the ideal for thoracoscopic procedures.

[Unexpected tumour of the distal esophagus]

We report a patient with unexpected intraoperative diagnosis of a big leiomyoma of the distal esophagus found during laparoscopic repair of a typ III hiatal hernia complicated by Cameron ulcer and chronic anaemia. Laparoscopic transhiatal enucleation of the tumour was performed with closure of the myotomy, Nissen fundoplication, and crural repair. Briefly, the literature of leiomyoma of the esophagus is reviewed with special regard to different therapeutic strategies.

Thoracoscopic enucleation of a large esophageal leiomyoma using a three thoracic ports technique

Background

Video assisted thoracoscopic resection of an esophageal leiomyoma offers distinct advantages over an open approach. Many papers have described various techniques of thoracoscopic resection.

Case presentation

We describe a 32-year old man who presented with intermittent dysphagia. Imaging studies showed a large esophageal leiomyoma. He underwent thoracoscopic enucleation using a three thoracic-ports technique.

Conclusion

Thoracoscopic enucleation can be technically performed using a three thoracic-ports technique.

Enucleation of Esophageal Leiomyoma with Azygos Continuation of the Inferior Vena Cava: Report of a Case

We herein report a rare case of esophageal leiomyoma in an 18-year-old woman with azygos continuation of the inferior vena cava. A submucosal tumor was located in the left wall of the esophagus behind the carina. The enlarged azygos vein made video-assisted thoracic surgery so difficult that conversion to a minithoracotomy and transection of the right superior intercostal vein were necessary to fully visualize the tumor. A pathological diagnosis revealed leiomyoma. Our experience suggests that a transection of the right superior intercostal vein is effective for the proper exposure of an esophageal tumor located behind the carina in a patient with an enlarged azygos vein.

Thoracoscopic enucleation of a giant submucosal tumor of the esophagus

Since the introduction of thoracoscopy in the surgical field, many thoracic interventions have been considered feasible via thoracoscopic route. The authors reported a case of thoracoscopic enucleation of a giant esophageal submucosal tumor (8.5 cm in diameter) situated along the left side of the midesophagus. Histopathologic evaluation revealed a gastrointestinal stromal tumor (GIST). Postoperative period was uneventful and the patient was discharged on the eighth postoperative day. Given the well-known advantages of minimally invasive surgery, we assume that the removal of esophageal submucosal tumors can first be attempted by thoracoscopic approach, even if the tumor is of a big size. In cases of histopathologically unknown tumors preoperatively, definitive examination of the complete specimen provides the basis for further therapeutic decisions.

Thoracoscopic enucleation of esophageal stromal tumor

Gastrointestinal stromal tumor is a rare entity, especially in the esophagus. We report a patient with a stromal tumor of the esophagus who underwent a thoracoscopic enucleation of the tumor. The patient was a 61-year-old man complaining of slight dysphagia. A submucosal tumor of the middle thoracic esophagus was found endoscopically. The tumor was approximately 4.0 cm in diameter measured by endoscopic ultrasonography. On 17 May 2001, thoracoscopic enucleation of the esophageal tumor was performed using a Kodama Di-suction. The Kodama Di-suction was useful for the thoracoscopic enucleation of the submucosal tumor of the esophagus, acting as both a dissector and a sucker. The patient's course was uneventful after surgery. Histopathologically the esophageal tumor revealed a high cellularity, consisting of spindle cells, and the tumor cells were immunohistochemically positive for CD34 and c-kit protein, but not for a-smooth muscle actin or S-100 protein. From these findings, the esophageal submucosal tumor was diagnosed as gastrointestinal stromal tumor, distinguished from leiomyoma.

Enucleation of submucosal tumors of the esophagus: minimally invasive versus open approach

BACKGROUND

Surgical enucleation of submucosal tumors (SMTs) of the esophagus (mostly leiomyomas) is indicated when either the tumors are symptomatic or their biological behavior is unclear. The classic approach is a thoracotomy, but tumor enucleation can now also be performed via thoracoscopy or, for distal tumors, via laparoscopy.

METHODS

We assessed our experience with the different approaches in a total of 25 patients (n = 13 minimally invasive approach and n = 12 open surgery). Enucleation of the SMT was the basic surgical principle; the choice of the approach was based on the preference of the surgeon.

RESULTS

Compared to open surgery, the minimally invasive approach reduced pulmonary complications, hospital stay, and postoperative wound-related pain. The operating time was the same for both approaches.

CONCLUSION

Minimally invasive approaches are suitable for the surgical enucleation of submucosal esophageal tumors. Thoracoscopic and laparoscopic techniques are recommended as standard procedures in experienced centers.

Thoracoscopic enucleation of a leiomyoma of the upper thoracic esophagus

The authors present two cases of leiomyoma of the upper esophagus. Both of the cases presented with dysphagia, and one patient complained of pyrosis. An upper gastrointestinal endoscopy showed midesophageal narrowing without mucosal irregularity, suggestive of leiomyoma. The patients were successfully treated by thoracoscopic enucleation of the leiomyoma, using four thoracic trocars. In one patient (Case 1), the azygus vein had to be divided. Both of the patients are asymptomatic in the late-postoperative period.

Minimally invasive techniques for resection of benign esophageal tumors

With the emergence of minimally invasive surgery (MIS), laparoscopy and thoracoscopy have become feasible and safe alternatives to open surgical procedures in the management of esophageal leiomyomas. The indications for MIS resection of leiomyomas at our institution include the presence of symptoms, confirmation of pathology to exclude malignancy, tumors greater than 2 cm in size or tumors that show evidence of growth. Our approach of choice is right video-assisted thoracoscopic surgery (VATS) for tumors of the thoracic esophagus and laparoscopy for tumors of the intra-abdominal esophagus or gastroesophageal junction. A detailed description of these surgical approaches is outlined in the following chapter. At our institution, nine patients, 8 males and 2 females with a mean age of 54 years (range 42-67 years) had a minimally invasive surgical resection of an esophageal leiomyoma between 1995 and 2001. The surgical approaches included right VATS enucleation (6) and laparoscopic enucleation (3). There were no major morbidities, including postoperative leaks or mortalities. The mean hospital stay was 2.3 days. All tumors were benign leiomyomas with average size of 2.73 cm (range 0.9-8 cm) and there was no evidence of recurrence at a mean follow-up of 10 months. Video-assisted enucleation has shown in our institution, as well as in others, that the procedure can be performed safely with low mortality and morbidity. A VATS or laparoscopic approach to the removal of leiomyomas should be the treatment of choice in centers experienced in minimally invasive surgery.

Video-assisted thoracic surgery for diseases within the mediastinum

VATS and concepts of minimal access thoracic surgery have revitalized many aspects of general thoracic surgery, including the surgical approach to diseases and conditions of the mediastinum. Proven surgical options that have been shunned by patients and referring physicians because of the perceived morbidity of thoracotomy have been reconsidered with the emergence of these minimal access surgical options. Continued critical review of the accumulating experience in VATS techniques will refine the surgical indications for VATS and open thoracotomy.

Thoracoscopic enucleation of an esophageal leiomyoma

A series of reports in the literature suggest that video assisted thoracoscopic resection of an esophageal leiomyoma offers distinct advantage over open approach. We describe a patient with esophageal leiomyoma who underwent surgical resection via thoracoscopic approach using four thoracic trocars. The postoperative period was uneventful and the patient was discharged on postoperative day 3.

Giant leiomyoma of the oesophagus and cardia. Diagnostic and therapeutic considerations: case report and literature review

A case of giant leiomyoma of the oesophagus and cardia is presented. Magnetic resonance imaging was particularly useful for assessing the relationship of the tumour to the neighbouring structures. Radical resection was performed by partial oesophagogastrectomy with intrathoracic oesophagogastrostomy. Giant oesophageal leiomyomas present a diagnostic and therapeutic challenge because of their size and the possibility of malignant behaviour.

VATS resection of an oesophageal leiomyoma in a patient with neurofibromatosis Recklinghausen

A series of reports in the literature suggest an association of neurofibromatosis Recklinghausen with intestinal tumors as carcinoids, leiomyomas and leiomyosarcomas. We present a case of a 23-year-old man with severe cutaneous manifestation of neurofibromatosis. Dysphagia was the main symptom. CT scan suggested the diagnosis of an oesophageal leiomyoma. The oesophageal muscle layers were split and the tumor was enucleated by video assisted thoracoscopic surgery (VATS). The postoperative course was uneventful. The patient was drinking liquids from day 1 and was eating a normal diet from day 3 postoperatively. He was dismissed from the hospital on the 4th postoperative day. We conclude that in patients with neurofibromatosis and oesophageal symptoms an intestinal manifestation of the disease in the oesophagus has to be considered and that VATS resection of intramural and extrinsic oesophageal leiomyomas is the treatment of choice.