Technical aspects of endoscopic removal of benign tumors of the esophagus

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 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.

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.

Thoracoscopic resection of an esophageal stromal tumor through the left pleural cavity

We describe the technique for endoscopic removal of a stromal tumor of the lower third of the esophagus through the left thoracoscopic approach. The tumor resembled a leiomyoma and was classified as a borderline, potentially malignant lesion after thoracoscopic removal. The technique and clinical implications in such cases are discussed on the basis of current knowledge.

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.

Videothoracoscopic treatment of oesophageal leiomyoma

BACKGROUND

Oesophageal leiomyomas are usually so easily removed that thoracotomy seems out of proportion and thoracoscopic removal is therefore highly desirable.

METHODS

Out of a total of 1003 thoracoscopic operations undertaken between July 1991 and December 1996, seven patients underwent thoracoscopic removal of oesophageal leiomyoma. All of them had been preoperatively studied by oesophagogastroscopy and computed tomographic scanning of the chest which had confirmed the presence of a lesion with benign features. The surgical technique required intubation with a double lumen tube. Operative access was gained through the right chest via three ports and a small utility thoracotomy in the inframammary sulcus. The mean operating time was 120 minutes.

RESULTS

Conversion to open thoracotomy was necessary in one case with a very large horseshoe-shaped leiomyoma which was firmly adherent. The mean postoperative hospital stay was seven days. No intraoperative deaths or postoperative complications occurred.

CONCLUSIONS

The simplicity and safety of the thoracoscopic approach, combined with reduced surgical trauma and postoperative pain and functional and cosmetic advantages, make this technique the approach of choice for the removal of oesophageal leiomyomas.

Thoracoscopic enucleation of an esophageal leiomyoma with balloon dilator assistance

In consideration of the fact that procedures performed thoracoscopically cause less operative trauma and postoperative pain than those performed through an open thoracotomy, we believe that thoracoscopy should replace thoracotomy for the extraluminal transthoracic resection of benign esophageal tumors. We describe herein a new videothoracoscopic technique for performing the enucleation of an esophageal leiomyoma with balloon dilator assistance. The use of the balloon dilator facilitates separation of the tumor from both the mucosal and muscular layers of the esophagus, and may help to prevent perforation.