Diagnosis and surgical management of benign diseases of the esophagus

Partial oesophagectomy for giant leiomyoma of the oesophagus: report of 7 cases

OBJECTIVES

Oesophageal leiomyoma is the most common benign tumour of the oesophagus. The incidence of leiomyomas larger than 10 cm, defined as giant oesophageal leiomyomas (GELs), has been reported in 17% of all cases. Although computed tomographic scan and endoscopy are usually useful for diagnosis, big and symptomatic masses located in the lower mediastinum remain both a diagnostic and therapeutic challenge.

METHODS

We describe our experience in the management of 7 patients (4 males and 3 females, with a mean age of 41 years) with GEL treated in our department. Radical resection was performed in all cases with partial oesophagectomy in order to relieve symptoms and to obtain a definitive diagnosis.

RESULTS

There was no perioperative mortality. The minimum diameter of the tumours was 15 cm and the maximum was 30 cm. Definitive histological examination confirmed the diagnosis of leiomyoma in all cases without any sign of malignancy. No major postoperative complications developed. Minor complications included partial abdominal wound dehiscence in 1 case, and retention of secretions requiring bronchoscopy in 2. The mean length of hospital stay was 12 days (ranging between 9 and 14 days). After a mean follow-up of 5.4 years (ranging between 12 and 2 years), no sign of recurrence was observed.

CONCLUSIONS

Whereas removal of small oesophageal leiomyomas can be performed by simple enucleation by conventional thoracotomy or video-assisted thoracoscopy, partial oesophagectomy is often necessary for giant lesions. Since it is not possible preoperatively to distinguish GEL from leiomyosarcoma when metastases are absent, partial oesophageal resection is not to be considered an overtreatment and radical resection should always be planned. A gastric tube, in our experience employed as an oesophageal substitute, is effective and could reduce the risk of significant postoperative gastro-oesophageal reflux.

Thoracoscopic enucleation of esophageal leiomyoma in prone position and single lumen endotracheal intubation

INTRODUCTION

Esophageal leiomyomas are the most common benign tumors of the esophagus. Surgical enucleation is warranted for symptomatic patients. Thoracoscopic enucleation is the preferable approach for being less invasive by avoiding the discomfort and complications associated to larger thoracic incisions. The purpose of this study was to review our experience with enucleation of esophageal leiomyoma using a prone-position thoracoscopy technique.

METHODS

Between January 2009 and July 2012, ten patients underwent resection of esophageal leiomyoma by thoracoscopy approach in prone position. Indications for surgical treatment were symptomatic tumors (dysphagia). All patients were followed postoperatively for at least 3 months with contrast x-ray of the esophagus. After single-lumen endotracheal intubation (nonselective intubation) in supine, patients were placed in prone position. Pneumothorax was kept at 6 to 8 mmHg using CO2 insufflation. A myotomy was performed over the tumor using hook cautery carefully protecting the mucosa from injuries. The myotomy was closed with continuous sutures.

RESULTS

The procedures were completed in the prone position in all cases, without any conversion. Mean operative time was 89.2 ± 28.7 minutes. Bleeding was negligible, and there were no intraoperative or postoperative complications. No intensive care unit support was needed for any patient. Chest x-ray in the first postoperative day showed no significant changes in any patient. The mean hospital stay was 3.2 days. Contrast x-ray of the esophagus was normal in all patients at 3 months postoperatively.

CONCLUSIONS

Thoracoscopic enucleation of esophageal leiomyoma is a feasible, simple, and safe procedure. Thoracoscopy in the prone position with CO2 insufflation allows the use of usual technique of intubation and also provides optimal operative field. The advantages of the thoracoscopic approach are less postoperative discomfort and lower risk of complications from open thoracotomy (especially pulmonary).

Robotic-assisted enucleation of a large lower esophageal leiomyoma and review of literature

Leiomyoma is the most common benign esophageal neoplasm. Different invasive surgical approaches have been described for management of such lesions. The literature is reviewed and a robotic assisted left thoracoscopic enucleation with the patient in the right side position is described. A 40-year-old male patient, otherwise healthy, found to have a lower midiastinal mass on screening X-ray, is described. Physical examination and blood tests were within normal limits. Diagnostic work-up included: computerized tomography (CT) scanning of the chest and midiastinum that revealed a 40 × 30 mm mass of the distal esophagus, an upper gastrointestinal endoscopy showed a lower protruding esophageal submucosal mass with intact mucosa, a filling defect was apparent on esophagography. Endoscopic ultrasonography (EUS) showed the same findings, biopsies were taken and leimyoma was diagnosed. Under general anesthesia with a double-lumen endotracheal tube, the patient was positioned on his right side. A 30 robotic scope was introduced in the left 7th intercostal space on the posterior axillary line. Two 8-mm robotic trocars were inserted in the left 5th and 9th intercostals spaces on the same line. Operative field was clearly exposed and an additional 5-mm ethicon trocar was inserted. The inferior pulmonary ligament was released, the parietal pleural space opened, proximal and distal control was achieved using Penrose. The muscular layer of the lower esophagus was opened by coagulation hook, the lesion was enucleated without mucosal penetration. Intraoperative endoscopy permitted localization of the lesion and ensured mucosal integrity. The muscular layer was not closed and the chest drain was left. Total operative time was 200 min and blood loss was less than 20 mL. A Gastrograffin swallow on the first post-operative day showed good esophageal clearance and absence of leak, the patient was allowed a liquid diet. He was discharged on the third post-operative day in a good general condition, benign pathology was confirmed.

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.

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.

Laparoscopic transhiatal approach for benign supra-diaphragmatic lesions of the esophagus: a replacement for thoracoscopy?

Benign esophageal lesions are rare conditions and tumors account for about 10% of all esophageal neoplasms. Epiphrenic diverticula occur in the distal esophagus (the lower 10 cm). Currently, thoracotomy/thoracoscopy is the most popular approach for these conditions. We present our experience of 13 patients (1994-2006) with benign supra-diaphragmatic esophageal lesions that we treated with a laparoscopic transhiatal approach. The lesions included in the series were lower esophageal tumors (n = 8) and epiphrenic diverticula (n = 5). Laparoscopic transhiatal stapler excisions of diverticulum and enucleation of tumors were performed for all patients. Intra-operative endoscopy was used in all the procedures. All patients had an uneventful recovery except one with posterior diverticulum, who had an anastomotic leak. He had a prolonged hospital stay and recovered eventually. There was no mortality. Benign lesions of the lower third of the esophagus can be adequately treated through the transhiatal route. This is probably superior to the traditional approaches of thoracotomy/thoracoscopy as it does away with increased morbidity while maintaining adequate access. An endoscopy is of great value in localizing the lesion and assessing the esophageal lumen size during the application of staples. A laparoscopic transhiatal excision is technically feasible for all benign supra-diaphragmatic lesions and epiphrenic diverticula and is the approach of choice.

Ruptura pós-emética do esôfago: a síndrome de Boerhaave

A ruptura pós-emética do esôfago, também chamada ruptura espontânea ou síndrome de Boerhaave, foi descrita pela primeira vez em 1724 por Herman Boerhaave. Trata-se de uma doença grave, de alta mortalidade e de difícil diagnóstico, tanto por ser rara como por ser freqüentemente confundida com quadros graves mais comuns, como o infarto agudo do miocárdio, a úlcera péptica perfurada e a pancreatite aguda. Descrevemos, a seguir, três casos de pacientes com esta síndrome. Dois foram submetidos ao reparo primário da lesão e um foi submetido à esofagectomia com posterior reconstrução. Houve um óbito por choque séptico no pós-operatório imediato. Os outros dois casos tiveram boa evolução a longo prazo.

The congenital duplication cyst: a rare differential diagnosis of retrosternal pain and dysphagia in a young patient

Congenital cysts are malformations developing from the endoderm and mesoderm of the digestive and respiratory system in the early weeks of gestation. Unilocular or multilocular dysontogenic cysts are most commonly thoracically located adjacent to the trachea and bronchus and the development of an oesophageal duplication cyst in the oesophageal wall is extremely rare. The duplication cyst in the adult is usually asymptomatic and an incidental diagnosis. Potential symptoms include dysphagia and retrosternal pain. Next to endoscopy and computer tomography, endoscopic ultrasonography is mandatory for a distinguished and accurate preoperative evaluation. Transthoracic excision is crucial for definitive diagnosis and inhibition of complications.

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.

Selective application of fundoplication in achalasia

Although esophagomyotomy alone may effectively relieve dysphagia in patients with achalasia, utilization of a complementary fundoplication procedure should be considered for selected patients. Fundoplication is a sensible addition to myotomy in circumstances that suggest high risk for the development of reflux esophagitis. Also, in complicated achalasia, relief of esophageal obstruction by simple myotomy may not be achieved safely. Identification of those pathological features associated with achalasia that merit consideration of fundoplication should improve operative results and reduce morbidity. This paper examines the application of a complementary fundoplication procedure in the operative management of 21 patients with achalasia over a ten-year period.

Benign tumours of the oesophagus and oesophageal cysts

Eighteen patients with benign tumour or cyst of the oesophagus were operated on over a 26-year period at the Department of Thoracic and Cardiovascular Surgery of Uppsala University Hospital. The series comprised 11 cysts and 7 benign tumours, including one case of the rare myoblastoma. The incidence of operations was 0.33 per million population. There was no operative mortality and no subsequent morbidity from the oesophageal disease. The follow-up is complete. A review of the literature confirms that these lesions are rare and that they usually are submucosal. Many are asymptomatic (in our series only about 1/3 caused symptoms). The most common symptoms are those resulting from compression of the oesophagus, which can lead to obstruction and pulmonary complications. It may therefore be warrantable to operate on benign oesophageal tumours and cysts even in the absence of symptoms, thereby also confirming the diagnosis.

Benign tumors and cysts of the esophagus

A large variety of benign tumors has been reported in the esophagus, but the leiomyoma is the most common. The importance of accurate diagnosis and appropriate treatment has been emphasized.

Operation for motor dysfunction of the esophagus

Modern operative treatment of motor dysfunction of the esophagus began in 1949 with the recognition that anastomotic procedures that bypass or destroy the distal esophageal sphincter are associated with the development of reflux esophagitis and stricture. Thirty years later, reflux esophagitis related to esophagomyotomy or intrinsic esophageal disease remains the dominant concern and challenge. This review examines the current status of operative procedures for the management of three important primary disorders of esophageal motility: achalasia, diffuse esophageal spasm, and scleroderma. Relief of esophageal obstruction by esophagomyotomy or reconstruction is the common surgical goal. The addition of a fundoplication procedure to discourage esophageal reflux remains controversial in each disorder. Esophageal resection may become necessary when stricture persists or esophagomyotomy fails to provide lasting relief of dysphagia.

Colon interposition for benign esophageal disease

Our experience for the past seven years with colon interposition is reviewed. Colon interposition resulted in all patients being relieved of symptoms and satisfied with their result. Colon interposition for nondilatable benign esophageal stricture was shown to be efficacious. In patients undergoing colon interposition for a failed esophagomyotomy, excellent or good results were obtained in a thirty month follow-up period with no operative failures.

Acute hiatal hernia with oesophageal perforation following Heller's operation

The unusual complication of acute hiatal hernia with oesophageal rupture following transthoracic oesophagomyotomy is described in 2 cases. Inadvertent disruption and widening of the oesophageal hiatus at the time of surgery coupled with increased intragastric and intra-abdominal pressure were the probable causes. The hiatus should be carefully inspected on completion of the myotomy and anatomical restoration performed if necessary in order to avoid this complication. Urgent surgical intervention, gastric fundal serosal patch repair and intravenous alimentation proved successful in the management of these patients.