Thoracoscopic enucleation of a gastrointestinal stromal tumor of the esophagus

Minimally Invasive, Organ-preserving Surgery for Large Submucosal Tumors in the Abdominal Esophagus

BACKGROUND

Surgical resection of submucosal tumors (SMTs) in the abdominal esophagus is not standardized. Enucleation may be a minimally invasive option, whereas its oncological validity is not very clear. Moreover, how to treat the esophageal wall defect after enucleation and necessity of additional antireflux procedure are also undetermined.

METHODS

In 13 patients with a SMT originating the abdominal esophagus laparoscopic enucleation was performed with preserving the integrity of submucosa. When the muscular layer defect was <4 cm it was directly closed by suturing, whereas it was left open in case the defect was larger. Fundoplication was added when the esophagus was dissected posteriorly or the myotomy was not closed.

RESULTS

Tumors were resected en-bloc without rupture in all cases. In 5 patients myotomy was closed, whereas in the remaining 8 it was left open. In 11 patients fundoplication was added (Toupet in 5 and Dor in 6). The patients developed neither regurgitation nor stenosis postoperatively. The histopathologic findings revealed leiomyoma in 9 patients, whereas the other 4 were miscellaneous. The average tumor size was 5.5 cm (range, 2.8 to 8.8). Microscopically surgical margin was negative in all cases.

CONCLUSIONS

Laparoscopic enucleation of SMTs in the abdominal esophagus seems to be safe, reproducible operation enabling preservation of function of the lower esophagus and esophagogastric junction. Even when the muscular defect is not approximated additional fundoplication can minimize the risk of postoperative reflux disease.

Clinicopathologic Features and Clinical Outcomes of Esophageal Gastrointestinal Stromal Tumor: Evaluation of a Pooled Case Series

Clinicopathologic features and clinical outcomes of gastrointestinal stromal tumors (GISTs) in esophagus are limited, because of the relatively rare incidence of esophageal GISTs. Therefore, the aim of the current study was to investigate the clinicopathologic features and clinical outcomes of esophageal GISTs, and to investigate the potential factors that may predict prognosis.Esophageal GIST cases were obtained from our center and from case reports and clinical studies extracted from MEDLINE. Clinicopathologic features and survivals were analyzed and compared with gastric GISTs from our center.The most common location was lower esophagus (86.84%), followed by middle and upper esophagus (11.40% and 1.76%). The majority of esophageal GISTs were classified as high-risk category (70.83%). Mitotic index was correlated with histologic type, mutational status, and tumor size. The 5-year disease-free survival and disease-specific survival were 65.1% and 65.9%, respectively. Tumor size, mitotic index, and National Institutes of Health risk classification were associated with prognosis of esophageal GISTs. Only tumor size, however, was the independent risk factor for the prognosis of esophageal GISTs. In comparison to gastric GISTs, the distribution of tumor size, histologic type, and National Institutes of Health risk classification were significantly different between esophageal GISTs and gastric GISTs. The disease-free survival and disease-specific survival of esophageal GISTs were significantly lower than that of gastric GISTs.The most common location for esophageal GISTs was lower esophagus, and most of the esophageal GISTs are high-risk category. Tumor size was the independent risk factor for the prognosis of esophageal GISTs. Esophageal GISTs differ significantly from gastric GISTs in respect to clinicopathologic features. The prognosis of esophageal GISTs was worse than that of gastric GISTs.

Tunneling endoscopic muscularis dissection for subepithelial tumors originating from the muscularis propria of the esophagus and gastric cardia

BACKGROUND AND AIMS

Endoscopic resection of esophageal or cardial subepithelial tumors (SETs) originating from the muscularis propria (MP) is rarely done due to the high risk of perforation, fistula formation, and secondary infection. The aim of this study was to evaluate the preliminary clinical feasibility and safety of tunneling endoscopic muscularis dissection (tEMD) for resection of SETs located in the esophagus and gastric cardia

METHODS

Twelve patients with SETs originating from the MP of the esophagus (n = 7) or cardia (n = 5) were treated by tEMD. The procedure included creation of a submucosal tunnel to reach the tumor, dissection of the tumor from the surrounding submucosal tissue and the unaffected MP layer, full-thickness resection of the tumor and affected MP, and subsequent closure of the tunnel mucosal entry with endoscopic clips.

RESULTS

The en bloc resection rate was 100 % (seven lesions affected the deep MP so complete MP resection was performed; five lesions affected the superficial MP for a partial MP resection). The average tumor size was 18.5 ± 6.9 (range 10-30) mm. The mean operating time was 78.3 ± 25.5 (range 50-130) min. The histological diagnoses were two gastrointestinal stromal tumors with very low risk, nine leiomyomas, and one schwannoma. Air leakage and effusion included subcutaneous and mediastinal emphysema in eight patients (66.7 %), pneumothorax in four (33.3 %), pneumoperitoneum in three (25.0 %), and small pleural effusion in two (16.7 %). All air leakage and effusion cases were resolved with conservative management. No patient developed delayed hemorrhage and chronic fistula after tEMD. During the mean follow-up time of 7.1 ± 4.3 (range 2-15) months, no tumor recurrence was found in any patient.

CONCLUSIONS

tEMD appears to be a feasible minimally invasive and effective treatment for patients with SETs originating from the MP layer of the esophagus and cardia.