Complete thoracoscopic enucleation of giant leiomyoma of the esophagus: a case report and review of the literature

Thoracoscopic enucleation of a large esophageal leiomyoma in the lower esophagus: challenges and solutions

Esophageal leiomyomas are rare tumors which have been conventionally managed using open surgery. Only few reports describe the enucleation of large or circumferential leiomyoma successfully managed by thoracoscopy. We herein describe a case of a large circumferential esophageal leiomyoma successfully enucleated using thoracoscopy. An asymptomatic 28-year-old gentleman was diagnosed with a posterior mediastinal mass on a screening chest radiograph. On further investigations with computerized tomography scan and endoscopy, he was diagnosed to have a circumferential homogenous 7×5 cm submucosal lesion in the lower end of the esophagus. Magnetic resonance imaging was performed to rule out duplication cyst and positron emission scan to rule out malignancy in view of suspicious features on endoscopic ultrasound. The final provisional diagnosis was benign lesion of the esophagus. Biopsy of tumor was avoided preoperatively to decrease the chances of intraoperative mucosal injury. The patient was planned for a thoracoscopic enucleation. The tumor was enucleated with meticulous dissection in the submucosal plane with use of stay sutures and minimal use of cautery. There was a pinpoint mucosal perforation which was repaired. The integrity of repair was checked using methylene blue insufflation test and endoscopy. The patient had an uneventful recovery with postoperative gastrografin showing no leak or stricture. Conclusively, a large esophageal leiomyoma may be safely enucleated thoracoscopically with meticulous dissection.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12055-021-01196-z.

Robot-assisted thoracoscopic enucleation for a large esophageal leiomyoma: a case report

Background

Video-assisted thoracoscopic surgery (VATS) is being used to treat esophageal submucosal tumors (SMTs) all over the world. However, this technique is difficult when the tumor is large and located on the left side wall of the esophagus, within the upper mediastinum. This is because, with VATS, the surgical forceps have a limited range of motion. Robot-assisted thoracoscopic surgery (RATS) using the da Vinci surgical system may be extremely useful for enucleation of esophageal SMTs within the narrow upper mediastinum.

Case presentation

A female in her thirties experiencing epigastric pain visited our hospital and was diagnosed with a large esophageal leiomyoma within the upper mediastinum. From its size (10 cm), it was judged to have malignant potential. We performed SMT enucleation using RATS with a da Vinci surgical system Xi. This was our second case using this system. The patient was placed in the left lateral position. Four da Vinci trocars (8 mm) were inserted into the 10th, 7th, 5th and 3rd intercostal spaces (ICS), and an assist port was added in the 5th ICS. We opened the superior mediastinal pleura cranially and caudally from the arch of the azygos vein and expanded the superior mediastinum after dividing the azygos vein. We made an incision in the muscular layer of the esophagus and, using a monopolar hook and monopolar scissors, enucleated the esophageal tumor in a protective manner so as not to damage its capsule or mucosa while applying appropriate robot-specific counter traction. We then sewed up the muscularis using 4–0 Vicryl, inserting the endoscope into the thoracic esophagus to substitute for a bougie. In addition, the pleura was sutured using barbed suture. The surgical procedure was straightforward and smooth. The patient was discharged on postoperative day 4 with no surgical complications. The tumor was definitively diagnosed pathologically from paraffin sections as a benign esophageal leiomyoma.

Conclusions

RATS enables more delicate and precise esophageal SMT enucleation without surgical complications, though various challenges remain to be overcome.

Supplementary Information

The online version contains supplementary material available at 10.1186/s40792-021-01212-9.

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.

Extra-mucosal enucleation is still a safe and feasible treatment option of giant esophageal leiomyomas

Esophageal leiomyoma (EL) is rare but still the most common benign tumor of the esophagus. Extra-mucosal enucleation (EME) is the treatment of choice. Many recent reports have favored esophageal resection for giant Esophageal leiomyomas (ELs). The consequence of esophageal resection is well known and it would be radical to consider it as a preferred treatment for giant EL since most of them are still benign. We share case series of five giant ELs managed by EME, avoiding a mucosal breach and hence avoiding potentially morbid esophageal resections.

Laparoscopic approach in the treatment of large leiomyoma of the lower third of the esophagus

Leiomyoma of the lower third of the esophagus is a relatively rare disorder but the most common benign tumor of the esophagus. We present a case of an involuted esophageal leiomyoma, 11 cm in size, treated by the laparoscopic approach. The preoperative computed tomogram visualized a mass 3 × 1.5 cm in diameter in the lower esophagus without an eccentric lumen or compression of nearby organs. Resection of the tumor was indicated according to the patient‘s symptoms and to exclude malignancy. Laparoscopic enucleation of esophageal leiomyoma was performed. The overall operative time was 205 min. The diagnosis of leiomyoma was established on histopathology and immunohistochemistry staining. The patient resumed the intake of a normal diet on the 5^th postoperative day and was discharged from hospital 8 days after the surgery. We have found this minimally invasive operation to be an effective and well-tolerated treatment option, determined by the experience of the surgeon.

A case report of giant esophageal neurofibroma

Esophageal neurofibroma is a rare type of benign esophageal tumor. We presented a case of a 63-year-old man with a 12-cm diameter upper-thoracic esophageal submucosal tumor. Surgery of a thoracotomy was performed to remove the lesion. The postoperative course was uneventful and the patient was discharged on the postoperative day 10. Immunohistochemical staining confirmed the diagnosis of esophageal neurofibroma.

Minimally invasive surgery for giant esophageal leiomyoma: a case report & review of the literatures

Despite the rapid development of minimally invasive surgery, the treatment of esophageal lesions remains controversial. Giant esophageal leiomyoma could be removed once diagnosed, but its operative method is not quite the same as esophageal leiomyoma of small size. We report a case of giant esophageal leiomyoma and review published cases of giant leiomyomas in the past 10 years. A 29-year-old man was admitted to the clinic for the complaints of 2-month history of dysphagia and discomfort. Radiologic and endoscopic findings suggested esophageal lesion in the muscular layer. The VATS enucleation was performed to relieve the patient's symptoms. The patient started oral intake on the 1st postoperative day, with following solid meal. The postoperative course was uneventful, and the patient was discharged on the 8^th postoperative day.

Video Assisted Thoracoscopic Surgical Enucleation of a Giant Esophageal Leiomyoma Presenting with Persistent Cough

Esophageal leiomyoma is a relatively rare tumor of esophagus but it is the most common benign neoplasm of the esophagus. Small esophageal leiomyoma can be observed but larger ones and those producing symptoms should be excised. As observed for other esophageal tumors, dysphagia is its main symptom. Traditionally, open thoracotomy and enucleation are its main treatment but in the last few years video assisted thoracoscopic surgical (VATS) enucleation is gaining recognition with proven advantages of minimally invasive surgery. Herein we present our experience with patient presenting with cough rather than dysphagia as a main symptom, who was diagnosed to be having giant esophageal leiomyoma. VATS guided enucleation was accomplished successfully. Size of lesion was 16 × 4 × 3 cm. Postoperative recovery was uneventful and patient is not having any signs of recurrence, after three years during follow-up period.

Benign esophageal lesions: Endoscopic and pathologic features

Benign esophageal lesions have a wide spectrum of clinical and pathologic features. Understanding the endoscopic and pathologic features of esophageal lesions is essential for their detection, differential diagnosis, and management. The purpose of this review is to provide updated features that may help physicians to appropriately manage these esophageal lesions. The endoscopic features of 2997 patients are reviewed. In epithelial lesions, the frequency of occurrence was in the following order: glycogenic acanthosis, heterotopic gastric mucosa, squamous papilloma, hyperplastic polyp, ectopic sebaceous gland and xanthoma. In subepithelial lesions, the order was as follows: hemangioma, leiomyoma, dysphagia aortica and granular cell tumor. Most benign esophageal lesions can be diagnosed according to their endoscopic appearance and findings on routine biopsy, and submucosal lesions, by endoscopic resection. Management is generally based upon the confidence of diagnosis and whether the lesion causes symptoms. We suggest endoscopic resection of all granular cell tumors and squamous papillomas because, while rare, these lesions have malignant potential. Dysphagia aortica should be considered in the differential diagnosis of dysphagia in the elderly.