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A-Lai GH, Hu JR, Yao P, Lin YD. Surgical Treatment for Esophageal Leiomyoma: 13 Years of Experience in a High-Volume Tertiary Hospital. Front Oncol 2022; 12:876277. [PMID: 35530349 PMCID: PMC9071360 DOI: 10.3389/fonc.2022.876277] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 03/16/2022] [Indexed: 12/24/2022] Open
Abstract
BackgroundEsophageal 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.MethodsWe 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.ResultsA 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.ConclusionThoracotomy 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.
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Affiliation(s)
- Gu-Ha A-Lai
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Jian-Rong Hu
- Operating Room of Anesthesia Surgery Center, West China Hospital/West China School of Nursing, Chengdu, China
| | - Peng Yao
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
| | - Yi-Dan Lin
- Department of Thoracic Surgery, West China Hospital, Sichuan University, Chengdu, China
- *Correspondence: Yi-Dan Lin,
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2
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Oyama K, Ohuchida K, Shindo K, Moriyama T, Hata Y, Wada M, Ihara E, Nagai S, Ohtsuka T, Nakamura M. Thoracoscopic surgery combined with endoscopic creation of a submucosal tunnel for a large complicated esophageal leiomyoma. Surg Case Rep 2020; 6:92. [PMID: 32377803 PMCID: PMC7203408 DOI: 10.1186/s40792-020-00854-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 04/23/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND The standard surgical method for symptomatic submucosal tumors (SMTs) or tumors with unclear biological behavior is enucleation. Minimally invasive approaches are usually considered appropriate for surgical enucleation; thus, thoracoscopic and laparoscopic enucleation is performed widely and safely. However, it is sometimes difficult to enucleate large and complicated esophageal tumors using thoracoscopic surgery, and even if rare, there is the risk of requiring thoracotomy or esophagectomy. In the present case, we enucleated a large and complicated leiomyoma safely using a new combined method with endoscopic and thoracoscopic procedures. CASE PRESENTATION A 42-year-old woman presented to our hospital for a detailed examination of an abnormal finding in her health check-up chest X-ray images. She complained of upper abdominal pain after eating, and computed tomography revealed an esophageal tumor measuring 60 mm in length surrounding her lower thoracic esophagus. Esophagogastroduodenoscopy revealed a huge complicated SMT at the esophagogastric junction. Cytological examination with endoscopic ultrasound-guided fine-needle aspiration showed that the tumor was a leiomyoma. To enucleate this large and complicated esophageal SMT safely and without damaging the esophageal mucosa, we performed endoscopic and thoracoscopic procedures. We created a submucosal tunnel, endoscopically, and then performed thoracoscopic surgery to enucleate the tumor completely from the esophageal muscularis. Using these combined procedures, we were able to easily mobilize even a complicated tumor of this size from the mucosa and completed the surgery thoracoscopically without difficulty. As a result, the tumor was dissected safely with a minimal defect in the muscularis and without damaging the mucosa. Finally, we closed the defect in the esophageal muscularis with continuous sutures, thoracoscopically, and closed the entry of the submucosal tunnel using clips, endoscopically. CONCLUSIONS Using these combined procedures, we safely enucleated a huge complicated esophageal SMT. The increased mobility of the tumor after creating the submucosal tunnel contributed to the minimal defect in the muscular layer and prevented injury to the esophageal mucosa, possibly leading to fewer postoperative complications such as esophageal stenosis and local infection.
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Affiliation(s)
- Koki Oyama
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Kenoki Ohuchida
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan. .,Center for Advanced Medical Innovation, Kyushu University, Fukuoka, Japan.
| | - Koji Shindo
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.,Center for Advanced Medical Innovation, Kyushu University, Fukuoka, Japan
| | - Taiki Moriyama
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan.,Department of Diagnostic and Therapeutic Endoscopy, Kyushu University Hospital, Fukuoka, Japan
| | - Yoshitaka Hata
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Masafumi Wada
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Diagnostic and Therapeutic Endoscopy, Kyushu University Hospital, Fukuoka, Japan
| | - Eikichi Ihara
- Department of Medicine and Bioregulatory Science, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan.,Department of Gastroenterology and Metabolism, Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan
| | - Shuntaro Nagai
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Takao Ohtsuka
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
| | - Masafumi Nakamura
- Department of Surgery and Oncology, Graduate School of Medical Sciences, Kyushu University, 3-1-1 Maidashi, Higashi-ku, Fukuoka, 812-8582, Japan
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3
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Concurrent esophageal dysplasia and leiomyoma. Case Rep Gastrointest Med 2014; 2014:804175. [PMID: 25093127 PMCID: PMC4100387 DOI: 10.1155/2014/804175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2014] [Accepted: 06/06/2014] [Indexed: 01/22/2023] Open
Abstract
Esophageal leiomyomas (ELMs) are rare but described in the literature. They are usually benign and do not require resection unless they are large and symptomatic. Most of such masses arise from the muscularis mucosa. It is very uncommon to find epithelial dysplasia overlying a subepithelial leiomyoma. A review of the literature reveals only one prior case of ELM with an overlying epithelia dysplasia and here we report a second case.
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4
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Coskun A, Unubol M, Yukselen O, Yukselen V, Aydin A, Şen S, Onder Karaoglu A. Esophageal Leiomyoma in Patients with Megaloblastic Anemia. Euroasian J Hepatogastroenterol 2014; 4:98-100. [PMID: 29699356 PMCID: PMC5913904 DOI: 10.5005/jp-journals-10018-1110] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Accepted: 06/05/2014] [Indexed: 12/01/2022] Open
Abstract
Esophageal leiomyoma is the most common benign intramural tumor of esophagus. Although its incidence is not exactly known, it is very rare (0.006%-0.1% in autopsy series). It is generally asymptomatic and detected incidentally. Here, we present a rare case report describing coexistence of megaloblastic anemia and esophageal leiomyoma. How to cite this article: Coskun A, Unubol M, Yukselen O, Yukselen V, Aydin A, Şen S, Karaoglu AO. Esophageal Leiomyoma in Patients with Megaloblastic Anemia. Euroasian J Hepato-Gastroenterol 2014;4(2):98-100.
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Affiliation(s)
- Adil Coskun
- Department of Gastroenterology, Adnan Menderes University, School of Medicine, Aydin, Turkey
| | - Mustafa Unubol
- Department of Endocrinology, Adnan Menderes University, School of Medicine, Aydin, Turkey
| | - Ozden Yukselen
- Department of Pathology, Adnan Menderes University, School of Medicine, Aydin, Turkey
| | - Vahit Yukselen
- Department of Gastroenterology, Adnan Menderes University, School of Medicine, Aydin, Turkey
| | - Ahmet Aydin
- Department of Gastroenterology, Ege University, School of Medicine, Izmir, Turkey
| | - Serdar Şen
- Department of Thoracic Surgery, Adnan Menderes University, School of Medicine, Aydin, Turkey
| | - Ali Onder Karaoglu
- Department of Gastroenterology, Adnan Menderes University, School of Medicine, Aydin, Turkey
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SAKAMOTO K, MIZOBUCHI N, NARUMI K, WATABE S, OKUZAWA A, SHIROTA S, KAJIYAMA Y, KOBAYASHI S, HAYASHIDA Y, KAMANO T, TSURUMARU M, FUNABIKI H. A Case of Esophageal Cyst Excised Successfully Using Laparoscopy. Dig Endosc 2007. [DOI: 10.1111/j.1443-1661.1999.tb00024.x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/23/2023]
Affiliation(s)
- Kazuhiro SAKAMOTO
- *First Department of Surgery, Juntendo University School of Medicine Tokyo, Japan
| | - Noboru MIZOBUCHI
- *First Department of Surgery, Juntendo University School of Medicine Tokyo, Japan
| | - Kenji NARUMI
- *First Department of Surgery, Juntendo University School of Medicine Tokyo, Japan
| | - Suguru WATABE
- *First Department of Surgery, Juntendo University School of Medicine Tokyo, Japan
| | - Atsushi OKUZAWA
- *First Department of Surgery, Juntendo University School of Medicine Tokyo, Japan
| | - Shigeru SHIROTA
- *First Department of Surgery, Juntendo University School of Medicine Tokyo, Japan
| | - Yoshiaki KAJIYAMA
- *First Department of Surgery, Juntendo University School of Medicine Tokyo, Japan
| | - Shigeru KOBAYASHI
- *First Department of Surgery, Juntendo University School of Medicine Tokyo, Japan
| | - Yasuo HAYASHIDA
- *First Department of Surgery, Juntendo University School of Medicine Tokyo, Japan
| | - Toshiki KAMANO
- *First Department of Surgery, Juntendo University School of Medicine Tokyo, Japan
| | - Masahiko TSURUMARU
- *First Department of Surgery, Juntendo University School of Medicine Tokyo, Japan
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6
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Mutrie CJ, Donahue DM, Wain JC, Wright CD, Gaissert HA, Grillo HC, Mathisen DJ, Allan JS. Esophageal leiomyoma: a 40-year experience. Ann Thorac Surg 2006; 79:1122-5. [PMID: 15797036 DOI: 10.1016/j.athoracsur.2004.08.029] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/13/2004] [Indexed: 01/04/2023]
Abstract
BACKGROUND Esophageal leiomyomas, although infrequent, are the most common benign intramural tumors of the esophagus. They represent 10% of all gastrointestinal leiomyomas and frequently cause symptoms, necessitating resection. METHODS The Massachusetts General Hospital Pathologic Database was reviewed over a 40-year period for patients who underwent surgical resection of esophageal leiomyomas. Data analyzed included demographic information, presenting symptoms, tumor location, tumor characteristics and histology, diagnostic procedures, and treatment modalities/outcomes. Fifty-three patients were identified; 31 patients were symptomatic from their leiomyomas. RESULTS Symptomatic patients presented at a mean age of 44 years old and exhibited a twofold male predominance. Mean tumor diameter among symptomatic patients was 5.3 cm, as compared to 1.5 cm in asymptomatic patients (p < 0.0001). Thirty of the symptomatic patients had solitary leiomyomas, and 1 patient had five separate leiomyomas. Eighty-four percent of the lesions in symptomatic patients occurred in the lower two-thirds of the esophagus, with epigastric discomfort being the most common presenting symptom. Among patients operated on solely for leiomyoma, 97% were enucleated without an esophageal resection. None of the leiomyomas showed malignant transformation or recurrence. All symptomatic patients had relief of symptoms, with no perioperative morbidity or mortality. CONCLUSIONS In a large pathologic series, over half of all patients with esophageal leiomyomas were symptomatic. Larger tumors were significantly more likely to be symptomatic. Local enucleation by a variety of surgical approaches was accomplished in most patients. All symptomatic patients had relief of symptoms, with no perioperative morbidity or mortality. There was no observed tendency for malignant transformation or recurrence.
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Affiliation(s)
- Christopher J Mutrie
- Division of Thoracic Surgery, Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts 02114, USA
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7
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Meirelles GSP, Ravizzini G, Yeung HWD, Akhurst T. Esophageal Leiomyoma: A Rare Cause of False-Positive FDG Scans. Clin Nucl Med 2006; 31:342-4. [PMID: 16714896 DOI: 10.1097/01.rlu.0000218771.35887.7a] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Gustavo S P Meirelles
- Nuclear Medicine Service, Department of Radiology, Sloan-Kettering Cancer Center, New York, NY 10021, USA
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8
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Noguchi T, Hashimoto T, Takeno S, Wada S, Tohara K, Uchida Y. Laparoscopic resection of esophageal duplication cyst in an adult. Dis Esophagus 2003; 16:148-50. [PMID: 12823217 DOI: 10.1046/j.1442-2050.2003.00314.x] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
We present the case of a 26-year-old woman who underwent a successful laparoscopic resection of an esophageal duplication cyst without any other congenital abnormalities. Although computed tomography (CT) scan and endoscopic ultrasonography (EUS) both assisted in determining the correct preoperative diagnosis, the definitive diagnosis was made following pathological examination of the resected lesion.
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Affiliation(s)
- T Noguchi
- Department of Oncological Science (Surgery II), Oita Medical University, Hasamamachi, Oita, Japan.
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9
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Behl A, Soni N, Bedi VS, Chawla N. LEIOMYOMA OF OESOPHAGUS (A Report on Two Cases). Med J Armed Forces India 2001; 57:174-6. [PMID: 27407332 PMCID: PMC4925845 DOI: 10.1016/s0377-1237(01)80149-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- A Behl
- Classified Specialist (Surgery and Oncosurgery), Mumbai-400 005
| | - N Soni
- Post Graduate Trainee (Surgery), Mumbai-400 005
| | - V S Bedi
- Classified Specialist (Surgery and Vascular Surgery), Mumbai-400 005
| | - N Chawla
- Classified Specialist (Pathology), INHS Asvini, Colaba, Mumbai-400 005
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10
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Abstract
BACKGROUND & AIMS Foregut duplication cysts are rare congenital anomalies of enteric origin found most commonly in children and rarely in adults. They are usually found in adults on routine radiological studies and represent a challenging diagnostic problem. Conventional imaging tests do not lead to a conclusive diagnosis. With endoscopic ultrasonography, it is possible to distinguish between cystic and solid masses and to accurately establish the location of the cyst in relation to the gastrointestinal wall and to the mediastinum. METHODS Seven patients who had endoscopic ultrasonography performed because of differentiation between a cystic or solid mass lesion in the chest or abdomen could not be made with conventional radiological methods are described. RESULTS In all patients, a definite diagnosis was established by endoscopic ultrasonography. The diagnosis was confirmed in 2 patients after surgical excision. CONCLUSIONS Surgery can be avoided in patients with asymptomatic enteric duplication cysts diagnosed by endoscopic ultrasonography.
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Affiliation(s)
- A Geller
- Department of Internal Medicine, Mayo Clinic, Rochester, Minnesota, USA
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11
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Gossot D, Fourquier P, el Meteini M, Celerier M. Technical aspects of endoscopic removal of benign tumors of the esophagus. Surg Endosc 1993; 7:102-3. [PMID: 8456366 DOI: 10.1007/bf00704389] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
We describe the technique of thoracoscopic removal of benign tumors of the esophagus. The technical problems of this new approach are described in the context of our initial experience of four cases.
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Affiliation(s)
- D Gossot
- Department of Surgery, Saint-Louis Hospital, Paris, France
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12
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Bondestam S, Salo JA, Salonen OL, Lamminen AE. Imaging of congenital esophageal cysts in adults. GASTROINTESTINAL RADIOLOGY 1990; 15:279-81. [PMID: 2210194 DOI: 10.1007/bf01888796] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
The radiologic imaging of esophageal cysts (EC) in adults is described. These rare cysts, often detected incidentally on routine chest radiographs, seldom produce symptoms, but they may cause precordial sensations, arrhythmias, and dysphagia. They may also bleed and become malignant. As surgical excision is the treatment of choice, the preoperative diagnosis must be exact. For this, magnetic resonance imaging (MRI) or endoscopic ultrasound seem to be the imaging methods of choice even if a plausible diagnosis can be advanced on computed tomography (CT). Chest x-ray or esophagus roentgenogram have little differential diagnostic value.
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Affiliation(s)
- S Bondestam
- Department of Diagnostic Radiology, Helsinki University Central Hospital, Finland
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Abstract
Alimentary tract duplications are rare congenital anomalies with the majority identified in the pediatric age group. However, duplications may be seen in the adult population and require operative excision. A 53-year-old man was seen with vague, nonspecific symptoms and was found to have a complete esophageal and gastric duplication with communication to the normal alimentary tract. Appropriate-for-structure epithelium was noted throughout the length of the duplication.
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Affiliation(s)
- C M Dresler
- Division of Thoracic Surgery, University of Toronto, Ontario, Canada
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Abstract
We present the case of a 67-year-old man with a stenosing leiomyoma of the esophagus, which led to dysphagia. Because of severe concomitant diseases, thoracotomy was not possible in this patient. Endoscopic laser ablation was a fast and successful treatment; more than 2 years have passed without any sign of recurrence.
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Affiliation(s)
- V Lange
- Department of Surgery, Medical University Lübeck, Federal Republic of Germany
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15
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Abstract
Sixteen adult patients with congenital esophageal cysts were operated on between 1957 and 1979. Preoperatively, 7 patients (44%) were asymptomatic and the cyst was found incidentally on a routine chest roentgenogram. Esophageal symptoms were present in only 3 patients (19%), whereas most symptomatic patients had precordial sensations or arrhythmias. A correct preoperative diagnosis was made in only 1 patient. After enucleation of the cyst, preoperative symptoms were alleviated in all patients and short-term results were excellent. However, long-term follow-up 13.2 +/- 5.6 (+/- standard deviation) years later revealed moderate reflux in 9 (64%) of the surviving 14 patients. During esophagoscopy, macroscopic esophagitis was found in 12 (92%) of 13 patients. On histological examination of specimens obtained by forceps biopsy, esophagitis was present in 10 (77%) of 13 patients and included Barrett esophagus in 2. We conclude that, despite excellent early results, long-term follow-up of patients who undergo operation for congenital esophageal cysts is indicated because of the increased incidence of reflux esophagitis.
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16
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Fox V, Neill SA. Thoracotomy for esophageal leiomyomas. Preoperative, intraoperative, and postoperative care. AORN J 1987; 45:1136-47. [PMID: 3647739 DOI: 10.1016/s0001-2092(07)69851-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
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17
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Hjelms E, Thomsen P. Large granular-cell myoblastoma of the oesophagus. SCANDINAVIAN JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 1986; 20:261-5. [PMID: 3027887 DOI: 10.3109/14017438609105935] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
A granular-cell tumour of the oesophagus, the largest hitherto described, was found in a 44-year-old woman. Histologic examination showed an infiltratively growing granular-cell myoblastoma without pleomorphism or mitotic activity. Local extirpation of the tumour was attempted in order to preserve oesophageal continuity. However, a tracheo-oesophageal fistula and stenosis of the previously tumour-bearing area developed and necessitated nasogastric tube feeding for 18 months. Two attempts to close the fistula, including resection of the fistula-bearing tracheal area, failed. Final cure was achieved by subtotal extirpation of the oesophagus and gastro-oesophageal anastomosis in the neck with the stomach placed retrosternally. Normal intake of food was restored after this operation and 30 months later the patient is doing well.
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