Surgical Treatment for Esophageal Leiomyoma: 13 Years of Experience in a High-Volume Tertiary Hospital

MIS for enucleation of leiomyoma of the oesophagus-strategic approach and experience of 19 cases

INTRODUCTION

Leiomyoma of the oesophagus, although rare, is the most common benign tumour to occur in the organ. Surgical approaches have evolved over time from an open thoracotomy or laparotomy to video-assisted thoracoscopic or laparoscopic and now robotic enucleation. We report a series of 19 cases of leiomyoma of the middle- and lower-third oesophagus treated by minimally invasive surgery.

PATIENTS AND METHODS

A retrospective analysis of 19 cases operated at a single tertiary care centre in India was performed. After the diagnosis of a benign oesophageal neoplasm on computed tomography (CT) and endosonography, laparoscopic transhiatal enucleation of the tumour for lower third ( n = 16) and right-sided video-assisted thoracoscopic excision for middle-third tumours ( n = 3) were performed. Dor fundoplication was done after the excision of leiomyomas from the lower oesophagus.

RESULTS

The most common symptom at presentation was retrosternal burning in lower oesophageal tumours, while tumours in the middle third of the oesophagus were asymptomatic and incidentally detected. The size of the tumour ranged from 3 cm to 8 cm in the largest dimension on contrast-enhanced CT scan. The mean operative time was 93 min ranging from 61 to 137 min. The average blood loss was 53 ml. No patient had an iatrogenic oesophageal mucosal injury. There were no conversions to open surgery or major complications including post-operative leak or death. Post-operative recovery was uneventful.

CONCLUSION

The transhiatal approach to lower oesophageal leiomyomas is strategic to avoid complications of thoracoscopy, minimally invasive, cost-effective as compared to robotic surgery, suitable for adequate exposure and safe in the hands of an experienced laparoscopic surgeon.

Circumferential esophageal leiomyoma: Management by combined robotic surgery and intraoperative endoscopy

Leiomyoma is the most common benign tumor of the esophagus. Open thoracotomy, the traditional approach adopted for the enucleation of the esophageal leiomyoma, over the years, has been gradually replaced by video-assisted thoracoscopic surgery. However, this minimally invasive approach has limitations, such as two-dimensional vision and reduced range of motion, which have recently been overcome by technical advantages of robot-assisted surgery. In the surgical management of circumferential esophageal leiomyoma, a combined use of robotic surgery and intraoperative endoscopy may be helpful to facilitate tumor enucleation and to prevent esophageal mucosal injury during the surgical procedure.

Dysphagia Unmasked: A Case Report of Esophageal Leiomyomatosis

Esophageal leiomyomatosis, an uncommon benign condition marked by the proliferation of smooth muscle cells within the esophageal wall, frequently presents diagnostic challenges due to its rarity and diverse clinical manifestations. In this case report, we document the clinical journey of a 28-year-old female who presented with a two-year history of progressive dysphagia. Upon physical examination and endoscopy, a submucosal mass in the lower esophagus was identified, prompting further imaging and subsequent biopsy, which confirmed the diagnosis of leiomyomatosis. A multidisciplinary team recommended surgical intervention, leading to a minimally invasive laparoscopic resection of the esophageal leiomyomas. Postoperatively, the patient experienced a substantial improvement in her dysphagia and was discharged in stable condition. This case not only underscores the importance of a multidisciplinary approach in achieving an accurate diagnosis but also highlights the successful application of minimally invasive surgical techniques for alleviating symptoms in esophageal leiomyomatosis patients. The rarity and varied clinical presentation of this condition emphasize the need for individualized and tailored management strategies.

Esophageal low-grade intraepithelial neoplasia overlying multiple leiomyomas: A case report and review of the literature

BACKGROUND

Esophageal leiomyoma is the most common benign submucosal mesenchymal tumor. Esophageal intraepithelial neoplasia includes low-grade and high-grade intraepithelial neoplasia. The coexistence of epithelial lesions and the subepithelial lesion is rare. We recorded a case of esophageal low-grade intraepithelial neoplasia (LGIN) overlying multiple esophageal leiomyomas and followed with a review of the literature.

CASE PRESENTATION

A 49-year-old female patient came for the treatment of esophageal lesions. The submucosal eminences were observed in the right posterior wall and the left anterior wall of the esophagus by Esophagogastroduodenoscopy (EGD). Additionally, we noticed the mucosa of the right wall with brown background color and the dilated, tortuous vessels by narrow-band imaging (NBI). Then we ensured that the submucosal lesions originated from the esophageal mucosal muscle by endoscopic ultrasonography (EUS) and enhanced CT. Subsequently, the submucosal eminence of the right posterior wall and the overlying mucosal lesion were removed together by endoscopic submucosal dissection (ESD). Postoperative pathological diagnosed esophageal submucosal leiomyoma with focal LGIN. Review EGD showed white scars on the right wall of the upper esophagus three months later, while pathological biopsy showed slight squamous epithelial hyperplasia in the left wall. We decided that the left submucosal lesion can be resected at a selective-time operation, and we continue to follow up as planned.

CONCLUSIONS

The case of intraepithelial neoplasia overlying the submucosal tumor is rare. Either missed diagnosis or overdiagnosis should be avoided through EGD and pathological biopsy.

Video-assisted thoracoscopic surgery (VATS) enucleation of large gastroesophageal junction leiomyoma: A case report

Introduction and importance

Esophageal leiomyomas are the most common benign esophageal tumors. They are typically smaller than 3 cm, but larger tumors can impede local structures to cause symptoms, including dysphagia and epigastric pain. Surgical treatment of esophageal leiomyomas has historically involved open thoracotomy, but this approach is being replaced by minimally invasive approaches, including video-assisted thoracoscopic surgery (VATS).

Case presentation

A 46-year-old female patient presented with upper abdominal pain. Computerized tomography (CT) scanning of the abdomen and chest revealed a large (6.0 × 4.0 × 3.0 cm) gastroesophageal junction (GEJ) mass. An endoscopic ultrasound (EUS) with fine needle aspiration confirmed diagnosis of esophageal leiomyoma. A right VATS esophageal mass resection was performed to enucleate the mass. An intraoperative EGD was performed to check mucosal integrity, ensure adequate lumen patency, and visualization and insufflation was negative for a mucosal leak. The post-operative course was unremarkable.

Clinical discussion

This case report adds to the emerging evidence that VATS can be utilized for enucleation of larger leiomyomas (>5 cm in largest dimension). Additionally, the use of direct intraoperative endoscopic evaluation via esophagoscopy suggests that larger esophageal masses could potentially be enucleated with a combined VATS and endoscopic approach.

Conclusion

The purpose of this report is to add to the limited literature on minimally invasive surgical treatment of a relatively large GEJ leiomyoma. This case highlights that VATS, in addition to simultaneous endoscopic visualization, is an efficacious and safe option for treatment of larger leiomyomas (>5 cm) and can be associated with minimal risk.

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VATS can be utilized for enucleation of larger gastroesophageal leiomyomas (>5 cm)

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Direct endoscopic evaluation can be used during VATS to examine mucosa integrity

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VATS may be associated with fewer intraoperative and post-operative complications