Esophageal Leiomyoma Research Articles

A novel hybrid approach for enucleation of esophageal leiomyoma

Esophageal leiomyoma is the most common benign tumor of the esophagus, which usually arises from the muscularis propria or muscularis mucosae. Incidence of benign esophageal neoplasms was reported to be in the range of 0.005% to 7.9% in autopsy cases, while leiomyomas account for 70–80% of them (1). Options for management include surveillance for small-sized tumors and surgical or endoscopic resection for large or symptomatic ones. Leiomyoma is commonly located in the lower two-thirds of the esophagus. In open surgery, right-sided surgical approach is preferred for lesions in the middle and upper esophagus, and left-sided approach for those in the distal lower esophagus. Video-assisted thoracoscopic surgery (VATS) for esophageal leiomyoma was first described by Everitt in 1992 (2,3). As scattered researches reported, enucleation of benign esophageal tumors can be performed effectively and safely with low morbidity (4-6), mostly through right-sided approach. The major complication after the enucleation of esophageal leiomyomas is mucosal injury, which may lead to esophageal leakage or perforation. We hereby report a novel approach using combined thoracoscopy and endoscopy to facilitate tumor removal and prevent mucosal injury.

Clinical Outcomes of Minimally Invasive Enucleation of Leiomyoma of the Esophagus and Esophagogastric Junction

ObjectiveMinimally invasive enucleation is the treatment of choice in symptomatic patients with esophageal leiomyoma. Comprehensive long-term follow-up data are lacking. Aim of this study was to review the clinical outcomes of three procedures for enucleation of leiomyoma of the esophagus and esophagogastric junction. MethodsA single institution retrospective review was performed using a prospectively collected research database and individual medical records. Demographics, presenting symptoms, use of proton-pump inhibitors (PPI), tumor location and size, treatment modalities, and subjective and objective clinical outcomes were recorded. Barium swallow and upper gastrointestinal endoscopy were routinely performed during the follow-up. Gastroesophageal Reflux Disease-Health Related Quality of Life (GERD-HRQL) and Short-Form 36 questionnaires were used to compare quality of life before and after treatment. ResultsBetween 2002 and 2017, 35 patients underwent minimally invasive leiomyoma enucleation through thoracoscopy (n = 15), laparoscopy (n = 15), and endoscopy (n = 5). The overall morbidity rate was 14.3% and there was no mortality. All patients had a minimum of 1-year follow-up. The median follow-up was 49 (IQR 54) months, and there were no recurrences of leiomyoma. At the latest follow-up, the SF-36 scores were unchanged compared to baseline. However, there was a higher incidence of reflux symptoms (p < 0.050) and PPI use (p < 0.050) after endoscopic treatment. ConclusionsMinimally invasive enucleation is safe and effective and can be performed by a variety of approaches according to leiomyoma location and morphology. Overall, health-related quality of life outcomes of each procedure appear satisfactory, but PPI dependence was greater in the endoscopic group.

Successful en bloc endoscopic full-thickness resection of a giant cervical esophageal leiomyoma originating from muscularis propria

BackgroundEsophageal leiomyomas, the most common benign primary tumors of the esophagus, are esophageal subepithelial lesions treated by surgery traditionally. In recent years, endoscopic submucosal dissection and related endoscopic treatment techniques are adopted by endoscopists to resect gastrointestinal submucosal tumors. But if a giant esophageal leiomyoma approaches the esophagus entrance and originates from the deep layer of muscularis propria, it will be difficult for both endoscopic resection and surgical treatment. Especially, endoscopic resection has a high risk of huge perforation difficult to be sutured.Case presentationA 72-year-old man with dysphagia underwent gastroscopy examination which indicated a large submucous eminence lesion, about 18–24 cm from the incisors. Endoscopic ultrasonography revealed the lesion was hypoechoic and originated from the muscularis propria with a clear boundary. The patient refused invasive surgical resection. Then, an en bloc endoscopic full-thickness resection was performed, which perforation was successfully closed with purse-string sutures using a novel endoloop device through standard single-channel endoscopy. Histopathologic examination showed an esophageal leiomyoma.ConclusionThis endoscopic procedure may be an alternative to avoid surgery for the removal of a giant upper esophagus tumor from muscularis propria layer.

Successful thoracoscopic esophageal leiomyomectomy in an adolescent

Leiomyoma of oesophagus is a rare tumour in adults and even more rare finding in pediatrics. Biopsy or enucleation of tumour is necessary to exclude malignancy, especially in a case of any malignancy symptoms, for example, severe weight loss. Total excision of benign tumour is curative. In our report we present the clinical case of successful thoracoscopic excision of esophageal leiomyoma in adolescent.

Diagnostics and treatment of patients with giant leiomyoma of the esophagus

Diagnostics and surgical treatment of 2 patients with giant esophageal leiomyoma are reported. The diagnosis was confirmed by chest computed tomography, MRI of the mediastinum, endoscopic ultrasound. Resection of tumor with mucosa suturing and Nissen fundoplication was performed in 1 case. There were no intraoperative complications. Postoperative partial failure of the seams of the esophageal wall occurred in 1 case. Drainage of posterior mediastinum was performed. Treatment resulted closure of the esophageal wall defect. Control postoperative examination confirmed patent esophagus and preserved passage through the esophagus. Multidisciplinary approach to diagnosis and treatment of these patients results favorable outcomes.

Труднощі променевої діагностики лейоміом стравоходу

Труднощі променевої діагностики лейоміом стравоходу

Rationale for the choice of operations in esophageal leiomyoma.

Operations on the esophagus occupy an important place in the surgery of the gastrointestinal tract, since this organ passes through three anatomical regions: the neck, thoracic and abdominal cavity. The main pathologies for surgical interventions are congenital malformations, injuries, foreign bodies, burns and scarr y strictures , neuromuscular diseases of the esophagus, hernia of the esophagus and reflux esophagitis, diverticula, acquired fistula, esophageal cancer, benign tumors and cysts. For the majority of these conditions clear recommendations o n diagnosis and treatment have been developed. In the literature, there is no consensus on indications for conservative or surgical treatment of patients with esophageal leiomyoma and the type of surgical intervention: 1) resection of the esophagus 2) removal of the tumor with part of the wall; 3) enucleation of the tumor; 4) endoscopic removal. Mortality after resection of the esophagus or its wall with plastic is 13%, and after enucleation of leiomyoma – 2%. In our clinical study, the analysis of the performed operations on patients with leiomyoma of the esophagus was performed. The aim – to make a retrospective analysis of different types of surgical interventions in patients with esophageal leiomyoma performed in the thoracic departments of the National Cancer Institute, Kiev City Clinical Cancer Center, Kiev Clinical Hospital N 17, Zhytomyr Regional Hospital, Vinnitsa Regional Hospital. Retrospective evaluation of 66 patients with morphologically confirmed esophageal leiomyoma was made . The following types of imagining were performed in patients: radiological examination of esophagus with solution of barium sulphate and radiography, computed tomography of the chest (CTc), computed tomography angiography (CTA), magnetic resonance contrast-enhanced imaging (MRI TO). Instrumental methods : esophagogastroduodenoscopy (EGD) with biopsy, endoscopic ultrasound, endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNA). The type of surgical interventions: proximal gastrectomy (n=3); Garlock operation (n=2); Lewis operation (n=3), resection of the tumor with part of the esophageal wall (n=6); tumor enucleation (n=52). Complications after operations in the early period: postoperative bleeding - the source is not identified, failure of the esophageal wall seam. In the late postoperative period – esophageal pleural fistula in two patients and esophageal stenosis in one patient. Indication for removal of leiomyomas: severity of symptoms, tumor size more than 5 cm, multiple leiomyomas, transition onto the stomach, patient's persistent desire, increase of volume in dynamics, changes in mucosa over the mass . Indications for resection options for surgery: adhesion of the tumor with the mucosa for more than three centimeters, the inability to exclude the malignant process, the giant esophageal leiomyoma with the transition onto the stomach. Patients who underwent non-surgical operations had a shorter postoperative hospital stay, fewer complications and a better quality of life. According to our results, preoperative biopsy with intact mucosa is not informative, but also does not increase the number of perforations.

Submucosal tunneling endoscopic resection for treatment of esophageal leiomyomas arising from the muscularis propria

Submucosal tunneling endoscopic resection for treatment of esophageal leiomyomas arising from the muscularis propria

PS01.100: THORACOSCOPIC MANAGEMENT OF ESOPHAGEAL LEIOMYOMA: 11 CASE REPORTS

Abstract Background The vast majority of esophageal tumors are cancer. Benign esophageal tumors constitute less than 1% of all esophageal tumors. Approximately 80% of benign esophagus tumors are leiomyomas. This study aims to evaluate outcomes of thoracoscopic management of esophageal leiomyomas. Methods Between January 2010 and December 2017, eleven cases (5 females, 6 males; mean age 45 years; range 30 to 59 years) who were operated with thoracoscopic resection due to esophageal leiomyoma were retrospectively analyzed. Age and sex of the patients, symptoms, localization of lesions, diagnosis, surgical modality, length of hospital stay and morbidity and mortality rates were reviewed. All cases were preoperatively examined using direct chest radiography, computed tomography (CT), and esophagoscopies, with endoscopic ultrasonography (EUS) also being employed in seven cases. Results Five patients had dysphagia and four patients were asymptomatic. Leiomyoma was located in 1/3 of the middle esophagus in all cases. All patients underwent right thoracoscopic enucleation (Single port incision in three cases). Leiomyoma was a solitary lesion in all cases. After the enucleation, 0.9% NaCl was inserted into the posterior mediastinal region. Nasogastric tube was inflated to check for leakage. Except for two cases, in all cases, the esophageal muscle layer was closed as an absorbable suture. The mean diameter of leiomyoma was 5.1 cm (range, 2 to 9 cm). Postoperative mortality was not observed in any of the cases. Postoperative pseudodiverticulum occurred in one of the cases. The mean length of hospital stay was 5.8 days (range, 4 to 11 days). Conclusion In esophageal leiomyomas, surgery provides both definitive diagnosis and treatment. Thoracoscopic enucleation in esophageal leiomyomas is an effective and safe treatment method. Disclosure All authors have declared no conflicts of interest.

VS02.07: ROBOTIC RESSECTION OF A GIANT THORACIC ESOPHAGEAL LEIOMYOMA

Abstract Description The authors present the video of robotic resection of extensive leiomyoma of the thoracic esophagus. We highlight the use of 4 robotic arms that allow the rotation of the leiomyoma of great proportions, as well as presentation of the contralateral face of the muscular breach to perform the repair of the esophageal wall. The removal of the tumor (in bag peacemeal) is still observed. Disclosure All authors have declared no conflicts of interest.

VS02.04: TOTAL THORACOSCOPIC ENUCLEATION FOR GIANT ESOPHAGEAL LEYOMIOMA: A CONSECUTIVE SERIES

Abstract Description Giant esophageal leiomyomas (GEL) are challenging benign conditions to treat in a total minimally invasive way. Here we show the management of a complete thoracoscopic enucleation (TE) of three giant esophageal masses in three different patients. Not only the size of these masses but mostly the position of them made the indication for TE borderline. Methods Every patient underwent a full diagnostic pre-op workup with CT scan, PET and EUS guided biopsies to rule out any malignancy. In this video, we show a full thoracoscopic approach with the patient on the left flank in a semi-prone/prone position and under general anesthesia without lung exclusion. We use a 3 trocars approach and low pressure(8mmHg) CO2 insufflation during the whole procedure. The dissection of the mass is carefully performed to keep the whole mucosal layer undamaged and minimizing the incision in the muscular layer. Careful reconstruction of the muscular layer is a mandatory step at the end of the procedure. Azygos vein resection is performed depending on the mass location. We extract the mass in a bag by enlarging the incision of the inferior scapular trocar. The integrity of the mucosal layer was constantly checked during the procedure either by direct endoscopic vision or by insufflation of air through a nasogastric tube. Results All the patients had an uneventful post-operative course, upper-GI series showed no leak, no stricture nor dilatation of the esophagus. On POD 4 a soft diet was administered. Conclusions Esophageal leiomyomas are a rare condition; the ones larger than 10cm are defined as GEL and they represent the 17% of the total. While, in advanced centers, Total TE for small leiomyomas is a standard of care, GELs are usually managed by open surgery, and in many cases, esophagectomy has to be performed. In our series of five consecutive GELs, located in the upper esophagus, TE proved to be safe and effective in all the patients. Disclosure All authors have declared no conflicts of interest.

PS01.102: MINIMALLY INVASIVE ENUCLEATION OF ESOPHAGEAL LEIOMYOMA: COMPARISON OF DIFFERENT TECHNIQUES WITH FOCUS ON QUALITY OF LIFE AND GASTROESOPHAGEAL REFLUX

Abstract Background Minimally invasive enucleation of esophageal leiomyoma may induce or aggravate gastroesophageal reflux disease, but scarce data are available in literature. Methods We conducted a retrospective, cross-sectional single-center study investigating long-term outcomes of laparoscopic, thoracoscopic, and endoscopic enucleation with focus on quality of life and gastroesophageal reflux. Postoperative clinical and endoscopic data were compared to baseline. All patients underwent barium swallow study, endoscopy and completed the GERD-HRQL questionnaire after a minimum 1-year follow-up. Results Thirty patients were included in the study. There were 19 females and 11 males, median age 48 years (range 28–67). Thirteen (43.3%) patients underwent laparoscopic enucleation plus fundoplication (9 Toupet, 3 Nissen, 1 Dor), 12 (40%) patients thoracoscopic enucleation, and 5 (16.7%) patients endoscopic enucleation. Mean operative time was 149.1 ± 62.6 min. Mean tumor diameter was 5.4 ± 3.2 cm. There was no operative mortality. Overall morbidity rate was 16.6%, and no mucosal perforations occurred. Mean hospital stay was 4.0 ± 1.8 days. The mean baseline GERD-HRQL score was 4.25 (range 0–21) in the laparoscopic group, 3.4 (range 0–12) in the thoracoscopic group, and 5.7 (range 0–13) in the endoscopic group. Preoperatively, hiatal hernia was present in 6 patients (46.1%) in the laparoscopic group, in 4 patients (33.3%) in the thoracoscopic group, and in 2 patients (40%) in the endoscopic group. The mean follow-up was 58 months (range 3–192) (Table 1). Conclusion GERD symptoms were more common in patients after endoscopic enucleation. Primary laparoscopic enucleation combined with fundoplication allows effective long-term reflux control. Disclosure All authors have declared no conflicts of interest.

PS01.116: EXTRAMUCOSAL ENUCLEATION IS SAFE AND FEASIBLE IN ESOPHAGEAL LEIOMYOMA IRRESPECTIVE OF SIZE: SINGLE INSTITUTION EXPERIENCE

Abstract Background Esophageal leiomyoma (EL) is the most common benign lesion of esophagus. Extramucosal enucleation (EME) is the treatment of choice however esophageal resection have been favoured by some particularly when they attain large size citing risk of malignant transformation. We share our experience of EME over the last 7 years. Methods Prospectively collected database on consecutive cases of EL managed surgically between March 2010 and March 2017 were analysed retrospectively. Our department policy is to consider EME in all. Routine preoperative workup included baseline blood tests, contrast enhance computed tomography chest and upper abdomen and endoscopic ultrasound. All perioperative details were recorded prospectively. All patient underwent CT with oral contrast on day 1 of surgery to exclude leak. Final histopathology were recorded and all of them were followed 6 monthly. Results Mean age of the patients analysed (n = 21; male = 16, female = 5) were 42.7 ± 10.7 years (range 22 to 61) with mean tumor size of 8.4 ± 2.8cm (range 4.2 to 15). Commonest tumour location was thoracic esophagus (n = 16; 76.1%) followed by abdominal (n = 4; 19.2%) and cervical esophagus (n = 1; 4.7%). Most tumor were asymptomatic (n = 9/21; 42.8%) while dysphagia was commonest among those who had symptoms at presentation(7/21; 33.3%). Five (23.8%) of these were of size ≥ 10 cm (giant EL). All of them underwent EME as planned. Majority (n = 17; 81%) underwent minimally invasive enucleation (Thoracoscopic = 14, Laparoscopic = 3) while rest 4 (19%) underwent open enucleation due to large size in 1, cervical location in 1 and intolerance to minimally invasive procedure in 2. The mean operative blood loss were 72.5 ± 22 ml and none required blood transfusion. The mean duration of surgery were 122 ± 27 minutes. There were no postoperative complications that required intervention. No leak reported on postoperative day 1 scan. All patients got discharged by a mean of 5.2 ± 1.8 days. The final diagnosis were leiomyoma in all. At a mean follow up of 36 ± 17.2 months none had recurrence or any long term complication attributable to enucleation. Conclusion Extramucosal enucleation is safe in esophageal leiomyoma irrespective of size and majority of them can be managed with minimally invasive surgery. Disclosure All authors have declared no conflicts of interest.

Gastrointestinal leiomyoma with interstitial cells of Cajal: mimicker of gastrointestinal stromal tumor

Objective: To study clinical and pathologic characteristics of leiomyomas of the gastrointestinal tract, and to investigate the distribution characteristics of interstitial cells of Cajal ( ICCs ) in gastrointestinal leiomyomas. Methods: One hundred and forty-seven cases of leiomyomas of gastrointestinal tract were collected at the Second Affiliated Hospital of Zhengzhou University from June 2012 to June 2017. Clinical and pathologic findings were analyzed, combined with immunohistochemistry, Alcian blue-osafranin staining and molecular study. Results: The age of patients ranged from 13-82 years with mean age of 52 years. Male to female ratio was about 1∶2. Histologically, all tumors were composed of ovoid to spindle cells arranged in short intersecting fascicles. All tumors were diffusely and strongly positive for smooth muscle antibodies, desmin and h-caldesmon by immunohistochemical staining. A prominent interspersed subpopulation of elongated/dendritic-like cells with CD117 and DOG1 positivity (accounting for 1% to 30% of all tumor cells) and negative for Alcian blue-osafranin staining was identified in all esophageal leiomyomas, 16 of 20 (80%) gastric leiomyomas and 3 of 12 small bowel leiomyomas, but none in colonic/rectal leiomyomas. Mutational analysis in 16 cases showed absence of mutation in exons 9, 11, 13 or 17 of C-KIT and exons 12 or 18 of PDGFRA. Conclusions: ICCs are identified in esophageal and gastric leiomyomas, as well as in small percentage of intestinal leiomyomas. Such findings may bring significant diagnostic pitfalls for misdiagnosis as gastrointestinal stromal tumor. Careful attention to the distribution of CD117 and DOG1 positive cells and molecular mutation analysis of C-KIT and PDGFRA may be necessary to establish the correct diagnosis.

Minimally Invasive Surgery for Giant Oesophageal and Gastric Leiomyomas

Minimally Invasive Surgery for Giant Oesophageal and Gastric Leiomyomas

Diagnosis and treatment of esophageal leiomyoma. Case study

The article presents the case of a rare pathology — esophageal leiomyoma. Features of clinical course, problems of early diagnosis and histological confirmation of this type of esophageal tumors are highlighted. The possible approaches to treatment and the difficulty in the appropriate tactics choice have been revealed.

Enucleación esofágica de leiomioma asistida por robot: reporte de caso y revisión de la literatura

Los leiomiomas esofágicos son tumores benignos resecados por enucleación esofágica cuando son mayores de 5 cm o en lesiones de cualquier tamaño que sean sintomáticas o con sospecha de malignidad. Tradicionalmente, la resección se ha realizado por técnica de enucleación abierta; sin embargo, la cirugía mínimamente invasiva surgió como una técnica con grandes ventajas, especialmente la tecnología robótica. Se reporta un caso de leiomioma esofágico del esófago medio con enucleación mediante el uso de una técnica de toracoscópica asistida por robot. La esofagoscopia intraoperatoria y transiluminación fueron complementos útiles para identificar el esófago y desarrollar un plano de disección extramucosa seguro que, junto con la asistencia robótica, parecen minimizar los riesgos intraoperatorios; entre ellos, la probabilidad potencial de lesión de la mucosa, así como también mejorar el tiempo de recuperación posoperatoria.

Cambios hacia el futuro de la Revista Colombiana de Neumología

Tengo el agrado de presentar este número de la Revista Colombiana de Neumología en el cual se encuentran novedades interesantes. Hemos modificado la portada de presentación de la revista en la que se adoptó un esquema más dinámico y moderno, para darle un espacio más relevante a las imágenes y anticipar el contenido de la misma; además, en conjunto con la nueva Junta Directiva Nacional, tomamos la decisión de alinearnos con la tendencia mundial de conservación ambiental y la iniciativa nacional de “cero papel” en las instituciones, de tal manera que pasamos a publicar nuestra revista solo en formato en línea.Con esta medida disminuimos el uso de recursos renovables tan valiosos como el papel, tenemos más libertad en el manejo, diseño, cantidad y calidad de las imágenes, y pretendemos llegar a muchos más usuarios con cada ejemplar. En este número, la revista tiene contribuciones de neumología, radiología, cirugía de tórax, neumología pediátrica, neumología intervencionista y patología, entre otras, tanto de Colombia como de Latinoamérica; se presenta una revisión sistemática de rehabilitación pulmonar en la que se exploran los resultados de esta intervención en el grupo específico de pacientes que tienen síndrome de superposición de la enfermedad pulmonar obstructiva crónica (EPOC) y asma. Incluye un artículo original que explora la contribución del destete temprano como factor de riesgo para la neumonía muy grave en el infante; en este estudio, más del 50% de la población presentó neumonía y destete temprano, lo que sugiere una relación entre este y la presentación de neumonía muy grave en niños, especialmente entre los niños mayores de 2 meses y menores de 5 años, por lo que se concluye que la lactancia materna sigue siendo un factor protector contra varias patologías, entre estas, las respiratorias.Se presenta un artículo de revisión con respecto al tratamiento con inhaladores de acción prolongada, que son una herramienta terapéutica para el tratamiento de pacientes con enfermedades bronco-obstructivas como la EPOC y el asma bronquial. También hay otro artículo que explora las implicaciones y perfil de seguridad infecciosa de la terapia biológica con omalizumab y mepolizumab en asma severa refractaria, con el fin de dar a conocer los riesgos relacionados con infecciones al usar estas moléculas y generar algunas recomendaciones para la prevención y manejo en el contexto latinoamericano. Además, se incluye una extensa revisión de las manifestaciones radiológicas típicas y atípicas de la sarcoidosis pulmonar, que tienen un amplio espectro desde el compromiso ganglionar típico (adenomegalias hiliares bilaterales y paratraqueales derechas), parenquimatoso (nódulos perilinfáticos, opacidades parahiliares bilaterales y cambios por fibrosis), hasta manifestaciones atípicas de compromiso ganglionar (adenomegalias unilaterales, asimétricas), parenquimatoso (sarcoidosis alveolar y masas pulmonares), enfermedad de vía aérea, pleural y otras (micetomas).En este número también se encuentran varios casos clínicos interesantes como el desarrollo de histoplasmosis en un individuo inmunocompetente, la enucleación de un leiomioma esofágico asistida por cirugía robótica, el diagnóstico y manejo de un tumor mucoepidermoide de la tráquea y el caso clínico de una paciente con fibroelastosis pleuroparenquimatosa idiopática; además de las secciones de glosario patológico, imágenes en broncoscopia y la información para pacientes que, en esta oportunidad, se relaciona con fibrosis quística.Esperamos que disfruten este número y reiteramos la invitación para que envíen sus manuscritos originales, revisiones, reflexiones, imágenes, inquietudes y propuestas, pues la revista es una ventana más de comunicación de nuestra Asociación con el mundo.

Esophageal Granular Cell Tumors Can Be Differentiated from Leiomyomas Using Endoscopic Ultrasonography

Objective Although esophageal granular cell tumors have been reported to present as hypoechoic tumors, we noticed that their echogenicity is similar to that of the submucosal layer. We investigated the sonographic features of esophageal granular cell tumors and the diagnostic accuracy of the features. Methods Seven patients with esophageal granular cell tumors who underwent endoscopic ultrasonography were retrospectively reviewed. Thirteen patients with esophageal leiomyoma were selected as historical control subjects. The brightness of the tumor on ultrasonography images was measured and the echogenicity was standardized according to the echogenicity of the proper muscle and submucosal layers. Ten board-certified endoscopists then independently evaluated the endoscopic pictures of the 20 patients (Test 1), as well as the endoscopic ultrasonography images together with endoscopic pictures of the same patient set (Test 2). Results The standardized echogenicity in granular cell tumors was significantly higher than that in leiomyomas. The diagnostic accuracy of the 10 evaluators using endoscopic pictures alone (Test 1) was 72.0%. The addition of endoscopic ultrasonography images (Test 2) significantly improved the accuracy to 93.0%. Conclusion The echogenicity of granular cell tumors was similar to that of the submucosal layer, and it was significantly higher than that of leiomyomas. Endoscopic ultrasonography images facilitate the accurate identification of esophageal granular cell tumors.

Robotic Laparoscopic Enucleation of a Giant Lower Esophageal Leiomyoma: Advantages of the Transabdominal Approach

Introduction: Esophageal leiomyomas are the most common benign tumors of esophagus, although rare.1,2 Treatment of esophageal leiomyomas depends on tumor size, location, patient condition, and surgeon experience. For tumors ≤5 cm, transthoracic enucleation is the treatment of choice.3–5 For tumors ≥8–10 cm, termed “giant leiomyomas,” enucleation may still be performed although with an associated higher incidence of both dysphagia after closure of the esophageal muscle defect and reflux if the lower esophageal sphincter is involved.5–8 We present a patient with a giant leiomyoma who underwent robotic laparoscopic enucleation. Case Details: The patient is a 56-year-old female with a body mass index of 32 kg/m2 who presents with 6 months of intermittent chest and epigastric pain and associated dysphagia. Her comorbidities included diabetes, hypertension, and gastroesophageal reflux disease. Esophagogastroduodenoscopy demonstrates external compression of distal esophagus without other intraluminal findings. A subsequent chest computed tomography scan reveals an 8-cm lobular soft tissue mass circumferentially involving the lower esophagus. Endoscopic ultrasound shows a multilobulated hypoechoic mass measuring 8 × 6.2 cm involving 75% of the esophageal circumference. Three distinct lobules were noted as were internal calcifications. Fine-needle aspiration biopsies showed leiomyoma with benign features. Surgical Technique: The patient was positioned supine with both arms extended laterally. The operating table was positioned in steep reverse Trendelenburg and right lateral decubitus. We used four 8 mm robotic trocars, one accessory 11 mm trocar, and a subxyphoid 5 mm skin incision for a Nathanson liver retractor. Upon access to the peritoneum, the gastrohepatic ligament was divided as was the phrenoesophageal membrane. The esophagus was circumferentially dissected from the hiatus. The gastric fundus was mobilized by dividing the short gastric vessels and retrogastric adhesions. The esophagus was enlooped with a Penrose drain to facilitate atraumatic esophageal retraction for further mobilization and mediastinal dissection. The tumor mass was observed and carefully dissected from the esophageal wall and other mediastinal attachments. Once the tumor was fully mobilized from the esophagus, the muscular defect in the esophagus was closed and a contralateral esophageal myotomy was performed. Cruroplasty was performed in a standard manner. Finally, a 270-degree posterior fundoplication was created. The tumor was removed from the abdominal cavity using a nylon-reinforced endobag through a dilated left lateral port site. Results: Our operative time was 132 minutes and the estimated blood loss was 5 mL. The patient was hospitalized overnight and discharged to home on postoperative day 1, on a full liquid diet. She was advanced to a soft diet at 1 week. The patient presented to the outpatient clinic at 2 weeks and 3 months for routine follow-up, and was noted to be doing very well without dysphagia or symptoms of gastroesophageal reflux. Discussion: Our operative technique demonstrates several advantages of the laparoscopic approach for enucleating distal esophageal leiomyomas, even when large. This approach allows direct access to both sides of the esophagus, facilitating the performance of a contralateral myotomy to lower risk of postoperative dysphagia after closure of the esophageal wall muscular defect. Similarly, creation of an antireflux fundoplication is readily performed to minimize risk for postoperative gastroesophageal reflux. In addition, the transabdominal approach for enucleating distal esophageal leiomyoma is more familiar to minimally invasive surgeons and allows a less morbid treatment option to thoracic surgery or esophageal resection. Conclusion: Robotic laparoscopic enucleation of lower esophageal leiomyomas is feasible and safe, even for large tumors. This approach also allows the benefit of concurrent myotomy and antireflux surgery. This technique should be preferred to the usual transthoracic approach when laparoscopic expertise is available. No competing financial interests exist. Runtime of video: 9 mins 20 secs