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| CASE REPORT |
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| Year : 2017 | Volume
: 14
| Issue : 4 | Page : 227-228 |
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Minimal invasive enucleation of leiomyoma of the esophagus: A fast-track approach
Priyanka Tiwari, Dinesh Zirpy, Juneed Mohammad Lanker, Prasanna Kumar Reddy
Department of Surgical Gastroenterology and Minimal Access Surgery, Apollo Main Hospital, Chennai, Tamil Nadu, India
| Date of Web Publication | 5-Feb-2018 |
Correspondence Address:
Priyanka Tiwari
72, Gengu Reddy Road, Apollo Girls Hostel, Near PT School, Egmore, Chennai - 600 006, Tamil Nadu
India
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/am.am_37_17
Although benign tumors of esophagus are rare (10%), leiomyoma of esophagus is the most common benign tumor and most commonly situated in the lower and middle-third of esophagus. Most of the tumors produce no symptoms and are found incidentally; however, when symptoms are present, dysphagia and pain predominate. While open surgical technique was the conventional mainstay of therapy for leiomyomas, combined esophagoscopy and video-assisted thoracoscopic surgery or laparoscopic transhiatal resection are being increasingly performed. We describe minimally invasive enucleation of esophageal leiomyoma with a fast-track approach with reduced postoperative pain and hospital stay. Keywords: Enucleation, esophagus, laparoscopy, leiomyoma
How to cite this article:
Tiwari P, Zirpy D, Lanker JM, Reddy PK. Minimal invasive enucleation of leiomyoma of the esophagus: A fast-track approach. Apollo Med 2017;14:227-8 |
| Introduction | |  |
Leiomyoma is most commonly located in the lower two-third of esophagus and most commonly occurs as intramural–extramucosal tumor. Sometimes, leiomyoma has been associated with achalasia, hiatus hernia, and diverticulum.[1],[2] Minimal invasive surgery for benign esophageal tumor reduces the morbidity than in comparison to open approach. We describe a case of leiomyoma of the esophagus and technique for the laparoscopic enucleation of leiomyoma involving lower one-third of the esophagus.
| Case Report | | |
A 39-year-old man with no known comorbidities presented with complaints of pain in the epigastrium and progressive dysphagia, more for the solids for 6 months. There was no history of vomiting, chronic cough, or fever. Appetite was preserved, and he denied any significant loss of weight. Vital parameters and clinical examination of the patient were normal. His hematological and biochemical parameters were normal.
| Method | | |
Diagnostic workup was done to evaluate the symptoms. Esophagoscopy showed that tumor was present at gastroesophageal junction and overlying mucosa over the tumor was normal. There was no associated gastroesophageal reflux disorder. Contrast-enhanced computed tomography (CT) of the thorax with upper abdomen and endoscopy ultrasound (EUS) showed a lesion in the distal third of esophagus with luminal obstruction; findings consistent with leiomyoma.
Laparoscopic enucleation of the lower esophagus was done. The patient was kept in supine with split leg position. Pneumoperitoneum created with veress needle. A 10-mm umbilical optic port was placed and 30° scope was introduced. Nathanson liver retractor was placed through 5-mm epigastric incision to retract the liver. Right 10 mm and left 5 mm working ports were placed in the midaxillary line under vision and one 5 mm retracting port in the left anterior axillary line was placed. Mobilization of proximal stomach and lower esophagus was done.
Short gastric vessels divided with harmonic scalpel and left crus of the diaphragm were exposed. Phrenoesophageal membrane was divided. Right side of the dissection started with division of parsflaccida and right crus of the diaphragm was exposed. Retroesophageal window was created to pass the umbilical tape and to retract the lower end of esophagus. Tumor was mobilized from the thorax into the peritoneal cavity. Longitudinal myotomy and enucleation were done.
Myotomy performed to separate the longitudinal fibers of the esophagus along the whole length of tumor. Tumor was exposed by retracting the muscle fibers and enucleated with blunt dissection. Mucosal integrity was confirmed with air leak test under fibro-optic esophagoscopy [Figure 1]. | Figure 1: Fiberoptic esophagoscopy showing intact esophageal mucosa after enucleation of leiomyoma and negative air leak
Click here to view |
Myotomy incision was closed with continuous suturing using 2-0 vicryl and cruroplasty was done with 3-0 Ethibond. Retrieval of tumor done was through 10-mm port in Endobag.
Operative time was 80 min. Postoperatively, he underwent gastrograffin study which showed no leak. The patient was allowed liquids on day 1 and was mobilized. Histopathology report showed that tumor composed of spindle cell arranged in whorls consistent with benign leiomyoma and no atypia was detected.
| Discussion | | |
Leiomyoma is the smooth muscle benign tumor. The symptoms of benign tumor of lower esophagus are chest pain, regurgitation, dysphagia, and weight loss. Multiplaner cross-sectional CT and magnetic resonance imaging evaluate the wall thickness, mediastinal involvement, and adjacent lymphadenopathy.[2] Leiomyoma can be easily differentiated from the hemangioma and cyst by endoscopic ultrasound.[3] However, leiomyomas cannot be exactly differentiated from gastrointestinal stromal tumors (GISTs) by endoscopy and EUS. Immunohistochemistry features are useful to differentiate GIST from leiomyoma.[4]
Most of the laparoscopic surgeons concomitantly perform Dor, Toupet, or Nissen fundoplication after enucleation of tumor. We do not perform any fundoplication procedure as an extra safety measure and so avoiding the morbidity associated with it unless there is concomitant gastroesophageal reflux.
Various studies reported that asymptomatic tumor is to be observed, and for symptomatic tumor <5 cm, endoscopic mucosal resection and laparoscopic enucleation are to be done. For tumor >5 cm, thoracotomy with or without resection is to be done.[5],[6],[7] We follow the algorithm as described in [Figure 2]. Thus, in this patient, as the tumor was <5 cm but symptomatic, we did minimal invasive transhiatal enucleation with closure of myotomy. | Figure 2: Algorithm showing the management of leiomyoma of the esophagus
Click here to view |
Wang et al. reported the endoscopic submucosal enucleation of such tumor with an average size of 3.3 ± 0.7 cm with minimal complications, but this technique cannot be considered standard of care for all tumors.[8]
Due to rapid advancement in technology, multiple options are available to treat this benign neoplasm of the esophagus, each of it aiming to decrease the postoperative morbidity and hospital stay with early recovery. Our technique emphasizes the minimal invasive laparoscopic surgery with fast-track approach for early recovery and decrease length of stay.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Mainieri-Breedy G, Mainieri-Hidalgo JA. Esophageal leiomyoma. Experience with nine surgical patients. J Acta Med Costarric 2012;54:165-9.  |
| 2. | Jang KM, Lee KS, Lee SJ, Kim EA, Kim TS, Han D, et al. The spectrum of benign esophageal lesions: Imaging findings. Korean J Radiol 2002;3:199-210. [ PUBMED] |
| 3. | Xu GQ, Zhang BL, Li YM, Chen LH, Ji F, Chen WX, et al. Diagnostic value of endoscopic ultrasonography for gastrointestinal leiomyoma. World J Gastroenterol 2003;9:2088-91. [ PUBMED] |
| 4. | Zhu X, Zhang XQ, Li BM, Xu P, Zhang KH, Chen J, et al. Esophageal mesenchymal tumors: Endoscopy, pathology and immunohistochemistry. World J Gastroenterol 2007;13:768-73. |
| 5. | Sun X, Wang J, Yang G. Surgical treatment of esophageal leiomyoma larger than 5 cm in diameter: A case report and review of the literature. J Thorac Dis 2012;4:323-6. [ PUBMED] |
| 6. | Mutrie CJ, Donahue DM, Wain JC, Wright CD, Gaissert HA, Grillo HC, et al. Esophageal leiomyoma: A 40-year experience. Ann Thorac Surg 2005;79:1122-5. [ PUBMED] |
| 7. | Luh SP, Hou SM, Fang CC, Chen CY. Video-thoracoscopic enucleation of esophageal leiomyoma. World J Surg Oncol 2012;10:52. [ PUBMED] |
| 8. | Wang L, Ren W, Zhang Z, Yu J, Li Y, Song Y, et al. Retrospective study of endoscopic submucosal tunnel dissection (ESTD) for surgical resection of esophageal leiomyoma. Surg Endosc 2013;27:4259-66. |
[Figure 1], [Figure 2]
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