[Leiomyoma of the esophagus : A further indication for robotic surgery?]

Achalasia or Pseudoachalasia: Incidental Esophagogastric Junction Submucosal Leiomyoma During Peroral Endoscopic Myotomy

The concomitant presence of esophageal achalasia and esophagogastric junction submucosal leiomyoma is extremely rare. Peroral endoscopic myotomy has been endorsed as one of the primary interventions to manage esophageal achalasia. We present a 49-year-old woman who had initial endoscopic evaluation and diagnosis of achalasia type II then underwent peroral endoscopic myotomy and found to have incidental submucosal leiomyoma at 1 cm distal to esophagogastric junction. It was removed successfully by submucosal tunneling endoscopic resection. This poses the question of whether this is a case of achalasia or pseudoachalasia caused by leiomyoma.

Robot-assisted resection of oesophageal leiomyoma: a single-centre retrospective analysis of 57 cases

BACKGROUNDS

Oesophageal leiomyoma is the most common benign tumour of the oesophagus, and complete tumour enucleation is the preferred treatment. The aim of this study is to evaluate the clinical application and technical advantages of Robotic-assisted Thoracoscopic Surgery (RATS) during the resection of oesophageal leiomyoma.

METHODS

A retrospective study was conducted on patients who underwent robotic surgery for oesophageal diseases at our hospital from September 2017 to December 2023. Demographic statistics and clinical pathological characteristics, intraoperative and postoperative outcomes, immune histopathological staining, tumour pathology diagnosis and follow-up were analyzed.

RESULTS

A total of 57 patients were enrolled in the study, including 42 males and 15 females with an average age of 49 years All patients received surgical treatment, with 54 patients undergoing robot-assisted resection of oesophageal tumour, one patient undergoing conversion to thoracotomy, and two patients undergoing exploratory surgery. The mean surgical time was 130 minutes, and the mean blood loss was 50 mL. Of the 55 patients who underwent tumour resection, 54 were pathologically diagnosed as oesophageal leiomyoma and one as atypical leiomyoma. Only one patient developed pulmonary infection after surgery, and there was no perioperative mortality. The average postoperative hospital stay was 9 days. All patients were followed up for a median time of 16 months (range: 1 to 70 months), and there was no recurrence or long-term complications after surgery.

CONCLUSION

Robot-assisted resection of oesophageal leiomyoma is safe and feasible, and can provide ideal short-and medium-term results.

Robotic-assisted surgery for esophageal submucosal tumors: a single-center case series

Esophageal submucosal tumors (SMTs) are rare heterogenous clinical entities. The surgical resection can be performed in different surgical approaches. However, the robotic surgical strategy is poorly documented in the treatment of SMTs. We present our series of operated esophageal SMTs approached via robotic-assisted surgery. Six patients with symptomatic esophageal submucosal tumors underwent robotic surgery within a 3-year period. The performed procedures were robotic-assisted enucleation, robotic esophagectomy (RAMIE) and reverse hybrid robotic esophagectomy. Patients’ clinical data, intra/postoperative outcomes, and histopathological features were retrieved from the institution’s prospective database. Five of six patients were scheduled for upfront surgery: four underwent robotic enucleation (three leiomyoma and one suspected GIST) and one underwent reverse hybrid robotic esophagectomy (suspected GIST). One patient, diagnosed with GIST, was treated with neoadjuvant Imatinib therapy, before undergoing a RAMIE. No major intra-operative complications were recorded. Median length of stay was 7 days (6–50), with a longer post-operative course in patients who underwent esophagectomy. Clavien–Dindo > 3a complications occurred in two patients, aspiration pneumonia and delayed gastric emptying. The final histopathological and immuno-histochemical diagnosis were leiomyoma, well-differentiated GIST, low-grade fibromyxoid sarcoma and Schwannoma. Robotic-assisted surgery seems to be a promising option for surgical treatment strategies of benign or borderline esophageal submucosal tumors.

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.

Complete laparoscopic-transhiatal removal of duplex benign oesophageal tumour: case report and review of literature

BACKGROUND

Leiomyoma is the most common benign oesophageal tumour. Half of all leiomyoma patients have oesophagus-associated complaints, such as dysphagia and epigastric pain, and the other 50% are asymptomatic with a diagnosis made on incidental discovery. Endoscopic ultrasonography is essential for an accurate preoperative workup and can enable guided-tissue acquisition for immunohistochemistry in certain cases. Smaller tumours are amenable to traditional and novel endoscopic removal in specialized centres, but some complex cases require surgical enucleation with a minimally invasive approach.

CASE PRESENTATION

An asymptomatic 60-year-old woman was accidentally diagnosed with a bifocal oesophageal mass, which was discovered by chest computed tomography. We report a rare case of a duplicated lower-third oesophageal leiomyoma, which was completely removed via the laparoscopic transhiatal approach. The patient has recovered successfully from the surgery. She has been followed up for six months with a normal oesophagram, adequate oesophageal function and no complaints observed. Pathological examination confirmed the diagnosis of leiomyoma in both lesions.

CONCLUSIONS

To the best of our knowledge, this is the first reported case of duplex oesophageal leiomyomas removed laparoscopically. Using the minimally invasive abdominal technique, the lower oesophagus can be mobilised to the mediastinum without pleura injury and offers a good alternative to the thoracoscopic approach in patients with possible intrathoracic difficulties. At experienced centres, laparoscopic transhiatal enucleation of lower oesophageal leiomyomas and other benign tumours with a combination of intraoperative oesophagoscopy is a safe, fast and effective operation.

Robotic enucleation for oesophageal benign and borderline tumours: Less is more?

BACKGROUND

Oesophageal benign to borderline tumours are rare entities, and their optimal treatment strategy remains controversial. Surgical robotic enucleation is an option to optimize their management.

METHODS

We prospectively collected data on seven consecutive oesophageal benign to borderline tumours operated robotically over a 4-year period. Patient baseline characteristics, perioperative outcomes and medium-term follow-ups were reviewed and analysed retrospectively.

RESULTS

Two patients underwent a robotic oesophagectomy and five underwent a simple enucleation. These last were the objective of the final analysis. Median operative time was 150 min. Neither deaths nor postoperative complications occurred. Median oral feeding started on postoperative day 3.5. The median postoperative stay was 5 days. Final histopathology confirmed two gastrointestinal stromal tumours, two leiomyomas and one simple cyst.

CONCLUSIONS

Robotic enucleation of oesophageal benign to borderline tumours is a feasible procedure in a dedicated oesophageal unit, with optimal perioperative outcomes in a small series of cases with limited follow-up.