Thoracoscopic enucleation of esophageal leiomyoma in prone position and single lumen endotracheal intubation

Slicing Through the Options: A Systematic Review of Esophageal Leiomyoma Management

Esophageal leiomyomas are rare, benign tumors that can remain asymptomatic or cause dysphagia and chest discomfort when they grow large. Despite advancements in diagnostic and therapeutic strategies, optimal management remains debated. This systematic review evaluates current diagnostic modalities and treatment approaches, synthesizing findings from a comprehensive PubMed search following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A total of 51 studies were included, comprising six original studies, 26 case reports, nine retrospective cohort studies, nine case series, and two cross-sectional studies. Findings indicate that endoscopic ultrasonography (EUS) is the most accurate diagnostic tool (89% accuracy), while computed tomography (CT) and barium swallow studies provide complementary structural assessments. Immunohistochemical staining differentiates leiomyomas from gastrointestinal stromal tumors (GISTs), with leiomyomas expressing desmin and smooth muscle actin (SMA) but lacking CD34 and KIT. Surgical intervention is recommended for symptomatic tumors or those exceeding 5 cm. Minimally invasive techniques, including robotic-assisted thoracoscopic surgery (RATS) and submucosal tunneling endoscopic resection (STER), offer superior outcomes compared to traditional open surgery. RATS demonstrates a negligible mucosal injury rate versus 1-15% for other approaches, while STER minimizes blood loss and accelerates recovery. Postoperative outcomes are generally favorable, though transient gastroesophageal reflux disease (GERD) is the most common complication. While STER and RATS present effective alternatives with reduced morbidity, this review highlights limitations, including variability in study designs, small sample sizes, and a lack of long-term follow-up data. Further prospective studies are needed to optimize patient selection and establish long-term efficacy. This review provides insights to inform clinical practice and guide future research in the management of esophageal leiomyomas.

Analysis of Thoracoscopic Enucleation Combined with Esophagoscopy in the Prone Position for Esophageal Submucosal Tumor

Background: Esophageal submucosal tumors (SMTs) are rare, occurring in less than 1% of esophageal neoplasms. For surgical treatment of esophageal SMTs, enucleation is usually the procedure of choice for benign tumors. This study aimed at evaluating the surgical technique and outcomes of thoracoscopic enucleation with esophagoscopy for esophageal SMTs. Methods: Patients with esophageal SMTs who underwent thoracoscopic enucleation between 2015 and 2022 were retrospectively investigated. Surgery was performed with the patient in the prone position. First, an esophagoscope was inserted, and a sodium hyaluronate solution with indigo carmine dye was injected into the submucosal layer just below the tumor. Next, under thoracoscopy, the tumor was exposed through a thoracoscopic incision and dissection of the muscularis propria and adventitia was performed at the tumor site. The colored layer resulting from the previously injected dye was identified, and tumor enucleation was performed under guidance of the dye so as not to damage the mucosa or pseudocapsule. Results: In total, 5 surgeries were performed. The mean operative time was 122.6 minutes (range 84-168 minutes), mean blood loss was 21.1 mL (range 0-80 mL), and mean postoperative hospital stay was 8 days (range 7-10 days). There were no postoperative complications. Pathological diagnosis revealed 2 cases of gastrointestinal stromal tumors, 2 cases of schwannoma, and 1 case of leiomyoma. Conclusions: We believe that this technique is a useful and safe method of performing thoracoscopic enucleation of esophageal SMTs because the injected dye provides an indicator of the resection line during enucleation.

Thoracoscopic enucleation of oesophageal submucosal tumours in prone position gives excellent long-term outcome: A single-centre experience

Background:

Thoracoscopic enucleation of oesophageal leiomyomas has been adopted by many centres. The procedure when performed in prone position gives good results. The long-term outcome has not been reported earlier. This single-centre study establishes the role of this particular technique.

Methods:

A retrospective analysis of a prospectively maintained hospital database was performed and after following the study criteria eleven cases of oesophageal submucosal tumours were included in the study. All patients underwent thoracoscopic enucleation in the prone position by a single surgeon. Peri-operative data were recorded and patients followed up for a mean period of 78 months (range = 24–120 months).

Results:

Thoracoscopic enucleation in prone position was done for all patients with no conversions to an open procedure. Two patients had a mucosal rent during dissection that was repaired. There was no post-operative morbidity greater than Clavien-Dindo Grade 2. Long-term follow-up is available for eight patients (73%) with no recurrence of disease or symptoms.

Conclusion:

Oesophageal submucosal tumours (predominantly leiomyomas) are benign neoplasms with an indolent biological behaviour and deserve a procedure that would serve the purpose of minimal post-operative morbidity coupled with excellent outcome. Thoracoscopic enucleation in the prone position provides a physiological benefit that translates into better peri-operative outcomes without compromising the long-term outcome and should be the preferred form of treatment for oesophageal submucosal tumours.

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.

Clinical outcomes in the surgical treatment of esophageal leiomyoma: A retrospective evaluation of 13 cases

Background

In this study, we aimed to evaluate the surgical outcomes after enucleation of esophageal leiomyomas and present the feasibility of enucleation using video-assisted thoracoscopic surgery.

Methods

The medical records of 13 patients (8 males, 5 females; mean age 45.9 years; range, 30 to 69 years) who underwent open or thoracoscopic surgery for an esophageal leiomyoma between April 2007 and June 2019 were retrospectively reviewed. The patients were evaluated with regard to age, sex, presenting symptoms, duration of symptoms, size and localization of tumors, diagnostic methods, surgical methods, conversion to open surgery, morbidity and mortality, discharge time, and follow-up period.

Results

Of the patients, four were operated via thoracotomy and nine via video-assisted thoracoscopic surgery. Enucleation was successfully completed with thoracoscopy in five patients. Four patients required conversion to thoracotomy. In the early postoperative period, two of these four patients developed complications and underwent re-thoracotomy. A solitary leiomyoma was detected in all, but one patient (multiple). The mean size of the tumors was 68.4 mm. Complications were seen in only one patient during follow-up and no recurrence was observed in any patient.

Conclusion

Our study results indicate that thoracoscopic enucleation of esophageal leiomyoma is a safe, feasible, and effective technique in selected patients and conversion to open surgery can be easily done for any reason during the procedure.

Combined thoracoscopic and endoscopic surgery for a large esophageal schwannoma

A 47-year-old woman presented to our hospital with complaints of dysphagia. Esophagogastroduodenoscopy identified a submucosal tumor in the left wall of the esophagus that was diagnosed as a benign schwannoma on biopsy. Computed tomography revealed a tumor of length 60 mm in the thoracic esophagus, with its cranial edge at the level of the aortic arch. On endoscopy, a submucosal tunnel was created 40 mm proximal to the cranial edge of the tumor, and its oral end was dissected from the mucosal and muscular layers. This was followed by the resection of the entire tumor by left-sided thoracoscopy. The esophageal defect was closed in layer by continuous suture from the thoracic side. Endoscopic closure was achieved by using clips. No postoperative complications were observed. Oral diet was resumed from postoperative day 7 and the patient was discharged on postoperative day 9. This combined approach has not been described for similar tumors. Our experience demonstrated that large esophageal tumors can be safely excised with minimally invasive surgery by using a combination of thoracoscopy and endoscopy.

Novel methylene blue staining technique for localizing small esophageal leiomyomas during thoracoscopic enucleation

The treatment of choice for leiomyoma, the most common benign esophageal tumor, is thoracoscopic enucleation. One of the most difficult aspects of thoracoscopic enucleation is the precise localization of small tumors (≤1.5 cm) and tumors without external protrusion. No simple, feasible solutions to this problem are available. We developed a novel methylene blue staining technique to localize small esophageal leiomyomas and evaluated the feasibility of our technique. Between January 2013 and July 2014, eight patients with small esophageal leiomyomas (≤1.5 cm) underwent thoracoscopic enucleation in Tongji Hospital. Preoperative endoscopic ultrasonography was performed in all patients. The leiomyomas were located in the middle (n = 5) and lower (n = 3) thirds of the esophagus. We preoperatively injected 0.5-1.0 mL methylene blue in the submucosa adjacent to the tumors under standard gastroscope guidance. The entire staining process took about 10 minutes. Staining was successful in all patients. The unstained tumor was exposed after the blue-stained mediastinal pleura, and overlying muscle were incised longitudinally. All procedures were successfully completed without conversion to open surgery. No abnormalities were detected in the esophageal mucosa. The median operating time was 60 minutes (range, 40-90 minutes). Postoperative histopathology confirmed leiomyoma in all patients. The median postoperative hospital stay was 6 days (range, 5-7 days). No major complications, such as esophageal leakage or esophageal diverticulum, occurred. Endoscopic methylene blue staining is safe and feasible for localizing small esophageal leiomyomas during thoracoscopic enucleation. This method will enable precise and easy enucleation.

Prone Position Is Useful in Thoracoscopic Enucleation of Esophageal Leiomyoma

A 36-year-old man was admitted to our institute due to the diagnosis of esophageal submucosal tumor detected by a periodical upper gastrointestinal endoscopic examination without any complaint. Thoracoscopic enucleation of the lesion with the preoperative clinical diagnosis of esophageal leiomyoma was performed under general anesthesia in the prone position. After immunohistochemical examination, the pathological diagnosis was leiomyoma. There was no remarkable event during the postoperative hospital stay, and the patient was discharged on the 12th day after surgery. This case report suggests that the prone position might be superior to the left lateral decubitus position in thoracoscopic enucleation of esophageal leiomyoma.

Retrospective analysis of thoracoscopic surgery for esophageal submucosal tumors

Background

Surgical enucleation is the treatment of choice for esophageal submucosal tumors (SMTs) with symptomatic, larger, or ill-defined lesions. The enucleation of SMTs has traditionally been performed via thoracotomy. However, minimally invasive approaches have recently been introduced and successfully applied. In this study, we present our experiences with the thoracotomic and thoracoscopic approaches to treating SMTs.

Methods

We retrospectively reviewed 53 patients with SMTs who underwent surgical enucleation between August 1996 and July 2013. Demographic and clinical features, tumor-related factors, the surgical approach, and outcomes were analyzed.

Results

There were 36 males (67.9%) and 17 females (32.1%); the mean age was 49.2±11.8 years (range, 16 to 79 years). Histology revealed leiomyoma in 51 patients, a gastrointestinal stromal tumor in one patient, and schwannoma in one patient. Eighteen patients (34.0%) were symptomatic. Fourteen patients underwent a planned thoracotomic enucleation. Of the 39 patients for whom a thoracoscopic approach was planned, six patients required conversion to thoracotomy because of overly small tumors or poor visualization in five patients and accidental mucosal injury in one patient. No mortality or major postoperative complications occurred. Compared to thoracotomy, the thoracoscopic approach had a slightly shorter operation time, but this difference was not statistically significant (120.0±45.6 minutes vs. 161.5±71.1 minutes, p=0.08). A significant difference was found in the length of the hospital stay (9.0±3.2 days vs. 16.5±5.4 days, p<0.001).

Conclusion

The thoracoscopic enucleation of submucosal esophageal tumors is safe and is associated with a shorter length of hospital stay compared to thoracotomic approaches.