Thoracoscopic enucleation of a giant submucosal tumor of the esophagus

Giant gastric stromal tumor mimicking as a posterior mediastinal mass: A case report and literature review

RATIONALE

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract. Mediastinal GISTs are rare and mostly arise from the esophagus.

PATIENT CONCERNS

A 68-year-old woman with dysphagia who presented with a huge posterior mediastinal mass.

DIAGNOSES

The patient was diagnosed with a GIST through chest computed tomography (CT)-guided core biopsy of the mass.

INTERVENTIONS

Complete excision including the tumor, lower part of the esophagus and fundus of the stomach were performed.

OUTCOMES

On follow-up after 48 months, the patient is currently alive without any evidence of tumor recurrence.

LESSONS

The case highlights GISTs are taken into consideration in the differential diagnosis of posterior mediastinal masses.

Minimally Invasive, Organ-preserving Surgery for Large Submucosal Tumors in the Abdominal Esophagus

BACKGROUND

Surgical resection of submucosal tumors (SMTs) in the abdominal esophagus is not standardized. Enucleation may be a minimally invasive option, whereas its oncological validity is not very clear. Moreover, how to treat the esophageal wall defect after enucleation and necessity of additional antireflux procedure are also undetermined.

METHODS

In 13 patients with a SMT originating the abdominal esophagus laparoscopic enucleation was performed with preserving the integrity of submucosa. When the muscular layer defect was <4 cm it was directly closed by suturing, whereas it was left open in case the defect was larger. Fundoplication was added when the esophagus was dissected posteriorly or the myotomy was not closed.

RESULTS

Tumors were resected en-bloc without rupture in all cases. In 5 patients myotomy was closed, whereas in the remaining 8 it was left open. In 11 patients fundoplication was added (Toupet in 5 and Dor in 6). The patients developed neither regurgitation nor stenosis postoperatively. The histopathologic findings revealed leiomyoma in 9 patients, whereas the other 4 were miscellaneous. The average tumor size was 5.5 cm (range, 2.8 to 8.8). Microscopically surgical margin was negative in all cases.

CONCLUSIONS

Laparoscopic enucleation of SMTs in the abdominal esophagus seems to be safe, reproducible operation enabling preservation of function of the lower esophagus and esophagogastric junction. Even when the muscular defect is not approximated additional fundoplication can minimize the risk of postoperative reflux disease.

Esophageal GIST: Case Report of Surgical Enucleation and Update on Current Diagnostic and Therapeutic Options

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract, but they have been rarely reported in the esophagus. The authors present the case of an esophageal GIST and discuss the diagnostic course and therapeutic options, as currently reported in the literature.

Esophageal gastrointestinal stromal tumors presenting as mediastinal mass

Gastrointestinal stromal tumors (GISTs) are the most common mesenchymal tumors of the gastrointestinal tract and are predominant in the stomach and intestine but rare in the esophagus. Here, we report a case of esophageal GIST which presented as a mediastinal mass on chest X-ray and dyspnea. The case was initially diagnosed as leiomyosarcoma, which could create a diagnostic dilemma. Therefore, recognizing this uncommon presentation as a mediastinal mass with esophageal GIST is important in the differential diagnosis.

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

INTRODUCTION

Esophageal leiomyomas are the most common benign tumors of the esophagus. Surgical enucleation is warranted for symptomatic patients. Thoracoscopic enucleation is the preferable approach for being less invasive by avoiding the discomfort and complications associated to larger thoracic incisions. The purpose of this study was to review our experience with enucleation of esophageal leiomyoma using a prone-position thoracoscopy technique.

METHODS

Between January 2009 and July 2012, ten patients underwent resection of esophageal leiomyoma by thoracoscopy approach in prone position. Indications for surgical treatment were symptomatic tumors (dysphagia). All patients were followed postoperatively for at least 3 months with contrast x-ray of the esophagus. After single-lumen endotracheal intubation (nonselective intubation) in supine, patients were placed in prone position. Pneumothorax was kept at 6 to 8 mmHg using CO2 insufflation. A myotomy was performed over the tumor using hook cautery carefully protecting the mucosa from injuries. The myotomy was closed with continuous sutures.

RESULTS

The procedures were completed in the prone position in all cases, without any conversion. Mean operative time was 89.2 ± 28.7 minutes. Bleeding was negligible, and there were no intraoperative or postoperative complications. No intensive care unit support was needed for any patient. Chest x-ray in the first postoperative day showed no significant changes in any patient. The mean hospital stay was 3.2 days. Contrast x-ray of the esophagus was normal in all patients at 3 months postoperatively.

CONCLUSIONS

Thoracoscopic enucleation of esophageal leiomyoma is a feasible, simple, and safe procedure. Thoracoscopy in the prone position with CO2 insufflation allows the use of usual technique of intubation and also provides optimal operative field. The advantages of the thoracoscopic approach are less postoperative discomfort and lower risk of complications from open thoracotomy (especially pulmonary).

Giant esophageal lipoma

A case of a giant esophageal pedunculated lipoma diagnosed in a 67-year-old male patient with recent onset of dysphagia is reported. Following the initial endoscopic and radiologic evaluation, the diagnosis was suspected by endo-ultrasonography and confirmed by histopathology. The treatment consisted of an esophagotomy with submucosal resection, through a left sided cervical incision. The review of the literature confirmed the rarity of this neoplasm, and the difficulty of a correct preoperative diagnosis, since a possible progression to squamous carcinoma has been demonstrated.

Enucleation of a leiomyoma of the mid-esophagus through a right thoracoscopy with the patient in prone position

BACKGROUND

Leiomyoma is the most common benign esophageal neoplasm. Different open and minimally invasive approaches have been described. We describe a right thoracoscopic enucleation with the patient in the prone position.

METHOD

A 49-year-old woman consulted us about solid-diet dysphagia without other symptoms. Preoperative work-up showed the presence of 50 x 28-mm leiomyoma of the middle esophagus, without satellite lymph nodes. The patient underwent general anesthesia with a double-lumen endotracheal tube, and subsequently was placed in the prone position. A 30 degrees scope was introduced in the right 7th intercostal space on the posterior axillary line. Perioperative gastroscopy permitted localization of the lesion, which appeared to be situated at the level of the azygos vein. Two 5-mm trocars were inserted in the right 5th and 9th intercostal spaces on one line with the first one. The azygos vein was ligated. The muscular layer of the mid-esophagus was opened by coagulating hook. Due to a 2-mm trocarless Cadière's forceps (Microfrance, France), introduced into the right 7th intercostal space, the operative field was well exposed and the lesion was enucleated without mucosal perforation. The muscular layer was closed by interrupted silk 2/0 stitches. A drain was left in the chest cavity.

RESULTS

Total operative time was 85 min and blood loss was less than 20 ml. The gastrograffin swallow on postoperative day 2 showed good clearance of the esophagus and absence of leak, hence the patient was allowed a liquid diet. The patient was discharged on postoperative day 3. Benign pathology was confirmed.

CONCLUSION

Thoracoscopy in the prone position permits the surgeon to reach the esophagus under excellent working conditions, despite an only partially deflated lung. Gravity displaces blood loss eventually, which allows good visualization, and the surgeon can operate in an ergonomic position. This approach allows for fewer trocars which favorably influences the patient's comfort and reduces the length of hospital stay.

Minimally invasive resection of gastrointestinal stromal tumors

Gastrointestinal stromal tumors (GISTs) are rare neoplasms. The advent of electron microscopy and immunohistochemistry has led to the realization that these tumors originate from a pleuropotential cell known as the interstitial cell of Cajal (ICC). The morphologic features demonstrated as most predictive of recurrence or metastases are tumor size and mitotic rate. There is oncologic justification for minimally invasive resection techniques with gross margins for GISTs. Minimally invasive resection provides advantages to patients in terms of morbidity and recovery. A variety of endoscopic, laparoscopic, and hybrid techniques are described for surgically excising GISTs in different anatomic locations.

Minimally invasive surgical enucleation or esophagogastrectomy for benign tumor of the esophagus

Experience in surgical resection of benign tumor of the esophagus is limited. Authors performed a chart review of 5 patients who underwent minimally invasive surgical resection of benign esophageal tumor. Main outcome measures included operative approaches, tumor's location and size, and outcomes. Tumor location were middle esophagus (n = 1), distal esophagus (n = 2), and gastroesophageal junction (n = 2). There were 4 females with a mean age of 55 years. Surgical approaches included thoracoscopic enucleation (n = 1), laparoscopic enucleation (n = 1), and laparoscopic and thoracoscopic Ivor Lewis esophagogastrectomy (n = 3). There were no open conversions. Mean operative time for enucleation was 127 minutes and 240 minutes for Ivor Lewis esophagectomy. Mean hospital stay was 5.8 days. There were no major or minor complications. Three patients developed stomal stenosis. The 30-day mortality was zero. Surgical pathology showed leiomyoma in 3 patients and gastrointestinal stromal tumor in 2 patients. Tumor size ranged from 1.1 to 10.5 cm. There has been no tumor recurrence at a mean follow-up of 14 months. Minimally invasive surgical enucleation or esophagogastrectomy for benign esophageal tumor is feasible and safe. The optimal approaches should be tailored based on the location and size of the tumor.

Minimally invasive therapy for benign tumors of the distal third of the esophagus--a single institute's experience

INTRODUCTION

Traditionally, the treatment of benign esophageal tumors is enucleation achieved via a thoracotomy. Since 1992, many reports of thoracoscopic and laparoscopic approaches have been published. In this paper, we present a retrospective study of 18 patients with benign distal esophageal tumors who underwent minimally invasive procedures.

MATERIALS AND METHODS

A total of 18 patients were treated in our institute form 1994 to 2006. Tumors of the middle third were approached thoracoscopically, and laparoscopic transhiatal enucleation was performed for tumors of the lower third. One patient had associated achalasia cardia, for which a cardiomyotomy with Toupet fundoplication was also performed, and another patient underwent an esophagectomy for a large tumor.

RESULTS

There were 12 males and 6 females and the average age was 59 years. The majority of the tumors were in the lower third, and the most common type of tumor was leiomyoma. Postoperative complications were recorded.

DISCUSSION

Leiomyomas are the most common benign tumors and are located frequently in the middle and lower third. Based on our experience, we feel that lower esophageal tumors are best approached by a laparoscopic transhiatal route and midesophageal tumors by a right thoracoscopic approach.

CONCLUSIONS

Minimally invasive surgery for benign esophageal tumors is ideal, reducing the morbidity of conventional methods.

Surgical considerations for the management and resection of esophageal gastrointestinal stromal tumors

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are the most common sarcoma of the gastrointestinal tract, but occur rarely in the esophagus. Use of tyrosine kinase inhibitors has revolutionized therapy for GISTs but complete resection remains the treatment of choice. Esophageal GISTs require special consideration regarding perioperative treatment, evaluation, and conduct of operation.

METHODS

We report our experience (from 2000 to 2003) with four patients who underwent resection of esophageal GIST, reviewed consensus management guidelines, and performed a literature review for reported cases. Query of the National Cancer Database was made to assess national experience with esophageal GISTs.

RESULTS

All four patients had esophageal GISTs successfully differentiated from leiomyomata by immunohistochemistry on fine needle aspirates obtained during endoscopic ultrasound. At the time of resection all tumors were noted to be adherent to tissues other than submucosa that required resection of esophageal muscularis, periesophageal tissue, or mucosa. All patients were thought to have complete resection and were alive at last contact (median, 33 months). Two of four patients recurred, one of whom underwent esophagectomy; the other patient is alive on imatinib. Seven case reports with median follow-up of three years reported no recurrence with either enucleation or esophagectomy. The National Cancer Database contains 33 cases of esophageal GIST reported since 1999. Nine of 24 patients died within six months of diagnosis.

CONCLUSIONS

Esophagectomy is the treatment of choice for esophageal GISTs but requires attention to operative details that emphasize complete en bloc excision of surrounding tissue. Preoperative imatinib may improve resectability.

Therapeutic procedures for submucosal tumors in the gastrointestinal tract

This review is part three of three and will present an update on the therapeutic options and procedures concerning gastrointestinal (GI) submucosal tumors (SMTs). The aim of this paper is to investigate the treatments of GI SMTs and to present a case of a gastrointestinal stromal tumor (GIST). Literature searches were performed to find information on therapy for GI SMTs. Based on these searches, the optimal therapeutic procedures could be outlined. The choice of treatment of localized tumors is endoscopic resection if possible or, alternatively, laparoscopic resection or surgical resection by an open procedure. However, benign SMTs should only be excised if symptoms are present, and GISTs should be treated with particular precautions. Irresectable or recurrent GISTs may be successfully treated with the tyrosine kinase inhibitor, imatinib.