Surgical treatment of esophageal leiomyoma located near or at the esophagogastric junction via a thoracoscopic approach

Robotic Enucleation of a Large Gastroesophageal Junction Leiomyoma

In this multimedia article, we demonstrate transabdominal robotic enucleation of a large, multilobulated leiomyoma at the gastroesophageal junction (GEJ). The robotic platform provides stereoscopic visualization and wristed motion, which improved ease of an organ-sparing resection in a challenging anatomic location. Alternative minimally invasive approaches to tumors in this location have been reported including endoscopic, endoscopic with laparoscopic assistance, laparoscopic, and thoracoscopic approaches, with choice of approach dependent upon the location and configuration of the tumor Milito et al. in J Gastrointest Surg 24:499-504, 2020;Li et al. in Dis Esophagus. 22:185-189, 2009;Armstrong et al. in Am Surg. 79:968-972, 2013;Kent et al. in J Thorac Cardiovasc Surg. 134:176-181, 2007.

Videoendoscopic surgery for the treatment of esophagus' leiomyoma

INTRODUCTION

Leiomyomas are the commonest benign esophageal neoplasms. Surgical treatment is the therapy of choice for such tumors. Open enucleation via thoracotomy has long been the standard procedure. With the emergence of thoracoscopic and laparoscopic approaches, minimally invasive surgery represent interesting alternatives to open surgical procedures.

AIM

To propose endoscopic technique for the treatment of these myomas avoiding thoracotomy.

TECHNIQUE

Enucleation of leiomyoma by: A) thoracoscopy, for thoracic esophageal tumors, or B) laparoscopy to the ones located in abdominal esophagus. A) The operations are performed under general anesthesia with selective intubation of the left lung. Patients are placed in the left lateral decubitus position and mild dorsiflexion. Four work trocars are used, two of 11 mm and two of 5 mm. One of the 11 mm is put in the 6(th) intercostal space in the posterior axillary line to use the 30° endoscope; another, at the same hemi-clavicular line, to take the lung away off surgical site. Other two trocars of 5 mm are installed for working tools of the surgeon, one in the 4(th) space in the posterior axillary line, and another in the 7(th), also in the posterior axillary line. Operations are always initiated by opening the mediastinal pleura, dissection of the tumor with opening the muscle of the esophageal wall, simple enucleation of the tumor and closure of esophageal parietal muscular layer. B) The interventions are done with patients undergoing general anesthesia and placed in the French position. The approach is the same performed to correct the hiatal hernia, and enucleation is done without difficulty.

CONCLUSION

Videosurgery for leiomyomas resection is safe and feasible and provides results similar to open procedure, but with a significant reduction in morbidity.

Retrospective study of endoscopic submucosal tunnel dissection (ESTD) for surgical resection of esophageal leiomyoma

BACKGROUND

Esophageal leiomyoma is benign and often asymptomatic, but if the tumor is too large or obstructive, it should be resected. The aim of this study was to compare a novel approach, endoscopic submucosal tunnel dissection (ESTD), with a more established method, endoscopic submucosal dissection (ESD).

METHODS

This was a retrospective study of 39 patients in Chongqing Xinqiao Hospital, China, undergoing resection for leiomyoma >2 cm in diameter, or 1.5-2.0 cm in diameter with symptoms of obstructive dysphagia. Epidemiological data, presenting symptoms, diagnostic investigations, tumor location, histopathological findings, and safety and efficacy of surgical resection were analyzed.

RESULTS

Mean tumor sizes in the ESTD (n = 18; mean age = 36.7 ± 6.3 years) and ESD (n = 21; age = 41.0 ± 4.4 years) groups were 3.3 ± 0.7 and 3.0 ± 0.4 cm, respectively. The male:female ratio was 25:14, with a distribution of lesions among the lower, middle, and upper esophagus of 22:14:3. Operating time was significantly shorter (p < 0.05) for ESTD (67.5 ± 9.5 min) than for ESD (87.2 ± 7.7 min), while incision healing was faster (p < 0.05) for ESTD (14.7 ± 2.5 days) than for ESD (57.9 ± 7.5 days). Hospital stay was also shorter (p < 0.05) for ESTD (2.3 ± 0.5 days) than for ESD (5.7 ± 1.0 days). Bleeding was the only complication with ESTD (3/18 patients), with no significant difference in the incidence of complications between groups. ESTD was rapidly learned by surgeons.

CONCLUSION

ESTD is a safe and effective treatment for esophageal leiomyoma, with advantages over ESD.

Combined endoscopic and laparoscopic approach to a gastroesophageal tumor

BACKGROUND AND OBJECTIVES

Smooth muscle tumors of the stomach, especially when benign, are a common clinical entity and can represent a therapeutic challenge. Classically the removal of such a tumor requires open laparotomy. We sought to perform this surgery utilizing minimally invasive technology.

METHODS

We describe a minimally invasive technique combining laparoscopy with endoscopy to remove a sub-mucosal leiomyoma at the gastroesophageal junction.

RESULTS

A 3.3-cm smooth muscle tumor of the gastroesophageal junction was removed completely and safely with the described procedure and thus saved the patient from requiring a laparotomy.

CONCLUSION

Minimally invasive techniques can be used in combination to tackle difficult problems in general surgery leading to shorter hospital stays and improved patient satisfaction.

Laparoscopic excision of esophageal leiomyoma

Esophageal leiomyoma is the most common benign tumor of the esophagus. The lower and middle thirds of the esophagus are the most frequent locations of these tumors and in about one-third of the patients they occur at the level of the gastroesophageal junction. They are less than 5 cm in size in 50% of the patients. A left thoracotomy, thoracoscopy or a laparoscopic approach can be used for lesions in the lower third of the esophagus. Esophageal leiomyomas should be considered for resection when symptomatic. Preoperative evaluation allows precise characterization of the diagnosis and location. Minimally invasive surgery is considered today the treatment of choice with the laparoscopic approach used for distal tumors. We present the case of a 63-year-old woman with an esophageal leiomyoma located above the gastroesophageal junction who underwent a successful laparoscopic excision of the tumor.