Surgical Treatment for Esophageal Leiomyoma: 13 Years of Experience in a High-Volume Tertiary Hospital

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.

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.

MIS for enucleation of leiomyoma of the oesophagus-strategic approach and experience of 19 cases

INTRODUCTION

Leiomyoma of the oesophagus, although rare, is the most common benign tumour to occur in the organ. Surgical approaches have evolved over time from an open thoracotomy or laparotomy to video-assisted thoracoscopic or laparoscopic and now robotic enucleation. We report a series of 19 cases of leiomyoma of the middle- and lower-third oesophagus treated by minimally invasive surgery.

PATIENTS AND METHODS

A retrospective analysis of 19 cases operated at a single tertiary care centre in India was performed. After the diagnosis of a benign oesophageal neoplasm on computed tomography (CT) and endosonography, laparoscopic transhiatal enucleation of the tumour for lower third ( n = 16) and right-sided video-assisted thoracoscopic excision for middle-third tumours ( n = 3) were performed. Dor fundoplication was done after the excision of leiomyomas from the lower oesophagus.

RESULTS

The most common symptom at presentation was retrosternal burning in lower oesophageal tumours, while tumours in the middle third of the oesophagus were asymptomatic and incidentally detected. The size of the tumour ranged from 3 cm to 8 cm in the largest dimension on contrast-enhanced CT scan. The mean operative time was 93 min ranging from 61 to 137 min. The average blood loss was 53 ml. No patient had an iatrogenic oesophageal mucosal injury. There were no conversions to open surgery or major complications including post-operative leak or death. Post-operative recovery was uneventful.

CONCLUSION

The transhiatal approach to lower oesophageal leiomyomas is strategic to avoid complications of thoracoscopy, minimally invasive, cost-effective as compared to robotic surgery, suitable for adequate exposure and safe in the hands of an experienced laparoscopic surgeon.

Circumferential esophageal leiomyoma: Management by combined robotic surgery and intraoperative endoscopy

Leiomyoma is the most common benign tumor of the esophagus. Open thoracotomy, the traditional approach adopted for the enucleation of the esophageal leiomyoma, over the years, has been gradually replaced by video-assisted thoracoscopic surgery. However, this minimally invasive approach has limitations, such as two-dimensional vision and reduced range of motion, which have recently been overcome by technical advantages of robot-assisted surgery. In the surgical management of circumferential esophageal leiomyoma, a combined use of robotic surgery and intraoperative endoscopy may be helpful to facilitate tumor enucleation and to prevent esophageal mucosal injury during the surgical procedure.

Dysphagia Unmasked: A Case Report of Esophageal Leiomyomatosis

Esophageal leiomyomatosis, an uncommon benign condition marked by the proliferation of smooth muscle cells within the esophageal wall, frequently presents diagnostic challenges due to its rarity and diverse clinical manifestations. In this case report, we document the clinical journey of a 28-year-old female who presented with a two-year history of progressive dysphagia. Upon physical examination and endoscopy, a submucosal mass in the lower esophagus was identified, prompting further imaging and subsequent biopsy, which confirmed the diagnosis of leiomyomatosis. A multidisciplinary team recommended surgical intervention, leading to a minimally invasive laparoscopic resection of the esophageal leiomyomas. Postoperatively, the patient experienced a substantial improvement in her dysphagia and was discharged in stable condition. This case not only underscores the importance of a multidisciplinary approach in achieving an accurate diagnosis but also highlights the successful application of minimally invasive surgical techniques for alleviating symptoms in esophageal leiomyomatosis patients. The rarity and varied clinical presentation of this condition emphasize the need for individualized and tailored management strategies.

Esophageal low-grade intraepithelial neoplasia overlying multiple leiomyomas: A case report and review of the literature

BACKGROUND

Esophageal leiomyoma is the most common benign submucosal mesenchymal tumor. Esophageal intraepithelial neoplasia includes low-grade and high-grade intraepithelial neoplasia. The coexistence of epithelial lesions and the subepithelial lesion is rare. We recorded a case of esophageal low-grade intraepithelial neoplasia (LGIN) overlying multiple esophageal leiomyomas and followed with a review of the literature.

CASE PRESENTATION

A 49-year-old female patient came for the treatment of esophageal lesions. The submucosal eminences were observed in the right posterior wall and the left anterior wall of the esophagus by Esophagogastroduodenoscopy (EGD). Additionally, we noticed the mucosa of the right wall with brown background color and the dilated, tortuous vessels by narrow-band imaging (NBI). Then we ensured that the submucosal lesions originated from the esophageal mucosal muscle by endoscopic ultrasonography (EUS) and enhanced CT. Subsequently, the submucosal eminence of the right posterior wall and the overlying mucosal lesion were removed together by endoscopic submucosal dissection (ESD). Postoperative pathological diagnosed esophageal submucosal leiomyoma with focal LGIN. Review EGD showed white scars on the right wall of the upper esophagus three months later, while pathological biopsy showed slight squamous epithelial hyperplasia in the left wall. We decided that the left submucosal lesion can be resected at a selective-time operation, and we continue to follow up as planned.

CONCLUSIONS

The case of intraepithelial neoplasia overlying the submucosal tumor is rare. Either missed diagnosis or overdiagnosis should be avoided through EGD and pathological biopsy.

Video-assisted thoracoscopic surgery (VATS) enucleation of large gastroesophageal junction leiomyoma: A case report

Introduction and importance

Esophageal leiomyomas are the most common benign esophageal tumors. They are typically smaller than 3 cm, but larger tumors can impede local structures to cause symptoms, including dysphagia and epigastric pain. Surgical treatment of esophageal leiomyomas has historically involved open thoracotomy, but this approach is being replaced by minimally invasive approaches, including video-assisted thoracoscopic surgery (VATS).

Case presentation

A 46-year-old female patient presented with upper abdominal pain. Computerized tomography (CT) scanning of the abdomen and chest revealed a large (6.0 × 4.0 × 3.0 cm) gastroesophageal junction (GEJ) mass. An endoscopic ultrasound (EUS) with fine needle aspiration confirmed diagnosis of esophageal leiomyoma. A right VATS esophageal mass resection was performed to enucleate the mass. An intraoperative EGD was performed to check mucosal integrity, ensure adequate lumen patency, and visualization and insufflation was negative for a mucosal leak. The post-operative course was unremarkable.

Clinical discussion

This case report adds to the emerging evidence that VATS can be utilized for enucleation of larger leiomyomas (>5 cm in largest dimension). Additionally, the use of direct intraoperative endoscopic evaluation via esophagoscopy suggests that larger esophageal masses could potentially be enucleated with a combined VATS and endoscopic approach.

Conclusion

The purpose of this report is to add to the limited literature on minimally invasive surgical treatment of a relatively large GEJ leiomyoma. This case highlights that VATS, in addition to simultaneous endoscopic visualization, is an efficacious and safe option for treatment of larger leiomyomas (>5 cm) and can be associated with minimal risk.

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VATS can be utilized for enucleation of larger gastroesophageal leiomyomas (>5 cm)

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Direct endoscopic evaluation can be used during VATS to examine mucosa integrity

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VATS may be associated with fewer intraoperative and post-operative complications