Resection of esophageal leiomyoma using an endoscopic submucosal dissection technique

 

 Permissions and Reprints

A 55-year-old woman with a positive fecal occult blood test was investigated by upper endoscopy. This revealed an esophageal submucosal tumor, 18 cm from the incisors (Figure [1 a]). Endoscopic ultrasound confirmed that this lesion, which measured 10 mm × 10 mm, arose from the muscularis mucosae and involved only the submucosa. The tumor was removed by endoscopic resection, with initial marking by electrocautery and submucosal injection of 15 ml of normal saline mixed with indigo carmine and epinephrine. An endoscopic submucosal dissection was performed using a triangular-tip knife, an insulated-tip knife, and a Hook knife (Olympus, Tokyo, Japan) (Figure [1 b], Video 1). Histological examination of the tumor confirmed that it was a leiomyoma. The patient was discharged from hospital 3 days after the endoscopic submucosal dissection procedure and she had an uneventful recovery.

Figure 1 Esophageal leiomyoma, seen before treatment (a) and after near-complete resection using an endoscopic submucosal dissection technique (b).

Indications for surgical resection of esophageal leiomyoma include unremitting symptoms, increasing tumor size, ulceration of the tumor, or the need for a histological diagnosis [1] [2]. Recently, thoracoscopy-assisted enucleation has proved feasible and this is associated with less postoperative pain and faster recovery [3].

Asymptomatic esophageal leiomyomas are commonly managed by observation. Endoscopic mucosal resection has recently emerged as an option for treating small esophageal leiomyomas, but the usefulness of conventional endoscopic mucosal resection is limited by the risk of perforation because the lifting effect of the submucosal injection may be hindered by the submucosal nature of the tumor [4]. An advantage of endoscopic submucosal dissection is that the dissection is performed within the submucosal plane, and enucleation of the tumor does not rely on lifting it. In our experience, different endoscopic knives suit different steps of the dissection: Hook and triangular-tip knives can be used for sharp submucosal dissection, while an insulated-tip knife is employed for circumferential incision. The magnifying power of the endoscope clearly identified the plane of dissection, which allowed for precise dissection and hemostasis. Our experience concurred with the findings of a study that showed that submucosal tumors arising from the muscularis mucosae can be removed completely by endoscopic submucosal dissection [5]. Although our patient was asymptomatic, endoscopic enucleation of her tumor offered her the advantage of having it safely resected without morbidity and before it become symptomatic.

Endoscopy_UCTN_Code_TTT_1AO_2AG

References

• 1 Shim C S, Jung I S. Endoscopic removal of submucosal tumors: preprocedure diagnosis, technical options, and results.  Endoscopy. 2005;  37 646-654
  Article in Thieme ConnectPubMedGoogle Scholar
• 2 Lee L S, Singhal S, Brinster C J. et al . Current management of esophageal leiomyoma.  J Am Coll Surg. 2004;  198 136-146
  CrossrefPubMedGoogle Scholar
• 3 Von Rahden B H, Stein H J, Feussner H, Siewert J R. Enucleation of submucosal tumors of the esophagus: minimally invasive versus open approach.  Surg Endosc. 2004;  18 924-930
  CrossrefPubMedGoogle Scholar
• 4 Chen J B, Kudzu T, Hishikawa E, Miyazaki S. Endoscopic resection of a large esophageal leiomyoma.  Endoscopy. 2002;  34 428
  Article in Thieme ConnectPubMedGoogle Scholar
• 5 Park Y S, Park S W, Kim T I. et al . Endoscopic enucleation of upper-GI submucosal tumors by using an insulated-tip electrosurgical knife.  Gastrointest Endosc. 2004;  59 409-415
  CrossrefPubMedGoogle Scholar

P. W. Y. Chiu, FRCSEd

Division of Upper GI Surgery, Department of Surgery

Prince of Wales Hospital
The Chinese University of Hong Kong
30 - 32 Ngan Shing Street
Shatin, N.T.
Hong Kong

Fax: +852-26377974

Email: pwychiu@netvigator.com