Minimally invasive techniques in the surgical approach of esophageal leiomyoma: a report case
- Journal of Cancer Prevention & Current Research
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Hellen Cruz Xavier, Gilmar Ferreira do
Espírito Santo, Ana Rita de Oliveira Passos,
Gabriel Nogueira Zuntini, Maria Luisa
Buzatto, Amanda Moura da Silva, Pedro
Henrique Bertoleti Ribeiro, Beatriz Guedes
Fernandez
Abstract
Case report: A.L.R, female, complained dysphagia and heartburn with 1-year evolution,
not associated with weight loss or other symptoms. EGD (01/03/22): subepithelial lesion
in the middle third of the esophagus. Endoscopic ultrasound (01/03/22): hypoechoic,
heterogeneous lesion, with precise limits, in the smooth muscle, measuring 3.5x1.2cm.
Biopsy (01/06/22): mesenchymal neoplasm. Immunohistochemistry: compatible with
benign mesenchymal neoplasm of smooth muscle cells. Chest CT with IV contrast
(02/07/23): concentric thickening of the posterior wall in the middle third, extending
longitudinally for 4.2 cm. Surgical treatment was chosen due to persistence of symptoms
and enlargement of the lesion after 1 year of follow-up. Tumor resection was performed by
thoracoscopy with an approach through the right hemithorax. The patient evolved without
postoperative complications.
Discussion: Esophageal leiomyoma accounts for 60 –70% benign tumors of the esophagus and less than 1% of all esophageal neoplasms. Up to 50% of patients are asymptomatic and incidentally diagnosed. Symptomatic patients present with dysphagia, heartburn, regurgitation, retrosternal pain. Barium swallow, CT scan with oral contrast and endoscopic ultrasound represent the mainstay of diagnosis. The use of biopsy is controversial and is recommended in cases of diagnostic doubt. Surgery is indicated in symptomatic patients or with tumors > 5cm, or with unclear biological behavior. Thoracoscopy and thoracostomy are standard surgical approaches for upper and middle third tumors. Minimally invasive techniques can be used regardless of the size of the lesion, although lesions > 5cm carry a high risk of conversion to an open surgical. Right surgical approach could create more operating space and avoid affecting the heart and major vessels. Myotomy reapproximation is recommended to prevent loss of peristalsis, bulging of the mucosa and pseudodiverticulum.
Final considerations: Esophageal leiomyomas are rare and, in most cases, do not require surgical intervention. Thoracoscopy approach should be the first choice, whenever is possible, and performed by an experienced surgeon.
Discussion: Esophageal leiomyoma accounts for 60 –70% benign tumors of the esophagus and less than 1% of all esophageal neoplasms. Up to 50% of patients are asymptomatic and incidentally diagnosed. Symptomatic patients present with dysphagia, heartburn, regurgitation, retrosternal pain. Barium swallow, CT scan with oral contrast and endoscopic ultrasound represent the mainstay of diagnosis. The use of biopsy is controversial and is recommended in cases of diagnostic doubt. Surgery is indicated in symptomatic patients or with tumors > 5cm, or with unclear biological behavior. Thoracoscopy and thoracostomy are standard surgical approaches for upper and middle third tumors. Minimally invasive techniques can be used regardless of the size of the lesion, although lesions > 5cm carry a high risk of conversion to an open surgical. Right surgical approach could create more operating space and avoid affecting the heart and major vessels. Myotomy reapproximation is recommended to prevent loss of peristalsis, bulging of the mucosa and pseudodiverticulum.
Final considerations: Esophageal leiomyomas are rare and, in most cases, do not require surgical intervention. Thoracoscopy approach should be the first choice, whenever is possible, and performed by an experienced surgeon.
Keywords
esophageal leiomyoma, esophagus, thoracotomy, thoracoscopy, benign tumor
