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 Table of Contents  
CASE REPORT
Year : 2017  |  Volume : 2  |  Issue : 1  |  Page : 19-21

A case of surgical enucleation of a giant esophageal leiomyoma


1 Department of Thoracic Surgery, First Affiliated Hospital of the Chinese People's Liberation Army General Hospital, Beijing, China
2 Department of Cardiovascular Medicine, Xi Shan Clinic, The 309th Hospital of Chinese People's Liberation Army, Beijing, China

Date of Submission13-Mar-2016
Date of Acceptance20-Feb-2017
Date of Web Publication21-Mar-2017

Correspondence Address:
Shanshan Li
Department of Cardiovascular Medicine, Xi Shan Clinic, The 309th Hospital of Chinese People's Liberation Army, Hai Dian, Beijing 100091
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ts.ts_28_16

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  Abstract 


Esophageal leiomyoma is the most common benign esophageal tumor. When dealing with a giant esophageal tumor, tumor resection, and esophagogastric anastomosis are normally adopted by clinicians. However, postoperatively, patients always experience a poor quality of life because of the destruction of the normal anatomy. We present a case of resection of an esophageal leiomyoma with the integrity of esophagus maintained.

Keywords: Anastomosis, esophageal leiomyoma, surgery, treatment, tumor resection


How to cite this article:
Zhou S, Li S, Guo N, Zhang W. A case of surgical enucleation of a giant esophageal leiomyoma. Transl Surg 2017;2:19-21

How to cite this URL:
Zhou S, Li S, Guo N, Zhang W. A case of surgical enucleation of a giant esophageal leiomyoma. Transl Surg [serial online] 2017 [cited 2017 Oct 17];2:19-21. Available from: http://www.translsurg.com/text.asp?2017/2/1/19/202644




  Introduction Top


Benign tumors of the esophagus are rare. Leiomyomas are the most common of these otherwise rare tumors. Traditionally, leiomyomas have been uniformly classified with other tumors as gastrointestinal stromal tumors (GISTs), but late evidence in the immunochemistry field has shown that they are comprised two different entities.[1] Symptoms, usually nonspecific and long-lasting, do not seem to be related to size and location of tumor. These tumors are more likely to present in male patients. Male and female's prevalence ratios are of 2:1 and the peak incidence is between 20 and 50 years of age. They are located frequently in the distal two-thirds of the esophagus.[2] The treatment of these tumors is, in most cases, surgical enucleation, indicated in large or symptomatic tumors, or tumors that show growth after initial observation.[3] Traditionally, surgical excision has been performed through an open approach.[4] Small pedunculated leiomyomas can be treated with endoscopic band ligation or resected endoscopically.[5] We reported a rare case of a solitary giant esophageal leiomyoma. With our technique, we improve on the past surgical approach for large tumor surgery by maintaining the integrity of the esophagus and improving the quality of life for the patient.


  Case Report Top


A 46-year-old male presented symptoms of a 2-month history of heartburn and retrosternal pain. He had no history of dyspepsia, vomiting, weight loss, dysphagia, or esophageal reflux disease. The patient had an initial endoscopy which revealed external compression and normal esophageal mucosa. Endoscopic ultrasound showed a hypoechoic lesion arising from the esophageal muscular wall suggestive of leiomyoma. A computed tomography (CT) scan of the thorax confirmed a mass in the lower-esophagus [Figure 1]a. A barium swallow study showed a filling defect in the esophagus and a narrow esophageal lumen [Figure 1]b. He had been diagnosed with hypertension and diabetes mellitus for 3 and 2 years, respectively. Physical examination of the chest was normal. In our operation, the esophagus was approached through a left posterolateral thoracotomy. On palpation, there was a large spherical neoplasm palpated in the lower esophagus which pushed the nasogastric tube aside [Figure 2]. A longitudinal esophagotomy incision was made in the anterolateral esophageal wall and the muscle layers were divided meticulously to keep the mucosa intact. However, the esophagus mucosa had been damaged because of mucosal and submucosal scarring from the endoscopic biopsy. The esophagus mucosa was repaired with absorbable suture. After closed the mucosa, mucosal integrity was confirmed by lumen insufflation (with the esophagus submerged under water). The test proofed that the sutural esophageal mucosal was tight. The esophageal wall was closed with nonabsorbable interrupted sutures. A mass of 6.0 cm in diameter was enucleated with careful dissection [Figure 3]a. The histopathological report showed a well-circumscribed benign smooth muscle tumor with limited malignant potential [Figure 3]b. Immunohistochemical studies showed that the tumor cells were smooth muscle antigen positive, CD 34 negative, and CD 117 negative. After excision of the esophageal leiomyoma, the patient made an uneventful recovery. Barium swallow at day 5 revealed no leakage and the patient was started on a liquid diet on day 6.
Figure 1: (a) Computed tomography scan of the chest showing a mass in the wall of the esophagus displacing the lumen with normal surrounding structures. (b) Barium swallow study preoperatively showing a mass arising from the wall of the esophagus

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Figure 2: A large spherical neoplasm in the lower-esophagus

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Figure 3: (a) Macroscopic picture after excision of an 6 cm esophageal leiomyoma. (b) A well-circumscribed benign smooth muscle tumor. The picture showed the presence of interlacing fibers of smooth muscle cells arranged in a somewhat whorled appearance with areas of hyaline degeneration without any evidence of malignancy and was suggestive of leiomyoma of esophagus

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  Discussion Top


Benign tumors of the esophagus are rare. Leiomyomas are the most common in these rare tumors. Esophageal leiomyoma with no obvious clinical manifestations is most often found by accident.[6] Seremetis reported the most frequent symptoms were heartburn (46.15%), dysphagia (38.46%), and retrosternal pain (38.46%).[7] Other less common symptoms are dyspepsia, vague retrosternal discomfort, regurgitations and, very rarely, gastrointestinal bleeding secondary to erosion through the mucosa or weight loss caused by dysphagia. Radiological and endoscopic ultrasound examinations are useful diagnostic modalities. CT is very valuable in making diagnosis, not only because of its high sensitivity, but also to accurately estimate the nature, size, location and its relation to the surrounding organs.

Preoperative biopsy is not desirable. The complications with biopsy, such as infection, bleeding, increased intraoperative esophageal perforation rate,[3],[8],[9] have been described. As in our case, biopsy can cause increased technical difficulties in performing an extramucosal enucleation in subsequent surgical dissection due to mucosal and submucosal scarring.[10] In our case, although we divided the mass very carefully, the esophagus mucosa was not intact. Preoperative biopsy should only be performed in situ ations such as diagnostic doubt or the need of other neoadjuvant therapies for suspicion of malignancy or unresectable disease.[11]

We believe that systematic checking of esophageal mucosal integrity is necessary. In our case, we put the nasogastric tube back to the tumor segment of esophagus, then injected air into the esophageal lumen by stomach tube (with the esophagus submerged underwater). Alternative procedures can be performed, such as the use of methylene blue through a nasogastric tube, or performing an intraoperative endoscopy.

In addition, when dealing with the giant tumor of esophageal tumor, tumor resection and esophagogastric anastomosis are normally adopted by clinicians. However with this technique, the patients always present a poor postoperative quality of life because of the destruction of the normal anatomy.

Traditionally, surgical approach for giant esophageal leiomyoma has been opened thoracotomy or tumor resection through a thoracoabdominal incision, sometimes along with gastroesophagostomy.[12],[13],[14],[15],[16],[17] Surgical enucleation seems to be a good choice in order to reach a definitive histopathological diagnosis and to facilitate other surgical procedures in symptomatic tumors, with demonstrable increase in tumor size or with mucosal ulceration.,[8] However, there are different opinions about patients with asymptomatic tumors. Some authors recommend observation and follow-up in these cases, especially with lesions smaller than 5 cm.[3],[8],[18] On the other hand, other authors recommend their excision not only in symptomatic lesions, but also in those sized 1-5 cm, not only due to the rare possibility of malignant degeneration, but also to confirm histopathological diagnosis and differentiate them from GISTs. What seems clear is that surgery should be deferred with asymptomatic tumors smaller than 1 cm, because of the high difficulty to locate them in the surgical field.[19],[20],[21]

In our opinion, complete excision through thoracotomy is the gold standard treatment for leiomyomas over 5 cm. Tumor resection performed to maintain the integrity of the esophagus, as in our procedure, improves the life quality of patient, which is much preferable.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Zhu X, Zhang XQ, Li BM, Xu P, Zhang KH, Chen J. Esophageal mesenchymal tumors: Endoscopy, pathology and immunohistochemistry. World J Gastroenterol 2007;13 (5):768-73.  Back to cited text no. 1
    
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3.
von Rahden BH, Stein HJ, Feussner H, Siewert JR. Enucleation of submucosal tumors of the esophagus: Minimally invasive versus open approach. Surg Endosc 2004;18 (6):924-30.  Back to cited text no. 3
    
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Punpale A, Rangole A, Bhambhani N, Karimundackal G, Desai N, de Souza A, Pramesh CS, Jambhekar N, Mistry RC. Leiomyoma of esophagus. Ann Thorac Cardiovasc Surg 2007;13 (2):78-81.  Back to cited text no. 4
    
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Sun S, Jin Y, Chang G, Wang C, Li X, Wang Z. Endoscopic band ligation without electrosurgery: A new technique for excision of small upper-GI leiomyoma. Gastrointest Endosc 2004;60 (2):218-22.  Back to cited text no. 5
    
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Hu X, Lee H. Complete thoracoscopic enucleation of giant leiomyoma of the esophagus: A case report and review of the literature. J Cardiothorac Surg 2014;9(1):34.  Back to cited text no. 6
    
7.
Seremetis MG, Lyons WS, deGuzman VC, Peabody JW Jr. Leiomyomata of the esophagus. An analysis of 838 cases. Cancer 1976;38 (5):2166-77.  Back to cited text no. 7
    
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Lee LS, Sinighal S, Brinster CJ, Marshall B, Kochman ML, Kaiser LR, Kucharczuk JC. Current management of esophageal leiomyoma. J Am Coll Surg 2004;198 (1):136-46.  Back to cited text no. 8
    
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Bonavina L, Segalin A, Rosati R, Pavanello M, Peracchia A. Surgical therapy of esophageal leiomyoma. J Am Coll Surg 1995;181 (3):257-62.  Back to cited text no. 9
    
10.
Wang Y, Zhang R, Ouyang Z, Zhang D, Wang L, Zhang D. Diagnosis and surgical treatment of esophageal leiomyoma. Zhonghua Zhong Liu Za Zhi 2002;24 (4):394-6. (in Chinese)  Back to cited text no. 10
    
11.
Ramos D, Priego P, Coll M, Cornejo Mde L, Galindo J, Rodríguez-Velasco G, García-Moreno F, Carda P, Lobo E. Comparative study between open and minimally invasive approach in the surgical management of esophageal leiomyoma. Rev Esp Enferm Dig 2016;108 (1):8-14.  Back to cited text no. 11
    
12.
Aurea P, Grazia M, Petrella F, Bazzocchi R. Giant leiomyoma of the esophagus. Eur J Cardiothorac Surg 2002;22 (6):1008-10.  Back to cited text no. 12
    
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Rijcken E, Kersting CM, Senninger N, Bruewer M. Esophageal resection for giant leiomyoma: Report of two cases and a review of the literature. Langenbecks Arch Surg 2009;394 (4):623-9.  Back to cited text no. 13
    
14.
Georghiou GP, Greif F, Geller A, Vidne BA, Saute M. Enucleation of giant leiomyoma of the esophagus. Asian Cardiovas Thorac Ann 2006;14 (6):536.  Back to cited text no. 14
    
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Prenzel KL, Schäfer E, Stippel D, Beckurts KT, Hölscher AH. Multiple giant leiomyomas of the esophagus and stomach. Dis Esophagus 2006;19 (6):504-8.  Back to cited text no. 15
    
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Candela G, Varriale S, Di Libero L, Maschio A, Manetta F, Giordano M, Nunziata A, Santini L. Thoracotomy enucleation of a giant leiomyoma of the upper esophagus. Case report and review of the literature. Chir Ital 2007;59 (1):123-9.  Back to cited text no. 16
    
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Tokitsu K, Kawakami M, Morita T, Hashimoto T, Hayashi T. Enucleation for a giant esophageal leiomyoma; report of a case. Kyobu Geka 2004;57 (13):1245-9.  Back to cited text no. 17
    
18.
Glanz I, Grunebaum M. The radiological approach to leiomioma of the oesophagus with a long-term follow-up. Clin Radiol 1977;28 (2):197-200.  Back to cited text no. 18
    
19.
Jiang G, Zhao H, Yang F, Li J, Li Y, Liu Y, Liu J, Wang J. Thoracoscopic enucleation of esophageal leiomyoma: A retrospective study on 40 cases. Dis Esophagus 2009;22 (3):279-83.  Back to cited text no. 19
    
20.
Sun X, Wang J, Yang G. Surgical treatment of esophageal leiomyoma larger than 5 cm in diameter: A case report and review of the literature. J Thorac Dis 2012;4 (3):323-6.  Back to cited text no. 20
    
21.
Pinheiro FA, Campos AB, Matos JR, Araripe DP. Videoendoscopic surgery for the treatment of esophagus' leiomyoma. Arq Bras Cir Dig 2013;26 (3):234-7.  Back to cited text no. 21
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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