Enucleación esofágica de leiomioma asistida por robot: reporte de un caso y revisión de la literatura / Case report of robot-assisted esophageal enucleation of leiomyoma and literature review

Resumen Introducción: los leiomiomas esofágicos son tumores benignos, que son resecados por enucleación esofágica cuando son mayores de 5 cm o en lesiones de cualquier tamaño que sean sintomáticos o sospechosos de malignidad. Tradicionalmente, se ha realizado la resección por técnica de enucleación abierta; sin embargo, la cirugía mínimamente invasiva ha surgido como una técnica con grandes ventajas y, en especial, la tecnología robótica parece ofrecer ventajas. Caso clínico: se reporta un caso de leiomioma esofágico del esófago medio con enucleación mediante el uso de una técnica toracoscópica asistida por robot. La esofagoscopia intraoperatoria y la transiluminación fueron complementos útiles para identificar el esófago y desarrollar un plano de disección extramucosa seguro, que junto con la asistencia robótica parecen minimizar los riesgos intraoperatorios, entre ellos, potencialmente la probabilidad de lesión mucosa, y mejoran el tiempo de recuperación postoperatoria.

Abstract Introduction: Esophageal leiomyomas are benign tumors which are resected by esophageal enucleation when they are symptomatic, suspected of malignancy, or larger than 5 cm. Traditional resection uses the open enucleation technique, but minimally invasive surgery has emerged as a technique that has great advantages, especially when combined with robotic technology. Case report: We report a case of leiomyoma of the middle esophagus with treated with enucleation using a robotic-assisted thoracoscopic technique. Intraoperative esophagoscopy and transillumination were useful for identifying the esophagus and developing a plan of safe extra mucosal dissection. Together with robotic assistance this seems to minimize intraoperative risks including that of mucosal injury while also improving postoperative recovery time.

Endoscopic Ultrasonography in the Diagnosis and Treatment Strategy Choice of Esophageal Leiomyoma

OBJECTIVES: Esophageal leiomyoma is the most common benign tumor of the esophagus, and it originates from mesenchymal tissue. This study analyzed the clinicopathological characteristics of esophageal leiomyoma and aimed to evaluate the role of endoscopic ultrasonography in the diagnosis and treatment selection for these lesions. METHODS: Two hundred and twenty-five patients who had suspected esophageal leiomyomas in endoscopic ultrasonography were enrolled at the Endoscopy Center of The First Affiliated Hospital, Zhejiang University from January 1st, 2009 to May 31th, 2015. The main outcomes included the demographic and morphological characteristics, symptoms, comparisons of diagnosis and treatment methods, adverse events, and prognosis. RESULTS: One hundred and sixty-seven patients were diagnosed as having an esophageal leiomyoma by pathological examination. The mean patient age was 50.57±9.983 years. In total, 62.9% of the lesions originated from the muscularis mucosa, and the others originated from the muscularis propria. The median distance to the incisors was 30±12 cm. The median diameter was 0.72±0.99 cm. As determined by endoscopic ultrasonography, most existing leiomyomas were homogeneous, endophytic, and spherical. The leiomyomas from the muscularis mucosa were smaller than those from the muscularis propria and much closer to the incisors (p<0.05). SMA (smooth muscle antibody) (97.2%) and desmin (94.5%) were positive in the majority of patients. In terms of treatments, patients preferred endoscopic therapies, which led to less adverse events (e.g., intraoperative bleeding, local infection, pleural effusion) than surgical operations (p<0.05). The superficial leiomyomas presented less adverse events and better recovery (p<0.05) than deep leiomyomas. CONCLUSION: Endoscopic ultrasonography has demonstrated high accuracy in the diagnosis of esophageal leiomyomas and provides great support in selecting treatments; however, EUS cannot completely avoid misdiagnosis, so combining it with other examinations may be a good strategy to solve this problem.

Analysis of misdiagnosis of esophageal leiomyoma / 中华胸心血管外科杂志

Objective To analyze the causes of misdiagnosis of esophageal leiomyoma.Methods The clinical data of 20 patients who were preoperatively misdiagnosed as esophageal leiomyoma at our hospital in 16 years were retrospectively analyzed.There were 11 males(55%) and 9 females(45%) with a mean age of(45.9 ± 16.4) years(range, 13-71 years).The initial presentations were obstructive symptoms in 12 patients(60%).CT imaging were performed in 9 patients(45%), of which 4 cases were enhanced CT(20%).Results The misdiagnosed patients included 5 cases of extraesophageal lesions(4 cases of paraesophageal lymph node tuberculosis and 1 case of lymph node hyperplasia), 8 cases of begin interstitial diseases(3 cases of neurinoma, 3 cases of inclusion cyst, 2 cases of angioma), 5 cases of malignant interstitial diseases(4 cases of GIST, 1 case of PNET), and 2 cases of esophageal cancer.The 4 cases of esophageal tuberculosis were misdiagnosed due to the absence of CT examination.The patients with esophageal cancer were treated with esophageal resection and reconstruction without clear staging of the tumor.This might be associated with the neglection of the rapid symptom development and the characteristic lumen stenosis under the gastroscope.The characteristic mucosal ulcer in patients with highly malignant GIST was overlooked.The disease relapsed postoperatively because only tumor enucleation was performed.Conclusion Preoperative diagnosis of esophageal leiomyoma is not uncommon.This disease is most often misdiagnosed as paraesophageal lymph node tuberculosis or esophageal GIST.CT examination is useful in distinguishing esophageal leiomyoma and paraesophageal lymph node tuberculosis.The roles of reoperation and adjuvant therapy in the surgical treatment of esophageal leiomyoma need further investigation.

Imaging features of Alport syndrome combined with huge esophageal and gastric leiomyoma / 中华消化外科杂志

Alport syndrome is a hereditary glomerular basement membrane disease.Hematuria,sensorineural deafness and progressive renal function impairment is the main clinical symptoms.Alport syndrome can be associated with ocular abnormalities,and a few of patients were complicated with diffuse leiomyoma.The incidence of Alport syndrome with diffuse leiomyoma is low,and it mainly invades esophagus,the trachea and female genital tract,et al.Patients with Alport syndrome and diffuse leiomyoma have difficulty in swallowing and postprandial vomiting,recurrent bronchitis symptoms and dyspnea.Diffuse leiomyoma is commonly seen in the esophagus.Alport syndrome with huge esophageal and gastric leiomyoma is rarely seen in clinical practice.In this article,the imaging manifestations of Alport syndrome combined with huge esophageal and gastric leiomyoma is summarized to improve the understanding and diagnostic accuracy of this disease.

Thoracoscopic operation in the treatment of esophageal leiomyoma / 中国基层医药

Objective To explore the feasibility and reliability of thoracoscopic surgery in the treatment of esophageal leiomyoma.Methods According to the tumor site selection of incision,7 patients with esophageal leiomyoma were taken myomectomy by thoracoscopic surgery.Results All cases were cured,and there was no death and serious complication.The patients were followed up for 3 to 24 months.There was no recurrence.Conclusion The myomectomy by thoracoscopic surgery would be an alternative to open surgery for patients with esophageal leiomyomas,which is safe and effective.

Leiomioma esofágico: experiencia con diez casos operados en el "Hospital Dr. Rafael Angel Calderón Guardia" / Esophageal leiomyoma: experience with nine surgical patients

Objetivo: informar la experiencia adquirida con la cirugía para leiomiomas esofágicos en el Servicio de Cirugía de Tórax del Hospital Dr. R.A. Calderón Guardia. Métodos: durante el período de 12 años comprendido entre 1999 y 2011, fueron referidos 14 pacientes con tumores submucosos del esófago al Servicio de Cirugía de Tórax del Hospital Calderón Guardia. En cuatro pacientes asintomáticos con tumores pequeños se decidió observar, y diez fueron operados, confirmándose el diagnóstico histológico de leiomioma. Previa autorización del Comité de Ética del Hospital, se revisaron los expedientes clínicos, analizando las características personales, los síntomas, los métodos de diagnóstico, el tratamiento quirúrgico y la evaluación de los pacientes operados...

The value of endoscopic ultrasonography for management of esophageal leiomyoma / 中华消化杂志

Objective To investigate clinical value of endoscopic ultrasonography (EUS) on diagnosis and treatment of esophageal leiomyoma.Methods The clinical feature of patients diagnosed as esophageal leiomyoma by EUS was analyzed.All patients underwent conventional gastroscopy and EUS examination as well as blood test.The EUS findings were compared with histopatholoical diagnosis for endoscopically or surgically resected specimens.All patients were followed-up with EUS for 14.3 months (range 2-36 months) for leiomyoma recurrence.Results A total of 191 patients were diagnosed with esophageal leiomyomas by EUS.Clinical manifestation,serum examination,conventional gastroscopy and spiral CT were not helpful for diagnosing esophageal leiomyoma,One hundred and sixteen patients with esophageal leiomyomas were treated by either endoscopic resection (111 cases) or surgical excision (5 cases).of which,101 resected specimens were pathologically confirmed as leiomyomas.The diagnostic accuracy of EUS was 87%.The follow-up study showed that there was no change of leiomyomas in 75 untreated patients and no recurrence was found in 116 surgically treated patients.Conclusion Esophageal leiomyoma is a benign tumor,EUS plays a very important role in diagnosis and treatment of this disease.

A Case of Esophageal Leiomyoma Showing High FDG Uptake on F-18 FDG PET / 핵의학분자영상

An esophageal leiomyoma is the most common benign tumor of the esophagus mainly occurred in intramural portion. Occasionaly, it is difficult to discriminate esophageal malignancy from large leiomyoma. Although F-18 FDG PET has been used for differentiating malignant from benign disease, false-positive cases have been reported. Recently, uterine leiomyoma has been reported to have relatively high F-18 FDG uptake in some patients but little is known about how an esophageal leiomyoma might be showed on F-18 FDG PET. We report a case of esophageal leiomyoma that showed high FDG uptake on PET images.

A Case of a False Positive FDG-PET/CT Scan in Esophageal Leiomyoma / 대한소화기내시경학회지

Esophageal leiomyoma is relatively rare disease, but can appears with a high uptake of fluorodeoxuglucose (FDG), a false-positive finding on a FDG PET/CT scan. A 64- year-old woman after a total thyroidectomy due to papillary and follicular carcinoma showed a high uptake of FDG in the distal esophagus on a subsequent FDG PET/ CT scan. The presence of an esophageal leiomyoma was suspicious from preoperative findings of endoscopic ultrasound and computed tomography, and an esophagectomy and proximal gastrectomy were performed, as the presence of a malignant lesion could not be excluded. As high uptake of FDG in the lesion on an FDG PET/CT scan corresponds to an esophageal cancer, an esophagectomy and proximal gastrectomy were performed and the lesion was confirmed as an esophageal leiomyoma after surgical biopsies. We report this case with a review of the relevant literature.

A Case of Esophageal Carcinoma Coexisting with Leiomyoma Removed by Endoscopic Resection / 대한소화기내시경학회지

The coexistence of esophageal submucosal tumors and carcinomas is rare and the association between them is still unclear. Here, we report a case of a superficial esophageal carcinoma that developed over an esophageal leiomyoma, which was removed successfully by an endoscopic mucosal resection. A 76-year-old man was admitted for the treatment of an esophageal carcinoma. The endoscopic examination revealed a 1 cm-sized round, flat, elevated lesion located at the 25 cm mark of the endoscopy. Endoscopic ultrasonography revealed the carcinoma to be limited to the mucosal layer. Interestingly, a 1.2 cm sized, hypoechoic, subepithelial mass was present beneath the carcinoma. An endoscopic resection was performed simultaneously using a suction and snaring method with a transparent cap attached to the tip of the endoscope. A histopathology examination revealed a squamous cell carcinoma restricted to the mucosa immediately over the benign leiomyoma arising from the muscularis mucosa. The patient has remained well during 1 year follow-up period and has shown no evidence of recurrence.

Resección endoscópica de un leiomioma de esófago mediante la ligadura con banda elástica / Endoscopic resection of esophageal leiomyoma with elastic band ligation

Leiomyoma is the most frequent esophageal benign tumor. It represents 70% of these tumors and 1 to 8% of all esophageal tumors. The majority of cases are asymptomatic and are discovered by chance in endoscopic examinations, and a conservative management is adopted. An endoscopic or surgical treatment can be applied in symptomatic cases, basically depending on the size and the underlying layer. OBJECTIVE: To report the endoscopic resection of an esophageal leiomyoma by using an elastic band ligation. Case report: A 55 year-old man complained of prolonged upper dysphagia with solids during three months. An upper gastrointestinal endoscopy was performed and an elevated lesion of 1 cm in diameter was found in the esophagus, at 25 cm from the upper dental arcade, with smooth surface and adjacent areas of normal mucosa. It was interpreted as a submucosal lesion. A hypoechoic mucosal and submucosal formation with well delimited borders was observed in an endoscopic ultrasonography. The lesion was resected by using an endoscopic band ligation and a subsequent section with a polypectomy snare. The patient evolved uneventfully and was discharged in 24 hours. The endoscopic examinations during the follow-up showed the healing of the resulting scar. Pathologists diagnosis was esophageal leiomyoma. CONCLUSION: The elastic band ligation is a simple, safe, effective and cheap method to be taken into account for the treatment of mucosal and submucosal esophageal lesions.

El leiomioma es el tumor esofágico benigno más frecuente;representa el 70 % de los mismos y el 1 a 8% de todos los tumores del esófago. La mayoría de los casos son asintomáticos y su hallazgo es accidental en estudios endoscópicos, tomándose una conducta conservadora.En los casos sintomáticos se puede decidir un tratamiento quirúrgico o endoscópico, dependiendo fundamentalmente del tamaño y la capa de la pared en la que asienta. Objetivo: Comunicar una resección endoscópicade un leiomioma esofágico mediante el uso de la ligadura con banda elástica. Caso clínico: Se presenta un paciente de 55 años de edad que consultó pordisfagia alta para sólidos, continua y de tres meses de evolución. Se realizó una endoscopía en la que se observóuna lesión elevada de 1 cm de diámetro en esófago, a 25 cm de la arcada dentaria superior, con superficielisa y áreas adyacentes de mucosa sana. Se interpretó la lesión como submucosa. En la ecoendoscopia se apreció una formación hipoecoica de bordes bien delimitados, ubicada en mucosa y submucosa. Se decidió realizar una resección de la lesión utilizando la ligadura endoscópica con banda elástica y posterior sección con asa de polipectomía. El paciente evolucionó favorablemente y fue dado de alta a las 24 horas. Los controles endoscópicos posteriores mostraron una buena cicatrización de la escara resultante. El informe anatomopatológico fue leiomioma esofágico. Conclusión: Laaplicación de la banda elástica es un método simple, seguro, eficaz y de bajo costo para considerar en el manejode las lesiones mucosas y submucosas esofágicas.

Treatment of Esophageal Leiomyoma by Video-assisted Thoracoscopic Surgery / 中国微创外科杂志

Objective To evaluate the efficacy and safety of video-assisted thoracoscopic surgery in the treatment of esophageal leiomyoma.Methods Clinical data of 49 patients with esophageal leiomyoma from September 1996 to February 2009 treated by video-assisted thoracoscopic enucleation were reviewed retrospectively.Three or four trocars were used during the operation.The procedure of the surgery was similar to that of open thoracoscopic enucleation.Results In the 49 patients,video-assisted thoracoscopic leiomyoma enucleation was successfully completed in 42 cases.The other 7 patients were converted to open thoracotomy because of the following reasons:dense pleural adhesion in 2,location failure of small tumor(

Treatment of esophageal leiomyoma by minimally invasive surgery / 中国微创外科杂志

Objective To discuss the application of minimally invasive surgery in the treatment of esophageal leiomyoma. Methods Clinical data of 26 patients with esophageal leiomyoma from September 1996 to October 2002 treated by minimally invasive surgery were reviewed retrospectively. Results Video-assisted thoracoscopic leiomyoma enucleations were performed in 23 patients, and a conversion to mini-thoracotomy was required in 3 of them because of dense pleural adhesion (2 patients) or location failure of tumor (1 patient). The remaining 3 patients underwent transjugular leiomyoma enucleation (2 patients) or esophagoscopic resection of leiomyoma (1 patient), respectively. All the procedures were completed smoothly and the postoperative recovery was uneventful, without mortality or severe complications. All the patients were pathologically diagnosed as leiomyoma after surgery. Follow-up for 2 ～ 73 months (mean,32.3months) found no recurrence. Conclusions Video-assisted thoracoscopic enucleation can be the first choice for the esophageal leiomyomas that derived from lamina propria, while esophagoscopic removal may be considered for those from muscularis mucosa.

Treatment of Esophageal Leiomyoma with Video-assisted Thoracoscope / 中国微创外科杂志

Objective To discuss the value of video-assisted thoracoscope in the treatment of esophageal leiomyoma. Methods Clinical data of 19 patients with esophageal leiomyoma treated by video-assisted thoracoscopy from July 2000 to October 2007 were reviewed retrospectively.Under general anaesthesia with the patients at the lateral position according to the location of esophageal leiomyoma,3 incisions were made on the chest wall for insertion of the trocars.Gastroscope was applied for intraoperative auxiliary operation.Results Under a video-assisted thoracoscope,enucleation of the leiomyoma was performed on 18 of the patients,the other one,who were diagnosed with esophageal leiomyoma(3 cm ? 2 cm) was converted to thoracotomy because of the tumor was confirmed huge during the thoracoscopy.No postoperative death or severe complications occurred.Pathological examination confirmed the diagnosis of leiomyoma in all of the cases.The patients were followed up for a mean of 24.5 months(5-35 months),no recurrence was found during the period. Conclusions Video-assisted thoracoscopy can be the first choice for the treatment of esophageal leiomyoma.Open surgery should be considered if the tumor is huge.