Endoscopy 2020; 52(07): 622
DOI: 10.1055/a-1167-8295
Letter to the editor

Reply to Matsushita et al.

Martin Dahan
1   Service d’Hépato-gastro-entérologie, CHU Dupuytren, Limoges, France
,
Anne Guyot
2   Service d’anatomopathologie, CHU Dupuytren, Limoges, France
,
Aurelie Charissoux
2   Service d’anatomopathologie, CHU Dupuytren, Limoges, France
,
Marion Schaefer
3   Service dʼHépato-gastro-entérologie, CHU de Nancy, Vandoeuvre-lès-Nancy, France
,
Romain Legros
1   Service d’Hépato-gastro-entérologie, CHU Dupuytren, Limoges, France
,
Mathieu Pioche
4   Service d’Hépato-gastro-entérologie, Hôpital Edouard Herriot, CHU Lyon, France
,
Jérémie Jacques
1   Service d’Hépato-gastro-entérologie, CHU Dupuytren, Limoges, France
5   BioEM, XLim, UMR 7252, CNRS, Limoges, France
› Author Affiliations

We thank Matsushita et al. for their comment on our report of a giant lymphangioma of the esophagus [1]. They believed that endoscopic submucosal dissection (ESD) is too invasive and risky for the resection of such a benign lesion. As an alternative, they proposed an unroofing technique, which is reportedly safe for treating lymphangioma of the gastrointestinal tract.

We wish to emphasize several issues that motivated us to perform ESD. First, we were unaware of the diagnosis before performing resection. Despite a literature review and considerable discussion among the members of the multidisciplinary team, no clear diagnosis could be made before resection of the 15-cm submucosal lesion, which was causing dysphagia. A benign lesion was strongly suspected, but the multidisciplinary team requested endoscopic resection with carcinologic quality criteria for this 56-year-old female patient; only ESD can provide this.

Second, the unroofing procedure, which is typically performed once a diagnosis has been established, has been reported only for lymphangioma of the colon [2]. By contrast, even in cases of misdiagnosis or difficult-to-treat recurrence, laparoscopic surgery is an easy, safe, and effective rescue procedure. To date, only 30 cases of esophageal lymphangioma have been reported [3], and those that were larger than 2.5 cm were treated by morbid surgery. Third, because of the lesion size (15 cm), it is unclear whether a simple unroofing procedure would have completely removed the lesion.

Finally, Matsushita et al. argued that ESD has a risk of morbidity. However, our team has considerable expertise in ESD, and we developed the effective and safe tunnel plus clip strategy for esophageal ESD [4]. Submucosal tunnelling ensures that a submucosal plan can be found beneath the lesion. Moreover, clip and line traction after tunnel creation facilitates exposure of the lateral submucosal fibers, enabling safe resection.

In this rare situation, ESD was, for us, the optimal procedure for diagnostic confirmation and treatment.



Publication History

Article published online:
24 June 2020

© Georg Thieme Verlag KG
Stuttgart · New York

 
  • References

  • 1 Dahan M, Guyot A, Charissoux A. et al. Endoscopic submucosal dissection as a diagnostic procedure for a giant submucosal “sausage” causing dysphagia. Endoscopy 2019; 51: E368-E369
  • 2 Mimura T, Kuramoto S, Hashimoto M. et al. Unroofing for lymphangioma of the large intestine: a new approach to endoscopic treatment. Gastrointest Endosc 1997; 46: 259-263
  • 3 Cheng Y, Zhou X, Xu K. et al. Esophageal lymphangioma: a case report and review of literature. BMC Gastroenterol 2019; 19: 107
  • 4 Jacques J, Legros R, Rivory J. et al. The “tunnel + clip” strategy standardised and facilitates oesophageal ESD procedures: a prospective, consecutive bi-centric study. Surg Endosc 2017; 31: 4838-4847