THE DOUBLE TUNNEL TECHNIQUE FOR SUCCESSFUL TRANSESOPHAGEAL REMOVAL OF A MOSTLY MEDIASTINALLY LOCATED CALCIFIED LYOMYOMA ORIGINATING FROM THE CIRCUMFERENTIAL ESOPHAGEAL MUSCULAR LAYER

Aims:

A 52 year old patient was admitted for discussion of the resection of an oligosymptomatic 3.5 × 2,5 cm tumor of the esophagus located mostly at the level of the aortic arch (24 – 27 cm aborally. Leiomyoma was postulated. As the lesion was partially calcified a GIST tumor could not be excluded. Observation versus FNA versus surgical resection versus submucosal endoscopic tunnel enucleation (SET, SETE) of the tumor was discussed. Due to the size of the tumor and increasing operative risk with age the patient decided to have the tumor resected.

Methods:

The intervention was carried out in an operative setting with patient being bi-laterally intubated and in left lateral position. Surgical intervention was possible at any time of the intervention. An esophageal submucosal tunnel in POEM technique was created with entrance 5 – 7 cm cranially to the lesion. The whitish-yellow lesion could be completely separated form the overlaying mucosa without any mucosal defect and be enucleated form the surrounding muscular layer. Astonishingly, there was no direct vision to the mediastinum after complete ESD enucleation of the tumor as the thin longitudinal esophageal muscle layer surrounded the tumor located mostly in the dorsal mediastinum. The cranial tunnel was first broadened to 2.5 cm and the tumor mobilized from its bed cranially. As a passage through the upper esophageal sphincter seemed to traumatic a second tunnel was created caudally to the cardia and the mucosa opened form inside towards the esophageal lumen.

Results:

Using this technique the tumor could transported to the stomach with intact capsule where it was cut into seven pieces and removed perorally. The enterences where the closed my clips and an esophageal vacuum sponge placed. The patient had an uneventful recovery two weeks later.

Conclusions:

The double tunnel technique facilitates the peroral removal of large sm esophageal tumors to big for primary transsphincteric extraction.