Submucosal tunneling endoscopic resection (STER) with full-thickness muscle excision for a recurrent para-aortic esophageal leiomyoma after surgery

We report the case of a 49-year-old woman with a recurrent esophageal leiomyoma following two surgical resections. The surgical procedures had been performed 23 and 21 years previously. Follow-up showed lesion recurrence in the mid esophagus ([Fig. 1] and [Fig. 2]).

Fig. 1 Endoscopic view showing a recurrent leiomyoma in the mid-esophagus.

Fig. 2 Endoscopic ultrasound (EUS) showing a huge para-aortic leiomyoma developing from the muscularis propria layer.

Submucosal endoscopic tunneling resection (STER) was preferred to surgery because of the previous interventions. A single shot of 2 g ceftriaxone was administered intravenously prior to the procedure. Submucosal injection, mucosal incision, and tunnel creation was started 5 cm above the lesion. Enucleation was performed using a DualKnife J (Olympus, Tokyo, Japan). The lesion was close to the aorta, so the final dissection was carried out by synchronizing with aortic movements. Full-thickness muscle resection was required to achieve en bloc resection being careful to preserve the esophageal adventitia ([Video 1]). The leiomyoma was grasped with a 30-mm snare and was easily removed ([Fig. 3]). Six standard clips (QuickClip Pro; Olympus) were deployed to close the mucosal incision.

Video 1: Peroral endoscopic tunneling dissection of a huge recurrent para-aortic esophageal leiomyoma. Muscularis propria dissection and full-thickness resection was necessary to mobilize the lesion with preservation of the esophageal adventitia.

Fig. 3 Endoscopic view showing the 15 × 30-mm leiomyoma being grasped by a 30-mm snare.

A computed tomography (CT) scan with swallow study was performed on postoperative day 1; oral diet was restarted on day 2. Histological examination did not show any malignancy.

Tumors originating from the muscularis propria require surgery in most cases [1]. STER is a novel approach for the treatment of subepithelial tumors of the gastrointestinal tract. The risk of perforation may reach up to 15 % [2]. If the tumor develops from the muscularis propria, preservation of the serosal layer is difficult; circumferential incision of the serosa is therefore often required to complete en bloc resection [3]. Even though a large muscular defect exists, mediastinitis does not occur if the mucosal continuity is maintained [4].

Recurrent esophageal leiomyoma has been anecdotally reported and is usually related to incomplete resection or enlargement of a previously undetected nodule [5]. Here, we report the first STER treatment for recurrent esophageal leiomyoma with full-thickness muscle resection, which was required because of involvement of the deep muscularis propria and fibrosis deriving from previous surgery.

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• References

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• 5 Standerfer RJ, Paneth M. Recurrent leiomyoma of the oesophagus. Thorax 1982; 37: 478-479