A 63-year-old woman was referred for evaluation of a subepithelial esophageal mass
and dysphagia. Endoscopy at an outside hospital reported an increase in the size of
the mass. Endoscopic ultrasound showed a hypoechoic well-defined subepithelial mass
originating within the submucosa and measuring 23 mm in maximum diameter. Fine-needle
aspiration of the mass was nondiagnostic. Owing to the dysphagia and the increase
in size, we proceeded with endoscopic resection ([Video 1]).
Video 1 Endoscopic submucosal dissection with complete en bloc removal of an esophageal cavernous
hemangioma.
The patient was placed in the supine position and the procedure was performed under
general anesthesia. A GIF-HQ190 endoscope (Olympus Corp., Center Valley, Pennsylvania,
USA) fitted with a transparent cap was advanced and identified a subepithelial mass
in the mid esophagus, extending 20 cm to 24 cm from the incisors ([Fig. 1 a]). A submucosal injection of 0.9 % saline and methylene blue was made approximately
2 cm proximal to the lesion. A hybrid multipurpose T-knife (Erbe, Marietta, Georgia,
USA) was used to make a 1.5-cm mucosal incision to create an entry point to the submucosal
space. The submucosal layer was visualized with blue hue and further injected. The
lateral margins were then carefully dissected with an insulated-tip knife IT2 (Olympus
Corp.), in a proximal to distal direction. Using the pocket technique, dissection
of the submucosal space was performed to expand the tunnel down to the distal end
of the esophageal mass (settings: endocut Q current effect 3, interval 1, period 1,
soft coag effect 2) ([Fig. 1 b]). Any visible vessels or bleeding were treated by coagulation using the hybrid knife
or coagulation graspers. The lesion was then completely removed en bloc ([Fig. 1 c, d]). The defect was closed using a 2.0 polypropylene suture in a running suture pattern
from the distal to the proximal end of the lesion. A cinching device was then used
to cinch the suture. Finally, Duraclips (ConMed Corp., Utica New York, USA) were used
to reinforce closure of the proximal defect.
Fig. 1 Endoscopic images. a The esophageal subepithelial lesion. b The submucosal tunnel after dissection. c The subepithelial lesion after complete en bloc resection. d The subepithelial lesion after retrieval, measuring 4 cm.
Low-power microscopic examination showed benign squamous mucosa with a submucosal-based
benign vascular proliferation. Higher-power examination revealed large cystically
dilated vessels with thin, focally fibrotic walls and a benign, flattened, endothelial
lining, which was consistent with cavernous hemangioma ([Fig. 2]).
Fig. 2 The low-power examination (top row) showed benign squamous mucosa with a submucosal-based
benign vascular proliferation. Higher-power examination (lower row) showed large cystically
dilated vessels with thin, focally fibrotic walls and a benign, flattened, endothelial
lining.
Barium swallow study showed no leak and the patient tolerated a regular diet. She
was discharged home in a good condition and was completely asymptomatic at 1 month
follow-up.
Cavernous hemangioma in the esophagus is a rare benign tumor. Small lesions are usually
asymptomatic, but large tumors can often cause dysphagia. Histopathological examination
establishes a definitive diagnosis, as radiographic and endoscopic features are inconclusive,
accentuating the importance of a multidisciplinary therapeutic approach [1]
[2]. Complete en bloc removal can be successfully achieved using endoscopic submucosal
dissection, with resolution of symptoms.
Endoscopy_UCTN_Code_TTT_1AO_2AG
Endoscopy E-Videos is a free access online section, reporting on interesting cases and new techniques
in gastroenterological endoscopy. All papers include a high
quality video and all contributions are
freely accessible online.
This section has its own submission
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https://mc.manuscriptcentral.com/e-videos
