Huge pedunculate esophageal submucosal tumor resected under endoscopy with peduncle ligation

Esophageal submucosal tumors can be treated by endoscopic resection [1] [2] [3]. However, resection of large submucosal tumors is difficult due to the narrow cavity of the esophagus. Here, we present a case of huge pedunculate esophageal submucosal tumor resected under endoscopy with innovative peduncle ligation.

A 29-year-old man presented with a history of progressive dysphagia for 1 year and moderate fever for 1 week; he was admitted to the hospital. Esophagogastroduodenoscopy showed a huge pedunculate esophageal submucosal tumor with partial erosion on the surface. The root of the peduncle was located in the anterior wall at 20 cm from the incisors ([Fig. 1]). Computed tomography showed a huge intraluminal mass (5.6 × 4.4 × 14.7 cm) ([Fig. 2]). After multidisciplinary team discussion, endoscopic resection was considered.

Fig. 1 Esophagogastroduodenoscopy showed a huge pedunculate submucosal tumor in the esophagus. a The root of the peduncle. b The body of the tumor. c Partial erosion on the surface of the tumor (retroflexed endoscopic view).

Fig. 2 Computed tomography scan showed a huge (5.6 × 4.4 × 14.7 cm) intraluminal mass (arrows) in the esophagus.

A 0 PDS II suture (Johnson & Johnson, New Brunswick, New Jersey, USA) was brought into the esophageal cavity through the gastroscope (Olympus GIF Q260 J; Olympus, Tokyo, Japan) and placed around the peduncle. A knot was tied in vitro and pushed into the esophageal cavity using a laparoscopic knot pusher. The root of the peduncle was ligated by three sutures and then resected using a HookKnife (Olympus) between the ligations. The specimen could not be retrieved through the mouth and was instead pushed into the stomach. The tumor was removed by incision of the stomach through a single-port laparoscope ([Fig. 3], [Video 1]). The patient resumed a liquid diet 3 days after surgery and body temperature returned to normal.

Fig. 3 The resected tumor specimen.

Video 1 Endoscopic peduncle ligation of huge pedunculate esophageal submucosal tumor.

Histopathology revealed spindle cell tumor, without mitosis ([Fig. 4]). Immunohistochemistry showed Dog (–), Desmin (partial +), Actin (partial +), CD117 (–), S-100 (–). A diagnosis of inflammatory fibrous polyp was made.

Fig. 4 Histopathology revealed spindle cell tumor, without mitosis.

No residual or recurrent tumor was found at surveillance endoscopy 3 months post-procedure and wound healing was satisfactory ([Fig. 5]).

Fig. 5 No residual or recurrent tumor was found and wound healing was satisfactory at surveillance endoscopy after 3 months.

Peduncle ligation provides a new approach to the endoscopic resection of pedunculate submucosal tumors in the esophagus.

Endoscopy_UCTN_Code_TTT_1AO_2AG

• References

• 1 Chen T, Zhou P-H, Chu Y. et al. Long-term outcomes of submucosal tunneling endoscopic resection for upper gastrointestinal submucosal tumors. Ann Surg 2017; 265: 363-369
• 2 Tang X, Tan Y, Lv L. et al. Submucosal tunneling endoscopic resection for seven esophageal leiomyomas. Endoscopy 2018; 50: 59-60
• 3 Ye L, Sharma M, Yang D. et al. Open dissection for resection of a large submucosal tumor in the esophagus. Endoscopy 2019; 51: 243-244