Unroofing technique: effective “incomplete” endoscopic resection of large esophageal lymphangiomas

We read with interest the article by Dahan et al. [1] on a large symptomatic esophageal lymphangioma resected by endoscopic submucosal dissection (ESD). After computed tomography and endosonography revealed potentially benign features, the authors resected the lesion en bloc by ESD without complications. Although they suggest ESD as a diagnostic and therapeutic procedure for these submucosal lesions, we recommend the unroofing technique, effective “incomplete” endoscopic resection, in this patient.

Lymphangiomas are benign submucosal tumors that consist of dilated lymphatic vessels [2] [3] [4]. The lesions usually occur in the head and neck region, and only 1 % of lesions originate in the gastrointestinal tract, mostly in the colon followed by the stomach, duodenum, small intestine, and esophagus [3] [4]. Although large symptomatic lymphangiomas have traditionally been resected surgically, endoscopic resection has become an effective alternative.

Although ESD enables complete en bloc resection of large mucosal cancers, it requires a long procedure time and is associated with technical difficulties and a high risk of complications [5]. Dahan et al. [1] resected the large lymphangioma en bloc by ESD but fragmented it and extracted the pieces because of its large size. Endoscopic piecemeal resection of esophageal lymphangioma is also reported without complications or remnants [4]. We believe that ESD could be dangerous and requires advanced endoscopic skills. Endoscopic en bloc resection with tumor-free margins is required for early malignant tumors but not for benign lymphangiomas.

The unroofing technique cuts off only the upper part of the lymphangioma, thus preventing perforation [2]. During snaring of lymphangiomas, lymphatic fluid flows out, thereafter resulting in a complete scar without remnants [2]. After endoscopic biopsy, spontaneous complete resolution of lymphangiomas without any specific treatment was also reported [3]. We believe that endoscopic unroofing is easy, safe, and sufficient for the treatment of large lymphangiomas, whereas ESD might be more difficult, dangerous, and time-consuming.

Publication History

Article published online:
24 June 2020

• 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: E368-369
• 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 Lee JM, Chung WC, Lee KM. et al. Spontaneous resolution of multiple lymphangiomas of the colon: a case report. World J Gastroenterol 2011; 17: 1515-1518
• 4 Luo D, Ye L, Wu W. et al. Huge lymphangioma of the esophagus resected by endoscopic piecemeal mucosal resection. Case Rep Med 2017; 2017: 5747560
• 5 Matsushita M, Danbara N, Kawamata S. et al. Endoscopic removal of large colonic lipomas: difficult submucosal dissection or easy snare unroofing?. Endoscopy 2009; 41: 475