Intraoperative esophagoscopy provides accuracy and safety in video-assisted thoracoscopic enucleation of benign esophageal submucosal tumors

Abstract

Benign esophageal tumors are rare; complete surgical resection is essential for the management of the submucosal tumors. Larger, symptomatic, or non-diagnostic lesions should be resected for both diagnostic and therapeutic indications. Video-assisted thoracic surgery has become a popular treatment in the field of thoracic surgery; however, thoracoscopic esophageal surgery may lead to an increase in operative complications. The effect and safety of thoracoscopic surgery for esophageal submucosal lesions were evaluated. A retrospective study evaluated patients undergoing thoracoscopic treatment of benign submucosal tumors. Between March 2011 and December 2013, 17 patients underwent thoracoscopic resection of benign submucocal tumors. Intraoperative esophagoscopy was performed for tumor localization by transillumination and confirmation of mucosal integrity after enucleation in every patient. Median patient age was 47 years (range 30-65). The median surgery time was 170 minutes (range 80-429). The median tumor size was 3.8 cm (range 1.3-9). The median hospital stay was 4 days (range 2-12). There were 16 leiomyoma and 1 neurogenic tumor. There was one case of conversion to thoracotomy because of residual tumor after enucleation. Mucosal injuries occurred in three patients, two accidentally and one intentionally; each patient was treated with primary repair and confirmed integrity with flexible esophagoscopy at operating room. The small sized tumor with intraoperative esophagoscopy could be localized. Esophagoscopic assistance was necessary in eight patients to have better idea where to make myotomy. There were no major morbidities such as postoperative leakage or mortality. Esophageal submucosal tumors can be treated safely with thoracoscopic surgery. However, intraoperative esophagoscopy allows accurate tumor localization, direction of esophageal access incision, and decreases complications during VATS enucleation of esophageal submucosal tumors.

Novel methylene blue staining technique for localizing small esophageal leiomyomas during thoracoscopic enucleation

“…1 Most esophageal leiomyomas originate from the muscularis propria, with some others originating from the muscularis mucosa. 13 These tumors are most commonly diagnosed on esophagoscopy, EUS, or contrast esophagography. Leiomyomas tend to be located in the lower and middle thirds of the esophagus.…”

“…12 The incidence of these tumors is higher between the ages of 20 and 50 years. 1,12,13 There are several options for the treatment of esophageal leiomyomas, including observation, endoscopic treatment, and surgical treatment. 13 These tumors are most commonly diagnosed on esophagoscopy, EUS, or contrast esophagography.…”

“…13 These tumors are most commonly diagnosed on esophagoscopy, EUS, or contrast esophagography. [12][13][14][15] This minimally invasive approach for esophageal leiomyomas has yielded satisfactory results with the least wound pain and pulmonary atelectasis, excellent cosmetic outcomes, and no early or late major complications. Dysphagia is the most common symptom.…”

“…Dysphagia is the most common symptom. 12,13 However, Jiang and associates suggested that the shape and size of the esophageal leiomyoma are key criteria for thoracoscopic enucleation. 1,12,13 There are several options for the treatment of esophageal leiomyomas, including observation, endoscopic treatment, and surgical treatment.…”

“…Leiomyomas constitute 70-80% of all benign esophageal neoplasms, representing about 10% of all gastrointestinal leiomyomas. [10][11][12] Therefore, instead of using conventional intraoperative endoscopy, 7,12,13 we developed a new technique for localizing small esophageal leiomyomas using methylene blue staining. [2][3][4][5][6][7][8] With the development of endoscopic ultrasonography (EUS), the nature, size, number, and originating layer of the lesions, even small lesions, have become easy to define.…”