Submucosal tunneling endoscopic resection for multiple esophageal leiomyomas

A 61-year-old man presented for treatment of esophageal submucosal tumors (SMTs). The SMTs had been found 1 month previously at his local hospital during a health examination. Upon presentation, his physical examination and laboratory tests were unremarkable. Esophagogastroduodenoscopy (EGD) revealed two protruded lesions in the middle of the esophagus ([Fig. 1]; [Video 1]). Endoscopic ultrasonography (EUS) revealed that the tumors were originating from the muscularis propria layer ([Fig. 2]). Computed omography (CT) also showed the lesions in the mid-esophagus, which were suspected to be benign tumors ([Fig. 3]; [Video 2]).

Fig. 1 Endoscopic view showing two protruding lesions in the mid-esophagus.

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Endoscopy showing two protruding lesions in the esophagus.

Fig. 2 Endoscopic ultrasonography (EUS) view showing that the tumors were originating from the muscularis propria layer.

Fig. 3 Computed tomography (CT) scan of the lesion, which was suggestive of benign tumors.

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Computed tomography (CT) scan of the lesion.

A submucosal tunneling endoscopic resection (STER) was performed. After a longitudinal mucosal incision had been made, a submucosal tunnel was created, which allowed us to see the first SMT. Submucosal injection of methylene blue was performed to help locate the second tumor, and two separate tumors about 2 cm apart from each other could then be seen ([Fig. 4 a]; [Video 3]). The tumors were carefully dissected off the muscularis propria layer ([Fig. 4 b]). The tunnel entry had to be enlarged to allow successful extraction of the larger SMT ([Video 4]). The mucosal entry was then closed. The STER procedure was completed uneventfully within 110 minutes. The resected SMTs measured 3.8 × 3.2 cm and 1.5 × 0.9 cm ([Fig. 5]) and, histopathologically, they were both leiomyomas.

Fig. 4 Endoscopic views showing: a the two tumors found in the submucosal tunnel; b the wound surface after removal of the tumors.

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After the first tumor had been successfully exposed, the second one could not be seen so methylene blue was injected submucosally to help locate it.

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En bloc extraction of the larger tumor was difficult, so the mucosotomy was enlarged, the tumor then dropped into the stomach allowing it to be extracted en bloc with a snare.

Fig. 5 Macroscopic appearance of the resected tumors.

STER has been demonstrated to be safe and effective for treating upper gastrointestinal SMTs; most of the reported cases were with solitary and small SMTs (≤ 3.5 cm) [1]. Although several cases/studies have been reported regarding STER for multiple SMTs and large SMTs, the procedure is technically difficult and has a higher rate of complications [2] [3] [4] [5].

In the present case, two SMTs were found, which were not strictly in a straight plane and one of them was larger than 3.5 cm. We successfully removed them both using the STER technique uneventfully within a single submucosal tunnel after locating the second tumor with methylene blue and enlarging the tunnel entry.

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• References

• 1 Chen T, Zhou PH, Chu Y et al. Long-term outcomes of submucosal tunneling endoscopic resection for upper gastrointestinal submucosal tumors. Ann Surg 2016;
• 2 Wang H, Tan Y, Zhou Y et al. Submucosal tunneling endoscopic resection for upper gastrointestinal submucosal tumors originating from the muscularis propria layer. Eur J Gastroenterol Hepatol 2015; 27: 776-780
• 3 Chen T, Zhang C, Yao LQ et al. Management of the complications of submucosal tunneling endoscopic resection for upper gastrointestinal submucosal tumors. Endoscopy 2016; 48: 149-55
• 4 Chen H, Xu Z, Huo J et al. Submucosal tunneling endoscopic resection for simultaneous esophageal and cardia submucosal tumors originating from the muscularis propria layer (with video). Dig Endosc 2015; 27: 155-158
• 5 Zhang C, Hu JW, Chen T et al. Submucosal tunneling endoscopic resection for upper gastrointestinal multiple submucosal tumors originating from the muscular propria layer: a feasibility study. Indian J Cancer 2015; 51 (Suppl. 02) e52-e55