MIS for enucleation of leiomyoma of the oesophagus-strategic approach and experience of 19 cases

Abstract

Introduction: Leiomyoma of the oesophagus, although rare, is the most common benign tumour to occur in the organ. Surgical approaches have evolved over time from an open thoracotomy or laparotomy to video-assisted thoracoscopic or laparoscopic and now robotic enucleation. We report a series of 19 cases of leiomyoma of the middle- and lower-third oesophagus treated by minimally invasive surgery.

Patients and methods: A retrospective analysis of 19 cases operated at a single tertiary care centre in India was performed. After the diagnosis of a benign oesophageal neoplasm on computed tomography (CT) and endosonography, laparoscopic transhiatal enucleation of the tumour for lower third ( n = 16) and right-sided video-assisted thoracoscopic excision for middle-third tumours ( n = 3) were performed. Dor fundoplication was done after the excision of leiomyomas from the lower oesophagus.

Results: The most common symptom at presentation was retrosternal burning in lower oesophageal tumours, while tumours in the middle third of the oesophagus were asymptomatic and incidentally detected. The size of the tumour ranged from 3 cm to 8 cm in the largest dimension on contrast-enhanced CT scan. The mean operative time was 93 min ranging from 61 to 137 min. The average blood loss was 53 ml. No patient had an iatrogenic oesophageal mucosal injury. There were no conversions to open surgery or major complications including post-operative leak or death. Post-operative recovery was uneventful.

Conclusion: The transhiatal approach to lower oesophageal leiomyomas is strategic to avoid complications of thoracoscopy, minimally invasive, cost-effective as compared to robotic surgery, suitable for adequate exposure and safe in the hands of an experienced laparoscopic surgeon.

Figure 1

(a and b) CECT scan images of benign oesophageal lesion (arrow) partially obliterating the oesophageal lumen due to compression with no extra-oesophageal extension and absence of mediastinal lymphadenopathy. CECT: Contrast-enhanced computed tomography

Figure 2

EUS picture of benign oesophageal lesion (arrow). EUS: Endoscopic ultrasound

Figure 3

Port placement

Figure 4

Intraoperative picture – Leiomyoma being dissected from the oesophageal mucosa

Figure 5

Intraoperative picture – Use of scissors for sharp dissection close to the mucosa to avoid thermal injury

Figure 6

Intraoperative endoscopy to rule out oesophageal perforation