Efficacy of endoscopic submucosal tunnel dissection in the management of a large esophageal cavernous hemangioma

A 44-year-old man presented with symptoms of gastroesophageal reflux disease and dysphagia. Gastroscopy revealed a 3-cm, half-circumferential, bluish-purple esophageal mass located in the mid-esophageal region ( Fig. 1 a ). Computed tomography revealed a soft tissue nodule causing significant stenosis of the esophageal lumen. Endoscopic ultrasound confirmed a well-demarcated, moderately hyperechoic submucosal lesion, characteristic of an esophageal cavernous hemangioma ( Fig. 1 b ). Subsequent to a detailed consultation, endoscopic submucosal tunnel dissection (ESTD) was undertaken ( Video 1 ).

Fig. 1.

Colonoscopy and endoscopic ultrasound. a Gastroscopy revealed a 3-cm, half-circumferential, bluish-purple esophageal mass located in the mid-esophageal region. b Endoscopic ultrasound confirmed a well-demarcated, moderately hyperechoic lesion within the submucosal layer.

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Efficacy of endoscopic submucosal tunnel dissection for the management of a large esophageal cavernous hemangioma.

Video 1

Using a hybrid knife (Erbe Elektromedizin GmbH, Tübingen, Germany), saline mixed with indigo carmine was injected 0.5 cm proximal to the lesion, followed by a 1.5-cm transverse incision to create a submucosal tunnel extending 1 cm distally ( Fig. 2 a ). A significant presence of perforating vessels was observed in the submucosal layer, prompting the use of soft electrocoagulation for meticulous hemostasis ( Fig. 2 b ). An additional 1.5-cm incision was made distally. Incremental dissection along both tunnel margins was performed, achieving complete en bloc resection with a 0.5-cm margin from the tumorʼs edge. Electrocoagulation was applied to exposed vessels to control bleeding, with no damage to the muscular layer ( Fig. 2 c ). The procedure was completed in 30 minutes without complications, including perforation, hemorrhage, or fever. Histopathological analysis confirmed esophageal cavernous hemangioma ( Fig. 2 d ). The patient was discharged on postoperative day four and remained symptom-free during 12 months of follow-up.

Fig. 2.

Endoscopic submucosal tunnel dissection. a A transverse incision was made on the oral side of the lesion to establish the tunnel entry point. b The submucosal layer revealed a notable abundance of perforating vessels. c A submucosal tunnel was meticulously fashioned, extending 1 cm distally from the incision. d Postoperative wound. e The tumor was successfully resected in its entirety. f Histopathological examination confirmed the diagnosis of esophageal cavernous hemangioma.

Esophageal cavernous hemangioma is a rare benign tumor ¹ , with management options for asymptomatic cases typically involving observation, whereas symptomatic cases may necessitate intervention. Treatment approaches include esophageal resection, tumor dissection, endoscopic sclerotherapy, and laser therapy ² . Endoscopic submucosal dissection has been utilized for esophageal hemangiomas ^{3 4} , and our case illustrates that ESTD enhances submucosal visualization and expedites dissection. This represents the first successful en bloc resection of a symptomatic esophageal cavernous hemangioma via ESTD.

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