Introduction
Submucosal tunneling endoscopic resection (STER) for the treatment of upper gastrointestinal submucosal tumors originating from the muscularis propria was first introduced by Xu et al. [1] in 2012. It has been demonstrated to be safe and effective for treating small (<3.5 cm) esophageal leiomyoma. However, sometimes the esophageal leiomyoma may be a giant mass and protrude into the mediastinum. It is uncertain whether STER can be used to resect the mass in the mediastinum. In this case, we successfully carried out STER in a patient with giant leiomyoma protruding into the mediastinum.
Case presentation
A 40-year-old male was accidently found to have an esophageal mass of 36–39 cm from the incisors during gastroscopy on 12 February 2019 (Figure 1A). Endoscopic ultrasound revealed a mass of ∼23.8 × 24.7 mm arising from the muscularis propria (Figure 1B). Computed tomography (CT) showed that the mass was 4.2 × 2.4 × 5.2 cm located in the lower esophagus; no enlarged lymph nodes were discovered (Figure 1C).
Figure 1.
The feature and submucosal tunneling endoscopic resection procedure of the mass. (A) Upper endoscopy reveals an esophageal mass of 36–39 cm from the incisors. (B) Endoscopic ultrasound shows a mass of 23.8 × 24.7 mm arising from the muscularis propria. (C) CT shows that the mass is 4.2 × 2.4 × 5.2 cm located in the lower esophagus; no enlarged lymph nodes are discovered. (D) A submucosal tunnel was made to expose the mass and the main part of the mass was protruding into the mediastinum and near to the vagus. (E) The mass in the mediastinum. (F) The resected tumor. (G) Closure of the mucosal incision site. (H) The routine gastroscopy during follow-up shows no recurrence.
STER was conducted for the mass as previously described [1]. During the operation, we found that the main part of the mass was protruding into the mediastinum and near to the vagus (Figure 1D–G). Therefore, we resected it carefully in the mediastinum and the mass was completely resected (Video 1). The patient was discharged from hospital 5 days after STER, without complications including perforation and bleeding. The pathological result of the mass was leiomyoma. The follow-up showed no recurrence or adverse events during the routine gastroscopy and CT scan (Figure 1H).
Discussion
Esophageal leiomyoma is a benign submucosal tumor that is derived from the muscularis propria of the esophagus [2]. A giant leiomyoma that protrudes into the mediastinum is uncommon [3]. At present, complete surgical excision of the mediastinal tumor with symptoms by thoracotomy or thoracoscopy is recommended. STER has been demonstrated to be safe and effective for treating small and solitary esophageal submucosal tumors with low complication rates [4–6]. In this case, we used STER to treat the exogenic esophageal mass in the mediastinum. The difficulties of the operation were as follows: (i) complete resection of the mass without nerve injury; and (ii) closure of the mucosal incision site.
In conclusion, STER may serve as a minimally invasive, safe, and effective treatment for mediastinal tumors; however, long-term outcomes should be evaluated further.
Funding
This work was supported by the Beijing Science and Technology Program [D17110002617004]; the Sanming Project of Medicine in Shenzhen [SZSM201911008]; the CAMS Innovation Fund for Medical Sciences (CIFMS) [grant no. 2016-I2M-1–001,2017-I2M-1–001,2019-I2M-2–004]; the National Key Research and Development Program of China [grant no. 2016YFC1302800, 2018YFC1313103]; the PUMC Youth Fund and the Fundamental Research Funds for the Central Universities [grant no. 2017320012]; and the PUMC Graduate Innovation Fund [grant no. 2019–1002-81].
Conflicts of interest
None declared.
References
- 1.Xu MD, Cai MM, Zhou PMP. et al. Submucosal tunneling endoscopic resection: a new technique for treating upper GI submucosal tumors originating from the muscularis propria layer (with videos). Gastrointest Endosc 2012;75:195–9. [DOI] [PubMed] [Google Scholar]
- 2.Wang L, Ren W, Zhang Z. et al. Retrospective study of endoscopic submucosal tunnel dissection (ESTD) for surgical resection of esophageal leiomyoma. Surg Endosc 2013;27:4259–66. [DOI] [PubMed] [Google Scholar]
- 3.Soomro NH, Naeem BK, Hussain S. et al. Giant esophageal leiomyoma: incidentally found tumor, on thoracotomy for bronchogenic mediastinal cyst. J Dow Univ Health Sci 2016;10:39–40. [Google Scholar]
- 4.Zhang SL, Du X, Tang XY. et al. Submucosal tunneling endoscopic resection for an unusually sized esophageal submucosal tumor protruding into the mediastinum. Rev Esp Enferm Dig 2019;111:710–1. [DOI] [PubMed] [Google Scholar]
- 5.Liu BR, Song JT, Kong LJ. et al. Tunneling endoscopic muscularis dissection for subepithelial tumors originating from the muscularis propria of the esophagus and gastric cardia. Surg Endosc 2013;27:4354–9. [DOI] [PubMed] [Google Scholar]
- 6.Chen T, Zhou P, Chu Y. et al. Long-term outcomes of submucosal tunneling endoscopic resection for upper gastrointestinal submucosal tumors. Ann Surg 2017;265:363–9. [DOI] [PubMed] [Google Scholar]