Thoracoscopic enucleation of a giant horseshoe-shaped esophageal leiomyoma

Leiomyomas are the most common esophageal benign tumors. Interventions are undertaken if these are large or actively growing or the patients are symptomatic. Though more invasive than enucleation, esophagectomy has been performed in several giant esophageal leiomyoma cases because enucleation requires advanced surgical skills.

A 42-year-old woman presented with an abnormality on chest radiography. Although she was asymptomatic, enhanced computed tomography revealed a 10-cm solid homogeneous tumor in the lower thoracic esophagus. Esophagogastroscopy visualized the submucosal tumor without mucosal invasion. Endoscopic ultrasonography revealed that the tumor was almost entirely circumferential in the submucosal layer. Biopsy examination revealed a leiomyoma, and thoracoscopic enucleation was attempted. Right-sided thoracoscopy was performed in the prone position. The giant tumor in the lower thoracic esophagus, which did not invade the neighboring organs, was identified easily and exposed by separating the esophageal muscle layer overlying it. The tumor was difficult to detach from the left side of the esophagus; therefore, Endoloop™ (Johnson & Johnson, NJ, USA) was used for traction without risking tumor damage. After successful tumor enucleation, the muscle layer was closed without stenosis by suturing.

As tumor cell dissemination due to messy tumor handling must be avoided, the Endoloop was very useful for maneuvering the tumor on the narrow surgical field. A key element of esophageal tumor enucleation was proper preservation of the mucosa and muscular layer.

Minimally invasive thoracoscopic enucleation may be a treatment option for even large esophageal leiomyomas.