Strategies for Resection of Esophageal and Gastroesophageal Junction Submucosal Tumors

Background: Submucosal tumors (SMT) of the esophagus and gastroesophageal junction (GEJ) are rare entities, which often present a significant challenge to surgeons. Prior studies have reported only single-modality approaches. We report our experience with SMTs using multiple surgical techniques with the intent of margin-negative resection and organ preservation. Methods: Between 2001 and 2022, a total of 55 patients underwent surgical resection for SMT of the esophagus or GEJ at our institution. We reviewed the electronic medical records to obtain demographic information and details of the operation. We also report peri- and early (<30 days) postoperative outcomes. Results: Median age at operation was 62 years (22-93), and 54.5% were male. Endoscopic ultrasound was used in 45 (81.8%) patients preoperatively to classify tumors as possibly amenable for enucleation versus requiring mucosal resection. Forty-eight (87.3%) patients underwent minimally invasive procedures. Enucleation was performed in 23 (41.8%) patients, whereas 32 (58.2%) required full-thickness resection (wedge: 18; segmental: 11) or tumor resection with mucosectomy. One patient experienced Clavien-Dindo grade III or greater complications. There were no reoperations or postoperative mortality. Pathology revealed gastrointestinal stromal tumor in 25 (45.5%) patients, leiomyoma in 22 (40%), and other histology in 8 (14.5%). Negative surgical margins were achieved in 100% of the cases. Involvement of the cardia was associated with the need for full-thickness or tumor resection with mucosectomy (68.4% versus 31.5%, P = .0214). Surveillance was conducted in 20 (36.4%) patients with a median follow-up of 656 days (210-3091). One patient had progressive multifocal disease, and another went on to develop metastatic disease. Conclusion: Minimally invasive approaches are appropriate in most esophageal and GEJ SMTs and are associated with low complication rates and disease recurrence. Involvement of the gastric cardia increases the likelihood of requiring full-thickness resection or tumor resection with mucosectomy rather than enucleation.