Proposed morphological classification and robotic portal enucleation of esophageal leiomyoma: a multicenter study

To propose a morphological classification system for esophageal leiomyomas using multicenter data to standardize decision-making, and evaluate the safety and feasibility of robotic portal enucleation for this disease.

This retrospective multicenter study analyzed 39 patients undergoing robotic portal enucleation for esophageal leiomyomas at three tertiary centers (2012-2025) using da Vinci Si/Xi systems. Tumors were classified according to the proposed ICOS morphological system based on longitudinal axis and circumferential relationships, with perioperative outcomes evaluated for both safety and feasibility.

All 39 patients underwent successful tumor enucleation without conversion to thoracotomy or esophagectomy. Tumors originated from the muscularis propria, primarily located in the middle or lower thoracic esophagus (median size, 3.0 cm). According to the ICOS classification, tumors were categorized into four types: Type I (38.4%), C (25.6%), O (23.0%), and S (12.8%). The median operative time was 119 minutes, with median blood loss of 60 mL and a median hospital stay of 5 days. One intraoperative mucosal perforation was repaired without further complications. The overall postoperative complication rate was 15.4%. During a median follow-up of 52 months, no tumor recurrence or disease-related deaths were observed, and postoperative symptom resolution was observed in 18 of 21 (85.7%) symptomatic patients.

The proposed ICOS morphological classification provides a standardized framework to guide personalized therapeutic strategies for esophageal leiomyomas. Robotic portal enucleation is a safe and effective minimally invasive technique even for complicated esophageal leiomyomas.