Video-Assisted Thoracoscopic Surgery for Esophageal Leiomyoma: A Ten-Year Single-Institution Experience

Introduction

Esophageal leiomyomas are benign tumors of the smooth muscle layers that usually involve the muscularis propria but occasionally arise from the muscularis mucosae. They are the most common benign tumors of the esophagus. ¹ Studies have reported an incidence of benign esophageal tumors ranging from 0.005% to 7.9% in autopsy cases.^2,3 Leiomyomas constitute 70%–80% of all benign esophageal neoplasms. ⁴ The true incidence of esophageal leiomyoma is uncertain because many leiomyomas are asymptomatic and are often incidental findings. Leiomyoma is found most often in the middle and distal thirds of the esophagus. One-half of all leiomyomas are asymptomatic, and the most common initial symptoms are dysphagia, chest tightness, and pain.

Traditional options for treatment are surveillance for smaller tumors and surgical resection for larger or symptomatic tumors. The thoracoscopic resection of benign esophageal tumors was first described in 1992. ⁵ Open thoracotomy for the enucleation of leiomyomas has been gradually replaced by minimally invasive thoracoscopic approaches. The aim of this retrospective study is to report our experience with treating esophageal leiomyomas and to compare the differences between open and minimally invasive approaches.

Materials and Methods

Thoracoscopic approach

The video-assisted thoracoscopic surgery (VATS) procedure was performed under general anesthesia with double-lumen intubation. Four trocars were introduced. A 10-mm camera port was placed at the seventh intercostal space at the middle axillary line. Another 10-mm trocar was placed at the sixth intercostal space at the anterior axillary line. One 5-mm trocar was placed at the fourth intercostal space at the anterior axillary line. Another 5-mm trocar was placed at the sixth intercostal space at the scapular line (Fig. 1). The tumor location was identified by palpation under thoracoscopy. The mediastinal pleura was incised at the level of the tumor. Then, the esophagus was circumferentially mobilized, and a longitudinal myotomy was performed. The tumor was identified, and blunt dissection was performed around the mass.

OPEN IN VIEWER

FIG. 1.

The distribution of trocars. A 10-mm camera port was placed at the seventh intercostal space at the middle axillary line. Another 10-mm trocar was placed at the sixth intercostal space at the anterior axillary line. One 5-mm trocar was placed at the fourth intercostal space at the anterior axillary line. Another 5-mm trocar was placed at the sixth intercostal space at the scapular line.

The esophageal bed was exposed, and the tumor was explored. If the location of the tumor was not clear, a gastroscope was introduced to assist with positioning. Careful dissection was performed to separate the mass from the underlying mucosa. After the tumor was extracted, the mucosal integrity was evaluated with air insufflation and with the use of saline. The muscle and mediastinal pleura were reapproximated with an interrupted suture pattern. A 32Fr chest tube was placed through the lowest port.

Patients were kept nil per os for 48 hours, followed by a soft diet for 2 weeks and then a normal diet. An esophagogram was performed ∼5–7 days after surgery, and the chest tube was removed when the integrity of the mucosa was confirmed.

Results

A total of 56 patients were enrolled in this study from January 2008 to August 2017. There were 37 men and 19 women with a mean age of 48.04 (range of 21–67 years). Sixteen patients were asymptomatic. The most common symptom was dysphagia (n = 25). Other symptoms included epigastric discomfort (n = 8) and chest pain (n = 7). The main preoperative evaluations included barium esophagography, chest computed tomography, esophagoscopy, and EUS. Endoscopic biopsy is not recommended in our hospital, and there were no patients who had undergone biopsy in this cohort. Thirty-five leiomyomas were located in the middle third of the thoracic esophagus, 16 in the lower third, and 5 in the upper third. There were no significant differences between the two groups regarding gender, age, tumor location, or symptoms (Table 1). The mean tumor size in the thoracotomy group was larger than that in the VATS group (3.63 ± 2.15 versus 2.23 ± 1.30, P = .01).

From 2008 to 2011, open surgery was the main method used to treat esophageal leiomyomas. From 2011 to 2017, the thoracoscopic method was the preferred approach. Thoracotomy was performed in 40 patients and VATS in 16 patients. No cases were converted to open procedures. Patient sex, operative time, the amount of blood loss, and chest tube duration were not significantly different between the two groups (Table 2). There was no perioperative mortality. Mucosal injuries occurred in 5 patients. Five patients were treated with a primary repair. The treatment modality and tumor location were not related to the incidence of mucosal injury (Table 3). Before beginning a normal diet, esophageal leakage was tested with esophagography using Gastrografin.

Discussion

Leiomyomas are the most common benign esophageal tumors. We reported a recent 10-year single-institution case series of esophageal leiomyomas. Our data show that the male-to-female ratio in patients with esophageal leiomyomas is 1.9:1, which is similar to that reported in previously published series. ⁶ In a review of 838 cases, Seremetis and colleagues reported that 56% of esophageal leiomyomas were found in the distal third of the thoracic esophagus, 33% in the middle third, and 11% in the upper third. ⁷ In our cohort, 35 (62.5%) cases of esophageal leiomyoma were located in the middle third of the thoracic esophagus, 16 in the lower third (38.6%), and 5 (8.9%) in the upper third. The mean age at the time of diagnosis was 46.04 years in this study, which was similar to the peak time of presentation between 30 and 50 years of age that was previously published. ⁸

Hatch and colleagues found that the most common initial symptoms were dysphagia and/or chest pain. ⁹ This pain was usually located in the epigastrium and/or retrosternal region and was described as a pressure-like pain. In these 56 cases, the most common symptom was dysphagia (44.6%). Other symptoms included epigastric discomfort (14.3%) and chest pain (12.5%). Surgical excision is necessary for symptomatic or enlarged tumors to obtain a definitive histopathological diagnosis and to facilitate other surgical procedures. Sixteen (28.6%) patients were asymptomatic. For these asymptomatic patients, there are different treatment opinions. Some authors recommend observation and follow-up in these cases, especially if the lesions are smaller than 5 cm.^10,11 Codipilly and colleagues reported an experience from the Mayo Clinic in Rochester in 2018. They concluded that for small asymptomatic lesions that appear to be benign leiomyomas, resection is unnecessary. ¹² Surveillance may be another alternative method for these asymptomatic patients.

Leiomyoma enucleation was first reported in 1933 by Ohsawa. ¹³ Since then, enucleation has become the gold standard procedure. ¹⁴ In our study, all 56 patients underwent enucleation, and no esophageal resection was performed. Forty patients underwent surgery through an open approach. This classical thoracotomy enucleation showed a high success rate and a low complication rate. Five patients had mucosal injuries that were repaired in an interrupted suture pattern with 2–0 absorbable suture material. Repairing the mucosa during an open surgical approach is a simple and reliable method. The tumor size in the open group was larger than that in the VATS group. For larger leiomyomas, surgeons may prefer an open approach.

However, since the first minimally invasive enucleations were performed in 1992, ¹⁵ many studies have demonstrated that compared with open thoracotomy enucleations, thoracoscopic enucleations are associated with a shorter postoperative stay, less complications, and reduced wound-related pain and postoperative discomfort.^16,17 In our series, there were no statistically significant differences in operative time, the amount of blood loss, chest tube duration, and the length of postoperative stay in the VATS group compared with the thoracotomy group. In our institution, minimally invasive surgery did not show any distinct advantages. We suggest that a certain surgical volume of thoracoscopic enucleations must be performed to achieve favorable outcomes.

There were no perioperative deaths in either group. The perioperative complications in both groups were similar. There was no esophageal leakage, esophageal rupture, or esophageal stricture. Mucosal injury can lead to esophageal perforation. Five patients had mucosal injuries, and all of them were in the thoracotomy group. Among our cases, the treatment modality and tumor location were not related to the incidence of mucosal injury. Endoscopic biopsy is contraindicated in lesions suspected to be benign tumors in our hospital. No preoperative endoscopic biopsies were performed in these 56 patients. Choi and colleagues found that a preoperative endoscopic biopsy before surgery was the only risk factor for mucosal injury. ¹⁸ If a biopsy was performed, we recommend that surgery be postponed for at least 1 month.

The limitations of the present study include its retrospective design and relatively small sample; thus, a large, prospective, randomized study is warranted. In conclusion, this study showed that thoracoscopic enucleation was safe and effective for the treatment of esophageal leiomyoma. Patients undergoing thoracotomy had a higher intraoperative (12.5% versus 0%, P = .31) and postoperative (12.5% versus 6.25%, P = .55) complication rate compared with thoracoscopy patients (25% versus 6.25%). The thoracoscopic enucleation of esophageal leiomyomas should be performed at experienced centers.