Vivek Kumbhari, MD from the Department of Medicine and Division of Gastroenterology and Hepatology at Johns Hopkins Medical Institutions in Baltimore, Maryland, USA presents this video case “Submucosal tunneling endoscopic resection of a giant esophageal leiomyoma.”
A 53-year-old woman presented for evaluation of a 2-month history of progressive dysphagia and chest pain. A chest CT scan revealed a 6 x 2.8 x 2.2-cm esophageal mass adjacent to the descending aorta and azygos vein. EUS-guided core biopsy confirmed the diagnosis of leiomyoma. A submucosal tunnel was created and extended distal to the lesion. The leiomyoma was then carefully dissected off the muscularis propria en bloc. The lesion was not able to be extracted from the tunnel en bloc due to the size mismatch between the lesion and the mucosal incision. Therefore, the lesion was fragmented and then subsequently removed. As the mucosal entry was now large, closure was not achieved despite using an over-the-scope clip. Therefore, a 23 x 105-mm fully covered self-expandable metal esophageal stent was placed across the mucosal entry. Repeat endoscopy and removal of the stent 10 days after the procedure revealed closure of the mucosal entry. A repeat EUS at 12 months confirmed normal esophageal wall layers.
This video demonstrates the key steps of performing a submucosal tunneling endoscopic resection (STER) procedure for the removal a a large mid esophageal lesion arising from the muscularis propria. This minimally invasive approach avoids the morbidity of thoracic surgery. We demonstrate that even a large lesion (>3cm) is amenable to STER in selected instances. The main challenge faced when removing these large lesions is the mismatch between the lesion size and the mucosal entry. As this lesion was ‘benign’ and it was not essential for it to be removed en bloc, we chose to fragment the lesion to facilitate removal. Care must be taken to fragment the lesion as the operator must avoid cautery injury to the mucosal flap and structures of the mediastinum. We thereofore opted to fragment the lesion at the site of the mucosal entry after dragging the lesion proximally. If the lesion was a gastrointestinal stromal tumor (GIST) then this would not have been possible as maintanence of the capsule of the lesion is critical to prevent recurrence. In such circumstances, options to aid removal would be significantly extending the mucosal incision and closing this with endoscopic suturing, or diverting oral residue way using an esophageal fully covered self-expandable metallic stent (FCSEMS). If a FCSEMS is used then we would recommend securing the stent with endoscopic sutures as this is no stricture to hold the stent in place. The stent can be removed at 2 weeks and an intraprocedural check esophagram can be used to confirm closure.
We believe that the STER technique should be performed by expert endoscopists with experience in submucosal endoscopic techniques. In particular, the operator must be able to manage adverse events of the procedure such as bleeding within the submucosal tunnel, inadvertent mucostomy which results in perforation and closure of a large mucosal incision.
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