Hong Kong Society of Upper Gastrointestinal Surgeons CLINICAL MEETING 29 NOV 2012

Transcription

1 Hong Kong Society of Upper Gastrointestinal Surgeons CLINICAL MEETING 29 NOV 2012

2 Esophageal Leiomyoma Introduction Case presentation Operative video Discussion

3 Esophageal Leiomyoma Benign tumors of the esophagus: uncommon Leiomyomas: 70-80% of all benign esophageal neoplasms years old M>F Lower 2/3 Thoracoscopic enucleation of esophageal leiomyoma: a retrospective study on 40 cases. Dis Esophagus 2009, 22:

4 Ms. WONG F/48 Non-drinker Non-smoker Good past health

5 Presentation Epigastric pain & hematemesis in April 2011 Hold up sensation after food intake No weight loss/constitutional symptoms Blood tests: unremarkable

6 Upper endoscopy 1 April 2011 Oesophagus: 2.5 cm whitish submucosal mass at 26 cm from incisor, no evidence of recent hemorrhage Oesophageal mass biopsy: Normal squamous mucosa No tumor

7 Endoscopic Ultrasound 8 April 2011

8 Computer Tomography of Thorax 6/2011

9 Computer Tomography of Thorax 6/2011

10 Video assisted thoracoscopy + enucleation of oesophageal tumor 31 Jul 2012 Findings: 2.5cm oesophageal submucosal lesion, lobulated and horseshoe shaped Just inferior to the arch of azygos vein No mucosal attachment

11 Progress Pathology: Leiomyoma of the oesophagus Smooth post-op recovery Follow-up at 3 months: no dysphagia/reflux

12 Background Most common benign tumor 1% of the esophageal neoplasms M:F (1.9:1.0) Mean age of diagnosis: 44 Distal 1/3: 90% Arise from smooth muscle cells/ precursors in muscularis mucosa/propria Endo/exocentric growth Benign tumors and cysts of the esophagus. In Shackelford's surgery of the Alimentary Tract. Volume 1. 4th edition. Edited by Zuidema GD, Yeo CJ, Orringer MB. Philadelphia: WB Saunders; 1996

13 Symptoms Symptomatic 50% Dysphagia 50% Retrosternal pain 50% Cough Odynophagia Bleeding Minimally invasive resection of benign esophageal tumors. J Thorac Cardiovasc Surg 2007, 134:

14 Investigation CXR: calcification Barium swallow: Smooth crescent shaped defect in contour of oesophageal lumen without a mucosal abnormality Abrupt sharp angle where lesion meets esophageal wall both proximal & distally OGD/EUS: Homogenous & hypoechoic lesion with clear margin Originating from muscularis mucosa/propria, intact mucosa Lymph node involvement

15 Investigation Contrast CT thorax: Extent of extraluminal involvement Endoscopic biopsy a debating issue Fistula formation/mediastinitis Hamper surgical dissection & enucleation However differentiate leiomyomas from other mesenchymal or epithelial malignancies At least two weeks after biopsy Minimally invasive resection of benign esophageal tumors. J Thorac Cardiovasc Surg 2007, 134:

16 Histology Histopathological examination with immunohistochemical staining Differentiate benign or malignant esophageal mesenchymal tumors Firm/round grey yellow unencapsulated mass, composed of spindle shaped smooth muscle cells with cigar shaped elongated nuclei Esophageal leiomyoma: a 40-year experience. Ann Thorac Surg 2005

17 Treatment Non operative: Indication: Asymptomatic Small size with low risk of malignancy Operative: enucleation Indication: Symptomatic Risk of malignancy Unclear diagnosis Larger size Enucleation of submucosal tumors of the esophagus: minimally invasive versus open approach. Surg Endosc 2004 Thoracoscopic enucleation of leiomyoma of the oesophagus. Br J Surg 1992

18 Operative management Open thoracotomy/segmental esophagectomy: Indication: Giant esophageal leiomyomas Failed enucleation Transthoracic approach: Upper 2/3: right-sided thoracotomy Lower 1/3: left-sided thoracotomy Transdiaphragmatic approach: Lower 1/3 Extrathoracic cervical approach: Proximal lesions

19 Operative management Video/Robotic-assisted thoracoscopy: Indication: Any location Any size Upper 2/3: right-sided VATS approach Lower 1/3: left-sided VATS/ laparoscopic approach Intraoperative OGD: Precise localisation of small lesion Checking mucosal integrity Advantages: Avoid morbidity associated with open thoracotomy Safe & effective Short hospital stay Low recurrence rate Disadvantage: Pseudodiverticulum Video-thoracoscopic enucleation of esophageal leiomyoma World Journal of Surgical Oncology 2012, 10:52 doi: /

20 Operative management Endoscopic: Indication: <2cm Arise from muscularis mucosa Snare polypectomy Endoscopic aspiration lumpectomy Endoscopic band ligation Endoscopic laser ablation Disadvantage: Incomplete removal of lesion Perforation Endoscopic aspiration lumpectomy of esophageal leiomyomas derived from the muscularis mucosae. The American Journal of Gastroenterology 1995

21 Our choice Patient factor: Good & fit for GA Good lung function Disease factor: 2.5cm Mid oesophagus Our operation of choice: Video assisted thoracoscopy + enucleation

22 Reference 1. Postlethwait R, Musser A. Changes in the esophagus in 1,000 autopsy specimens. J Thorac Cardiovasc Surg. 1974;68: Kramer M, Gibb S, Ellis F. Giant leiomyoma of the esophagus. J Surg Oncol. 1986;33: Mutrie C, Donahue D, Wain J, et al. Esophageal leiomyoma: a 40-year experience. Ann Thorac Surg. 2005;79: Fountain S. Leiomyoma of the esophagus. Thorac Cardiovasc Surg.1986;34: Bonavina L, Segalin A, Rosati R, et al. Surgical therapy of esophageal leiomyoma. J Amer Coll Surg. 1995;181: Roviaro G, Maciocco M, Varoli F, et al. Videothoracoscopic treatment of esophageal leiomyoma. Thorax. 1998;53: Bardini R, Asolati M. Thoracoscopic resection of benign tumors of the esophagus. Int Surg. 1997;82: von Rahden B, Stein H, Feussner H, Siewert J. Enucleation of submucosal tumors of the esophagus: minimally invasive versus open approach. Surg Endosc. 2004;18: Wehrman T, Martchenko K, Nakamura M, Riphaus A, Stergiou N. Endoscopic resection of submucosal esophageal tumors: a prospective case series. Endoscopy. 2004;36:802-7.

23 Thank you

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25 EXTRA

26 Investigations Endoscopic ultrasonography 8/4/2011: Tumour arising from muscular layer, intact serosa and mucosa, Smooth, slightly lobulated, 2.3cm Hypoechonic, homogenous At the level of azygous vein No lymph node enlargement

27 Imaging Computer Tomography of Thorax 6/2011: A 2.7cm(W) x 1.3cm(D) x 2.7cm(H) homogenous, mildly enhancing soft tissue mass Right side of mid-esophagus Relations: just inferior to the carina, anterior to the azygous vein and posterior to the right pulmonary artery

28 Progress Offered thoracoscopic +/- open enucleation Patient agreed due to progressive dysphagia Pre-operative preparation: satisfactory lung function

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