What is the optimal management of esophageal leiomyoma?

Optimal Management of Esophageal Leiomyoma

The optimal management of esophageal leiomyoma is esophagomyotomy and enucleation, preferably through minimally invasive approaches such as thoracoscopy or laparoscopy depending on tumor location. 1, 2

Understanding Esophageal Leiomyoma

• Leiomyomas are benign tumors and account for approximately two-thirds of all spindle cell tumors of the esophagus 1
• They are the most common benign tumors of the esophagus, typically arising from the muscularis propria layer 2, 3
• Most esophageal leiomyomas are found in the middle and lower thirds of the esophagus 2

Diagnostic Approach

• Histologic evaluation is necessary to differentiate leiomyoma from GIST (gastrointestinal stromal tumor) 1
• Tissue sampling using fine needle aspiration (FNA) or fine needle biopsy (FNB) can be useful to confirm diagnosis 1
• Caution should be exercised with endoscopic biopsies within 1 month of planned surgery as this increases risk of mucosal injury during enucleation 4

Treatment Algorithm

For Asymptomatic Leiomyomas

• Small (<1.5 cm) asymptomatic leiomyomas may be monitored without immediate intervention 4
• Regular surveillance may be considered as an alternative approach for very small tumors 4

For Symptomatic or Larger Leiomyomas

• Enucleation is the treatment of choice for symptomatic leiomyomas or those requiring definitive diagnosis 2, 3
• Minimally invasive approaches (thoracoscopic or laparoscopic) should be considered as the standard surgical method 4
  • Right-sided thoracoscopic approach for upper two-thirds of esophagus 5
  • Left-sided thoracoscopic approach for lower third of esophagus 5
  • Laparoscopic approach for tumors within 4-5 cm of lower esophageal sphincter or at gastroesophageal junction 2

Technical Considerations

• Intraoperative endoscopy with air insufflation is recommended to:
  • Confirm mucosal integrity during enucleation 2
  • Help with tumor localization through illumination 5
  • Prevent esophageal perforation 2
• Reapproximation of muscle layers after enucleation is important to:
  • Prevent development of pseudodiverticulum 2, 6
  • Preserve esophageal propulsive activity 6
  • Reduce incidence of postoperative reflux esophagitis 6
• For tumors at the gastroesophageal junction, addition of a fundoplication (Nissen or Toupet) may be beneficial 2

Why Enucleation is Superior to Esophageal Resection

• Enucleation preserves normal esophageal function while completely removing the tumor 2, 3
• More extensive resections (Ivor-Lewis, transhiatal, or segmental) are unnecessarily invasive for benign disease 1
• Minimally invasive enucleation is associated with:
  • Low morbidity and mortality rates 2, 3
  • Shorter hospital stays compared to open approaches 4, 6
  • Excellent symptom relief, particularly for dysphagia 3
  • No tumor recurrence in long-term follow-up 3

Potential Challenges and Complications

• Conversion to open thoracotomy may be necessary in cases of:
  • Very small tumors (<1.5 cm) that are difficult to visualize 4
  • Very large tumors (>5 cm) or those circumferentially surrounding the esophagus 3
  • Thoracic cavity adhesions 3
• Mucosal injury during enucleation, particularly in patients who have had recent endoscopic biopsies 4, 6
• Small utility incisions (4-6 cm) may be required in some cases for better exploration and manipulation 5

Follow-up Recommendations

• Endoscopic follow-up to ensure complete resolution of symptoms 2
• Monitor for rare complications such as pseudodiverticulum formation 2, 6
• No specific surveillance is needed for recurrence as recurrences are extremely rare after complete enucleation 6