Thoracoscopic Resection of Esophageal Leiomyoma

The patient was a 51-year-old female who presented with shortness of breath, low appetite, weight loss, and thoracic discomfort for a year. A CT scan of the thorax revealed an esophageal mass measuring 5cm, with no other specific pathology. She underwent a gastroscopy, which demonstrated a submucosal finding at a depth of 20 cm, with no lumen narrowing. The finding was biopsied under endoscopic ultrasound, and esophageal leiomyoma was diagnosed. 
 
Surgical Technique 

The patient was intubated with a double lumen tube and was placed in the lateral decubitus position right side up. After the right lung was deflated, a 10mm camera port was made in the 8th intercostal space on the mid-axillary line. The surgeons then added a lateral working incision at the 4th intercostal space. The deflated right lung was retracted anteriorly, and the tumor bulge in the posterior mediastinum was revealed. Opening the parietal pleura longitudinally allowed access to the posterior mediastinum and exposure of the esophagus.  The longitudinal and circular muscle layers of the esophagus were longitudinally dissected using diathermy cautery, exposing the tumor. Blunt dissection of the leiomyoma was then performed. In this case, relatively robust adhesions to the lesion were encountered. In the surgeons’ experience, tumor adhesions can vary; in some cases the tumor adhesions are very light and, in other cases, as shown here, some are not. Some believe that the biopsy of such lesions during the diagnosis process may contribute to adhesions formation. Adding a holding suture to help tumor mobilization during dissection can facilitate the procedure. After complete release of the tumor, the surgeons examined the esophageal mucosa to ensure that it was still intact.  This exam can be enhanced with a leakage test by either using a methylene blue or an underwater bubble test. The free edges of the esophageal muscles were reattached by interrupts Vicryl 3-0 sutures. The authors tend to wet the suture prior to suturing to minimize friction. Reinforcement of the suture line with pleural flap is not always necessary in this procedure due to the esophageal mucosa being intact, but the authors believe it is good practice for all types of esophageal surgery. The flap can be made from any close anatomical tissue, such as pericardial fat, pleura, or intercostal muscle.  

Patient Outcome 

The patient had an uneventful postoperative course. A CT swallow test was performed on postoperative day 3 and showed no sign of esophageal leakage. Soft diet was resumed after the negative swallow test. The patient was discharged on postoperative day 4. Outpatient clinic follow-ups showed good signs of early overall recovery. The preoperative biopsy of esophageal leiomyoma was reassured in the final pathology. 

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