Endoscopic Enucleation for Submucosal Tumor of the Esophagus – Usefulness of Balloon Push-out Method

Kei Sakamoto, Yosuke Izumi, Akinori Miura, Masatake Miyamoto, Tsuyoshi Kato. Department of Surgery, Tokyo Metropolitan Cancer and Infectious Diseases Center Komagome Hospital

INTRODUCTION

Submucosal tumor (SMT) of the esophagus is treated surgically, if the patient has any symptom or if there is a possibility of malignancy. The enucleation of the tumor is often performed under endoscopic procedure, however this is not necessarily easy. In some cases, intraoperative detection of the tumor is difficult. Esophagus is located in the narrow space that we have difficulty developing an optimal surgical field. In addition, the capsule of the tumor is so delicate that there are some risk of destruction of the tumor, leading to dissemination of tumor cell, and risk of mucosal injury while dissecting the tumor from the submucosal layer. To overcome these problems, we introduced a new technique called “balloon push-out method.” Instead of grasping the delicate tumor, we pushed the tumor out of the esophageal wall with a balloon-mounted intraluminal endoscope in order to perform the operation more safely. We report the treatment outcome and the usefulness of this method.

METHOD

From January 2000 to September 2014, we performed endoscopic enucleation of submucosal tumor of the esophagus in seven cases.

RESULTS

Of seven cases, the enucleation was performed by thoracoscopic approach in the left lateral decubitus position in five cases, which the tumor was mainly located in upper thoracic esophagus or middle thoracic esophagus. And it was performed by laparoscopic approach in the lithotomy position in the two remaining cases, which the tumor was located in lower thoracic esophagus. After enucleation, intact esophageal mucosa was confirmed by intraoperative endoscopy in each case. We covered the defect of the muscle layer by suturing the peripheral esophagus in thoracoscopic cases, and by Dor fundoplication technique in laparoscopic cases. The average operation time and the amount of bleeding in thoracoscopic cases and laparoscopic cases were 187 minutes / 154 minutes, and 57 ml / 100 ml respectively. The margin of the specimen was pathologically negative in every case. Five cases were diagnosed as leiomyoma, and two cases as gastrointestinal tumor (GIST). No postoperative complication was reported, and the oral ingestion after the operation was favorable. Every patient was discharged from the hospital within eight days after operation. Postoperative contrast study showed no diverticular change and stricture of esophagus, and no evidence of recurrence is reported so far.

CONCLUSION

“Balloon push-out method” is effective and safe technique for endoscopic enucleation of submucosal tumor of the esophagus.