Giant Fibrovascular Polyp of the Esophagus David Lolley, M.D., Maruf A. Razzuk, M.D., and Harold C. Urschel, Jr., M.D. only when her husband inadvertently witnessed such an episode was the true nature of her swallowing difficulties disclosed and proper medical attention initiated. She had lost 13.6 kg during this time, but she maintained good health and her physical examination was unremarkable. Work-up included an esophagogram that showed a large polypoid mass attached to the cervical esophagus by a stalk at the level Fibrovascular polyps of the esophagus occur in- of the cricopharyngeus muscle (Fig 1). Cine frequently and usually produce symptoms of esophagography showed the mass to move up progressive dysphagia at the outset. They are and down in the esophagus, at times reaching pedunculated and can attain giant proportions, the hiatus. At rest it assumed a position in the sometimes exceeding 14 cm in length. Clinical midesophagus. attention is attracted by their bizarre manifestaAt operation attempts to snare the stalk of the tions of dysphagia, nausea, regurgitation, and polyp during esophagoscopy failed because of the tendency to produce sudden death by as- its firmness and broad base. Surgical resection phyxiation [2, 5, 8, 121. The following case is was carried out through a transverse lower cerreported to call attention to this rare lesion and vical incision and esophagotomy. The stalk was to emphasize the need for prompt surgical resec- divided with a rim of esophageal mucosa. The tion to relieve symptoms and circumvent the latter was repaired and the esophagotomy was possible complication of asphyxia. closed. Frozen sections of the mass, stalk, and A 53-year-old woman was admitted to the surrounding esophageal mucosa showed no hospital with a six-year history of progressive malignancy. Postoperatively the patient had a dysphagia, nausea, intermittent regurgitation benign course and was completely relieved of all of digested and undigested food, substernal dis- her symptoms. tress, and gradual restriction of oral intake to Grossly the lesion had a smooth, shiny surface clear fluids only. Four years previously she had with no ulcerations (Fig 2). Microscopically the undergone an upper gastrointestinal series and tumor was lined by normal-looking, nonesophagogram, which had been interpreted as keratinized, stratified squamous epithelium. Its demonstrating a scarred duodenum. However, main bulk was composed of vascular fibroduring all this time she had been having adipose tissue infiltrated by chronic inflamepisodes of regurgitation of a fleshy, gourd- matory cells. Scattered foci of ossification were sized mass between her teeth, associated with encountered. severe respiratory distress relieved when the patient manually reduced the mass into her Comment esophagus. She had managed to conceal this Benign pedunculated fibrovascular polyps of from her family and physicians for years, and the esophagus are uncommon. Despite early medical interest, only 41 cases have been reFrom the Department of Thoracic Surgery, Baylor University ported [lo]. Characteristically these lesions arise Medical Center, Dallas, TX. in the upper third of the esophagus, often adjaAccepted for publication Jan 29, 1976. cent to the cricopharygeus muscle [6]. Peristalsis Address reprint requests to Dr. Razzuk, Baylor Medical Plaza, 1201 Barnett Tower, 3600 Gaston Ave, Dallas, TX and the molding effect produced by the muscu75246. lar action of the esophagus have been thought ABSTRACT A case of giant fibrovascular polyp of the esophagus with a review of the literature is presented. The lesion is benign and pedunculated and may attain giant proportions. Symptoms are related to esophageal obstruction. Death by asphyxia can occur. Small lesions can be removed endoscopically with a snare. Larger lesions should be excised using a formal surgical approach.

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384 The Annals of Thoracic Surgery

Vol 22 No 4

October 1976

Fig 1 . Barium swallow showing filling defect in m idesoph agus .

responsible for the pedunculated shape and giant proportions of these lesions. Symptoms are due chiefly to esophageal obstruction and include dysphagia, regurgitation and aspiration of food, and dyspepsia. Dramatic presentations occur when the mass is regurgitated between the teeth, often accompanied by respiratory distress due to laryngeal obstruction. Sudden death by asphyxiation has been reported [l]. Severe disturbances in nutrition and loss of weight because of interference with dietary intake, significant upper gastrointestinal bleeding due to ulceration of the tumor, and respiratory distress from posterior compression of the trachea by the mass can occur 13, 41.

Fig 2 . Gross specimen offibrovascular polyp. The mass is being delivered through the esophagotomy. The stalk is seen to be attached to the esophageal wall.

Characteristically, fibrovascular polyps are seen on barium swallow as a smooth, mobile filling defect that causes forking of the barium stream. This picture can be confused roentgenographically and grossly with other pedunculated tumors of the esophagus including lipoma, myxosarcoma, fibrosarcoma, leiomyosarcoma, rhabdomyosarcoma, carcinosarcoma, and pseudosarcoma. Small polyps can be removed endoscopically with a snare. However, large lesions (more than 10 cm) and those with a broad base should be removed during a formal surgical procedure, by

385 Case Report: Lolley, Razzuk, and Urschel: Giant Fibrovascular Polyp of the Esophagus

either a transcervical or transthoracic approach, if the patient’s condition permits. This approach affords accurate control of the large vessels in the stalk, which have been reported to be a serious source of hemorrhage when divided by the snare-cautery technique [91. This also allows a biopsy of the surrounding mucosa to be obtained to rule out malignancy and permits accurate repair of the excision site [7, 111. References 1. Allen MS, Talbot WH: Sudden death due to regurgitation of a pedunculated esophageal lipoma. J Thorac Cardiovasc Surg 54:756, 1967 2. Bernatz PE, Smith JL, Ellis FH, et al: Benign pedunculated intraluminal tumors of the esophagus. J Thorac Surg 35:503, 1958 3. Boyd DP, Hill LD: Benign tumors and cysts of the esophagus. Am J Surg 93:252, 1957 4. Harrington SW: Surgical treatment of benign and

secondarily malignant tumors of the esophagus. Arch Surg 58:646, 1949 5. Lejune FE: Benign pedunculated esophageal tumors: report of a case. Ann Otol Rhino1 Laryngo1 64:1261, 1955 6. Postlethwaite RW, Sealy WC: Surgery of the Esophagus. Springfield, IL, Thomas, 1961 7. Razzuk MA, Urschel HC, Race GJ, et al: Pseudosarcoma of the esophagus. J Thorac Cardiovasc Surg 61:650, 1970 8. Samson PC, Zelman J: Pedunculated tumors of the esophagus. Arch Otolaryngol36:203, 1942 9. Schmidt HW, Clagett OT, Harrison EG: Benign tumors and cysts of the esophagus. J Thorac Cardiovasc Surg 41:717, 1961 10. Shah B, Unger L, Heimlich HJ: Hamartomatous polyp of the esophagus. Arch Surg 110:326,1975 11. Stout AP, Humphreys GH, Rottenberg LA: Acase of carcinosarcoma of the esophagus. Am J Roentgen01 Radium Ther Nucl Med 61:461, 1949 12. Watson-Williams E: Polyp of esophagus which caused fatal tracheal obstruction. J Laryngol Otol 50:922, 1935

Giant fibrovascular polyp of the esophagus.

Giant Fibrovascular Polyp of the Esophagus David Lolley, M.D., Maruf A. Razzuk, M.D., and Harold C. Urschel, Jr., M.D. only when her husband inadverte...
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