HOW TO DO IT
Videothoracoscopic Enucleation of Esophageal Leiomyoma Romeo Bardini, MD, Andrea Segalin, MD, Alberto Ruol, MD, Maurizio Pavanello, MD, and Alberto Peracchia, MD Department of Surgery, University of Padova, Padova, Italy
A new thoracoscopic technique to enucleate esophageal leiomyomas is described. The procedure has been successfully performed in 3 patients. All patients benefited by this new surgical approach due to the decreased operative trauma, reduced postoperative pain, quick recovery, and minute skin scars. Although further clini-
cal experience and longer periods of follow-up are needed to evaluate the full benefits and limits of this new access, the early results of the thoracoscopic approach are promising.
L
structures. Computed tomographic scan confirmed the homogeneous density of the mass, the absence of infiltration of contiguous structures, and the absence of enlarged mediastinal lymph nodes. On the basis of preoperative work-up the diagnosis of leiomyoma was confirmed and concomitant esophageal diseases were excluded. The tumor size was 3 X 2 X 4 cm, 3 x 4 x 6 cm, and 3 x 2 x 2 cm, respectively. General anesthesia was carried out with selective left bronchial intubation. The patients were placed on the operating table in the left lateral position and the right lung was excluded from ventilation. The first 10-mm trocar, to be used to introduce a straight forward 0-degree wide-angle optic, was inserted into the pleural space after visual surgical dissection; in this way a pneumothorax was already present when the trocar was inserted, therefore reducing the risk of lung injuries. We have always inserted the optic on the middle axillary line: in a position cranial to the tumor for leiomyomas of the lower thoracic esophagus, and in a caudal position in the case of tumors located in the upper thoracic esophagus. Two more 5-mm trocars, to be used to introduce the surgical instruments, were inserted under visual control anteriorly and posteriorly at the level of the tumor. The pneumothorax allowed good exposure of the operative field, and the connection with the CO, insufflator was usually unnecessary. When the mediastinal exposure had to be further improved, we set the cut-off pressure of the automatic insufflator not higher than 8 mm Hg. At thoracoscopy, the tumor was easily located in all the patients. In 1 patient the cross of the azygos vein lying over the leiomyoma was ligated and divided by means of a Vascular EndoGIA 30 (United States Surgical Corp, Norwalk, CT). The mediastinal pleura and the muscular layer of the esophagus were longitudinally opened by scissors and cautery, and a 2-0 traction suture was placed through the leiomyoma. The tumor was then pulled up and was easily dissected from both the mucosa and the muscular layer.
eiomyoma is the most common benign tumor of the esophagus, accounting for 70% to 80% of all benign tumors [I, 21. The main indications for surgical excision are the relief of dysphagia or pain, when present, and the prevention of the disorganization of the muscular anatomy due to the progressive increase in size of the tumor 131. The relationship between the tumor and both the mucosal and muscular layers is usually loose, and therefore a leiomyoma can be easily enucleated by gentle blunt dissection. Ready acceptance of the procedure, especially in asymptomatic patients, may sometimes be tempered by the serious trauma due to the thoracotomy access. In the present article we report on a thoracoscopic technique for the enucleation of leiomyomas of the esophagus that was successfully used in 3 patients.
Patients and Technique Since 1967, 54 patients with a leiomyoma of the thoracic esophagus were treated through a thoracotomy approach in our department. In the latest period 3 more patients were operated on through a thoracoscopic approach. There were 2 men and 1 woman, aged 57, 47, and 30 years, respectively. All patients were symptomatic: retrosternal pain or discomfort was present in 2 patients and dysphagia in 1. The tumor was located in the upper thoracic esophagus in 1 patient and in the lower thoracic esophagus in 2. In all these cases esophagography, esophagoscopy, endoscopic ultrasonography, and computed tomographic scanning were performed. Barium swallow showed smooth filling defects, and esophagoscopy revealed a submucosal tumor with no mucosal infiltration. Endoscopic ultrasonography showed a sharply delineated mass lesion of lower echodensity, with regular echopattern, compressing but not invading the surrounding Accepted for publication May 15, 1992. Address reprint requests to Dr Bardini, C1. Chirurgica 1, Via Giustiniani, 2, 35128 Padova, Italy.
0 1992 by The Society of Thoracic Surgeons
(Ann Thorac Surg 1992;54:576-7)
0003-4975/92/$5.00
HOW TO DO IT BARDINI ET AL VIDEOTHORACOSCOFICENUCLEATION
Ann Thorac Surg 1992;54:576-7
All the leiomyomas were easily extracted from the pleural cavity through a 2-cm intercostal incision. During the dissection of leiomyomas, videoesophagoscopy was carried out to assist the thoracoscopic maneuvers and to verify step by step, from inside, the integrity of the mucosa. Esophagoscopy allows inflation and deflation of the esophagus, making easier for the surgeon the identification of the border between the mucosa and the leiomyoma. Moreover, minimal perforation of the mucosa can be immediately recognized by endoscopic insufflation. After leiomyoma enucleation, the split muscular layer was longitudinally sutured with three 2-0 stitches in 1 patient. At the end of the procedure the pleural cavity was irrigated with saline solution and the integrity of the mucosa was verified during endoscopic insufflation. A nasogastric tube was placed under endoscopic control, and a chest tube was placed through the incision of the posterior 5-mm trocar.
Results On the average, the procedure lasted 2 hours. The postoperative course was uneventful in all the patients, who experienced only minimal postoperative pain. On the 4th postoperative day a Gastrografin (Schering SPA, Germany) swallow was performed, showing the absence of leaks. In the 2 patients in whom the muscle layer was not reapproximated, minimal mucosal bulging was evident. The nasogastric tube was removed and the patients were discharged receiving a soft diet on the 6th postoperative day.
577
troesophageal reflux, and epiphrenic diverticulum [11. When an antireflux repair also is indicated, the two procedures are commonly performed through a left thoracotomy. For an isolated and uncomplicated leiomyoma of the thoracic esophagus a right approach is recommended. For this kind of lesion the trauma due to thoracotomy may represent a problem even greater than the enucleation of the tumor itself. In our experience, the videothoracoscopic approach allowed easy enucleation of esophageal leiomyomas, and the procedure was not more difficult or prohibitively longer than the transthoracic technique. We believe that this technique could be indicated in benign esophageal tumor smaller than 5 x 5 X 5 cm in which the diagnosis of leiomyoma is made preoperatively by means of endoscopy, endoscopic ultrasonography, and computed tomographic scan. If a malignant esophageal tumor was suspected a thoracotomy would represent the approach of choice. After the enucleation, the reapproximation of the split esophageal muscular layer may be indicated to prevent mucosal bulging at the level of the enucleated tumor. The advantages of the thoracoscopic surgical treatment are as follows: rapid, full reexpansion of the lung; decreased postoperative pain; short postoperative hospital stay; and early return to normal physical activity. In addition, the avoidance of a painful thoracotomy wound and its adverse effects on pulmonary function carries important implications in patients with chronic obstructive disease. The full benefits and limits of this new access to enucleate esophageal leiomyomas will be clarified with further clinical experience and a longer period of followUP.
Comment
References
Surgical enucleation is the treatment of choice of esophageal leiomyomas. As stated by Ohsawa [4] in 1933, the procedure is easy and fast due to the loose relationship between the leiomyoma and both the mucosa and the muscular layer. The surgical approach is determined by the location of the tumor and by the possible concomitance of esophageal diseases, such as hiatal hernia, gas-
1. Altorki N, Sunagawa M, Migliore M, Skinner DB. Benign esophageal tumors. Dis Esoph 1991;1:159. 2. Daniel RA, Williams RB. Leiomyoma of the esophagus. J Thorac Surg 1950;19:800-5. 3. Skinner DB, Belsey RH. Management of esophageal disease. Philadelphia: W.B. Saunders, 1988:717-27. 4. Ohsawa T. Surgery of the esophagus. Arch Jpn Chir 1933;lO: 60595.
Videothoracoscopic Enucleation of Esophageal Leiomyoma Romeo Bardini, MD, Andrea Segalin, MD, Alberto Ruol, MD, Maurizio Pavanello, MD, and Alberto Peracchia, MD Department of Surgery, University of Padova, Padova, Italy
A new thoracoscopic technique to enucleate esophageal leiomyomas is described. The procedure has been successfully performed in 3 patients. All patients benefited by this new surgical approach due to the decreased operative trauma, reduced postoperative pain, quick recovery, and minute skin scars. Although further clini-
cal experience and longer periods of follow-up are needed to evaluate the full benefits and limits of this new access, the early results of the thoracoscopic approach are promising.
L
structures. Computed tomographic scan confirmed the homogeneous density of the mass, the absence of infiltration of contiguous structures, and the absence of enlarged mediastinal lymph nodes. On the basis of preoperative work-up the diagnosis of leiomyoma was confirmed and concomitant esophageal diseases were excluded. The tumor size was 3 X 2 X 4 cm, 3 x 4 x 6 cm, and 3 x 2 x 2 cm, respectively. General anesthesia was carried out with selective left bronchial intubation. The patients were placed on the operating table in the left lateral position and the right lung was excluded from ventilation. The first 10-mm trocar, to be used to introduce a straight forward 0-degree wide-angle optic, was inserted into the pleural space after visual surgical dissection; in this way a pneumothorax was already present when the trocar was inserted, therefore reducing the risk of lung injuries. We have always inserted the optic on the middle axillary line: in a position cranial to the tumor for leiomyomas of the lower thoracic esophagus, and in a caudal position in the case of tumors located in the upper thoracic esophagus. Two more 5-mm trocars, to be used to introduce the surgical instruments, were inserted under visual control anteriorly and posteriorly at the level of the tumor. The pneumothorax allowed good exposure of the operative field, and the connection with the CO, insufflator was usually unnecessary. When the mediastinal exposure had to be further improved, we set the cut-off pressure of the automatic insufflator not higher than 8 mm Hg. At thoracoscopy, the tumor was easily located in all the patients. In 1 patient the cross of the azygos vein lying over the leiomyoma was ligated and divided by means of a Vascular EndoGIA 30 (United States Surgical Corp, Norwalk, CT). The mediastinal pleura and the muscular layer of the esophagus were longitudinally opened by scissors and cautery, and a 2-0 traction suture was placed through the leiomyoma. The tumor was then pulled up and was easily dissected from both the mucosa and the muscular layer.
eiomyoma is the most common benign tumor of the esophagus, accounting for 70% to 80% of all benign tumors [I, 21. The main indications for surgical excision are the relief of dysphagia or pain, when present, and the prevention of the disorganization of the muscular anatomy due to the progressive increase in size of the tumor 131. The relationship between the tumor and both the mucosal and muscular layers is usually loose, and therefore a leiomyoma can be easily enucleated by gentle blunt dissection. Ready acceptance of the procedure, especially in asymptomatic patients, may sometimes be tempered by the serious trauma due to the thoracotomy access. In the present article we report on a thoracoscopic technique for the enucleation of leiomyomas of the esophagus that was successfully used in 3 patients.
Patients and Technique Since 1967, 54 patients with a leiomyoma of the thoracic esophagus were treated through a thoracotomy approach in our department. In the latest period 3 more patients were operated on through a thoracoscopic approach. There were 2 men and 1 woman, aged 57, 47, and 30 years, respectively. All patients were symptomatic: retrosternal pain or discomfort was present in 2 patients and dysphagia in 1. The tumor was located in the upper thoracic esophagus in 1 patient and in the lower thoracic esophagus in 2. In all these cases esophagography, esophagoscopy, endoscopic ultrasonography, and computed tomographic scanning were performed. Barium swallow showed smooth filling defects, and esophagoscopy revealed a submucosal tumor with no mucosal infiltration. Endoscopic ultrasonography showed a sharply delineated mass lesion of lower echodensity, with regular echopattern, compressing but not invading the surrounding Accepted for publication May 15, 1992. Address reprint requests to Dr Bardini, C1. Chirurgica 1, Via Giustiniani, 2, 35128 Padova, Italy.
0 1992 by The Society of Thoracic Surgeons
(Ann Thorac Surg 1992;54:576-7)
0003-4975/92/$5.00
HOW TO DO IT BARDINI ET AL VIDEOTHORACOSCOFICENUCLEATION
Ann Thorac Surg 1992;54:576-7
All the leiomyomas were easily extracted from the pleural cavity through a 2-cm intercostal incision. During the dissection of leiomyomas, videoesophagoscopy was carried out to assist the thoracoscopic maneuvers and to verify step by step, from inside, the integrity of the mucosa. Esophagoscopy allows inflation and deflation of the esophagus, making easier for the surgeon the identification of the border between the mucosa and the leiomyoma. Moreover, minimal perforation of the mucosa can be immediately recognized by endoscopic insufflation. After leiomyoma enucleation, the split muscular layer was longitudinally sutured with three 2-0 stitches in 1 patient. At the end of the procedure the pleural cavity was irrigated with saline solution and the integrity of the mucosa was verified during endoscopic insufflation. A nasogastric tube was placed under endoscopic control, and a chest tube was placed through the incision of the posterior 5-mm trocar.
Results On the average, the procedure lasted 2 hours. The postoperative course was uneventful in all the patients, who experienced only minimal postoperative pain. On the 4th postoperative day a Gastrografin (Schering SPA, Germany) swallow was performed, showing the absence of leaks. In the 2 patients in whom the muscle layer was not reapproximated, minimal mucosal bulging was evident. The nasogastric tube was removed and the patients were discharged receiving a soft diet on the 6th postoperative day.
577
troesophageal reflux, and epiphrenic diverticulum [11. When an antireflux repair also is indicated, the two procedures are commonly performed through a left thoracotomy. For an isolated and uncomplicated leiomyoma of the thoracic esophagus a right approach is recommended. For this kind of lesion the trauma due to thoracotomy may represent a problem even greater than the enucleation of the tumor itself. In our experience, the videothoracoscopic approach allowed easy enucleation of esophageal leiomyomas, and the procedure was not more difficult or prohibitively longer than the transthoracic technique. We believe that this technique could be indicated in benign esophageal tumor smaller than 5 x 5 X 5 cm in which the diagnosis of leiomyoma is made preoperatively by means of endoscopy, endoscopic ultrasonography, and computed tomographic scan. If a malignant esophageal tumor was suspected a thoracotomy would represent the approach of choice. After the enucleation, the reapproximation of the split esophageal muscular layer may be indicated to prevent mucosal bulging at the level of the enucleated tumor. The advantages of the thoracoscopic surgical treatment are as follows: rapid, full reexpansion of the lung; decreased postoperative pain; short postoperative hospital stay; and early return to normal physical activity. In addition, the avoidance of a painful thoracotomy wound and its adverse effects on pulmonary function carries important implications in patients with chronic obstructive disease. The full benefits and limits of this new access to enucleate esophageal leiomyomas will be clarified with further clinical experience and a longer period of followUP.
Comment
References
Surgical enucleation is the treatment of choice of esophageal leiomyomas. As stated by Ohsawa [4] in 1933, the procedure is easy and fast due to the loose relationship between the leiomyoma and both the mucosa and the muscular layer. The surgical approach is determined by the location of the tumor and by the possible concomitance of esophageal diseases, such as hiatal hernia, gas-
1. Altorki N, Sunagawa M, Migliore M, Skinner DB. Benign esophageal tumors. Dis Esoph 1991;1:159. 2. Daniel RA, Williams RB. Leiomyoma of the esophagus. J Thorac Surg 1950;19:800-5. 3. Skinner DB, Belsey RH. Management of esophageal disease. Philadelphia: W.B. Saunders, 1988:717-27. 4. Ohsawa T. Surgery of the esophagus. Arch Jpn Chir 1933;lO: 60595.
