Subepithelial tunneling endoscopic resection with intratunnel morcellation for a giant esophageal leiomyoma

Subepithelial tunneling endoscopic resection is an accepted minimally invasive therapy for esophageal subepithelial tumors arising from the muscularis propria layer [1]. Subepithelial tunneling endoscopic resection is highly successful for subepithelial tumors < 4 cm. Larger lesions pose technical challenges for this procedure and for specimen delivery with resultant inferior outcomes [2]. Several techniques have been described to overcome this problem, such as double-opening subepithelial tunneling endoscopic resection, intracorporeal morcellation, or a thoracoscopy-assisted approach [2] [3] [4] [5]. This video demonstrates subepithelial tunneling endoscopic resection for a giant esophageal leiomyoma with intratunnel morcellation.

A 37-year-old man presented with dysphagia. Computed tomography (CT) scan, esophagogastroduodenoscopy (EGD), and endoscopic ultrasound (EUS)-guided fine needle biopsy confirmed a muscularis propria layer leiomyoma at 22 cm measuring 6.5 × 2.5 × 4 cm ([Fig. 1], [Fig. 2]). Subepithelial tunneling endoscopic resection was performed ([Video 1]). After submucosal elevation, a mucosal incision was made at 17 cm using a triangular tip TT-J knife (Olympus, Tokyo, Japan) and Endocut current (Erbe Vio 200D; Erbe, Tübingen, Germany). The subepithelial tumor was enucleated by generous lateral and forward dissection using forced coagulation current (Erbe). Hemostasis was achieved using a Coagrasper (Olympus). Care was taken to maintain an intact capsule around the leiomyoma. The lesion was too bulky to be delivered en bloc from the tunnel. Therefore, intratunnel morcellation was performed and morcellated tumor fragments were retrieved from the tunnel and esophagus ([Fig. 3]). The mucosal incision was closed using endoclips. The procedure time was 210 min. The patient was maintained nil orally for 48 hours followed by an oral diet and was discharged on day 6. No adverse events were recorded ([Fig. 4]). Final histopathology confirmed leiomyoma. Follow-up EGD at 4 weeks revealed a healthy scar ([Fig. 5]). The patient reported dysphagia resolution.

Fig. 1 Endoscopic view of subepithelial esophageal tumor (outline marked).

Fig. 2 Radial endoscopic ultrasonography view of the esophageal subepithelial tumor. Note the aorta in close relation to the tumor.

Video 1 This narrated video demonstrates the technique of subepithelial tunneling endoscopic resection for a giant esophageal leiomyoma followed by intratunnel morcellation of the specimen to facilitate specimen delivery.

Fig. 3 External view of the final resected specimen showing the morcellated tumor fragments.

Fig. 4 Post-operative contrast swallow demonstrating no leak of contrast from the esophageal lumen.

Fig. 5 Endoscopic view of healed site scar on follow-up endoscopy at 4 weeks.

This video highlights the importance of intratunnel morcellation to facilitate specimen delivery after subepithelial tunneling endoscopic resection. It also highlights the importance of a preprocedural EUS-guided fine needle biopsy to confirm the tumor is benign, because only then could we perform morcellation. In conclusion, subepithelial tunneling endoscopic resection with intratunnel morcellation is a safe and effective technique for resection of a giant esophageal leiomyoma.

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Competing interests

The authors declare that they have no conflict of interest.

• References

• 1 Xu MD, Cai MY, Zhou PH. et al. Submucosal tunneling endoscopic resection: a new technique for treating upper GI submucosal tumors originating from the muscularis propria layer (with videos). Gastrointest Endosc 2012; 75: 195-199 DOI: 10.1016/j.gie.2011.08.018.
• 2 Bapaye A, Korrapati SK, Dharamsi S. et al. Third space endoscopy: lessons learnt from a decade of submucosal endoscopy. J Clin Gastroenterol 2020; 54: 114-129 DOI: 10.1097/MCG.0000000000001296.
• 3 Zhang Q, Cai JQ, Xiang L. et al. Modified submucosal tunneling endoscopic resection for submucosal tumors in the esophagus and gastric fundus near the cardia. Endoscopy 2017; 49: 784-791 DOI: 10.1055/s-0043-111236.
• 4 Du C, Linghu E. Submucosal tunneling endoscopic resection for the treatment of gastrointestinal submucosal tumors origin-ating from the muscularis propria layer. J Gastrointest Surg 2017; 21: 2100-2109 DOI: 10.1007/s11605-017-3579-7.
• 5 Zhong YS, Shi Q, Guo WG. et al. Thoracoscope assisted tunnel endoscopic resection for esophageal SMT from the muscularis propria. Zhonghua Weichang Waike Zazhi 2012; 15: 404-405

Publication History

Article published online:
09 August 2021