A 26-year-old man presented with substernal discomfort. Enhanced computed tomography scans revealed a significant submucosal tumor with dimensions of 8.19×4.55×2.69 cm ([Fig. 1]
a). Endoscopy revealed a huge tumor on the posterior wall of the esophagus, protruding into the lumen [Fig. 1]
b). Three-dimensional reconstruction demonstrated that the lesion was situated on the posterior wall of the esophagus, in proximity to the thoracic aorta ([Fig. 1]
c). After a thorough discussion regarding the risks and benefits, piecemeal submucosal tunnel endoscopic resection (P-STER) was performed to remove the tumor ([Video 1]).
Fig. 1 Computed tomography (CT) and endoscopy images of the lesion (arrow). a Enhanced CT scans revealed a significant submucosal tumor with dimensions of 8.19 × 4.55 × 2.69 cm. b Endoscopy revealed a huge tumor on the posterior wall of the esophagus, protruding into the lumen. c Three-dimensional reconstruction demonstrated that the lesion was situated on the posterior wall of the esophagus, in proximity to the thoracic aorta.
Piecemeal submucosal tunnel endoscopic resection for a giant esophageal leiomyoma larger than 8 cm.Video 1
A mucosal incision was made 5 cm above the lesion to establish a broad submucosal tunnel ([Fig. 2]
a). Dissection was performed within this tunnel along the tumor margins to free the submucosal and muscularis propria layers ([Fig. 2]
b). We attempted other methods without success. Finally, a high-frequency incision knife in conjunction with a snare was used to segment and excise the tumor ([Fig. 2]
c). Once hemostasis was achieved, the tunnel entrance was closed ([Fig. 2]
d). The patient resumed a liquid diet 4 days post-procedure and was discharged from hospital after a total of 15 days. Histopathological and immunohistochemical analyses confirmed a diagnosis of leiomyoma ([Fig. 3]).
Fig. 2 Surgical procedure images. a A submucosal tunnel was established. b Dissection was performed along the tumor margins to free the submucosal and muscularis propria layers. c The tumor was segmented and removed. d Titanium clips were applied to close the tunnel entrances securely.
Fig. 3 Histological evaluation. a The specimen was fixed outside the
body, and measured approximately 9×6×3 cm. b Immunohistochemistry
indicated DOG(–). c Immunohistochemistry indicated desmin
(+++).
P-STER, a variant of the submucosal tunnel endoscopic resection (STER) technique, is commonly used for treating submucosal tumors. In this case, P-STER has proven successful for treating esophageal submucosal tumors exceeding 8 cm in size, offering both safety and efficacy. European guidelines recommend a maximum size of 35 mm for endoscopic en bloc resection [1]. We have shown that P-STER is feasible for esophageal leiomyomas larger than 8 cm, even though such cases exceed the size limits recommended by expert consensus. In our experience, P-STER broadens the applicability of STER surgery, effectively minimizing trauma and surgical risk [2]
[3]. Further studies are needed to evaluate the clinical value of this approach.
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E-Videos is an open access online section of the journal Endoscopy, reporting on interesting cases and new techniques in gastroenterological endoscopy. All papers include a high-quality video and are published with a Creative Commons CC-BY license. Endoscopy E-Videos qualify for HINARI discounts and waivers and eligibility is automatically checked during the submission process. We grant 100% waivers to articles whose corresponding authors are based in Group A countries and 50% waivers to those who are based in Group B countries as classified by Research4Life (see: https://www.research4life.org/access/eligibility/).
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