Giant leiomyoma of the gastroesophageal junction: technique and results of endoscopic full-thickness resection

Clinical and Experimental Gastroenterology Dovepress open access to scientific and medical research R ap i d C omm u n i cat i o n Clinical and Experimental Gastroenterology downloaded from https://www.dovepress.com/ by 213.32.59.121 on 12-Jul-2018 For personal use only. Open Access Full Text Article Giant leiomyoma of the gastroesophageal junction: technique and results of endoscopic full-thickness resection This article was published in the following Dove Press journal: Clinical and Experimental Gastroenterology 29 November 2011 Number of times this article has been viewed Davide Bona Alberto Aiolfi Stefano Siboni Daniele Bernardi Luigi Bonavina Department of Surgery, IRCCS Policlinico San Donato, University of Milano School of Medicine, Milano, Italy Abstract: Four consecutive patients with a giant leiomyoma originating from the posterior aspect of the gastroesophageal junction were treated with full-thickness endoscopic retroflex dissection. A complete removal of the lesion was obtained in all cases. No complications were observed except for some degree of air filtration causing symptomatic pneumoperitoneum in one patient. Retroflex endoscopic full-thickness resection of giant leiomyoma at the gastroesophageal junction is feasible and safe. Keywords: gastroesophageal junction, leiomyoma, endoscopic submucosal dissection, pneumoperitoneum Background Leiomyoma is the most common smooth muscle tumor of the stomach and represents 80% of all gastric stromal tumors. About one-third of these neoplasms are located at the gastroesophageal junction and are often asymptomatic or minimally symptomatic.1–3 Surgical removal can be required when the lesion is large or rapidly increasing in size.4 Resection of leiomyoma of the gastroesophageal junction has been traditionally performed via laparotomy.5 When the tumor originates from the anterior wall of the cardia and exhibits an endophytic growth pattern, a hybrid approach through transgastric laparoscopy combined with endoscopic assistance has been shown to be safe and feasible.6–8 It is particularly challenging to treat submucosal lesions located at the posterior aspect of the gastroesophageal junction with this combined approach because of a high risk of causing deformity, stricture, or leakage. Park et al9 first proposed a new endoscopic approach for enucleation of upper gastrointestinal submucosal tumors by using an insulated-tip electrosurgical knife. We present our experience with full-thickness endoscopic resection of giant leiomyomas originating from the posterior side of the gastroesophageal junction. Methods Correspondence: Luigi Bonavina Dipartimento Universitario di Chirurgia, IRCCS Policlinico San Donato, Piazza E Malan 2, 20097 San Donato Milanese, Milano, Italy Tel +39 02 52774621 Fax +39 02 52774622 Email submit your manuscript | www.dovepress.com Dovepress http://dx.doi.org/10.2147/CEG.S26119 Powered by TCPDF (www.tcpdf.org) Between October 2008 and December 2010, four consecutive patients with leiomyoma of the gastroesophageal junction were treated endoscopically at our institution. The standard preoperative examinations included barium swallow study, upper gastrointestinal endoscopy, endoscopic ultrasonography, and thoracoabdominal computed tomography scan. No endoscopic biopsies were performed. One patient underwent esophageal manometry and 24-hour esophageal pH monitoring because of intermittent complaints of retrosternal heartburn and dysphagia. Clinical and Experimental Gastroenterology 2011:4 263–267 © 2011 Bona et al, publisher and licensee Dove Medical Press Ltd. This is an Open Access article which permits unrestricted noncommercial use, provided the original work is properly cited. 263 Dovepress Clinical and Experimental Gastroenterology downloaded from https://www.dovepress.com/ by 213.32.59.121 on 12-Jul-2018 For personal use only. Bona et al All patients were clearly informed about the planned p rocedure, including the possibility of switching to a l aparoscopic/laparotomic approach, depending on the occurrence of intraoperative technical difficulties. Intravenous cefazoline (2 g) was given to all patients before the procedure. The procedure was performed in the operating room, under general anesthesia, with orotracheal intubation and with the patient in the supine position. A standard 9 mm endoscope with a soft, transparent hood attached to its tip was advanced through an overtube into the stomach and then retroflexed (Figure 1). After submucosal injection of 10 mL of diluted epinephrine, an incision of the gastric mucosa overlying the mass was carried out with a retroflexed approach by using an insulated-tip diathermic electrosurgical knife (IT-Knife 2; Olympus, Tokyo, Japan) and a hook knife (Olympus Optical, Tokyo, Japan). In all cases the dissection started along the lower border of the lesion and then was extended circumferentially (Figure 2). Once the submucosal layer was reached, the tumor was gradually enucleated and then extracted from the mouth with an endocatch. Finally, the gastric mucosal edges were approximated under mild suction and closed with three to five metallic clips (Boston Scientific, Natick, MA) (Figures 3 and 4). Results There were three females and one male with a mean age of 44 years (range 36–58 years). None of them had previous gastric surgery or signif icant comorbidity. The mean duration of symptoms was 10 months (range 4–18 months). The predominant symptom was reflux-like Figure 1 Retroflexed endoscopic view of a giant leiomyoma of the gastroesophageal junction. 264 Powered by TCPDF (www.tcpdf.org) submit your manuscript | www.dovepress.com Dovepress Figure 2 Submucosal dissection of the leiomyoma started along the lower border of the lesion and was facilitated by the endoscopic cap. dyspepsia in two patients and dysphagia to solid food in the other two. On imaging, the tumor appeared as a C-shaped lesion o riginating from the posterior aspect of the gastroesophageal junction and involving between 50% and 75% of the circumference of the cardia. On endoscopic ultrasound examination, the tumor appeared Figure 3 Aspect of the mucosal defect in the subcardial region before application of the endoclips. Clinical and Experimental Gastroenterology 2011:4 36 20 11 10 Pneumoperitoneum None None None Leiomyoma Leiomyoma Leiomyoma Leiomyoma 6 6.5 12 4 180 150 220 190 Muscolaris propria Muscolaris propria Muscolaris mucosae Muscolaris propria Posterior wall Posterior wall Posterior wall Posterior wall Cardia Cardia Cardia Cardia Tumor size (cm) Operative time (min) Endoscopic ultrasound layer Side Location 38 42 36 58 1 2 3 4 Gender Female Female Female Male Follow-up (months) Histologic diagnosis Complications Clinical and Experimental Gastroenterology 2011:4 Age (years) Figure 5 Operative specimen after endoscopic enucleation. The overlying mucosa was resected en bloc. Case to originate from the muscolaris propria in three patients an (...truncated)