S4159 Beyond the Surgical Scope: Endoscopic Removal of a Large Esophageal Leiomyoma

Introduction: Submucosal esophageal leiomyomas are rare benign tumors, originating from the smooth muscle layer. Rarely grows large enough to cause compression of adjacent structures. Traditionally treated via surgical resection. Endoscopic techniques like submucosal tunneling endoscopic resection (STER) offer minimally invasive options with potentially fewer complications. Case Description/Methods: A 34-year-old man with no significant medical history presented with chest pain and dysphagia. Initial computed tomography (CT) imaging revealed a 4 cm lesion in the mid-esophagus, raising concern for a submucosal mass or subcarinal adenopathy. An upper endoscopy with endoscopic ultrasound (EUS) identified a non-obstructive, hypoechoic, well-defined submucosal mass, measured 30 × 40 mm in diameter in the middle third of the esophagus. Fine-needle biopsy was performed and results were positive for smooth muscle markers, consistent with leiomyoma. After a multidisciplinary discussion, the patient opted for STER as a minimally invasive treatment option. During the procedure, submucosal injection with methylene blue and saline facilitated mucosal lifting, followed by a mucosal incision at 27 cm from the incisors using a (triangular tip) TT knife. Submucosal tunneling extended from 29 to 35 cm, allowing safe resection of the lesion using a TT knife. Hemostasis was achieved with hemostatic forceps. Due to its size, the lesion was divided using a hot snare, and both halves were retrieved with a Roth net. The tunnel entrance was closed with endoscopic clips. Pathology confirmed the diagnosis of leiomyoma. Discussion: STER has emerged as a viable alternative to surgery for resecting submucosal esophageal tumors. This case highlights its feasibility for a large leiomyoma, along with the need for careful monitoring and prompt management of potential complications, such as fistula formation. STER offers a minimally invasive approach for submucosal esophageal leiomyoma resection with favorable outcomes when performed by experienced endoscopists. This case emphasizes the importance of a multidisciplinary approach and endoscopic techniques in managing complications to ensure a successful recovery. Watch the video: https://tinyurl.com/ACG25S4159