Minimally invasive surgical and endoscopic management of esophageal leiomyoma

Esophageal leiomyoma, the most common benign esophageal tumor, has transitioned from invasive thoracotomy to minimally invasive techniques. Endoscopic mucosal resection (EMR) for small tumors, thoracoscopic/laparoscopic approaches for larger lesions, and Robotic-assisted techniques have shown promising preliminary results in selected case series, with early evidence suggesting potential benefits in reducing postoperative morbidity and hospitalization; however, these findings require validation through larger prospective studies. The data sources of this review included multicenter findings for EMR, endoscopic submucosal dissection (ESD), submucosal tunneling endoscopic resection (STER), and robotic techniques. The review also highlights clinical innovations, including carbon dioxide (CO₂) insufflation to reduce the risk of mediastinal emphysema, intraoperative endoscopy to prevent esophageal leakage or mucosal injury during enucleation, and postoperative enhanced recovery (ERAS) protocols to shorten hospital stays. We emphasize tailored approaches based on tumor characteristics, with dynamic growth monitoring for asymptomatic lesions. By integrating novel decision algorithms, this review presents a practical management framework for the evolving therapeutic landscape. This review further provides a novel evidence-based decision algorithm that integrates tumor size, morphology, growth dynamics, and anatomical location, alongside a GRADE-informed assessment of evidence quality across techniques. We critically compare the latest 2024–2025 evidence, including the largest robotic series to date and multi-center endoscopic cohorts, to identify key knowledge gaps—particularly the paucity of long-term comparative data and cost-effectiveness analyses—thereby guiding future research priorities and refining personalized surgical selection.