Successful resection of the complex encircling giant leiomyoma of esophagus by Endoscopic and Laparoscopic Combined Treatment

Recently, Professor Fan Zhining, the chief physician of the Gastrointestinal Endoscopy Department at Jiangsu Province Hospital and the director of the Nanjing Medical University Gastrointestinal Endoscopy Research Institute, collaborated with the general surgery department of Changzhou No.2 People’s Hospital, including Dean Tang Liming, Director Qian Jun, Professor Huang Jin from the Department of Gastroenterology, and Associate Professor Lin Min. They successfully performed a endoscopic and laparoscopic combined resection surgery for a giant leiomyoma encircling the lower esophagus and the cardia. The patient, a female, is now recovering well and is expected to be discharged soon.

Operation team photo（the 5th from the left is Prof. Fanzhining,the 3rd from theright is Director Qian Jun, the 4th from the left is Associate Professor Lin Min）

The patient, a 30-year-old female visited hospital with belching and difficulty swallowing symptoms and sought medical attention in Changzhou No.2 People’s Hospital. An enhanced chest CT scan indicated significant thickening of the lower esophageal wall near the cardia, with the thickest part measuring approximately 2.5 cm, showing mild enhancement in CT examination.

The endoscopic ultrasound showed a submucosal tumorin the lower segment of the esophagus, with a smooth surface and a ring-shaped tumor at the cardia. A hypoechoic mass is located at 37-43 cm from the incisors, with uneven internal echoes, pressing against the esophageal wall and having indistinct boundaries with the esophageal wall, measuring 5.8*3.7 cm in section.

The 3D reconstruction indicates that a large tumor encircles the esophagus and it is adjacent to the aorta. The tumor has a "hoof-shaped" around the junction of the esophagus and the cardia, with the major axis measuring approximately 6.4 cm and the minor axis measuring approximately 3.7 cm.

The patient has been diagnosed and treated in several large-scale hospitals in cities such as Shanghai and was considered to require esophago-cardiac resection surgery. Later, upon visiting the hospital in Changzhou, Professor Fan Zhining, after a comprehensive review of the patient's various examinations and a serious preoperative multidisciplinary discussion, unanimously decided that the patient could undergo an endoscope and laparoscope combined surgery that preserves the cardia.

During the surgery, Professor Fan Zhining performed endoscopic submucosal tunneling to dissect the tumor, resecting the tumor's root while ensuring the integrity of the mucosa. Dean Tang Liming, under laparoscopic guidance, completely separated and resected the tumor.

endoscope and laparoscope combined surgery by Professor Fan Zhining and Dean Tang Liming

The tumor was smoothly dissected and placed into a retrieval bag.

With the assistance of the endoscope, the entire surgical procedure did not damage the esophageal mucosa, and the postoperative pathology indicated an esophageal leiomyoma. Ultimately, a tumor measuring 7×4×4cm was completely removed.

The tumor resembles a dumbbell encircling the upper segment of the esophagus.

The patient recovered well and left hospital soon.

A photo was taken with the surgeon and the patient's family (Professor Fan Zhining: the third from the left; Associate Professor Lin Min: the first on the right).

Submucosal tumors of the upper gastrointestinal tract are a collective term for lesions originating from the layers beneath the mucosa of the upper gastrointestinal tract. Common types include leiomyomas, gastrointestinal stromal tumors (GISTs), and cysts, with esophageal and gastric submucosal tumors being more frequently seen. Leiomyomas are the most common in esophageal submucosal tumors; while GISTs are the most common in gastric submucosal tumors, followed by leiomyomas. Submucosal tumors of the upper gastrointestinal tract are often discovered during endoscopic examinations, especially those mesenchymal tissue-origin tumors originating from the muscularis propria, which may have malignant potential.

With the advancement of technology, endoscopic surgery has become the preferred method for the removal of esophageal submucosal tumors, offering the advantages of minimal trauma, rapid recovery, and preservation of organ integrity. However, for large tumors that grow outward from the lumen, simple endoscopic treatment carries high risks, is operationally difficult, and can easily damage adjacent blood vessels and organs. This surgery adopts a dual-scope treatment combining endoscopy and laparoscopy, which can completely remove and extract the lesion without damaging the esophageal mucosa throughout the entire surgical process. It adheres to the oncological principle of no-tumor and protects the integrity of the organ, avoiding the fistulas and strictures of traditional surgery, with complementary advantages of safety and effectiveness. Professor Fan Zhining and Dean Tang Liming stated that the successful implementation of this surgery reflects the advantages of super-minimally invasive surgery under the dual-scope. It also indicates that Changzhou No.2 People’s Hospital (Nanjing Medical University Changzhou Medical Center) has reached a new level in the treatment of complex gastrointestinal sub mucosal tumors, achieving a leading position both internationally and domestically, providing more precise treatment for patients.