Background: Esophageal submucosal tumors (SMTs) are rare, occurring in less than 1% of esophageal neoplasms. For surgical treatment of esophageal SMTs, enucleation is usually the procedure of choice for benign tumors. This study aimed at evaluating the surgical technique and outcomes of thoracoscopic enucleation with esophagoscopy for esophageal SMTs. Methods: Patients with esophageal SMTs who underwent thoracoscopic enucleation between 2015 and 2022 were retrospectively investigated. Surgery was performed with the patient in the prone position. First, an esophagoscope was inserted, and a sodium hyaluronate solution with indigo carmine dye was injected into the submucosal layer just below the tumor. Next, under thoracoscopy, the tumor was exposed through a thoracoscopic incision and dissection of the muscularis propria and adventitia was performed at the tumor site. The colored layer resulting from the previously injected dye was identified, and tumor enucleation was performed under guidance of the dye so as not to damage the mucosa or pseudocapsule. Results: In total, 5 surgeries were performed. The mean operative time was 122.6 minutes (range 84-168 minutes), mean blood loss was 21.1 mL (range 0-80 mL), and mean postoperative hospital stay was 8 days (range 7-10 days). There were no postoperative complications. Pathological diagnosis revealed 2 cases of gastrointestinal stromal tumors, 2 cases of schwannoma, and 1 case of leiomyoma. Conclusions: We believe that this technique is a useful and safe method of performing thoracoscopic enucleation of esophageal SMTs because the injected dye provides an indicator of the resection line during enucleation.

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BACKGROUND: Neuromuscular choristoma (NMC) is a rare peripheral nerve lesion that is composed of ectopic mature muscle fibers and nerve fascicles, typically involving major nerve roots or trunks, such as the cranial nerves, brachial plexus, and sciatic nerves. The onset of NMC frequently occurs in the first decade of life. Here, we present the first documented case of a case of esophageal NMC in an adult patient.
METHODS: A 46-year-old male patient presented in 2018 with a submucosal tumor of the esophagus. Upon presentation, the tumor was approximately 10 mm in diameter, covered by normal mucosa, and located in the left posterior wall of the esophagus in a position that was 30 cm from the incisor. The tumor was discovered incidentally during gastroscopic examination. In March 2021, endoscopic re-examination revealed no significant changes in the tumor. Endoscopic ultrasound revealed an oval hypoechoic mass with a homogeneous internal echo that originated from the muscularis propria with a maximum cross section of 13 mm × 6 mm. Resection was performed under gastroscopy. The resection specimen was 12 mm × 5 mm in size and was a well-demarcated, elastic, hard, and tough with a gray section. Histologically, the specimen consisted of an abundance of smooth muscle fiber bundles intercalated among nerve fibers, but without malignancy. Immunohistochemical examinations revealed positivity for S-100 protein, caldesmon, NSE and desmin, but negativity for CD117, DOG-1, HMB45, and Melan A. There was also aberrant nuclear localization of beta-catenin. Collectively, these findings led to a diagnosis of esophageal NMC.
CONCLUSIONS: NMC is extremely rare, especially esophageal NMC, and is very challenging to accurately diagnose prior to resection. It is important that we can differentiate NMC from other types of tumors.

Esophageal submucosal tumors (SMTs) are rare heterogenous clinical entities. The surgical resection can be performed in different surgical approaches. However, the robotic surgical strategy is poorly documented in the treatment of SMTs. We present our series of operated esophageal SMTs approached via robotic-assisted surgery. Six patients with symptomatic esophageal submucosal tumors underwent robotic surgery within a 3-year period. The performed procedures were robotic-assisted enucleation, robotic esophagectomy (RAMIE) and reverse hybrid robotic esophagectomy. Patients\' clinical data, intra/postoperative outcomes, and histopathological features were retrieved from the institution\'s prospective database. Five of six patients were scheduled for upfront surgery: four underwent robotic enucleation (three leiomyoma and one suspected GIST) and one underwent reverse hybrid robotic esophagectomy (suspected GIST). One patient, diagnosed with GIST, was treated with neoadjuvant Imatinib therapy, before undergoing a RAMIE. No major intra-operative complications were recorded. Median length of stay was 7 days (6-50), with a longer post-operative course in patients who underwent esophagectomy. Clavien-Dindo > 3a complications occurred in two patients, aspiration pneumonia and delayed gastric emptying. The final histopathological and immuno-histochemical diagnosis were leiomyoma, well-differentiated GIST, low-grade fibromyxoid sarcoma and Schwannoma. Robotic-assisted surgery seems to be a promising option for surgical treatment strategies of benign or borderline esophageal submucosal tumors.

Bronchogenic cyst is very difficult to diagnose preoperatively. We report two cases of bronchogenic cyst of the esophagus diagnosed and treated by thoracoscopic resection or endoscopic mucosal incision. Thoracoscopic resection was performed to diagnose and treat case 1, while in case 2, histological diagnosis was obtained with an endoscopic mucosal incision. On endoscopic ultrasonography, the lesion characteristically demonstrated two components consisting of an anechoic and homogeneous echoic pattern. Although it is very rare for bronchogenic cyst to be complicated by malignancy, histological diagnosis is necessary. If tumor localization is in the esophageal wall and the safety of a mucosal incision can be confirmed, endoscopic incision is a good alternative that allows less invasive diagnosis and treatment than surgery or thoracoscopy.

BACKGROUND: Esophageal schwannomas are rare esophageal submucosal tumors. We herein report a case of a lobulated esophageal schwannoma resected with concurrent approach from the thorax and cervix.
METHODS: A 74-year-old woman visited our hospital with complaint of loss of consciousness, and a lobulated mediastinal tumor was discovered by chance in computed tomography. Upper gastrointestinal endoscopy showed a smooth elevated lesion at a position of 23-28 cm from the incisor teeth. A hypermetabolic appearance was noted on positron emission tomography. Based on these data, a gastrointestinal stromal tumor was suspected. The tumor was enucleated at the thoracic cavity while being pushed from the cervical incision. Pathological examination showed an esophageal schwannoma.
CONCLUSIONS: We experienced a case of lobulated esophageal schwannoma with fluorodeoxyglucose accumulation. We resected the tumor with concurrent approach from the thorax and cervix.

Esophageal submucosal tumors are occasionally detected incidentally during a gastrointestinal survey. In the present study, a case of esophageal leiomyoma is reported, which was incidentally detected by chest radiography during an annual survey of mass-screening for lung cancer. The patient underwent a laparoscopic lower esophagectomy, a proximal gastrectomy and a gastric tube reconstruction. Macroscopic examination revealed a 50×40×28-mm mass, while microscopic examination identified submucosal smooth muscle tissue without mitotic activity or necrosis. The tumor was diagnosed as an esophageal leiomyoma. The patient was asymptomatic during the three-month follow-up period. However, when a mass lesion adjacent to the gastrointestinal tract is detected during chest radiography, the possibility of a rare disease should be considered. Therefore, further investigation with upper gastrointestinal radiography and gastroendoscopy should be performed.