Ann Thorac Surg 2001;72:1754-1755
© 2001 The Society of Thoracic Surgeons
Case report
Minimal access thoracic surgery for esophageal hemangioma
Yi-Cheng Wu, MD*a,
Hui-Ping Liu, MDa,
Yun-Hen Liu, MDa,
Ming-Ju Hsieh, MDa,
Pyng-Jing Lin, MDa
a Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taipei, Taiwan
Accepted for publication November 27, 2000.
* Address reprint requests to Dr Wu, Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, 199 Tun-Hwa N Road, Taipei, Taiwan 105
e-mail: expert96{at}ms11.hinet.net
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Abstract
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Esophageal hemangioma is a rare tumor. This report describes the case of a 69-year-old woman with an esophageal tumor at the middle portion of the esophagus. The patient was successfully treated with minimal access thoracic surgery, and at the 6 month follow-up, the patient was free of any symptoms or recurrence.
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Introduction
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Esophageal hemangioma is a rare tumor. To our knowledge, there are only 30 clinical case reports reported in the medical literature [1]. Removal of the esophageal hemangioma is recommended for possible lethal bleeding [2], or obstructive symptoms [3]. Various options for the removal of the esophageal hemangioma are proposed since the first case was discussed. We add a new case of esophageal hemangioma with treatment by minimal access thoracic surgery, and discuss appropriate treatment strategies for this disease.
A 69-year-old woman with a history of gastric ulcer underwent a Billroth II gastrojejunostomy procedure 20 years ago. The patient was doing well until she complained of melena shortly before admission. She also complained of lower substernal pain after eating, but without obvious dysphagia. The results of physical and laboratory examinations were unremarkable. However, endoscopic examination showed a protruding mass in the middle third of the esophagus. The tumor was located on the right esophageal wall 24-cm from the incisors, and was covered with smooth mucosa with bluish coloration (Fig 1). Due to the high probability of a vascular lesion and unavoidable massive bleeding, an endoscopic biopsy was not performed. An upper gastrointestinal series showed a filling defect in the middle portion of the esophagus. Endoscopic ultrasonography (EUS) (Fujinon Optical Co Ltd, and Aloka Co, Ltd, Japan) showed a hypoechoic submucosal mass compatible with a vascular structure, projecting into the gut lumen (Fig 2). Computed tomography (CT) revealed an esophageal tumor in the middle third portion, without obvious mediastinal lymph node enlargement or distant metastases. Angiography excluded thoracic aneurysm.
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Fig 2. Endoscopic ultrasonography reveals an nonhomogeneous mixed echoic (arrow) tumor, the underlying proper muscle layer is difficult to inspect.
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Under general anesthesia, a double-lumen endotracheal tube was inserted, and the patient was put in a left lateral decubitus position. A trocar, 10 mm in diameter, was introduced through a 2-cm incision into the pleural cavity (usually in the seventh intercostal space at the posterior axillary line). The thoracoscope was introduced through this trocar channel. With the aid of video-TV monitors, the operative field of the pleural cavity was investigated. After localizing the lesion, the main incision was made close to this lesion and was extended transversely (approximately 4 to 5 cm). This allowed insertion of conventional thoracic or endoscopic instruments. After complete exposure of the esophagus under image visualization, the mediastinal pleura was grasped, pulled upward, and opened with electrocautery. The mobilization of the esophagus was initially carried out in an area that was not involved with tumor. Once partly freed, the esophagus was grasped and elevated. Subsequently, esophageal muscle layers were dissected to expose the esophageal hemangioma, without injury to the feeding and drainage vessels. The tumor was removed. No complications such as perforation of the esophageal mucosa occurred; blood loss was minimal. The patient restarted oral intake 3 days after the surgical procedure, and was discharged 5 days later.
The resected specimen consisted of a lesion 35x40x10 mm with reddish-colored and irregular dilated vessels of varying size. The pathologic data of the specimen showed a single layer of endothelial cells. There was no cellular atypia, and the final diagnosis of this tumor was cavernous hemangioma.
The 3-month follow-up showed no complaints or clinical signs. Endoscopy did not reveal any tumor recurrence 6 months later.
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Comment
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Benign esophageal tumors are relatively rare compared to carcinoma, and only 2% to 3% are hemangiomas. A literature review showed that only 30 cases of esophageal hemangioma have been diagnosed and treated since 1926 [1]. According to Araki and colleagues [1] and our case, 18 males, 13 females were recorded. The range of patient’s ages is from newborn to 72 years peaking in the fourth decade for both sexes; males reach another peak in the sixth decade. Thirteen esophageal hemangiomas were located in the upper portion, eight in the middle, and six in the lower esophagus. The three most common complaints were dysphagia (45.2%), followed by hematemesis (25.8%), melena (12.9%), and retrosternal pain (12.9%).
Araki and associates showed that esophageal hemangioma can be biopsied without serious sequelae [1], nevertheless the possibility of major bleeding still exists. Hence, we do not perform esophageal biopsy prior to tumor excision. With the aid of EUS, the esophageal tumor can be evaluated precisely, regarding location, depth, and size. On CT images, the esophageal hemangioma showed a well-defined soft tissue mass in the wall of the esophagus. Both EUS and CT examinations can easily differentiate between benign and malignant esophageal tumors, and can also help to determine the best approach for excising the tumor.
Minimally invasive endoscopic resection is becoming popular throughout the world since the 1980s. It is suggested that superficial tumor sizes less than 2.5 cm in diameter, with a thin pedicle may be suitable for endoscopic resection. Surgical resections are still the main option for most physicians. However, one case was treated using endoscopic injection sclerotherapy with a successful outcome [4]. Classically, a long and painful surgical incision is the standard approach for resecting an esophageal lesion. However, the incision pain, poor cosmetic effect, and possible respiratory function impairment are occasionally troublesome. Video-assisted thoracic surgery (VATS) is a useful and rapid modality for the surgical treatment of intrathoracic disease [5–8]. Based on our experience [7, 9], we believe that the minimal access approach for excising an esophageal hemangioma is a good choice. The obvious benefits of VATS allow surgeons to manipulate esophageal lesions without hesitation.
We conclude that esophageal hemangiomas should be excised due to the possibility of major hemorrhage in spite of their benign nature. For small tumors, with a thin pedicle lying just below the mucosa, endoscopic excision could be the first choice. Whenever surgery is advised, minimal access thoracic surgery is an excellent option.
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References
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Abstract
Introduction
