SURGICAL THERAPY OF ESOPHAGEAL LEIOMYOMA

BACKGROUND: Surgical enucleation is the treatment of choice in selecte d patients with esophageal leiomyoma. The video-thoracoscopic approach can potentially cause less patient discomfort postoperatively and red uce the hospital stay and recovery period. STUDY DESIGN: A retrospecti ve evaluation of 66 patients who underwent surgical therapy for esopha geal leiomyoma over a 27-year period was done. The main symptoms were dysphagia in 35 (53 percent) patients, heartburn or regurgitation, or both, in 11 (17 percent) patients, and retrosternal pain in ten (15 pe rcent) patients. Associated esophageal disorders were found in 19 pati ents (some patients had more than one disorder): hiatal hernia in 15 ( 23 percent), epiphrenic diverticulum in four (6 percent), and achalasi a in three (5 percent). The operation consisted of leiomyoma enucleati on in 63 patients, and esophageal resection in three. In six patients, the enucleation was successfully performed by video-thoracoscopy comb ined with intraoperative esophagoscopy. The muscle layer of the esopha gus was approximated in the majority of the patients after tumor enucl eation. RESULTS: There was no operative mortality. The incidence of in traoperative esophageal perforation was greater in patients who had pr eviously undergone endoscopic biopsy (p<0.01). In one patient, a pseud odiverticulum developed after thoracoscopic enucleation, requiring reo peration with approximation of the muscle layer for relief of dysphagi a. The length of hospital stay was shorter in patients undergoing the video-assisted operation (p<0.05). The median follow-up period was 53 months (range, 12 to 248 months). No recurrence of leiomyoma was obser ved. Overall, seven (11 percent) patients complained of heartburn or e pigastric pain, or both, which was responsive to antisecretory drugs, but only three had such symptoms induced by the operation. In two pati ents the symptoms appeared after combined treatment of an epiphrenic d iverticulum, and in one patient after simple leiomyoma enucleation. CO NCLUSIONS: Enucleation of esophageal leiomyoma is a safe and effective operation. The video-thoracoscopic approach combined with intraoperat ive esophagoscopy allows performance of this procedure with the added advantage of shortening hospital stay. The muscle layer of the esophag us should be approximated to avoid decreasing the propulsive activity of the esophageal. body. This may improve the long-term outcome of the operation by preserving the acid-clearing mechanism of the esophagus and reducing the incidence of postoperative reflux esophagitis.