A case report of piecemeal submucosal tunnel endoscopic resection for a giant esophageal leiomyoma larger than 8 cm

A 26-year-old man presented with substernal discomfort. Enhanced computed tomography scans revealed a significant submucosal tumor with dimensions of 8.19×4.55×2.69 cm ([Fig. 1] a). Endoscopy revealed a huge tumor on the posterior wall of the esophagus, protruding into the lumen [Fig. 1] b). Three-dimensional reconstruction demonstrated that the lesion was situated on the posterior wall of the esophagus, in proximity to the thoracic aorta ([Fig. 1] c). After a thorough discussion regarding the risks and benefits, piecemeal submucosal tunnel endoscopic resection (P-STER) was performed to remove the tumor ([Video 1]).

Fig. 1 Computed tomography (CT) and endoscopy images of the lesion (arrow). a Enhanced CT scans revealed a significant submucosal tumor with dimensions of 8.19 × 4.55 × 2.69 cm. b Endoscopy revealed a huge tumor on the posterior wall of the esophagus, protruding into the lumen. c Three-dimensional reconstruction demonstrated that the lesion was situated on the posterior wall of the esophagus, in proximity to the thoracic aorta.

Piecemeal submucosal tunnel endoscopic resection for a giant esophageal leiomyoma larger than 8 cm.Video 1

A mucosal incision was made 5 cm above the lesion to establish a broad submucosal tunnel ([Fig. 2] a). Dissection was performed within this tunnel along the tumor margins to free the submucosal and muscularis propria layers ([Fig. 2] b). We attempted other methods without success. Finally, a high-frequency incision knife in conjunction with a snare was used to segment and excise the tumor ([Fig. 2] c). Once hemostasis was achieved, the tunnel entrance was closed ([Fig. 2] d). The patient resumed a liquid diet 4 days post-procedure and was discharged from hospital after a total of 15 days. Histopathological and immunohistochemical analyses confirmed a diagnosis of leiomyoma ([Fig. 3]).

Fig. 2 Surgical procedure images. a A submucosal tunnel was established. b Dissection was performed along the tumor margins to free the submucosal and muscularis propria layers. c The tumor was segmented and removed. d Titanium clips were applied to close the tunnel entrances securely.

Fig. 3 Histological evaluation. a The specimen was fixed outside the body, and measured approximately 9×6×3 cm. b Immunohistochemistry indicated DOG(–). c Immunohistochemistry indicated desmin (+++).

P-STER, a variant of the submucosal tunnel endoscopic resection (STER) technique, is commonly used for treating submucosal tumors. In this case, P-STER has proven successful for treating esophageal submucosal tumors exceeding 8 cm in size, offering both safety and efficacy. European guidelines recommend a maximum size of 35 mm for endoscopic en bloc resection [1]. We have shown that P-STER is feasible for esophageal leiomyomas larger than 8 cm, even though such cases exceed the size limits recommended by expert consensus. In our experience, P-STER broadens the applicability of STER surgery, effectively minimizing trauma and surgical risk [2] [3]. Further studies are needed to evaluate the clinical value of this approach.

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Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Deprez P, Moons L, OʼToole D. et al. Endoscopic management of subepithelial lesions including neuroendocrine neoplasms: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy 2022; 54: 412-429
• 2 Cui J, Nie Z, Tao L. et al. Progress in diagnosis and endoscopic treatment of esophageal leiomyoma. Gastroenterology 2023; 28: 371-375
• 3 Zhang W, Wang J, Chai N. et al. Comparison between submucosal tunneling endoscopic resection and endoscopic submucosal dissection for prepyloric submucosal tumors: a case-matched controlled study. Gastroenterol Res Pract 2023; 2023: 5931360

Publication History

Article published online:
12 March 2025