Endoscopic combined esophageal semi-tunnel and gastric exposed resection for a large transesophagogastric leiomyoma: a case report.

BACKGROUND

Resection of large subepithelial tumors at the gastroesophageal junction remains technically demanding because of the narrow operating space, the need to preserve junctional function, and the risk of postoperative reflux or stenosis.

CASE PRESENTATION: A 36-year-old man was referred after a gastric cardia lesion was detected during routine endoscopy at an outside hospital. Contrast-enhanced CT with axial, coronal, and sagittal reconstructions showed a well-defined 30 × 18 mm lesion in the cardia-gastric fundus region. Endoscopy, however, revealed a subepithelial lesion extending from the distal esophagus across the gastroesophageal junction into the gastric cardia, suggesting a greater longitudinal extent than CT indicated. Endoscopic ultrasound had been performed at the outside hospital; however, the report did not clearly document the full longitudinal extent across the gastroesophageal junction. Because the lesion appeared low risk and the patient refused surgery, endoscopic resection was planned.Under general anesthesia, endoscopy showed a subepithelial elevated lesion centered at the gastroesophageal junction, extending into the distal esophagus and gastric cardia. A gastric mucosal incision was made to expose the lesion, and an esophageal submucosal semi-tunnel was created from approximately 5 cm above the gastroesophageal junction and terminated above the cardia to preserve the mucosa. The two operative fields were then connected to achieve en bloc resection. The specimen measured 7 × 2 cm. Histopathology confirmed leiomyoma, and the postoperative course was uneventful.

CONCLUSION

This case suggests that CT may underestimate the longitudinal extent of a transesophagogastric subepithelial lesion. In a selected case, a combined endoscopic esophageal semi-tunnel and gastric exposed resection approach with cardia mucosal preservation enabled en bloc resection. Further experience is needed to better define its indications and technical boundaries.