Successful en bloc resection of an esophageal hemangioma by endoscopic submucosal dissection.

benign tumors [1]. Esophagectomy is the conventional surgical approach to treatment, but recently less invasive approaches by endoscopic therapy have become more widely used [2,3]. However, because conventional endoscopic therapy cannot obtain specimens for pathological examination and is associated with a risk of residual or recurrent hemangioma [4], en bloc removal is another possible treatment option. We report here the first case of a submucosal esophageal hemangioma successfully removed en bloc by endoscopic submucosal dissection (ESD). A 41-year-old woman presented with dysphagia. Upper gastrointestinal endoscopy revealed a 25-mm diameter, bluish submucosal mass in the upper esophagus (●" Fig. 1). Endoscopic ultrasound (EUS) showed a hypoechoic mass localized to the submucosa (●" Fig. 2) [5] and computed tomography (CT) revealed a hyperdense mass that was not invading the surrounding organs. The mass was diagnosed as a submucosal hemangioma of the esophagus. After informed consent had been obtained, ESD was performed under general anesthesia. Following an incision of the mucosal layer in the side of the stomach made using an improved insulated-tip (IT-2) knife (KD-611L; Olympus, Tokyo, Japan), the submucosal layer was dissected from the oral side using a needle knife (Dual knife, KD-650Q; Olympus). Although a submucosal vascular plexus was found, loose connective tissue was present in the submucosa directly above the muscular coat, which enabled dissection of the target layer. There were several large blood vessels running from the muscular coat but hemostasis was secured with coagulation forceps (Coagrasper, FD411QR; Olympus), which blocked the flow from these vessels (●" Fig. 3). As a result of having a clear operative field for ESD, the dissection could be performed leaving the hypervascular hemangioma undisturbed (●" Fig. 4). The resected specimen contained a dark purple mass (●" Fig. 5). Histopathological results revealed outgrowths of dilated blood vessels surrounded by flat endothelial cells in the Successful en bloc resection of an esophageal hemangioma by endoscopic submucosal dissection