Submucosal tunneling endoscopic resection for multiple esophageal leiomyomas.

A 61-year-old man presented for treatment of esophageal submucosal tumors (SMTs). The SMTs had been found 1month previously at his local hospital during a health examination. Upon presentation, his physical examination and laboratory tests were unremarkable. Esophagogastroduodenoscopy (EGD) revealed two protruded lesions in the middle of the esophagus (●" Fig.1; ●" Video1). Endoscopic ultrasonography (EUS) revealed that the tumors were originating from the muscularis propria layer (●" Fig.2). Computed omography (CT) also showed the lesions in the mid-esophagus, which were suspected to be benign tumors (●" Fig.3; ●" Video 2). A submucosal tunneling endoscopic resection (STER) was performed. After a longitudinal mucosal incision had been made, a submucosal tunnel was created, which allowed us to see the first SMT. Submucosal injection of methylene blue was performed to help locate the second tumor, and two separate tumors about 2 cm apart from each other could then be seen (●" Fig.4a; ●" Video3). The tumors were carefully dissected off the muscularis propria layer (●" Fig.4b). The tunnel entry had to be enlarged to allow successful extraction of the larger SMT (●" Video4). The mucosal entry was then closed. The STER procedure was completed uneventfully within 110 minutes. The resected SMTs measured 3.8×3.2cm and 1.5×0.9cm (●" Fig.5) and, histopathologically, they were both leiomyomas. STER has been demonstrated to be safe and effective for treating upper gastrointestinal SMTs; most of the reported cases were with solitary and small SMTs (≤3.5cm) [1]. Although several cases/ studies have been reported regarding STER for multiple SMTs and large SMTs, the procedure is technically difficult and has a higher rate of complications [2–5]. In the present case, two SMTs were found, which were not strictly in a straight plane and one of them was larger than 3.5cm. We successfully removed them both using the STER technique uneventfully within a Fig.3 Computed tomography (CT) scan of the lesion, which was suggestive of benign tumors. Fig.2 Endoscopic ultrasonography (EUS) view showing that the tumors were originating from the muscularis propria layer.