Extra-mucosal enucleation of a giant circular leiomyoma of the middle esophagus

.IntroductionAlthough being the most frequent benign neoplasm of the esophagus, leiomyoma represents only 1%of all esophageal masses. In the vast majority of cases it measures less than 5 cm, is asymptomaticand requires no treatment (if < 2 cm in diameter) or enucleation (if up to 8 cm) through minimally toinvasive techniques (endoscopy, videothoracoscopy, videolaparoscopy or robotic-assisted excision).Only 5% of lesions is larger than 10 cm and causes frank symptoms: such tumors go under the nameof giant esophageal leiomyomas (GELs). Performing enucleation for GELs, although feasible, provedto be less safe than for smaller leiomyomas. In GELs, in fact, the tract of mucosa left exposed bythe iatrogenic muscular defect is often too large: on the one hand, if left uncovered, it is likely todevelop pseudo-diverticulum and dysphagia, on the other hand, if treated with a primary closureof the muscular edges, this is supposed not to be tension-free thereby resulting in achalasia anddysphagia. To obviate such and other complications, two surgical options are generally recommendedfor GELs: esophageal resection and extra-mucosal enucleation combined with several techniques ofplastic surgery for covering and buttressing the muscular defect.