Peroral endoscopic tumor resection for an esophageal leiomyoma using a novel therapeutic thin endoscope

Abstract

Peroral endoscopic tumor resection (POET) is a less invasive treatment for esophageal subepithelial tumors (SET)^1-3; however, it is challenging to approach SETs in narrow submucosal tunnels. Herein, we report a case of POET using a novel thin endoscope for an esophageal leiomyoma. A 45-year-old man with moderate dysphagia was referred to our hospital for further examination of a SET in the abdominal esophagus (Fig. 1a). Endoscopic ultrasonography revealed a 30 mm tumor in the second and the third layers, originating from the fourth layer (Fig. 1b). Pathological analysis of fine-needle aspiration specimens identified leiomyoma. POET was performed using a thin therapeutic endoscope with a 7.9 mm diameter (EG-840TP; Fujifilm, Tokyo, Japan) under general anesthesia (Video S1). A 2 cm longitudinal mucosal incision was made using ProKnife (Boston Scientific, Tokyo, Japan) on the proximal side (Fig. 1c). Subsequently, a submucosal tunnel was created from the mucosal entrance to the tumor (Fig. 1d). To avoid injury to the tumor, this endoscope was important to precisely identify the tumor edge in a narrow submucosal space. Clutch Cutter (Fujifilm) and a clip with a thread for traction were used to dissect the muscularis propria, which was continuous with the tumor. We achieved en-bloc enucleation (Fig. 1e). The lesion was removed using an endoscopic net after widening the mucosal entrance (Fig. 1f). We then sutured the mucosal entrance using the reopenable clip-over-the-line method⁴ (Fig. 1g). The patient had slight cutaneous emphysema immediately after the procedure but was discharged on postoperative day 5 with a good clinical course. The final pathology was leiomyoma with negative margins (Fig. 1h–k). This thin endoscope has an accessory channel of the same size as that of the conventional endoscope. Therefore, it minimizes the submucosal tunnel using conventional endoscopic devices (Fig. 2). Thus, this thin endoscope may facilitate POET for esophageal leiomyoma treatments.

Authors declare no conflict of interest for this article.