Thoracoscopic Enucleation of a Mid-Esophageal Gastrointestinal Stromal Tumor: Key Technical Aspects

Abstract

Introduction:

Esophageal gastrointestinal stromal tumors (GISTs) represent <1% of all digestive tract GISTs. ¹ Surgery is mandated for lesions >2 cm. ^{2 , 3} However, radical resection may be particularly challenging. Formal esophagectomy and enucleation have been described, depending on tumor size (<45–65 mm), mucosal ulceration, and location. ^{1 –4} Tyrosine kinase inhibitors can be administered if the molecular profile is favorable to downsize the tumor and allow less extensive surgery. ^{2 , 4 , 5}

Materials and Methods:

Written consent for video recording and publication was given by the patient before the procedure. A 69-year-old woman presented mild anemia associated with weakness. An upper endoscopy was performed and revealed a mid-esophageal lesion that was consistent with a 28 mm mid-esophageal GIST. Staging included thoracoabdominal CT scan, and repeat endoscopy/ultrasonography with biopsies. Considering the dimensions of the lesion, neoadjuvant imatinib was administered for 10 months with partial regression (18 mm), and then surgical resection was performed. The patient was placed in the prone position, without pulmonary exclusion. Right thoracoscopy was performed with 8 mm Hg with CO₂. Segmental circumferential mobilization allowed clear observation of the tumor margins. The monopolar hook was used to incise the muscular layer, taking care to avoid prolonged contact of the hook with the esophageal wall. Using blunt dissection, the submucosal lesion was dissected from the underlying mucosa. Complete enucleation was obtained. After verifying mucosal integrity, the muscular layer was closed with a running tension-free absorbable suture.

Results:

Histopathologic analysis showed an R0 resection, a 15 mm GIST with a low mitotic index (1mitosis/50HPF). Imatinib treatment was stopped based on the characteristics of the lesion. The postoperative course of the patient was uneventful. The chest tube was removed on the first postoperative day, the mediastinal drain was removed on the second postoperative day. A diet was started and the patient was discharged on postoperative day five with no complications. After 18 months of follow-up, there are no radiologic signs of recurrence or residual symptoms.

Conclusions:

Small esophageal GISTs without mucosal ulcerations may be safely enucleated by thoracoscopy, without compromising oncologic standards. Careful tissue handling and sparing of the mucosal layer are key to avoid perioperative complications, and limit the risk of tumor rupture and dissemination.

No competing financial interests exist.

Runtime of video: 06 mins 48 secs