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STRATEGIES FOR RESECTION OF SUBMUCOSAL TUMORS OF THE ESOPHAGUS AND GASTROESOPHAGEAL JUNCTION
Jamii St. Julien*, January Moore, Mauricia Buchanan, C D. Smith, Enrique F. Elli, Mathew Thomas, Steven P. Bowers
General Surgery, Mayo Clinic Forida, Jacksonville Beach, FL
Background:
Submucosal tumors of the esophagus and gastroesophageal junction (GEJ) are rare entities that can present significant challenges to the surgeon. Prior studies have generally reported only single modality approaches in small numbers, leaving uncertainty as to the best approach. We report our experience in the evaluation and resection, using multiple surgical techniques with intent of margin-negative resection and organ preservation.
Methods:
We performed a retrospective review of 39 patients undergoing resection for submucosal tumors of the esophagus or GEJ at our institution from 2004 to 2015. Mean age was 59 years, and 18 (46%) were female. Endoscopic ultrasound was used in 34 patients (85%) preoperatively to classify tumors as possibly amenable to enucleation or requiring mucosal resection. Axial imaging was used in 33 patients (83%) to further guide the operative approach. Enucleation was performed in 10 patients (25%) via laparoscopic (5) or thoracic (5) approaches. Partial mucosal resection was performed in 23 patients (58%) by endoscopic (2), intragastric laparoscopic (5), laparoscopic (15), and thoraco-abdominal two-field (1) approaches. Segmental resection was required in 6 patients: GEJ resection (3), total gastrectomy (1), and esophagectomy (2).
Results:
All patients had complete resection with clear margins. Intraoperative change in the surgical approach occurred in 3 patients (8%). Clavien grade 3 or greater complications occurred in 2 patients (5%), and there was no 30-day mortality. Pathology revealed leiomyoma in 20 patients (51%), gastrointestinal stromal tumor in 14 (36%), and other histologies in 5 (13%). No patients developed local recurrence, and 2 patients developed metastatic disease over long-term follow up. Involvement of the cardia was strongly associated with requiring a mucosal resection (p=0.001 by Fisher’s exact test).
Conclusion:
Minimally invasive approaches with partial mucosal resection or enucleation is appropriate in the majority of esophageal and GEJ submucosal tumors, and is associated with good outcomes while avoiding segmental resections. Endoscopic ultrasound - in combination with axial imaging - allows the surgeon to accurately plan the approach with only occasional operative deviations. Additional approaches such as endoscopic mucosal resection and transgastric laparoscopy enhance the ability to preserve gastrointestinal continuity. In the modern era of minimally invasive surgery, segmental resections of esophageal and GEJ submucosal tumors should be restricted to very large or invasive tumors not amenable to partial resections.
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