Laparoscopic transgastric and endoscopic-assisted enucleation of horseshoe shaped leiomyoma of the cardia: surgical technique

Leiomyomas are rare benign esophageal tumors and represent less than 1% of all esophageal neoplasms. Those located at the esophagogastric junction (EGJ) are uncommon and challenging due to their proximity to the lower esophageal sphincter. Most cases are asymptomatic and discovered incidentally, though symptomatic patients may present with dysphagia, heartburn, regurgitation, or chest pain. Diagnosis typically involves barium swallow studies, upper endoscopy, endoscopic ultrasonography, and computed tomography. Surgical treatment is recommended for symptomatic patients or those with tumors larger than 3 cm or showing rapid growth. Traditionally, open enucleation or visceral resection has been used, but recent advances include endoscopic, laparoscopic, and hybrid methods to achieve tumor enucleation. This report demonstrates a laparoscopic transgastric and endoscopically assisted enucleation of a large, horse-shoe shaped EGJ leiomyoma. The patient complained epigastric pain, occasional solid food dysphagia and mild regurgitation. The upper endoscopy revealed a large horseshoe-shaped subcardial mass at the anterior, left-lateral, and posterior aspects of the subcardial junction. Abdominal computed tomography (CT) showed a large hypointense subcardial mass and endoscopic ultrasound identified a 5 cm submucosal hypoechoic lesion from the muscular layer with diagnosis of leiomyoma at fine needle biopsy. A minimally invasive transgastric enucleation was planned and successfully performed. The technique involved a vertical anterior gastrotomy, incision of the overlying mucosa, blunt tumor dissection with enucleation, and mucosal closure with intraoperative endoscopic assistance. The postoperative course was uneventful with no postoperative complication and patient hospital discharge on postoperative day four. Histological examination confirmed the diagnosis of esophageal leiomyoma. This minimally invasive approach offers a safe, effective alternative to EGJ resection, especially for "plongeant" endoluminal leiomyomas involving the posterior aspect of the EGJ.