P1.049. Horseshoe Intrathoracic Esophageal Leiomyoma Enucleation by Thoracoscopic-Endoscopic Cooperative Surgery (TECS) With Fluorescence to Preserve the Esophagus

Abstract

Abstract Topic Benign Disease: Other Background Horseshoe intrathoracic esophageal leiomyoma is a rare benign smooth muscle tumor that partially or completely encircles the esophagus and may cause mass effect, dysphagia, or respiratory symptoms. Diagnosis is established by endoscopic and imaging studies, and enucleation—regardless of surgical approach—is the treatment of choice to preserve the esophagus. Methods Male, 28-year-old, with no medical history. He started with a hypertensive crisis, and aortic arch malformation was suspected. A chest CT angiography was performed, which ruled it out but showed a 65 mm obstructive tumor in the esophageal wall, in contact with the aortic arch and the main bronchi. An endoscopic ultrasound was performed: a solid tumor of the 4th esophageal layer, over the carina, horseshoe-shaped (bilobed), causing 80% obstruction, with biopsy positive for leiomyoma. A complete tumor enucleation was performed via thoracoscopy, assisted by intraluminal endoscopy and guided by fluorescence to visualize submucosal vascularity without penetrating it, with primary closure of the muscular layer and fibrin application. No surgical complications occurred, the patient was discharged on the 5th day, tolerating a soft diet. The pathology report confirmed a leiomyoma measuring 8x3x3 cm. IHC: CALDESMOL(+), DOG1(-), S100(-), Ki-67 1%. On follow-up, the patient had no difficulty swallowing without reflux. Results The TECS (Thoracoscopic Endoscopic Cooperative Surgery) approach is a safe and effective method for resecting benign tumors, primarily of the muscular layer, with the main goal of avoiding an esophagectomy, which alters the patient's quality of life and carries a risk of major complications. This approach allows for less bleeding, reduced pain, faster postoperative recovery, a lower incidence of intrathoracic complications, and shorter hospital stays. However, it requires experience within both the surgical and endoscopic teams. The use of fluorescence enables real-time assessment of esophageal perfusion, particularly the blood supply to the submucosa, the most vascularized layer, to rule out ischemic areas that could compromise an anastomosis and reduce dehiscence. Additionally, as in this case, it allows visualization of the submucosa to avoid perforation, which is undesirable in these tumors. Conclusion We present a rare case of a horseshoe leiomyoma in the retrocarinal esophagus, successfully resected using a TECS approach. The use of fluorescence and endoscopy prevented mucosal-submucosal perforation, which was crucial to avoid major complications and to prevent an esophagectomy that would have a permanent impact on quality of life. Resection of a horseshoe leiomyoma in the esophagus is challenging due to the tumor's volume in a very small space, with a high risk of esophageal perforation.