Singapore฀Med฀J฀ 2006;฀47(10)฀:฀901 Leiomyoma of the oesophagus managed by thoracoscopic enucleation Tay Y C, Ng C T, Lomanto D, Ti T K Department of Surgery National University Hospital 5 Lower Kent Ridge Road Singapore 119074 Tay Y C Final Year Medical Student Ng C T Final Year Medical Student Ti T K, MD, FRCS, FRACS Senior Consultant Minimally Invasive Surgical Centre Lomanto D, MD, PhD Director Correspondence to: Prof Ti Thiow Kong Tel: (65) 6772 4240 Fax: (65) 6777 8427 Email: surtitk@ nus.edu.sg Case฀Report ABSTRACT The authors document two patients with oesophageal leiomyoma. In the first patient, a 41-year-old man, enucleation of the oesophageal leiomyoma was initially attempted by a thoracoscopic approach, but because of adherence of the tumour to the oesophageal mucosa, enucleation was completed by thoracotomy. Thoracoscopic enucleation was successfully performed in the second patient, a 62-year-old man. This paper includes a literature review on the pathology, diagnosis and surgical approach in the management of oesophageal leiomyoma. In conclusion, prudent use of thorascopic approach in the enucleation of oesophageal leiomyoma could potentially result in shorter hospital stay, decreased postoperative pain and reduced requirement for postoperative analgesia. Keywords: endoscopic ultrasonographic fine- needle aspiration biopsy, gastrointestinal stromal tumour, leiomyoma, oesophageal leiomyoma, thoracoscopy, thoracoscopic enucleation. Singapore Med J 2006; 47(10):901-903 INTRODUCTION Oesophageal leiomyomas are uncommon tumours (1-3) . Malignant transformation is extremely rare, but removal is often required in symptomatic patients with dysphagia, retrosternal discomfort or bleeding (2,4,5) . In leiomyomas of the thoracic oesophagus, open transthoracic extramucosal enucleation has traditionally been the standard surgical treatment (2,6) . Since 1992, thoracoscopic enucleation, with its advantages of reduced hospital stay, pulmonary complications and thoracotomy pain, has been reported (4,6-8) . However, there has not been any report of thoracoscopic enucleation of oesophageal leiomyomas being performed in Singapore. This report presents the experience of the thoracoscopic approach in the enucleation of oesophageal leiomyoma performed on two patients by one of the authors (TKT) at the National University Hospital, Singapore, and includes a review of the literature. CASE REPORTS Case 1 In 2001, a 41-year-old Bangladeshi man presented with retrosternal discomfort especially after meals. He was otherwise asymptomatic. Chest radiograph, electrocardiography and biochemical tests (including haemoglobin, urea, creatinine and electrolyte levels), were normal. Oesophagogastroduodenoscopy (OGD) showed a rounded submucosal mass at the mid- oesophagus. Endoscopic ultrasonography confirmed a well-defined 2.5 cm × 3.3 cm mass. There was no lymphadenopathy in the paraoesophageal region and the coeliac axis. Endoscopic ultrasonographic fine- needle aspiration biopsy (EUS-FNAB) showed a few cell clusters with occasional spindle shaped nuclei suggestive of benign non-epithelial tumour. Right thoracoscopy showed a firm mural mass in the oesophageal wall, located 30-35 cm from the incisors. Initial dissection to expose the tumour by diathermising the pleura and blunt dissection followed by splitting muscularis propria was performed. As the tumour appeared to be large and adherent to the mucosa, surgery was converted to open thoracotomy. An elongated, smooth-surfaced 5.0 cm × 2.5 cm × 1.5 cm well-encapsulated, greyish- white tumour was removed after separating the muscularis propria fibres, taking special care to avoid mucosal laceration. Oesophageal muscle and pleura were then apposed with interrupted sutures. The elongated, homogeneous tumour mass was sectioned to show a well-demarcated leiomyoma, with focal, spotty calcification. There was no evidence of malignancy detected histologically. Immunohistochemistry was not routinely performed at that time. In the follow-up period, the patient was