Letter to the Editor Open Access
Copyright ©The Author(s) 2023. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Clin Cases. Mar 26, 2023; 11(9): 2116-2118
Published online Mar 26, 2023. doi: 10.12998/wjcc.v11.i9.2116
Are biopsies during endoscopic ultrasonography necessary for a suspected esophageal leiomyoma? Is laparoscopy always feasible?
Hazem Beji, Mohamed Fadhel Chtourou, Slim Zribi, Yassine Kallel, Mahdi Bouassida, Hassen Touinsi, Department of General Surgery Hospital Mohamed Taher Maamouri Nabeul, University of Tunis El Manar-Faculty of Medicine of Tunis, Nabeul 8000, Tunisia
ORCID number: Hazem Beji (0000-0002-2376-5351); Mahdi Bouassida (0000-0002-4624-1905).
Author contributions: Beji H and Chtourou MF designed the study; Zribi S and Kallel Y performed the research; Chtourou MF analyzed the data; Beji H wrote the letter; Bouassida M and Touinsi H revised the letter.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Hazem Beji, MD, Surgeon, Department of General Surgery Hospital Mohamed Taher Maamouri Nabeul, University of Tunis El Manar-Faculty of Medicine of Tunis, 1007 Street Jabbari Tunis Tunisia, Nabeul 8000, Tunisia. hazembj@gmail.com
Received: December 12, 2022
Peer-review started: December 12, 2022
First decision: January 17, 2023
Revised: January 18, 2023
Accepted: March 3, 2023
Article in press: March 3, 2023
Published online: March 26, 2023

Abstract

The present letter to the editor is related to the work entitled “Large leiomyoma of lower esophagus diagnosed by endoscopic ultrasonography-fine needle aspiration: A case report.” Although endoscopic ultrasonography seems necessary in a suspected leiomyoma of the esophagus, the performance of biopsies via fine needle aspiration is controversial as it increases the risk of complications such as bleeding, infection, and intraoperative perforations. Laparoscopy is the best treatment strategy for small tumors. Laparotomy with tumor enucleation or esophageal resection can be considered in large leiomyomas.

Key Words: Esophageal Leiomyoma, Endoscopic ultrasonography, Biopsy, Surgical resection

Core Tip: Endoscopic ultrasonography seems necessary in a suspected leiomyoma of the esophagus. However, the performance of biopsies via fine needle aspiration is controversial. It increases the risk of complications such as bleeding, infection, and intraoperative perforations. Moreover, there is a possibility of an inconclusive biopsy due to inadequate material. Laparoscopy is the best treatment option for small tumors. Laparotomy with tumor enucleation or esophageal resection can be considered in large leiomyomas.



TO THE EDITOR

We read with interest a case report by Rao et al[1], who presented a patient having leiomyoma of the lower esophagus, successfully treated with laparoscopic local resection.

We agree with the authors on the importance of performing endoscopic ultrasonography (EUS) for large esophageal leiomyomas to rule malignancies. EUS is highly specific to leiomyoma with a diagnostic accuracy of 94.7%[2]. Esophageal leiomyoma presents on EUS as a homogenous, hypoechoic lesion with obvious margins, encircled by an hyperechoic area, and is easily distinguishable from an esophageal cyst, lipoma, or hemangioma[2,3]. However, performing biopsies via fine needle aspiration is controversial and presents many risks. It is associated with many complications such as intraoperative perforations, bleeding, and infection[3]. Moreover, an inconclusive biopsy is possible due to inadequate material[4]. Therefore, malignancy can only be ruled out after surgical resection[5-7].

The authors opted for laparoscopic local resection of the tumor. It is the treatment of choice, especially in small tumors < 5 cm[8]. However, a trans-Hiatal approach via laparotomy could have been discussed as a therapeutic option knowing that the tumor was large (8 cm × 6 cm × 3.5 cm), originated from the cardia, and entered the abdominal cavity next to the diaphragm and liver.

An esophageal resection can also be considered for big tumors situated at the gastroesophageal junction due to technical problems, poor wound healing in the defect of the esophageal muscle, and dysfunction of the lower esophageal sphincter following enucleation[9,10].

Submucosal tunneling endoscopic resection represents another therapeutic option. However this technique presents technical difficulties for tumors > 35 mm due to the reduced space of the submucosal tunnel[11].

Footnotes

Provenance and peer review: Invited article; Externally peer reviewed.

Peer-review model: Single blind

Specialty type: Medicine, research and experimental

Country/Territory of origin: Tunisia

Peer-review report’s scientific quality classification

Grade A (Excellent): 0

Grade B (Very good): 0

Grade C (Good): C, C

Grade D (Fair): 0

Grade E (Poor): 0

P-Reviewer: Sato H, Japan; Yalçınkaya İ, Turkey S-Editor: Li L L-Editor: Filipodia P-Editor: Li L

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