17 pgs lộc pt bóc u cơ trơn, eng

A Prof Le Loc Hue central Hospital -VN INTRODUCTION  Benign tumors, rarely  Intrawall, smooth fiber, white lobes covered by fibrosis tissue, no pedicle  1% of esophageal tumors and 70%- 80% of esophageal benign tumors  Epidemiology is not define  Another kind of esophageal benign tumors: GISTs, Granular cell tumors , Schwannomas  Almost is not clearly presentations when small diameter  Male/female >  Location: 2/3 lower – third  Giant tumor > 10cm METHODS  From 2010 – 2016, retrospective study based on cases were diagnosted esophageal leiomyoma and treated at Digestive surgery department of Hue central hospital – Viet Nam  male / femal  Median age: 42,86 ( 29 – 57 )  Long Follow-up : year RESULTS & DISCUSSION Age/sex Signs Endo EUS CT scan Treatments 47/ma II dysphagia and Retrosternal pain 28cm Stenosis, middle third, dilated of upper part, Clearly margin Right thoracoscopic enucleation 42/ma II dysphagia 34cm Stenosis, lower - third, dilated of upper part, Clearly margin Right thoracoscopic enucleation 57/ma II dysphagia 36cm Lower – third × 4cm Right thoracoscopic enucleation 34/fe III dysphagia and retrosternal pain 36cm Clearly margin many lobe Lower – third Laparotomy transhiatal enucleation 29/ma III dysphagia and pain related meal 26cm Stenosis, middle third, dilated of upper part, Clearly margin Right thoracoscopic enucleation 35/ma II dysphagia 25cm Stenosis, middle third, dilated of upper part, Clearly margin Right thoracoscopic enucleation 57/fe II dysphagia 30cm Stenosis, middle third, dilated of upper part, Clearly margin Right thoracoscopic enucleation Hypoechogenic, homogenous Clearly margin RESULTS & DISCUSSION clinical cases    - 100% dysphagia , degree II : 71% , degree III : 29% - Pain after swallow: cases ( 29%) Mutrie ( 2005 ):; dysphagia 52%, retrosternal pain 68% / 31 cases Aydın (2012) : dysphagia 7/8cases Punpale ( 2007 ): dysphagia 5, horseness 1, pain after swallow 1, epigastric pain 1/ cases Dysphagia and pain have relationship with diameter (5cm ) and location of tumor RESULTS AND DISCUSSION Subclinical exam: - EUS ( Endoscopic ultrasound ),    TOGD and Multislice – CT scan, biosy Aimoto Rowley: EUS can differential diagnose Leiomyoma and Leiomyosarcoma: - Leiomyosarcoma: Clearly margin, hyperechoic, homogenous from smooth layer - Leiomyoma: Hypoechogenic, homogenous, clearly margin located at submucous layer, origin from propriate muscle layer, spencially from mucous muscle layer Levine: CT Scan : unhomogenous lesion compare with extra part, hypodensity in central CT scan can be differential diagnose the tumor origin from esophagus or extra part compression EUS + Biosy ??? RESULTS AND DISCUSSION  Ohnishi: MRI , homogenous lesion in the T1và their high signal appearance in the T2 sequences  Pelissier ( 1989 ): intraoperative biosy may be not conclude benign or malignant tumor,  Visioli ( 1997 ): factors may be malignant: - Diameter u > 5-6cm; - Irregular celular; necrosis or bleeding; - Number of cell division; degenerate and invasive DIAGNOSE endo: submucosal lesions Lacking image DIAGNOSE Differential diagnose: GIST, leiomyosarcoma and leiomyoma belong to pathology and immunohistochemical results  Leiomyoma : Actin & Desmin (+) , CD117 (-)  Leiomyosarcoma: Desmin , Actin (+) : CD117 (-)  GIST : CD34 (+) CD117 (+), Desmin actin (-) RESULTS AND DISCUSSION       Surgical indications : Dysphagia is increasely Retrosternal pain after swallow Diameter > 5cm Zuccaro, Fleischer : clinical symptoms and diamter >5cm, increased tumor size, mucosal ulceration Some author comment: no surgical if no or mild clinical symptoms, but follow – up every year by endoscopy and radiology RESULTS AND DISCUSSION Surgical procedures: Clinical, dimeter and locations : Enucleation: Right thoracoscopic: 1/3 middle and 1/3 lower Laparotomy and transhiatal : giant tumors at 1/3 lower and cardia Esophagectomy ( thoracotomy or thoracoscopy ): Esophageal Very resection is indicated for tumors over cm, adherent to the tumors mucosa Extensive damage during mucosal dissection maneuvers RESULTS AND DISCUSSION  Bang-Chang Cheng: esophagectomy belong to:  Diameter is too big  Very adherent to the tumors mucosa  Mucosal injuries can not repair  Giant tumor at distal part invaded to cardia  Leiomyosarcoma  Pelissier : - Esophagectomy or enucleation belong to the access the tumor of surgeon RESULTS AND DISCUSSION  Myotomy is sutured with absorbable separate threads to prevent a pseudo diverticulum  Some authors: suture of myotomy is not necessary, but most agree that the suture of muscular tunic is necessary to prevent protrusion of the mucosa  Several techniques have been described to assist extramucosal enucleation using intraluminal tools - Esophageal bougies, A balloon dilator  Advantage of laparoscopic and thoracoscopic approach : short – time hospitalization, decrease pain, respiration complication RESULTS AND DISCUSSION SHAPE AND DIAMETER LOCATION PROCEDURE TIME OF OPERATIO N ( minutes ) THORACIX DRAIN (day ) ENTERA L FEDDIN G COMPLICATION Oval, lobes 3× 6cm Middle Right thoracoscopic enucleation 90 No Horseshoe 4×6cm Lower Right thoracoscopic enucleation 110 No Cycle 3×4cm Lower Right thoracoscopic enucleation 50 No Horseshoe 5×8cm Lower Laparotomy transhiatal enucleation 75 No Oval, lobes 4× 6cm Middle Right thoracoscopic enucleation 70 No Cycle 3×5cm Middle Right thoracoscopic enucleation 60 Stenosís Dialted transendoscopic Oval, lobes 4× 7cm Middle Right thoracoscopic enucleation 100 3 No  Seremetis et al Right thoracoscopic enucleation Horseshoes shaping FOLLOW - UP  Case of Stenosis was dialated via endoscopy  Aydın et al: A pseudodiverticulum  Bardini & Asolati: A pseudodiverticulum CONCLUSIONS  Preoperative diagnose is diffcult, based on EUS, CT scan, TOGD  The surgical procedure belong to the size, location and experiences of surgeon  Transthoracopic extramucosal nucleation is safe, effective ... suture of muscular tunic is necessary to prevent protrusion of the mucosa  Several techniques have been described to assist extramucosal enucleation using intraluminal tools - Esophageal bougies,... tumor of surgeon RESULTS AND DISCUSSION  Myotomy is sutured with absorbable separate threads to prevent a pseudo diverticulum  Some authors: suture of myotomy is not necessary, but most agree... - UP  Case of Stenosis was dialated via endoscopy  Aydın et al: A pseudodiverticulum  Bardini & Asolati: A pseudodiverticulum CONCLUSIONS  Preoperative diagnose is diffcult, based on EUS,