Minimally invasive hybrid surgery combined with endoscopic and thoracoscopic approaches for submucosal tumor originating from thoracic esophagus

Despite the efficacy of molecular targeted therapy, surgical resection remains the only curative primary treatment for gastrointestinal stromal tumors (GISTs). However, in cases when the tumor originates from the thoracic esophagus, conventional transthoracic approach is highly invasive. All procedures were performed with patients in a prone position through a double-lumen endotracheal tube for single-lung ventilation. First, to clarify the resection layer between the tumor and mucosal layer of the esophagus, a sodium hyaluronate solution colored with indigo carmine was injected into the submucosa via the esophagoscopic approach. Second, we thoracoscopically divided the longitudinal muscle of the esophagus and enucleated the tumor through three ports by dissecting along the artificially colored submucosa, thereby minimizing accidentally opening of the esophageal mucosa. Third, we sutured the divided longitudinal muscle layer and removed the tumor from the thoracic cavity. Four tumors, including one GIST, were successfully resected via this hybrid approach. The mean surgical time was 137.7 min (range, 60-231 min), and the mean blood loss was 21.2 ml (range, 3-65 ml). No perioperative complications occurred, including with accidental opening of the esophageal mucosa. Our minimally invasive hybrid surgery combined with esophagoscopic and thoracoscopic approaches demonstrated successful resection. This surgery could have advantages both for curing esophageal submucosal tumor and for minimizing surgical invasiveness.