P172 ESOPHAGEAL SUBMUCOSAL LIPOMA AND CONCOMITANT INEFFECTIVE MOTILITY: LAPAROSCOPIC TRANSHIATAL ENUCLEATION

Aim To describe an unusual case of benign esophageal submucosal tumor. Background Esophageal lipomas account for less than 1% of benign tumors of the esophagus, which represent less than 1% of all esophageal neoplasms. The presence of a concomitant esophageal motility disorder may be underestimated in patients with benign esophageal submucosal tumors. Case report A 77-year-old man was referred for a 12-year history of daily heartburn, occasional dysphagia progressively worsening during the last few months, and more recent onset of epigastric pain, regurgitation, and weight loss. Empirical therapy with proton-pump inhibitors was ineffective. The GERD-HRQL score was 22. Physical examination was unremarkable. Upper gastrointestinal endoscopy showed a soft submucosal mass in the posterior wall of the lower third of the esophagus, 3 cm above the esophago-gastric junction. The endoscopic finding was confirmed by a chest CT scan that documented a submucosal esophageal lesion with luminal narrowing. High resolution manometry did not reveal EGJ obstruction but showed a pan-esophageal pressurization in 100% of the swallows. The patient underwent laparoscopic transhiatal enucleation of a 11x4 cm mass, suture repair of the esophageal muscle layer, posterior cruroplasty, and 270° Toupet fundoplication. The postoperative course was uneventful. A gastrographin swallow study on day 1 showed the normal esophagogastric transit and the absence of leaks. The patient was discharged on postoperative day 2. Pathology confirmed the clinical suspicion of esophageal lipoma. At 3-month follow-up visit the GERD-HRQL score was 7 and the patient was very pleased with the results of the operation. Conclusion Esophageal lipoma is very rare. Laparoscopic transhiatal enucleation was feasible and safe in our experience. The choice of a Toupet fundoplication was justified by the finding of ineffective esophageal motility on high-resolution manometry.