Endoscopic dissection of long interaluminal esophageal libosarcoma. Differentiated libosarcomas. Soft tissue sarcomas represent an extremely rare cause of esophageal masses, and undifferentiated sarcoma are rarer. The proportion of differentiated libosarcoma is even lower. Due its rarity, the treatment experience with esophageal differentiated libosarcoma is limited. Tumor of the enchymal origin are rare in the gastrointestinal tract, with libosarcoma having an incidence of 0.1 to 5.8% at autopsy. It is particularly rare in the esophagus, accounting for 1.2 to 1.5% of all gastrointestinal libosarcoma, and even a smaller proportion of these tumors represent differentiated libosarcomas. Based on our experience, endoscopic resection of the lesion can be considered as a treatment of choice when visible. Previously, esophageal libosarcoma were treated by surgical methods, including simple inoculation and partial or total esophagectomy. However, this approach is more invasive with a longer postoperative recovery period, hospital stay, and cost, as compared to endoscopic resection. Our case today is 67 years old male patient presented with severe dysphagia, but regressed over years. CT shows the thoracic esophagus is distended by an intraluminal sizable soft tissue mass lesion composed of fat and soft tissue donestis indenting the posterior aspect of the trachea with suspicion of esophageal lipoma. Patient has multiple comorbidities, restrictive lung disease, dilated cardiomyopathy. Surgery and even endoscopy has a higher risk and preparation of ICU bed and every procedure. This is our procedure. We're beginning in the examination in the upper. This is the lesion start from the trachea. Going down this empty area, we saw that this transitional zone, this is the lipoma. That we thought it's a lipoma. We go insert the scope, 30 centimeter from oral cavity. We found this ulcer at the lower edge of the lesion. We saw this ulcer changes. When we go up, that is the lesion, partially obstruct the lumen. In this empty area, we saw that that is a stuck and this is the lipoma. And we went getting out the lesion attached to the trachea. That's the EOS. As you see, the stuck is empty except from blood vessels. This is the lesion. It is hypoechoic lesion and the lower part show hypoechoic with blue by elastography that confirms it's a hard lesion, hard area. We try first by endorope, but due to slippery of the edges of the lesion, couldn't do it. We try a snare and the snare over outer scope and getting with biopsy forceps inside the snare, but also failed due to slippery edges. So we start ESD. First we inject the stuck. When we saw this area is empty of lipoma tissue. After injection, we beginning to make the incision. We cut and every blood vessel we face, we coagulate it. We use also underwater to get any small blood vessels. As you see in the upper right on the screen, we coagulate all the vessels we found. It is a very narrow area, so in this area we put a clips above the stuck because minimal bleeding occurring after cutting the blood vessels. We succeed to do the clips and then we continue with insulated tip knife. This insulated tip we can cut and see the larger blood vessels like what we see. Then we soft coagulate all these large vessels that we see. We continue with the insulated tip knife. This is the large blood vessels after what we see. It is minimal oozing after soft coagulating it. It is from the distance, not very important. The important is the blood vessels come from the proximal part. We continue with insulated tip knife to cut the edges as you see, this is the last step. There is minimal oozing of blood coming from the proximal end and this is attached to the patient, so it is a very important area. The lesion is completely cut now. We use an end loop to close the stuck. Now it is smaller, so we can close it to prevent this minimal oozing and to prevent further bleeding from the stuck because it has a very large blood vessel as we see. We succeed to get the stuck inside the end loop and we close the end loop. And after that we clean all the area and careful examination. This is the stuck and this is the end loop closing it and this is the remnant area and the end loop closing the stuck well and the clips that we put in the first unfortunately is dislodged. We get out the lesion from the mouse by rolling because it is a very large lesion. We have some difficulty in getting this lesion out except by rolling method. We successfully get it out at the end, very large lesion. The histopatology show it is liposarcoma and not fibrovascular polyp or lipoma. Recommendation for surveillance. Recommendation for surveillance include annual upper endoscopy with biopsies and rigorous clinical follow-up with history and physical examination performed every three months to identify these with new onset of dysphagia. A chest x-ray is helpful to identifying asymptomatic lung diseases. A suspicious nodule identified on chest x-ray warrant further evaluation with computed tomography CT scan. Follow-up can be extended to every six months after the first three years. Annual visits are acceptable thereafter. It is important to educate the patient about the possibility of late relapse to ensure enrollment in long-term follow-up programs with close endoscopic and radiographic surveillance. Our case after three months and due to high risk of consent requested by the anesthesia team, patient refused to do upper endoscopy, so we do CT and PET-CT and we're done. That we're completely free of any esophageal lesion or abnormal uptake by PET-CT. Conclusion. Esophageal differentiated liposarcoma are rare tumors but should be considered a differential diagnosis when evaluating esophageal masses or polyp. Resection of esophageal differentiated liposarcoma can be considered as the treatment of choice and with recent advance in technology, endoscopic resection of such tumor is achievable, offering several potential benefits over surgical resection.

esophageal lipoma

dysphagia

endoscopic procedure

liposarcoma

lesion removal