Description:
A 61 y/o otherwise healthy man presented to his primary care provider complaining of 2 years of intermittent dysphagia primarily to meat.
An esophogram revealed a large polypoid filling defect in the thoracic esophagus and he was referred for an EGD.
Upon further questioning, the patient stated that he had intermittently had difficulty breathing, primarily at night and that on one occasion he “coughed” up a sausage shaped mass but was able to swallow it back down.
His EGD revealed a long, soft polyp beginning just distal to the upper esophageal sphincter. It measured 17 cm in length, beginning at 17 cm from the incisors and extending to 34 cm. His history and findings were consistent with a fibrovascular polyp so he was referred for EUS with possible endoscopic resection.
A limited EUS did not reveal a large feeding vessel. Therefore preparations were made for resection.
First, 5 cc of 1:10,000 epinephrine were injected at the base of the polyp. A polyloop was then successfully placed around the polyp about 1.5 centimeters from the wall of the esophagus to reduce the risk of perforation or transmural burn during resection. This caused blanching of the polyp. A snare was placed around the polyp distal to the polyloop. Cautery was then used to excise the lesion. Because of the thick stalk, initial attempts using ERBE endocut Q were unsuccessful. Ultimately, pure cut current at 30 watts successfully transected the lesion. It was retrieved with rat toothed forceps and measured 11 cm in length. Upon reinsertion, there was about 3 cm of a stump left and although it was not long enough to reach the airway and cause obstruction, an additional polyloop was placed to further strangulate the stump and promote sloughing.
Final pathology was consistent with a fibrovascular polyp which was contained fatty and fibromembranous tissue covered by normal squamous epithelium.
Fibrovascular polyps are uncommon benign tumors of the esophagus. 80% of the time, they originate just distal to the cricopharyngeus. The propulsive act of swallowing can cause massive elongation of the polyps which can then be regurgitated into the oropharyngeal cavity. This can cause respiratory distress and at least one death secondary to asphyxiation from laryngeal blockage has been reported. More commonly reported symptoms include: dysphagia, regurgitation of the polyp, vomiting, globus sensation, cough, stridor, wheezing and choking. Endoscopic and surgical resections have both been performed successfully 1,2. Some fibrovascular polyps are highly vascular, so an EUS is helpful to look for the presence of a feeding vessel before attempting endoscopic resection. Although we did not see one, given the size of the polyp, we were concerned about its blood supply. Therefore, we used a polyp loop prior to snare polypectomy and endotracheally intubated the patient for airway protection should there have been bleeding.
Two weeks after the procedure, the patient was doing well. His dysphagia had resolved, he was no longer snoring and he had noted no bleeding complications.
Bibliography
1. Pham AM, Rees CJ, Belafsky PC. Endoscopic removal of a giant fibrovascular polyp of the esophagus. Ann Otol Rhinol Laryngol 2008;117:587-90.
2. Sultan PK, Meyers BF, Patterson GA, et al. Fibrovascular polyps of the esophagus. J Thorac Cardiovasc Surg 2005;130:1709-1710.
Contributed By:
Jennifer E. Jorgensen, MD, University of Michigan
Mahmoud M. Al-Hawary, MD, University of Michigan
Henry D. Appelman, MD, University of Michigan
B. Joseph Elmunzer, MD, University of Michigan
