This document describes the case of a 54-year-old male presenting with difficulty swallowing solids for 5 months. Imaging revealed a large elongated polypoid lesion extending from the cervical esophagus to the GE junction, significantly narrowing the esophageal lumen. Endoscopy and EUS confirmed a long pedunculated polyp with a thick stalk arising from the submucosa. The final diagnosis was a fibrovascular polyp. Surgical excision is the first-line treatment for fibrovascular polyps, with the pedicle needing to be resected under direct vision at the site opposite its origin to avoid hemorrhage or incomplete resection.

1. Case capsule
Zeeshan
Surgery-III

2. History
• 54 M
• No comorbidities
• Difficulty in swallowing solids for 5 months
No dysphagia to liquids
• Progressively worsening
• ?Relevant history

3. Differentials

4. Neurologic
- CVA
- Parkinson’s disease
- Brainstem tumors
- Degenerative diseases (ALS/MS)
- Poliomyelitis
- Syphilis
- Myasthenia gravis

5. Non-neurologic
• Obstructive lesions
- Tumors
- Zenker’s diverticulum
- Esophageal webs
- Anterior mediastinal masses
- Strictures
- Schatzki’s ring

6. • Spastic motor disorders:
- Diffuse esophageal spasm
- Hypertensive LES
- Nutcracker esophagus

7. Investigations

8. Blood investigations
• Hb – 8.4 gm%
• TC – 4800 /mm3
• Electrolytes
Na – 138
K - 3.8
• SOB - Positive

9. What imaging?

11. Barium swallow

12. How would you like to proceed?

21. Diagnosis

22. CT neck and thorax
• A large elongated polypoid soft tissue
density lesion is seen extending inferiorly
from the level of cervical esophagus upto
GE junction, the lesion is filling and
distending the lumen of esophagus causing
luminal narrowing

23. UGI scopy
ESOPHAGUS: ESOPHAGEAL LUMEN WAS SIGNIFICANTLY
NARROWED STARTING FROM PROXIMAL ESOPHAGUS TILL
GE JUNCTION
THERE WAS A LARGE PEDUNCULATED POLYP DISTAL END
WHICH WAS ~3 CM. EROSIONS WERE NOTED NEAR THE GE
JUNCTION ON THE MUCOSA OVER POLYP.
THE PEDUNCLE EXTENTED FROM THE LARYNX THROUGH
THE ENTIRE LENGTH OF THE ESOPHAGUS. Z LINE AND GE
JUNCTION AT 39 CM.DIAPHRAGMATIC INDENTATION AT 40
CM

24. EUS
• ESOPHAGUS: A LONG PEDUNCULATED POLYP WITH A
THICK STALK OF ~ 2.0 CMS AND MEASURING ~ 22 CMS
IN LENGTH STARTING FROM 18 CMS AND EXTENDING TO
THE GE JUNCTION SEEN.
• THE TIP OF THE POLYP AT THE LEVEL OF GE JUNCTION
WAS ULCERATED.
• EUS: SHOWED A POLYP ARISING FROM SUBMUCOSA.
THERE WAS NO MAJOR VESSELS RUNNING WITHIN THE
POLYP

25. FINAL DIAGNOSIS

26. Fi Fibrovascular
Polyp

27. How will you proceed?

28. Fibrovascular polyp
Zeeshan

29. Introduction
• Benign tumors of esophagus – 20% of all
esophageal lesions
• 60 – 80% - Leiomyomas
• 2nd
MC – Squamous papillomas
• Hemangiomas – More common than
fibrovascular polyps

30. Incidence
• 1-2% of esophageal tumors
• MC in males
• Age group – 50 years

31. Anatomy of origin

32. Origin
• 2 areas of weakness:
1.Killian’s dehiscence:
Between fibres of thyropharyngeus and
cricopharyngeus.
2.Laimer Heckmann triangle:
Between fibres of cricopharyngeus and
circular fibres of esophagus

33. Factors
• Anatomical weakness
• Redundant submucosal folds
• Pronounced peristaltic activity

34. Presentation
• Dysphagia – MC symptom
• Other complaints:
- Retrosternal/ epigastric discomfort
- Odynophagia
- Vomiting
- Weight loss
- Respiratory symptoms : Shortness of breath;
persistent cough

35. MOST distinctive feature

36. Complications
• Asphyxia
• Laryngeal obstruction
• Aspiration pneumonia
• Hemorrhage – Secondary to twisting
• Occult GI bleed leading to anemia – Ulceration of tip
• Malignancy – Very rare

37. Investigations
• CXR – Posterior mediastinal mass
• Barium contrast studies
• Endoscopy
• CT Neck and thorax
• EUS

38. Management
• Endoscopic resection of polyp
- Predominantly fat
- Less vascularity
• Surgical excision – 1st
line of therapy

39. PRIOR to surgery
• Assess fitness of patient
• NPL scopy – Assess vocal cords
• Involve Plastic Sx – For local flap cover

40. Surgery
• Neck exploration
• Preferably a left sided approach
• Thoracotomy may be necessary
• Keep in mind the exact site of origin of polyp

41. Principles of surgery
• Pedicle has to be resected under DIRECT
vision
• Incision NEEDS to be made opposite to site of
origin of lesion
- Hemorrhage if opened at the site of
attachment
- Incomplete resection leading to recurrence

42. • It’s NOT a tongue – It’s a polyp

43. Reference
• Timmons B, Sedwitz JL, Oiler DW: Benign fibrovascular polyp of the
esophagus.
South Med J 1991, 84:1370-1372
• Drenth J, Wobbes T, Bonenkamp JJ, Nagengast FM: Recurrent esophageal
fibrovascular polyps: case history and review of the literature.
Dig Dis Sci 2002, 47:2598-2604
• Levine MS, Buck JL, Pantongrag-Brown L, Buetow PC, Hallman JR, Sobin
LH:Fibrovascular polyps of the esophagus: clinical, radiographic, and pathologic
findings in 16 patients.
• AJR 1996, 166:781-787.