Slipped Liver Segment Mimicking an Esophageal Stromal Tumor

Excerpt

A 36-year-old female patient with past medical history of a hiatal procedure in the neonatal period (which was not described in her medical history) for hiatal hernia was referred to our institution for thoracic pain. Abdominal examination was unremarkable. Initially, clinical tests (ECG and echocardiogram) were performed, ruling out cardiac pathology. Barium esophagram was carried out evidencing a slight filling defect on the distal third of the esophagus with no evidence of recurrent hiatal hernia. A CT scan with distention technique (PnCT) revealed a homogeneous 39 × 26 mm lesion located on the distal esophagus consistent with a submucosal tumor (Fig. 1). An upper gastrointestinal endoscopy showed no organic lesion on the mucosa. Due to the suspicion of esophageal stromal tumor, we executed an endoscopic ultrasound (EUS) which revealed a well circumscribed, hipoechoic, relatively homogeneous mass arising apparently from the fourth layer of the esophagus. The case was presented to a multidisciplinary committee and based on the presumptive diagnosis of esophageal stromal tumor, the patient was considered candidate for resection and underwent an initial laparoscopic approach. During exploration, adhesions consistent with previous hiatal surgery were evident. Opening of the minor omentum was performed to access the esophageal hiatus and upon completion of its dissection, unexpectedly no esophageal tumor was recognized. Instead, we encountered the left lateral segment of the liver protruding through the esophagus hiatus as content of a hiatal hernia (Fig. 2). After realizing adhesions of the slipped hepatic segment and due to the impossibility to rule out liver tumor in the slipped segment, we performed resection of it using one white cartridge of mechanical stapler. In order to repair the hiatal defect, primary closure of the diaphragm with non-absorbable suture and standard Nissen fundoplication was carried out. No postoperative complications were noted and she was discharged on the second postoperative day. Anatomopathological examination of the resected specimen evidenced normal liver parenchyma.

…