Leiomyoma is the most common benign tumor of the esophagus. Most commonly it originates from the muscular layer of the mid and lower esophagus. Benign tumors account for only 10% of all esophageal tumors and leiomyoma accounts for hardly 4% among them [5]. Leiomyoma usually is asymptomatic or may present with non-specific symptoms like dysphagia, pain, and pyrosis. Less commonly they may present with symptoms that include weight loss, hematemesis, or melena. Bleeding is a much more common symptom in gastric leiomyoma. In the present case patient presented with massive hematemesis and dysphagia which is rather uncommon. It can occur at any age, but 90% of them occur in the third to fourth decade of life with a proportional male to female incidence of 2:1 [6]. 

Radiological evaluation with a barium swallow, CECT, Upper gastrointestinal endoscopy, and endoscopic ultrasound may be useful to clinch the diagnosis [7]. CECT best describes the location, extent, and relation with surrounding structures. In the present case esophagoscopy showed an esophageal submucosal mass with a luminal compromise with dilated, tortuous vessels over it. However, the characteristic finding that has been described is esophageal narrowing with intact overlying mucosa [8]. A preoperative biopsy is however not mandatory since there is a risk of mucosal bleed. In most of the cases, biopsy material was insufficient to establish an accurate histopathological diagnosis [3].

Most leiomyomas are intramural and well encapsulated hence can be treated by enucleation. Up to 8 cm leiomyoma has been treated by enucleation provided there is a tension-free approximation of myotomy and that mucosa is intact. Proper approximation of the muscle layer of the esophagus is needed to maintain the propulsive activity of the esophagus and this prevents reflux esophagitis in long term [3,7]. Approximately 5 % of them are giant leiomyoma defined as size >10cm [9]. Large leiomyoma is often difficult to excise without mucosal breach due to tight and extensive adhesion. These factors further necessitate the need for esophagectomy over enucleation. Transformation of leiomyoma to sarcoma is also a rare possibility reported in <0.2% of cases. Hence esophagectomy should be done to distinguish benign from malignant neoplasm in GEL [10]. Esophagectomy is mostly done with gastric pull-up through a left posterolateral thoracotomy approach [7]. In our case, we performed the procedure through a single left thoracoabdominal incision. The main limiting factor for a thoracoscopic approach is the creation of a plane between the tumor and mucosa, albeit minimally invasive enucleation has also been reported for GEL [11].

Several reconstruction techniques have been described for esophageal reconstruction. Among them, gastric and colonic conduits have gained importance. The choice of conduit depends on the location of the tumor. The gastric pull-up is widely accepted because of its robust blood supply and requirement of only a single anastomosis. Colonic conduit is preferred by some authors when the tumor is located in the proximal part of the esophagus with the rationale of reducing the acid reflux when the whole stomach is used for anastomosis [12,13]. However gastroesophageal reflux has been significantly reduced by gastric tubulization along the greater curvature and maintaining at least 6cm of the gastric tube below the diaphragm [4]. Our case was exceptional since the tumor was extending to the cardia of the stomach and hence had to proceed with distal esophagectomy and proximal gastrectomy. This procedure has been described for benign tumors of the gastroesophageal junction by using isoperistaltic jejunal interposition by Merendino et al [14]. Although this procedure delivers a reliable antireflux mechanism, it’s a complex procedure requiring three anastomoses. Hence reconstruction of cardia with a gastric conduit was tried in our case. However, a comparison between the two procedures has shown that the Merendino procedure was associated with lower anastomotic leak and shorter hospital stay than the gastric conduit procedure [15]. However, we used a gastric conduit for anastomosis and the patient was discharged on postoperative day eight after tolerating a proper oral diet.