FVPs account for about 1% of all benign oesophageal lesions.1
Around 100 cases of giant FVPs have been reported in various literatures. Based on the histology, these lesions have been variously described as lipofibroma, fibromyxoma, fibrolipoma, hamartoma, fibroepithelial polyp, and so forth, until together they have been labelled as FVP.2
They are composed of loose and dense connective tissue, scattered adipocytes and fat globules, and are lined by non-keratinised stratified squamous epithelium. They are highly vascular and often have prominent central vessels. Giant FVPs most commonly occur in middle-aged and older men.3 4
They mostly originate in the upper part of the oesophagus with particular predilection for the area below the cricopharyngeus called Laimer–Haeckermann triangle.5
Most of the pedicle was attached to the posterior wall.6
Over the years the oesophageal peristalsis and the traction during swallowing acts on the loose tissue in this area allowing the polyp to become larger.1
The most common presenting symptom is the development of dysphagia.6
Other associated symptoms are those of chest pain, symptoms of regurgitation and weight loss. Ulceration of the polyp leading to bleeding and asphyxiation are the less common but more dangerous presentations of these polyps. The polyps are known to occur in multiple numbers and to recur.1 7
Malignant degeneration of these polyps is very rare with only a few cases reported.6 7
Multiple investigative modalities are required to diagnose giant FVP of the oesophagus. As they are lined by stratified squamous epithelium like the rest of the oesophagus, around 25% of them are missed on endoscopy8
where they are mistaken for the normal wall of the oesophagus. The pedicle could be missed on endoscopy leading to a misdiagnosis of malignant lesion.9
Barium swallow usually reveals a characteristic sausage-shaped intraluminal filling defect. However, they are not ideal to demonstrate the pedicle or its attachment.10
Both CT and MRI have the advantage of being non-invasive investigations yielding valuable information towards the diagnosis of these tumours. CT scan may reveal the heterogeneous nature of the intraluminal mass.11
As in our case, the CT scan can also reveal the large feeding central artery, which helps in operative management. MRI may show high signal intensity on T1-weighted image, which is typical of FVPs.12
Endoscopic ultrasonography is useful to provide information on the size and vascularity of the stalk, but also has the advantage of undertaking fine needle aspiration cytology towards confirmation of the diagnosis.1
For the relief of symptoms, as well as to prevent complications like bleeding and asphyxiation, resection of the polyp is mainstay of treatment. FVPs can be removed by endoscopic or operative approach or a combination of the two. In general, removal of polyps that are short and have a diameter smaller than 2 cm can be attempted via endoscopic approach.3
Operative excision and removal can be attempted via pharyngotomy, cervical oesophagotomy, thoracic oesophagotomy or gastrotomy. Sometimes more than one access is required, as in this case. There have only been two reported cases of removal of polyp using two surgical approaches3 13
and one involving three different surgical approaches.1
Another similar case in the same institution was managed by endoscopic division of the pedicle of the polyp and retrieval via laparoscopic gastrotomy. The primary difficulties faced with the removal of the polyp are the vascularity of the stalk and its control as well as the size of the polyp and its retrieval through the narrow oesophagotomy. The size of the polyp also restricts the ability to snare the stalk and retrieve the polyp via endoscopy.
While there have been reported cases of recurrence of giant FVP of the oesophagus, there is no consensus on further surveillance after removal of the polyp. One of the two cases of giant FVP encountered in this institution has already had a follow-up endoscopy, which was normal, and the other case is awaiting the same.
- Giant FVP is a rare benign lesion of oesophagus, which commonly presents with dysphagia.
- They are easily missed on endoscopy and preoperative identification of the base of the stalk of the polyp is vital.
- Management of giant FVP of the oesophagus involves endoscopic or operative removal of the polyp depending on its size.
- They have the potential for recurrence or to undergo malignant change.