Abstract
BackgroundSuperior posterior pulmonary vein anomaly in the right upper lobe (anomalous V2), which is one of the anomalies of the right superior pulmonary vein (RSPV), runs behind the right main or intermediate bronchus. Although this rarely occurs, attention should be given to this venous anomaly during thoracoscopic esophagectomy with subcarinal lymph node dissection. Here, we report a case of thoracoscopic esophagectomy with subcarinal lymph node dissection in the prone position for lower thoracic esophageal cancer with anomaly of the superior posterior pulmonary vein in the right lobe (anomalous V2).Case presentationA 61-year-old man was diagnosed as having lower esophageal cancer with swelling of multiple lymph nodes in the mediastinum and abdomen. His clinical diagnosis based on the eighth TNM classification system was cT3 N2 M0 stage IIIB. In addition, an anomalous V2 was recognized on preoperative computed tomography imaging before the operation. The vein ran behind the intermediate bronchus and drained into the RSPV located at the area of the subcarinal lymph node. We performed preoperative simulation by using virtual thoracoscopic imaging with the same view as that during operation to help us better dissect the lymph nodes. As a result, thoracoscopic esophagectomy and subcarinal lymph node dissection were performed in the prone position without injuring the anomalous V2. Severe complications did not occur in the postoperative course except for paralysis of the left recurrent laryngeal nerve. The patient was discharged on postoperative day 17.ConclusionsInjury to an anomalous V2 can cause severe hemorrhage during subcarinal lymph node dissection in esophagectomy. Preoperative simulation by using virtual thoracoscopic imaging is useful to avoid this complication in patients with an anatomical anomaly.
Highlights
Superior posterior pulmonary vein anomaly in the right upper lobe, which is one of the anomalies of the right superior pulmonary vein (RSPV), runs behind the right main or intermediate bronchus
We report a case of thoracoscopic esophagectomy with subcarinal lymph node dissection in the prone position for lower thoracic esophageal cancer with anomaly of the superior posterior pulmonary vein in the right lobe, which is one of the anomalies of the RSPV, in which the anomalous vein was identified before operation on computed tomography (CT)
Akiba et al reviewed cases of RSPV anomaly and showed that the occurrence rate of the anomaly running behind the intermediate bronchus was 0.3 to 9.3% [4]
Summary
The branch of the RSPV generally runs inside the right lung. this vein usually does not appear behind the right main or intermediate bronchus. Three reports have described esophagectomy and subcarinal lymph node dissection for patients with esophageal cancer who had a RSPV anomaly (Table 1). The anomalous pulmonary vein could be preserved during subcarinal lymph node dissection in all the cases but was not detected before the operation. Detection of anomalous V2 might be possible by using enhanced axial CT images [5], without 3-D reconstruction imaging, it is difficult to imagine the locational relationship between this vein and the subcarinal lymph node, right bronchus, and bronchial artery. The exact location of the anomalous V2 should be recognized before and during surgery, and virtual thoracoscopic imaging is useful for identifying its anatomical location This is the first report of the application of virtual thoracoscopic imaging for a case with an anatomical anomaly during esophageal cancer surgery. Abbreviations 3-D CTA: Three-dimensional computed tomographic angiography; Anomalous V2: Anomaly of the superior posterior pulmonary vein in the right upper lobe; CT: Computed tomography; NACRT: Neoadjuvant chemoradiotherapy; POD: Postoperative day; RSPV: Right superior pulmonary vein
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