Thoracoscopic Subtotal Esophagectomy Research Articles

Subtotal esophagectomy and concurrent reconstruction with free jejunal flap for primary esophageal cancer after pancreatoduodenectomy.

Pancreatoduodenectomy and subtotal esophagectomy are widely considered the most invasive and difficult surgical procedures in gastrointestinal surgery. Subtotal esophagectomy after pancreatoduodenectomy is expected to be extremely difficult due to complicated anatomical changes, and selecting an appropriate intestinal reconstruction method will also be a difficult task. Therefore, perhaps because the method is considered impossible, there have been few reports of subtotal esophagectomy after pancreatoduodenectomy. A 73-year-old man with a history of pancreatoduodenectomy was diagnosed with superficial thoracic esophageal squamous cell carcinoma. Definitive chemoradiation therapy was recommended at another hospital; however, he visited our department to undergo surgery. We performed the robot-assisted thoracoscopic subtotal esophagectomy. There were some difficulties with the reconstruction: the gastric tube could not be used, the reconstruction was long, and the organs reconstructed in the previous surgery had to be preserved. However, the concurrent reconstruction was achieved with the help of a free jejunal flap and vascular reconstruction. All reconstructions from the previous surgery, including the remnant stomach, were preserved via regional abdominal lymph node dissection. After reconstruction, intravenous indocyanine green showed that circulation in the reconstructed intestines was preserved. On postoperative day 1, no recurrent nerve paralysis was observed during laryngoscopy. The patient could start oral intake smoothly 2weeks after surgery and did not exhibit any postoperative complications related to the reconstruction. The patient was transferred to another hospital on postoperative day 21. Owing to the free jejunal flap interposition method, we safely performed one stage subtotal esophagectomy and concurrent reconstruction, preservation of the remnant stomach, and pancreaticobiliary reconstruction in patients with a history of pancreatoduodenectomy. We believe that this method is acceptable and useful for patients undergoing complicated reconstruction.

Aortoesophageal fistula due to esophageal cancer: a case report of successful management

BackgroundAortoesophageal fistula (AEF) is a rare but potentially life-threatening condition. The best treatment for the AEF due to esophageal carcinoma is still unresolved. Here, we report a rare case of AEF caused by esophageal cancer, that was successfully treated with emergency thoracic endovascular aortic repair (TEVAR), followed by esophagectomy and gastric tube reconstruction.Case presentationA 64-year-old man presented with loss of consciousness and hypotension during chemoradiotherapy for advanced esophageal cancer. Enhanced computed tomography showed extravasation from the descending aorta into the esophagus at the tumor site. We performed emergency TEVAR for the AEF, which stabilized the hemodynamics. We then performed thoracoscopic subtotal esophagectomy on day 4 after TEVAR to prevent graft infection, followed by gastric tube reconstruction on day 30 after TEVAR. At 9 months after the onset of AEF, the patient continues to receive outpatient chemotherapy and leads a normal daily life.ConclusionTEVAR is a useful hemostatic procedure for AEF. If the patient is in good condition and can continue treatment for esophageal cancer, esophagectomy and reconstruction after TEVAR should be performed to prevent graft infection and maintain quality of life.

Cardiac tamponade complicating esophagectomy and retrosternal gastric tube reconstitution in a patient with an abnormal ascending aorta position: a case report

BackgroundCardiac tamponade is a rare postoperative complication of esophageal cancer surgery, which leads to rapid hemodynamic changes and can be fatal if not treated properly and promptly. Herein, we report a case of cardiac tamponade after thoracoscopic subtotal esophagectomy and retrosternal gastric tube reconstitution for esophageal cancer that was successfully treated with surgical drainage.Case presentationAn 86-year-old man with lower thoracic esophageal cancer underwent thoracoscopic subtotal esophagectomy and retrosternal gastric tube reconstitution. No intra-operative complications were observed. On the first postoperative day, tachycardia and hypotension were observed, and pericardial effusion was identified on computed tomography images. The patient was diagnosed with obstructive shock secondary to cardiac tamponade. As percutaneous puncture drainage was not possible due to the presence of a retrosternal gastric tube, pericardiotomy with a small left anterior thoracotomy was performed, and a large amount of hematogenous fluid was drained, which instantly improved circulation. On the second postoperative day, the patient showed decreased pulse pressure, and computed tomography revealed a residual and enlarged hematoma around the right ventricle. The patient underwent surgical drainage and another pericardiotomy with a small right anterior thoracotomy was performed to drain the hematoma. At this time, multiple injuries to the fatty tissue, epicardium, and myocardium with active bleeding were observed on the anterior surface of the right ventricle near the root of the pulmonary artery. In this patient, the ascending aorta ran further to the right and dorsal sides than usual, causing the anterior wall of the right ventricle near the root of the pulmonary artery to be closer to the back of the sternum. This abnormality may have contributed to injury during the creation of the retrosternal pathway, leading to cardiac tamponade.ConclusionsCardiac tamponade after esophagectomy can occur because of manipulation during creation of the retrosternal route, with an anomaly in the aortic position being present in this case. Gentle manipulation and selection of the reconstruction route according to the patient’s condition are necessary in cases with such anatomical abnormalities.

Does Prehabilitation Reduce Postoperative Length of Hospital Stay after Esophageal Cancer Surgery?

At our hospital, prehabilitation has been provided to patients undergoing esophageal cancer surgery since October 2019. This study explored the effects of prehabilitation based on the accumulated database of these patients. This retrospective cohort study included 621 patients who underwent thoracoscopic subtotal esophagectomy. Multiple linear regression analysis was performed using postoperative hospital stay as the objective variable and age, sex, body mass index (BMI), preoperative ventilatory impairment, left ventricular ejection fraction, preoperative hemoglobin A1c, clinical stage, histological type, operative time, surgical blood loss, postoperative complications, and prehabilitation as explanatory variables. We also performed a multivariate analysis in the subgroup of patients who developed postoperative complications and adjusted for possible confounding factors. Postoperative complications and postoperative hospital stay were compared between patients without (n=416) and with (n=205) prehabilitation. Postoperative complications, age, blood loss, BMI, and ventilatory impairment influenced the overall length of hospital stay. When the analysis was restricted to patients with complications, prehabilitation was added to that list of factors as a substitute for BMI. The rate of postoperative complications was not affected by prehabilitation (P=0.1675). The number of hospital days did not change with or without prehabilitation in the overall population, but when restricted to patients with complications, the number of hospital days was significantly decreased in the prehabilitation group (P=0.0328). Prehabilitation as a perioperative approach has the potential to reduce the postoperative length of hospital stay in patients undergoing esophageal cancer surgery, and active intervention is recommended.

Successful conservative treatment for massive tracheal necrosis after lung segmentectomy

BackgroundTracheal necrosis, which is rare because the trachea has rich in blood supply, can be a serious condition. Herein, we report the case of extensive tracheal necrosis that developed after right apical segmentectomy for a metastatic lung tumor of esophageal cancer.Case presentationA 74-year-old man who had undergone thoracoscopic subtotal esophagectomy and gastric tube reconstruction via the posterior sternal route for esophageal adenocarcinoma 2 years previously was referred to our department with an enlarging nodal lesion in the right upper lung lobe. Computed tomography revealed a 30-mm tumor in the right apical segment with no lymph node enhancement, suggesting primary lung cancer or a metastatic lung tumor. The patient underwent right apical segmentectomy. The upper lobe was adherent to the chest wall and mediastinal fat from the apex of the lung to the dorsal side, with particularly strong adhesion at the esophagectomy site. After dissecting the adhesions, right apical segmentectomy was performed via complete video-assisted thoracic surgery. The patient was discharged on the 9th day after surgery without any complications. Pathologic findings revealed a metastatic lung tumor originating from the patient’s esophageal cancer. On the 26th day after surgery, the patient returned with dyspnea and increased sputum. Computed tomography images revealed that the posterior wall of the trachea was missing an area of 16 × 42 mm and was connected to the dead space after the right apical segmentectomy, with no effusion. We diagnosed extensive tracheal necrosis. Considering that the patient’s status was very well despite the extensive tracheal necrosis, we chose conservative treatment. After receiving 12 days of intravenous antibiotic treatment, his symptoms improved, and he was discharged on day 26 after admission.ConclusionsRight upper lung lobe resection after esophagectomy has a risk of tracheal necrosis. Conservative treatment is one approach to manage massive tracheal necrosis in patients with stable respiratory conditions.

Left recurrent nerve lymph node dissection in robotic esophagectomy for esophageal cancer without esophageal traction

BackgroundBecause the robotic arm is located on the dorsal side of the patient, when the esophagus is pulled dorsally for the left recurrent nerve lymph node (LRLN) dissection, the robotic arm interferes with the surgical field. This made it difficult to prepare for the left recurrent lymph node dissection. We developed LRLN dissection in robotic surgery with natural space creation by physiological organ movement and evaluated the short-term results.MethodsIn this retrospective study, we analyzed 102 cases of robot-assisted thoracoscopic subtotal esophagectomy (RATE) among radical subtotal esophagectomies performed between December 2018 and December 2022 using medical records. LRLN dissection is preceded by a dissection of the esophagus from the trachea. Leaving the esophagus on the vertebral side and away from the trachea resulted in a physiological elevation of the esophagus, providing space between the trachea and esophagus.ResultsThe thoracic surgery time in RATE was 181 (115–394) min. The number of LRLNs dissected was 4 (1–14). Six patients (6%) had a postoperative recurrence in the mediastinal lymph nodes. Seven patients (7%) had grade ≥ 1 left recurrent nerve palsy.ConclusionsLRLN dissection with RATE using natural space creation was performed safely with a sufficient number of dissected lymph nodes and little left recurrent nerve palsy.

Successful conversion surgery following chemotherapy with an immune checkpoint inhibitor in an older adult patient with stage IVB esophageal squamous cell carcinoma: a case report

BackgroundChemotherapy and chemoradiotherapy are common treatments for esophageal squamous cell carcinoma with distant metastasis; however, the prognosis remains poor, and complete remission is difficult to achieve. Here, we report a case of an older adult patient with esophageal squamous cell carcinoma who underwent surgery following combined treatment of immunotherapy and chemotherapy and achieved pathological complete response.Case presentationAn 80-year-old woman presenting with difficulty swallowing was referred to our hospital. She was diagnosed with esophageal squamous cell carcinoma with distant metastasis of the lymph node at the dorsal side of the IVC and the left supraclavicular lymph node. She was treated with pembrolizumab, cisplatin, and 5-fluorouracil. After four pharmacotherapy courses, primary tumor and metastatic lymph node shrinkage was observed. The patient underwent thoracoscopic subtotal esophagectomy and regional lymph node dissection. The lymph node at the dorsal side of the IVC was not resected, and the left supraclavicular lymph node was removed. Histological examination revealed complete response with no residual tumor or lymph node metastasis. The patient had no recurrence 10 months postoperatively without adjuvant chemotherapy.ConclusionsConversion surgery following preoperative therapy, including immunotherapy, may be an effective treatment strategy for improving survival in patients with esophageal squamous cell carcinoma even among older adult patients.

Large esophageal gastrointestinal stromal tumors resected thoracoscopically after oral imatinib therapy: a report of two cases

Esophageal gastrointestinal stromal tumors (GISTs) are very rare, accounting for 2–5% of all GISTs. As with other GISTs, the principle of surgical treatment is complete resection with negative margins. In addition to biological grades of GISTs itselves, local recurrence due to capsular damage is a known risk. We describe two cases of massive esophageal GISTs that were successfully resected thoracoscopically after 2 months administration of 400 mg imatinib, with some discussion of the literature. Case 1, the patient was a 51-years-old man. After treated with 400 mg of imatinib as preoperative chemotherapy for 2 months, we performed surgery that included right thoracoscopic subtotal esophagectomy, gastric tube reconstruction, and jejunostomy. The resection specimen and histopathology were esophageal GIST-LtMtAeG, 110 × 95 mm. The postoperative course was uneventful, and was discharged on postoperative day 14. The patient has been recurrence free for 11 months postoperatively. Case 2, the patient was a 70-years-old man. After treated with 400 mg of imatinib as preoperative chemotherapy for 2 months, we performed surgery that included right thoracoscopic subtotal esophagectomy, gastric tube reconstruction, and jejunostomy. The resection specimen and histopathology were esophageal GIST-LtAeG, 90 × 52 mm. The postoperative course was uneventful, and was discharged on postoperative day 14. The patient has been recurrence free for 9 months postoperatively.

A case of long-term survival treated with three metastasectomies and two subsequent adjuvant nivolumab therapies for recurrent malignant melanoma of the esophagus

BackgroundThe treatment strategy for metastatic lesions of primary malignant melanoma of the esophagus (PMME) is currently determined on a case-by-case basis, based on the National Comprehensive Cancer Network (NCCN) guidelines for cutaneous melanoma. The NCCN guidelines state that resection should be considered in patients with resectable metastatic recurrence. Herein, we report a case of long-term survival treated with three metastasectomies and two subsequent adjuvant nivolumab therapies for the metastatic recurrence of PMME.Case presentationA 65-year-old female patient with PMME underwent thoracoscopic subtotal esophagectomy, gastric tube reconstruction via the posterior mediastinal route, and cervical esophagogastric anastomosis. Histopathological examination of the resected specimen revealed that the tumor was PMME with tumor invasion into the muscularis propria and no lymph node metastasis. At the age of 68 years, she developed intestinal invagination due to jejunal metastasis of malignant melanoma and underwent resection of the jejunum. Histopathological examination of the resected specimen revealed two metastases of malignant melanoma in the jejunum and one metastasis to the mesenteric lymph node. At the age of 75 years, a recurrence of malignant melanoma was found in the cervical esophagus. She underwent thoracoscopic mobilization of the gastric tube and esophagus followed by cervical esophagectomy and reconstruction with a free jejunum flap. She received 24 courses of nivolumab therapy for 1 year as a postoperative adjuvant therapy. Subsequently, at the age of 78 years, an enlarged left cervical lymph node and a mass in the right lower lobe of the lung were found. She underwent left cervical lymph node dissection and thoracoscopic wedge resection of the right lung. Histopathological examination of the resected specimens revealed that both tumors were metastases of malignant melanoma. At age 79 years, she received eight courses of nivolumab therapy as a second postoperative adjuvant therapy, with no sign of recurrence in a 9-month follow-up period after the third metastasectomy.ConclusionIn cases of metastatic recurrence of PMME, aggressive resection of oligometastasis with postoperative adjuvant nivolumab therapy may result in long-term survival.

388. PREOPERATIVE TREATMENT AND THORACOSCOPIC ESOPHAGECTOMY FOR BORDERLINE RESECTABLE ESOPHAGEAL CANCER

Abstract Preoperative DCF therapy is recommended for cStage II/III esophageal cancer based on the results of JCOG1109. However, there is no established treatment strategy for Borderline Resectable (BR) esophageal cancer that is suspected of invading vital organs. And the pros and cons of thoracoscopic surgery have not been clarified. We have been performing preoperative chemoradiotherapy (NACRT) followed by thoracoscopic subtotal esophagectomy for BR esophageal cancer. Details and short-term results are presented. After 2 courses of FP therapy and 40 Gy total dose (2 Gy x 20 times) of fractionated conventional irradiation, patients underwent thoracoscopic subtotal esophagectomy with D2 dissection if T4 factor was considered to have been removed by CT evaluation. From April 2017 to present, NACRT was performed in 25 BR esophageal cancer patients. Two of them were unresectable, and thoracoscopic subtotal esophagectomy was performed in 23 cases. All patients had squamous cell carcinoma. 4 patients had complications of Clavien-Dindo Grade III or higher. The median postoperative hospital stay was 23 days. Of the 23 cases that were resectable, R0 resection could be performed in 21 cases (91.3%). The pathological response of the primary tumor was Grade3 in 11 patients (47.8%), Grade2 in 5 (21.7%), and Grade1 in 7 (30.4%). Pathological-CR including regional lymph nodes was 7 cases (30.4%). NACRT is effective for BR esophageal cancer, and thoracoscopic subtotal esophagectomy can be performed safely. We would like to continue to study the long-term results of NACRT with more cases in the future.

647. A CASE OF ACUTE GASTRIC TUBE ULCER BLEEDING SAVED BY EMERGENCY SURGERY

Abstract Gastric tube ulcer is recognized as one of the complications after esophageal cancer surgery. When a ulcer bleeds, or penetrates to the pericardial space, or perforates, it often follows a fatal course due to its anatomical position and the complexity of surgical treatment. We report a case of persistent bleeding from a gastric tube ulcer after esophageal cancer operation, which was unable to treat endoscopically. The case was a 67-year-old man. Thoracoscopic subtotal esophagectomy and posterior mediastinal route subtotal gastric reconstruction were performed for middle thoracic esophageal cancer. His fifth-year regular endoscopy revealed a gastric tube ulcer. As a cause of myalgia, the patient was prescribed NSAIDs every day by a nearby doctor. Initially, no bleeding was observed, and discontinuance of NSAIDs and conservative treatment with PPI was continued. However, five months later, sudden hematemesis was observed at night, and he was transferred to a nearby doctor. Emergency endoscopy revealed gastric tube ulcer bleeding. And he was transferred to our hospital in an emergency. However, two days later, hematemesis and persistent ulcer hemorrhage were observed. Due to the difficulty of cauterizing to heartbeat, emergency surgery was performed. The first attempt was made to approach by a posterior mediastinal route, but it was difficult to confirm the ulcer and it was difficult to control bleeding without compression. Adding the thoracotomy, the ulcer was confirmed under direct vision. An ulcer defect was about 5 cm, bleeding was from the ulcer margin. Barbed suture closure and the omental patch were performed. The postoperative course was uneventful and discharged from the hospital 21 days after the operation. We experienced a rare case of acute hemorrhagic gastric tube ulcer that was difficult to treat conservatively and was saved by emergency surgery. After reconstruction of esophageal cancer, there are complicated situations such as the route of the elevated gastric tube, the position of the ulcer, and the risk of perforation to the pericardial space. Prompt and accurate medical care is required.

623. A NEW PROGNOSTIC EVALUATION OF POSTOPERATIVE ESOPHAGEAL CANCER: LONG-TERM FLAIL INVESTIGATION

Abstract Recurrence-free survival and 5-year survival rates are still commonly used as prognostic indicators for gastrointestinal cancer. We believe that there is a need to find an appropriate index to evaluate changes in health status over time in postoperative patients. We evaluated changes in "frailty" after esophageal cancer surgery using the Kihon Checklist (KCL) developed by the Japanese Ministry of Health, Labour and Welfare, and examined risk factors for worsening health status after surgery. Twenty-four patients (21 thoracoscopic sub-total esophagectomy, 1 mediastinoscopic sub-total esophagectomy, and 2 total laryngopharyngoesophagectomy) who underwent esophageal cancer surgery in our department from December 2019 to April 2021 were included. Patients were asked to write down their KCL before surgery and one year after surgery at an outpatient clinic, and changes over time were checked. We compared the background factors in the "maintain" group (M group) and the "worsened" group (W group), and investigated the risk factors for pre-frail and frail states one year after the surgery. 8 patients worsened from robust to pre-frail to frail and pre-frail to frail, and 16 patients maintained their condition, with 33% of them worsening. Age (M/W: 70/72, p=0.296), male (M/W: 0.88/1.0, p=0.536), BMI (M/W: 22.4/19.6, p=0.142), pStage≥3 (M/W: 0.38/0.38, p=1.0), preoperative chemotherapy (M/W: 0.69/0.63, p=1.0), operative time (M/W: 566/610 minutes, p=0.327), blood loss (M/W: 103/151 ml, p=0.342), postoperative pneumonia (M/W: 0.25/0.25, p=1.0), and cancer recurrence (M/W: 0.19/0.50, p=0.167). The preoperative blood samples were Alb (M/W: 4.3/3.8 g/dl, p=0.046), Hb (M/W: 14.2/12.8 g/dl, p=0.015) and Cre (M/W: 0.85/0.79 mg/dl, p=0.713). At 1 year after esophageal cancer surgery, health worsened and 33% of patients were in a pre-frail or frail state. Risk factors for worsening health were low Alb and low Hb, which were not related to stage or actual age. Further study is needed to clarify risk factors for frailty.

A case of refractory pneumothorax and contralateral atelectasis after thoracoscopic subtotal esophagectomy treated with independent lung ventilation

BackgroundIndependent lung ventilation (ILV) allows separate positive end-expiratory pressures (PEEP) and inspiratory pressures for each lung. However, only a few articles have reported ILV management for lungs affected by different pathologies.Case presentationA 56-year-old man underwent video-assisted thoracic surgery for esophageal cancer. The right lung was injured during surgery, causing a bronchopleural fistula and necessitating chest drainage. On the third day in the intensive care unit, the patient’s oxygenation worsened during pressure support with continuous positive airway pressure ventilation. ILV was initiated for right-sided severe pneumothorax and left-sided atelectasis and pneumonia. ILV was continued for 2 days, and the patient’s trachea was successfully extubated the following day.ConclusionApplying high-level PEEP to the one lung and minimizing the airway pressure on the other lung could be achieved using ILV, which might contribute to successful tracheal extubation.

Left thoracoscopic approach in the supine position for torsion of the residual esophagus after esophagectomy: a case report

BackgroundAnastomotic stenosis can occur after esophagectomy and gastric tube reconstruction. The effective surgical treatment for refractory anastomotic stenosis, which seems difficult to resolve with endoscopic treatment, has not been established. We report a case of refractory stenosis due to esophageal torsion in which reconstructive surgery was possible using a left thoracoscopic approach in the supine position.Case presentationA 72-year-old man who underwent thoracoscopic subtotal esophagectomy and retrosternal gastric tube reconstruction for esophageal cancer 6 months previously presented to us. Postoperative endoscopy revealed that the residual esophagus was twisted approximately 360°, just above the anastomotic site. Conservative endoscopic treatment failed to improve the condition due to severe passage obstruction, and reconstructive surgery was repeated. Surgery was performed in the supine position using a left thoracoscopic approach. The entire circumferences of the gastric tube and residual esophagus were dissected from the inferior mediastinum to the top of the sternum, with focus on preserving the right gastroepiploic vein and gastric-tube wall. Subsequently, laparoscopic surgery was performed to remove the gastric tube from the thoracoabdominal junction. After separating the esophagus on the oral side of the torsion from the left cervical wound, the abdomen was opened, the gastric tube was pulled out through the abdominal wound, and adhesions in the abdominal cavity were peeled off to raise the gastric tube cranially via the retrosternal route. An end-to-side anastomosis was performed using a circular stapler, and the esophageal torsion and previous anastomosis were resected. Oral intake was resumed on the 7th postoperative day, and the patient was discharged on the 38th day.ConclusionsAfter subtotal esophagectomy and retrosternal gastric tube reconstruction, the left thoracoscopic approach is one of the most minimally invasive approaches and is especially useful for preserving the right gastroepiploic artery and veins and for mobilizing the gastric tube wall.

A right pulmonary vein abnormality treated with 3D CT assistance in thoracoscopic surgery for esophageal cancer: a case report

BackgroundAnomalous bifurcation of the right superior pulmonary vein is an important anomaly that should be recognized not only in respiratory and cardiac surgeries, but also in esophageal surgery for the safe performance of surgery. We report a case in which thoracoscopic esophagectomy was safely performed using preoperative three-dimensional computed tomography (3D CT) imaging.Case presentationAn 81-year-old male patient received an upper gastrointestinal endoscopy, which revealed a 20-cm incisor at the entrance, 43-cm EGJ, and 30-mm large type 1 + IIc lesion between the 23-cm and 26-cm incisors; biopsy showed squamous cell carcinoma (SCC). Contrast-enhanced CT showed wall thickening in the anterior wall of the upper thoracic esophagus, without evidence of multi-organ invasion or lymph node metastasis. In addition, a break in the right pulmonary vein passing dorsal to the right main bronchus and flowing directly into the left atrium was observed, and 3D CT was performed preoperatively to confirm the 3D positioning. Positron emission tomography (PET)–CT showed a high degree of accumulation (SUVmax 19.95) in the upper thoracic esophagus. The patient was diagnosed with upper thoracic esophageal cancer, cT2N0M0 cStage II, and underwent thoracoscopic subtotal esophagectomy (three-region dissection) and gastric tube reconstruction. The dorsal inflow of the pulmonary vein in the right main bronchus, which was recognized on preoperative CT, was confirmed and preserved. The pathological diagnosis was basaloid squamous cell carcinoma, pT1b(SM1)N0(0/58)M0 pStage I. The postoperative course was uneventful, and the patient was discharged on postoperative day 20.ConclusionsThe anomalous bifurcation of the pulmonary vein in the right upper lobe area required attention because of its potential to cause massive bleeding and difficulty in securing the operative field if misidentified and damaged during surgery. Although it is not frequently encountered, it is the bifurcation anomaly that esophageal surgeons must bear in mind due to its severe consequences. Preoperative image-reading and intraoperative manipulation of this vessel are imperative for surgical safety.

Successful treatment of enterocutaneous fistula after esophagectomy with scopolamine ointment and negative pressure wound therapy: a case report

BackgroundDespite improved surgical techniques and perioperative management, anastomotic leakage (AL) after esophageal cancer surgery remains a potential complication. In most cases, spontaneous healing upon proper drainage is observed, but sometimes, AL results in intractable enterocutaneous fistulas. We here report a case of intractable enterocutaneous fistula caused by post-esophagectomy AL and successfully treated by scopolamine ointment and negative pressure wound therapy (NPWT).Case presentationA 77-year-old man underwent thoracoscopic subtotal esophagectomy with 3-field lymph node dissection, followed by gastric tube reconstruction through the posterior mediastinal route. On the 6th postoperative day, AL was identified, forming an enterocutaneous fistula. Initially, conservative treatment was performed, but the fistula failed to close. We hypothesized that the substantial amount of exudate might be hampering fistula closure. Scopolamine ointment was used to reduce the amount of fluid. NPWT was also initiated to promote wound healing. Approximately 3 weeks after the beginning of the treatment, the fistula closed; oral intake became possible, and the patient was discharged from the hospital without any symptoms.ConclusionsThe combination of scopolamine ointment and NPWT may be regarded as one effective treatment option for intractable enterocutaneous fistula due to AL after esophagectomy.

Acute esophageal necrosis with esophagus perforation treated by thoracoscopic subtotal esophagectomy and reconstructive surgery on a secondary esophageal stricture: a case report

BackgroundAcute esophageal necrosis is defined as necrosis of the esophageal mucosa causing diffuse black pigmentation of the esophagus, the so-called black esophagus from its endoscopic findings. The prevalence is only 0.001~0.2%, while its mortality rate is up to 32%. However, most of the cases are fatal by comorbidities.Case presentationA 67-year-old female with diabetes mellitus was transported to the emergency room with hematemesis and disordered consciousness. She had suffered from nausea and epigastralgia for 2 days. The patient’s general status was shock evidenced by vital signs, and she did not respond to rehydration. After intubation, emergency endoscopic examination revealed black pigmentation of the esophageal mucosa, and the condition was diagnosed as acute esophageal necrosis. Antibiotics and plasmapheresis had been started, and the patient gradually stabilized. One week after the admission, esophagus perforation was suspected from the significant increase of the right pleural effusion and free air at the esophagus wall and the mediastinum on CT scan. Emergency thoracoscopy revealed an edematous esophagus which was colored black. Esophagectomy with esophagostomy and enterostomy was performed.On resected specimen, mucosal necrosis was found only on the squamous epithelium, with three perforating areas in the middle to lower thoracic esophagus. No signs of inflammation or ischemia were found on the gastric mucosa of the esophagogastric junction. After the operation, the patient recovered generally well, except for the severe stenosis of the cervical esophagus. Cervical esophagectomy, tracheotomy, and anterior thoracic route reconstruction with free jejunum interposition and gastric tube were performed 9 months after the first surgery. No postoperative complications occurred; on the 37th day after the operation, the patient was eating well and was transferred to continue swallowing rehabilitation.ConclusionIt is important to detect the esophagus perforation and mediastinitis early and thereby not to miss the chance of surgical intervention to save the patient’s life. Surgery should be minimized, and reconstruction should be considered next.If the cervical esophagus is also affected, reconstruction surgery should be performed by removing cervical esophagus and anastomosing it to the hypopharynx using a gastric tube and free jejunum interposition as needed.

Is complete right cervical paraesophageal lymph node dissection possible in the prone position during thoracoscopic esophagectomy?

Effective treatment of esophageal cancer requires dissection of the regional lymph nodes (LNs) from the cervical to the abdominal area. In this study, we hypothesized that adequate no. 101R dissection is achieved through a thoracoscopic approach in the prone position. The study cohort was limited to 42 patients who underwent thoracoscopic subtotal esophagectomy with bilateral cervical lymphadenectomy for thoracic esophageal cancer between January 2015 and March 2017. The number of LNs and the incidence of metastasis were analyzed. During the proposed thoracoscopic procedure, cervical paraesophageal LNs were dissected continuously, with the LNs surrounding the recurrent laryngeal nerve (RLN; no. 106rec) as an en bloc resection. In this study, LNs that required further picking up via a cervical incision were defined as no. 101. The recurrent sites among the consecutive patients during the 3-year follow-up, for whom bilateral cervical lymphadenectomy was omitted for lower and middle thoracic tumors between 2012 and 2014, were analyzed further. The data of 42 patients were analyzed. The lymphatic tissues dorsal to the right cervical RLN were almost completely dissected via thoracoscopy. A median of 0 (0-6) LNs were ventral to the right RLN (no. 101R) and no LN metastasis was observed. There were no lymph nodes in 27 patients (64%). By contrast, there was a median of 1(0-10) no. 101L nodes, and LN metastasis was observed in two patients (4.7%). The numbers of LNs at no. 106recR and no. 106recL were 3 (0-9) and 2(0-13), respectively, and the corresponding numbers of patients with metastases at these sites were 11(26%) and 5(12%), respectively. Among the 33 patients who completed the 3-year follow-up, 9 patients developed recurrence, but none involved 101R LNs. There were no residual LNs in the area ventral to the right cervical RLN in 64% of the patients who underwent additional cervical lymphadenectomy after the right thoracoscopic approach in the prone position. Further studies with larger patient cohort or randomization are required to confirm our results.

Preoperative Chemotherapy and Thoracoscopic Subtotal Esophagectomy for Esophageal Cancer with Dermatomyositis

Preoperative Chemotherapy and Thoracoscopic Subtotal Esophagectomy for Esophageal Cancer with Dermatomyositis

PS01.141: TREATMENT STRATEGY FOR THORACIC ESOPHAGEAL CARCINOMA COMPLICATED WITH HEAD AND NECK CANCER

Abstract Background The frequency of complication of head and neck cancer to thoracic esophageal cancer is high, and treatment methods and their order will be determined from the viewpoints of curability and quality of life. Methods We review the course of three cases we experienced and give some consideration. Results [Case 1] A 68-year-old man with cT2N0M0 Mt esophageal cancer and cT2N0M hypopharyngeal cancer. Two courses of DCF (DOC + CDDP + 5 FU) made the hypopharyngeal lesion CR. After thoracoscopic subtotal esophagectomy with three fields lymph nodes dissection, one course of DCF was added, and CRT (60 Gy/30 fr) combined with weekly CBDCA was administered to the neck. The case is alive without recurrence for 5 years and 9 months from the start of treatment. [Case 2] A 72-year-old man with cT2N0M0 Mt esophageal cancer and cT3N2bM0 hypopharyngeal cancer. Three courses of TCS (DOC + CBDCA + TS-1) made the hypopharyngeal lesion CR. After thoracoscopic subtotal esophagectomy, CRT (60 Gy) combined with biweekly CDDP was administered to the neck. The case is alive without recurrence for 5 years and 7 months. [Case 3] A 63-year-old man with LtMt multiple esophageal cancer (4 lesions, cT3N2M0) and cT2N1M0 hypopharyngeal cancer, and cT1bN0M0 gastric cancer. Though the hypopharyngeal cancer remained in PR after 2 courses of DCF, aiming at larynx preservation, thoracoscopic subtotal esophagectomy was performed, and gastric lesion was excised at the time of creating the stomach tube. After the operation, CRT (70 Gy) combined with weekly CBDCA made the hypopharyngeal lesion CR. Another cancer was demonstrated in the residual esophagus in 1 year and 3 months and surgical resection of the residual esophagus and the larynx with reconstruction with free jejunal transplantation was performed. The case is alive without recurrence for 2 years and 5 months after reoperation. Conclusion Salvage surgery may be necessary for metachronous multiple cancer cases, non-CR cases, and local recurrence cases as in case 3. We think that we can aim at compatibility of curability and maintenance of quality of life by treatment method which aims at preservation of larynx, combining with chemoradiotherapy and esophagectomy. Disclosure All authors have declared no conflicts of interest.