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Onodera Y, Nakano T, Heishi T, Sakurai T, Taniyama Y, Sato C, Ohuchi N, Kamei T. Bilateral approach for thoracoscopic esophagectomy with lymph node dissection in the dorsal area of the thoracic aorta in patients with esophageal cancer: A report of two cases. Int J Surg Case Rep 2017; 31:154-158. [PMID: 28161685 PMCID: PMC5293718 DOI: 10.1016/j.ijscr.2017.01.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 01/17/2017] [Accepted: 01/17/2017] [Indexed: 11/17/2022] Open
Abstract
We presented two esophageal cancer patients performed thoracoscopic esophagectomy. These two cases have lymph node metastasis of dorsal area of thoracic aorta (DTA). We performed successfully underwent the dissection of lymph node of DTA. The bilateral thoracoscopic approach performedsafely in the prone position. The long-term outcome of lymphadenectomy in the DTA among esophageal cancer patients remain controversial.
Introduction The incidence of lymph node metastasis in the dorsal area of the thoracic aorta (DTA) is relatively low in patients with esophageal cancer. It is difficult to approach the DTA using surgical procedures, such as an open thoracotomy and thoracoscopy in the left decubitus position. Case presentation Case 1: A 70-year-old man with esophageal cancer underwent thoracoscopic esophagectomy with mediastinal lymph node dissection via a right thoracoscopic approach, followed by lymphadenectomy in the DTA via left thoracoscopy in the prone position. Microscopic findings revealed two metastatic lymph nodes in the DTA. The definitive diagnosis was squamous cell carcinoma of the esophagus, and the pathological stage was T2N3M0 (Union for International Cancer Control [UICC], 7th edition). The patient showed lung metastasis 8 months after the surgery. Case 2: A 72-year-old man with esophageal cancer underwent esophagectomy via a bilateral approach in the prone position, using a similar procedure as in case 1. The definitive diagnosis was squamous cell carcinoma of the esophagus, and the pathological stage was T3N2M0. The patient showed a metastatic mediastinal lymph node 4 months after the surgery. Conclusion Bilateral thoracoscopic esophagectomy in the prone position can be safely performed, and it might be an alternative curative surgery for esophageal cancer. However, both our cases showed metastasis in the early postoperative period. The long-term outcome and significance of dissection of lymph nodes in the DTA in patients with esophageal cancer remains controversial. Further studies are required to establish the indications and efficacy of this therapeutic approach.
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Affiliation(s)
- Yu Onodera
- Division of Advanced Surgical Science and Technology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, 980-8574, Japan
| | - Toru Nakano
- Division of Advanced Surgical Science and Technology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, 980-8574, Japan.
| | - Takahiro Heishi
- Division of Advanced Surgical Science and Technology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, 980-8574, Japan
| | - Tadashi Sakurai
- Division of Advanced Surgical Science and Technology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, 980-8574, Japan
| | - Yusuke Taniyama
- Division of Advanced Surgical Science and Technology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, 980-8574, Japan
| | - Chiaki Sato
- Division of Advanced Surgical Science and Technology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, 980-8574, Japan
| | - Noriaki Ohuchi
- Division of Advanced Surgical Science and Technology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, 980-8574, Japan
| | - Takashi Kamei
- Division of Advanced Surgical Science and Technology, Tohoku University Graduate School of Medicine, Sendai, Miyagi, 980-8574, Japan
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Ninomiya I, Okamoto K, Tsukada T, Saito H, Fushida S, Ikeda H, Ohta T. Thoracoscopic radical esophagectomy and laparoscopic transhiatal lymph node dissection for superficial esophageal cancer associated with lymph node metastases in the dorsal area of the thoracic aorta. Surg Case Rep 2015; 1:25. [PMID: 26943393 PMCID: PMC4747922 DOI: 10.1186/s40792-015-0030-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2014] [Accepted: 02/18/2015] [Indexed: 12/29/2022] Open
Abstract
Esophageal cancer invading the muscularis mucosa sometimes involves regional lymph node metastases. However, lymph node metastases are rare in the dorsal area of the thoracic aorta. We describe a patient with an intramucosal esophageal cancer invading the muscularis mucosa, accompanied by lymph node metastases in the dorsal area of the thoracic aorta. These lesions were successfully resected by hand-assisted laparoscopic surgery using a transhiatal approach. A 60-year-old man was diagnosed with superficial esophageal cancer during a routine health examination. Endoscopic examination and ultrasonography revealed a superficial cancer, of diameter 6.0 cm, invading the submucosal layer and intramural metastases caudal to the primary tumor. Enhanced computed tomography and F-deoxyglucose positron emission tomography demonstrated the two metastatic lymph nodes, one in the dorsal area of the thoracic aorta and the other near the left gastric artery. Thoracoscopic radical esophagectomy with three-field lymph node dissection was performed. The metastatic lymph node in the dorsal area of the thoracic aorta was successfully removed by hand-assisted laparoscopic surgery using a transhiatal approach. Histopathological examination showed primary cancer invading the muscularis mucosa and intramural metastases in the lamina propria mucosa and submucosal layer. The pathological diagnosis according to the Japanese classification of esophageal cancer was MtLt, 47 mm, 0-IIa + IIb, pT1a-MM, ie(+), INF-b, ly3, v0, pN4(4a), pIM1, M0, and pstage IVa. The patient underwent two courses of adjuvant chemotherapy, consisting of CDDP and 5-fluorouracil. At present, 1 year and 8 months after surgery, the patient remains alive without tumor recurrence. Although the lymph node in the dorsal area of the thoracic aorta is not recognized as regional nodes of thoracic esophageal cancer, solitary mediastinal metastases from a mucosal cancer may indicate the existence of direct lymphatic flow from the thoracic esophagus to the retroaortic region. Transhiatal approach by hand-assisted laparoscopic surgery is useful to dissect the metastatic lymph node in the dorsal area of the thoracic aorta.
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Affiliation(s)
- Itasu Ninomiya
- Gastroenterologic Surgery, Department of Oncology, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, 13-1, Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan.
| | - Koichi Okamoto
- Gastroenterologic Surgery, Department of Oncology, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, 13-1, Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan.
| | - Tomoya Tsukada
- Gastroenterologic Surgery, Department of Oncology, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, 13-1, Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan.
| | - Hiroto Saito
- Gastroenterologic Surgery, Department of Oncology, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, 13-1, Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan.
| | - Sachio Fushida
- Gastroenterologic Surgery, Department of Oncology, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, 13-1, Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan.
| | - Hiroko Ikeda
- Section of Diagnostic Pathology, Kanazawa University Hospital, Kanazawa, Ishikawa, 920-8641, Japan.
| | - Tetsuo Ohta
- Gastroenterologic Surgery, Department of Oncology, Division of Cancer Medicine, Graduate School of Medical Science, Kanazawa University, 13-1, Takaramachi, Kanazawa, Ishikawa, 920-8641, Japan.
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Shiozaki A, Fujiwara H, Konishi H, Kinoshita O, Kosuga T, Morimura R, Murayama Y, Komatsu S, Kuriu Y, Ikoma H, Nakanishi M, Ichikawa D, Okamoto K, Sakakura C, Otsuji E. Laparoscopic transhiatal approach for resection of an adenocarcinoma in long-segment Barrett’s esophagus. World J Gastroenterol 2015; 21:8974-8980. [PMID: 26269688 PMCID: PMC4528041 DOI: 10.3748/wjg.v21.i29.8974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/22/2014] [Revised: 04/03/2015] [Accepted: 05/21/2015] [Indexed: 02/06/2023] Open
Abstract
Barrett’s esophagus (BE) is a precursor of esophageal adenocarcinoma and is associated with gastroesophageal reflux disease, which is often preceded by a hiatal hernia. We describe a case of esophageal adenocarcinoma arising in long-segment BE (LSBE) associated with a hiatal hernia that was successfully treated with a laparoscopic transhiatal approach (LTHA) without thoracotomy. The patient was a 42-year-old male who had previously undergone laryngectomy and tracheal separation to avoid repeated aspiration pneumonitis. An ulcerative lesion was found in a hiatal hernia by endoscopy and superficial esophageal cancer was also detected in the lower thoracic esophagus. The histopathological diagnosis of biopsy samples from both lesions was adenocarcinoma. There were difficulties with the thoracic approach because the patient had severe kyphosis and muscular contractures from cerebral palsy. Therefore, we performed subtotal esophagectomy by LTHA without thoracotomy. Using hand-assisted laparoscopic surgery, the esophageal hiatus was divided and carbon dioxide was introduced into the mediastinum. A hernial sac was identified on the cranial side of the right crus of the diaphragm and carefully separated from the surrounding tissues. Abruption of the thoracic esophagus was performed up to the level of the arch of the azygos vein via LTHA. A cervical incision was made in the left side of the permanent tracheal stoma, the cervical esophagus was divided, and gastric tube reconstruction was performed via a posterior mediastinal route. The operative time was 175 min, and there was 61 mL of intra-operative bleeding. A histopathological examination revealed superficial adenocarcinoma in LSBE. Our surgical procedure provided a good surgical view and can be safely applied to patients with a hiatal hernia and kyphosis.
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Fujiwara H, Shiozaki A, Konishi H, Komatsu S, Kubota T, Ichikawa D, Okamoto K, Morimura R, Murayama Y, Kuriu Y, Ikoma H, Nakanishi M, Sakakura C, Otsuji E. Hand-assisted laparoscopic transhiatal esophagectomy with a systematic procedure for en bloc infracarinal lymph node dissection. Dis Esophagus 2014; 29:131-8. [PMID: 25487303 DOI: 10.1111/dote.12303] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Laparoscopic transhiatal esophagectomy is a minimally invasive approach for esophageal cancer. However, a transhiatal procedure has not yet been established for en bloc mediastinal dissection. The purpose of this study was to present our novel procedure, hand-assisted laparoscopic transhiatal esophagectomy, with a systematic procedure for en bloc mediastinal dissection. The perioperative outcomes of patients who underwent this procedure were retrospectively analyzed. Transhiatal subtotal mobilization of the thoracic esophagus with en bloc lymph node dissection distally from the carina was performed according to a standardized procedure using a hand-assisted laparoscopic technique, in which the operator used a long sealing device under appropriate expansion of the operative field by hand assistance and long retractors. The thoracoscopic procedure was performed for upper mediastinal dissection following esophageal resection and retrosternal stomach roll reconstruction, and was avoided based on the nodal status and operative risk. A total of 57 patients underwent surgery between January 2012 and June 2013, and the transthoracic procedure was performed on 34 of these patients. In groups with and without the transthoracic procedure, total operation times were 370 and 216 minutes, blood losses were 238 and 139 mL, and the numbers of retrieved nodes were 39 and 24, respectively. R0 resection rates were similar between the groups. The incidence of recurrent laryngeal nerve palsy was significantly higher in the group with the transthoracic procedure, whereas no significant differences were observed in that of pneumonia between these groups. The hand-assisted laparoscopic transhiatal method, which is characterized by a systematic procedure for en bloc mediastinal dissection supported by hand and long device use, was safe and feasible for minimally invasive esophagectomy.
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Affiliation(s)
- H Fujiwara
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - A Shiozaki
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - H Konishi
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - S Komatsu
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - T Kubota
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - D Ichikawa
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - K Okamoto
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - R Morimura
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Y Murayama
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Y Kuriu
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - H Ikoma
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - M Nakanishi
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - C Sakakura
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - E Otsuji
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Shiozaki A, Fujiwara H, Murayama Y, Komatsu S, Kuriu Y, Ikoma H, Nakanishi M, Ichikawa D, Okamoto K, Ochiai T, Kokuba Y, Otsuji E. Perioperative outcomes of esophagectomy preceded by the laparoscopic transhiatal approach for esophageal cancer. Dis Esophagus 2014; 27:470-8. [PMID: 23088181 DOI: 10.1111/j.1442-2050.2012.01439.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
This study was designed to determine the efficacy of esophagectomy preceded by the laparoscopic transhiatal approach (LTHA) with regard to the perioperative outcomes of esophageal cancer. The esophageal hiatus was opened by hand-assisted laparoscopic surgery, and carbon dioxide was introduced into the mediastinum. Dissection of the distal esophagus was performed up to the level of the tracheal bifurcation. En bloc dissection of the posterior mediastinal lymph nodes was performed using LTHA. Next, cervical lymphadenectomy, reconstruction via a retrosternal route with a gastric tube and anastomosis from a cervical approach were performed. Finally, a small thoracotomy (around 10 cm in size) was made to extract the thoracic esophagus and allow upper mediastinal lymphadenectomy to be performed. The treatment outcomes of 27 esophageal cancer patients who underwent LTHA-preceding esophagectomy were compared with those of 33 patients who underwent the transthoracic approach preceding esophagectomy without LTHA (thoracotomy; around 20 cm in size). The intrathoracic operative time and operative bleeding were significantly decreased by LTHA. The total operative time did not differ between the two groups, suggesting that the abdominal procedure was longer in the LTHA group. The number of resected lymph nodes did not differ between the two groups. Postoperative respiratory complications occurred in 18.5% of patients treated with LTHA and 30.3% of those treated without it. The increase in the number of peripheral white blood cells and the duration of thoracic drainage were significantly decreased by this method. Our surgical procedure provides a good surgical view of the posterior mediastinum, markedly shortens the intrathoracic operative time, and decreases the operative bleeding without increasing major postoperative complications.
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Affiliation(s)
- A Shiozaki
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto, Japan
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Shiozaki A, Fujiwara H, Konishi H, Morimura R, Komatsu S, Murayama Y, Kuriu Y, Ikoma H, Kubota T, Nakanishi M, Ichikawa D, Okamoto K, Sakakura C, Otsuji E. Middle and lower esophagectomy preceded by hand-assisted laparoscopic transhiatal approach for distal esophageal cancer. Mol Clin Oncol 2013; 2:31-37. [PMID: 24649304 DOI: 10.3892/mco.2013.201] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 10/10/2013] [Indexed: 11/06/2022] Open
Abstract
Respiratory morbidity is the most frequent complication following an esophagectomy. This study was designed to determine the efficacy of middle and lower esophagectomies preceded by the hand-assisted laparoscopic transhiatal approach (LTHA) regarding the perioperative outcomes of distal esophageal cancer. The esophageal hiatus was opened and carbon dioxide was introduced into the mediastinum. Dissection of the distal esophagus was performed up to the level of the tracheal bifurcation. En bloc dissection of the posterior mediastinal lymph nodes was performed using the LTHA. Subsequently, a small thoracotomy (10 cm) was performed to divide the thoracic esophagus and allow middle mediastinal lymphadenectomy. Finally, reconstruction via the posterior mediastinal route with a gastric tube and anastomosis in the thoracic cavity were performed using a circular stapler. The treatment outcomes of 10 patients who underwent LTHA-preceded middle and lower esophagectomy were compared to those of 11 patients treated without prior LTHA (thoracotomy, 20 cm). The total operative time, the duration of one-lung ventilation and total operative blood loss were significantly decreased in the LTHA group. The number of resected lymph nodes did not differ significantly between the two groups. Postoperative respiratory complications occurred in 10.0% of patients treated with, and 36.3% of those treated without LTHA. The extubation time following surgery, the duration of thoracic drainage and postoperative hospital stay were significantly decreased by this method. In conclusion, middle and lower esophagectomies preceded by LTHA provides a good surgical view of the posterior mediastinum, markedly shortens the duration of one-lung ventilation and improves the perioperative outcome.
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Affiliation(s)
- Atsushi Shiozaki
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan
| | - Hitoshi Fujiwara
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan
| | - Hirotaka Konishi
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan
| | - Ryo Morimura
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan
| | - Shuhei Komatsu
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan
| | - Yasutoshi Murayama
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan
| | - Yoshiaki Kuriu
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan
| | - Hisashi Ikoma
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan
| | - Takeshi Kubota
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan
| | - Masayoshi Nakanishi
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan
| | - Daisuke Ichikawa
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan
| | - Kazuma Okamoto
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan
| | - Chouhei Sakakura
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan
| | - Eigo Otsuji
- Division of Digestive Surgery, Department of Surgery, Kyoto Prefectural University of Medicine, Kyoto 602-8566, Japan
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