Successful subcarinal dissection using a laparoscopic transhiatal approach for esophageal cancer with an anomalous pulmonary vein

Thoracoscopic esophagectomy with subcarinal lymph node dissection in the prone position for esophageal cancer with a right top pulmonary vein

The right top pulmonary vein (RTPV), a rare pulmonary vein (PV) variant draining the right upper lobe, arises independently from the right superior PV, travels posterior to the right bronchial tree and drains directly into the left atrium (LA) or another PV. We report an RTPV discovered on preoperative computed tomography (CT) scanning in a 60-y-old man who subsequently underwent prone thoracoscopic esophagectomy and subcarinal lymph node dissection. The preoperative CT scan showed an anomalous vessel 7.8 mm in diameter arising from the right upper lobe, running posterior to the right main bronchus (RMB), and draining directly into the LA. To our best knowledge, this is the largest reported RTPV (7.8 mm in diameter) and is an extremely rare variant, passing posterior to the RMB and draining into the LA.

Right top pulmonary vein is a venous anomaly of which surgeons should be aware in subcarinal dissection for thoracoscopic esophagectomy: a case report and literature review

Background

A right top pulmonary vein (RTPV) that crosses behind the right main or intermediate bronchus is a variation of the superior posterior pulmonary vein in the right upper lobe. Damage or ligation of this abnormal vessel can lead to massive intraoperative bleeding and serious complications, such as congestion of the posterior segment of the right upper lobe and cardiac tamponade. Subcarinal lymph node dissection is mandatory in radical thoracoscopic esophagectomy for esophageal cancer, and the RTPV is an anomalous vessel of which thoracic surgeons should be aware.

Case presentation

A 70-year-old man underwent thoracoscopic esophagectomy for esophageal cancer (T3N1M0). An anomaly of the superior posterior pulmonary vein in the right lobe was recognized on preoperative computed tomography imaging. With simulation and intraoperative navigation using three-dimensional imaging of the same view as that observed during the operation, radical subcarinal dissection could be performed with preservation of the RTPV.

Conclusion

In our review of the relevant literature, the incidence of RTPV ranged from 0.28 to 9.3%, and its mean vascular diameter was 7.0 mm at the maximum and 2.2 ± 0.72 mm at the minimum, with the right superior pulmonary vein being a relatively common inflow site. Our case in which the RTPV ran dorsal to the right main bronchus is very rare. In radical subcarinal dissection of thoracoscopic esophagectomy, it is important to recognize the posterior pericardial plane and release the ventral fixation of these lymph nodes to free space for the back side. This is also true in the case of RTPV, which should be noted to avoid injury. In cases involving an RTPV larger than 4.5 mm, ligation should be avoided, and preoperative recognition of the exact run of this abnormal vessel using three-dimensional imaging can be very useful.

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

BACKGROUND

Anomalous 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 PRESENTATION

An 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.

CONCLUSIONS

The 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.

Three-dimensional computed tomography image-oriented successful thoracoscopic subtotal esophagectomy for an esophageal cancer patient with an anomalous right superior pulmonary vein: A case report

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Case of esophageal cancer associated with an aberrant V2.

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Used preoperative 3D-CT for performing safe VATS-E.

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Preoperative contrast-enhanced 3D-CT clearly depicted the aberrant V2.

Background

Subcarinal lymphadenectomy is an essential procedure in curative esophagectomy for esophageal cancer. The right superior pulmonary vein (RSPV) and its branches are usually located in front of the right main or intermediate bronchus. However, an anomalous posterior branch (aberrant V2) of RSPV passes behind the right intermediate bronchus, where the aberrant V2 may be embedded in the subcarinal nodal packet. This can lead to unanticipated bleeding when dissecting the subcarinal lymph node. We present a case study on the use of preoperative three-dimensional contrast-enhanced computed tomography (3D-CT) for performing a safe video-assisted thoracoscopic surgery-esophagectomy in lower thoracic esophageal cancer.

Case presentation

A 77-year-old man had esophageal cancer associated with an aberrant V2 passing behind the right intermediate bronchus. Esophagogastroduodenoscopy revealed a type 1 tumor in the lower thoracic esophagus. Contrast-enhanced and 3D-CT scans showed a space-occupying lesion with contrast enhancement and an aberrant V2 passing behind the right intermediate bronchus, respectively. The patient was then diagnosed with lower thoracic esophageal cancer (cT2cN1cM0 cStage II). As per the patient’s request, he underwent a surgery-first approach followed by adjuvant chemotherapy. The patient underwent video-assisted thoracoscopic surgery-esophagectomy (VATS-E) with three-field lymphadenectomy, and a large aberrant V2 involving the subcarinal nodal packet was recognized behind the right intermediate bronchus. After the thoracoscopic subtotal esophagectomy with three-field lymph node dissection, laparoscopy-assisted reconstruction of the esophagus was performed with elevation of the gastric conduit to the neck. Recurrent laryngeal nerve palsy was not observed. He started to receive rehabilitation for swallowing on day 3 and resumed oral intake on day 10 after surgery. The final pathological diagnosis was squamous cell carcinoma of the esophagus (pT3N1M0 pStageIII).

Conclusions

Preoperative contrast-enhanced 3D-CT clearly depicted the aberrant V2, which enabled us to perform a safe VATS-E with three-field lymphadenectomy. Thorough understanding of the anatomical configuration of the pulmonary vessels and bronchus is important for avoiding unexpected bleeding during subcarinal lymphadenectomy. 3D-CT imaging study is useful for recognizing the anomalous RSPV before surgery.

Thoracoscopic esophagectomy with subcarinal lymph node dissection in the prone position for esophageal cancer with a right superior pulmonary vein anomaly: a case report

Background

Superior 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 presentation

A 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.

Conclusions

Injury 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.