Description
Mediastinoscopy-assisted esophagectomy in an upper thoracic esophageal squamous cell carcinoma in a patient with liver cirrhosisAbstract:
Background: Standard treatment for T1a esophageal cancer (EC) is endoscopic mucosal resection (EMR) or submucosal dissection (ESD). For T1b/SM1 a ESD can be performed, whereas in T1b/SM2, esophagectomy with lymph node dissection is recommended. Lesions infiltrating into the middle one-third of the submucosa (SM2) have in 36% of cases lymph node metastasis. Approximately, 41% of patients with SM2 EC with lymphovascular invasion can develop recurrent cancer. In patients with several chronic diseases it is necessary to develop less invasive surgical approaches.
Case: A 49-year-old man with Child Pugh Class A liver cirrhosis and portal hypertension underwent MAE with side to side anastomosis after a non-curative ESD of an upper (23-30 cm) pT1b (SM2) well differentiated squamous cell carcinoma with lymphovascular invasion.
Methods:
Bilateral recurrent laryngeal nerve lymph node dissection: supine position, bilateral cervical incision in medial side of sternocleidomastoid muscle, mobilization of cervical esophagus, cervical lymph nodes dissection.
Mediastinoscopy: insertion of The LapProtector into the both cervical incisions, attachment to the access port, insertion of two 5-mm trocars through the each EZ Access port, insertion of 5 mm flexible endoscope through the left side port, mobilization of esophagus from mediastinum beyond the azygos arch posterior to right side, detachment of the anterior side of esophagus from the trachea beyond the carina, mobilization of left side of esophagus by ligation of esophageal artery from descending aorta, dissection of bilateral vagus nerves to inferior pulmonary vein.
Mobilization of middle third of esophagus and stomach: after mobilization of the stomach, abdominal esophagus was transected by end linear stapler. Esophagus hiatus was extended by the litractor and the heart was pushed up to ventral. Middle to lower third of esophagus with paraesophageal lymph nodes were mobilized from posterior to right side, at last left side was mobilized.
Cervical anastomosis: stomach was pull out through umbilical mini-laparotomy. Gastric tube with 4 cm width was pull up to the cervical side via posterior mediastinal route and anastomosed by linear stapler.
Conclusions:
MAE is a feasible and less invasive surgical approach in EC patients with severe co-morbidities, although there is a limitation in the optimal dissection of mediastinal lymph nodes. Direct vision of the mediastinal structures during MAE predicts organ injury avoiding postoperative morbidity and mortality.
| Period | 20-Nov-2019 → 22-Nov-2019 |
|---|---|
| Event title | European Society for Diseases of the Esophagus Athens |
| Event type | Conference |
| Location | Athens, GreeceShow on map |
| Degree of Recognition | International |