Two cases of thoracoscopic total gastric tube resection after thoracoscopic subtotal esophagectomy with gastric tube reconstruction via a posterior mediastinal route: a video case report

Introduction

Recent advances in the treatment of esophageal cancer have improved the prognosis after esophagectomy. As a result, the number of metachronous cancers in the residual esophagus and gastric tube used for reconstruction has increase (1). Endoscopic resection is the least-invasive treatment for early-stage tumors in such cases. On the other hand, when surgical treatment is necessary for patients with a history of esophagectomy, the surgical procedure should be carefully planned because resection of the reconstructed gastric tube after esophagectomy is considered much more difficult and exposes serious risks due to adhesions to adjacent vital organs. Partial resection can be an option depending on the balance between the clinical status of the patient and the surgical risks (2-4). However, total gastric tube resection (TGTR) is often needed for cases with residual esophageal cancer near the anastomosis after subtotal esophagectomy or advanced gastric tube cancer (GTC). In recent years, minimally invasive surgery for esophageal cancer has become prevalent because of its utility as a less invasive technique providing good visibility (5,6). A few cases of thoracoscopic resection for GTC after retrosternal pathway reconstruction have been reported (7,8), but no reports appear to have described thoracoscopic TGTR after subtotal esophagectomy with gastric tube reconstruction via the posterior mediastinal route. We present this case in accordance with the CARE reporting checklist (available at https://ales.amegroups.com/article/view/10.21037/ales-25-9/rc).

Case presentation

All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s), and with the Declaration of Helsinki and its subsequent amendments. Written informed consent was obtained from the patients for publication of this case report, accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Case 1

A 73-year-old man underwent thoracoscopic subtotal esophagectomy with gastric tube reconstruction via a posterior mediastinal route for thoracic esophageal cancer. The procedure was complete resection with negative margin, including a three-field lymphadenectomy, encompassing cervical, mediastinal, and upper abdominal lymph node dissection. The histopathological diagnosis was moderately differentiated squamous cell carcinoma (SCC) invading the muscularis propria with lymph node metastasis (pT2N1M0, stage II). He was discharged 3 weeks after the operation with no postoperative complications. One year after the operation, residual esophageal SCC with a clinical stage of cT2N0M0 was detected just oral to the anastomosis. Definitive chemoradiotherapy was performed (radiation: 50 Gray; two courses of cisplatin, and 5-fluorouracil) and the patient achieved complete response. The patient underwent postoperative surveillance with both endoscopy and computed tomography (CT) every four months. However, after three years of chemoradiotherapy, Borrmann type 2 advanced tumor was again identified (Figure 1A). CT showed no invasion to adjacent organs and no lymph node metastasis (Figure 1B), so thoracoscopic TGTR and partial esophagectomy were planned.

Figure 1 Preoperative imaging of residual esophageal squamous cell carcinoma. (A) Endoscopic image showing a Borrmann type 2 advanced cancer located approximately 2 cm oral to the esophagogastric anastomosis (anastomosis at 21 cm, tumor at 19 cm from the incisors). (B) Axial CT image showing circumferential thickening of the mid-thoracic esophageal wall (arrow), without signs of invasion into adjacent organs or evidence of lymph node metastasis. CT, computed tomography.

The patient was placed in the thyroid position under general anesthesia, starting with cervical manipulation. After first making a collar incision in the neck, we added a longitudinal incision to the manubrium sterni. Strong adhesion was observed around the esophagogastric anastomosis. Although the left recurrent laryngeal nerve needed to be sacrificed, we could separate the anastomosis from the tracheal cartilage and carotid sheath without injury. The patient was changed to a semi-prone position. To avoid lung injury, the first port was inserted under the open method at the 5th intercostal space (ICS) at the level of the scapular tip, displaced one rib space from the previous port scar. After we confirmed the absence of adhesions between the chest wall and lung, all ports were inserted (5-mm trocars at the 3rd and 6th ICS along the posterior axillary line, a 12-mm trocar at the 3rd ICS along the anterior axillary line, and a 5-mm trocar at the 8th ICS at the scapular tip level). The gastric tube was firmly adherent, particularly on the stapler side and to the membranous portion of the trachea, but the adhesions could be detached without any injury to the gastric tube. Because the tumor was located at the esophagus, the greater omentum was resected only to a safe extent, and a portion was left in the thoracic cavity. After the gastric tube was cut with a surgical stapler at the level of the tracheal bifurcation, the gastric tube was dissected circumferentially as far as possible to each of the cranial and caudal sides. The surgical procedure is shown in the supplementary video (Video 1). The patient was again placed in the thyroid position. An upper abdominal median incision was made and the gastric tube was withdrawn into the abdominal cavity through the esophageal hiatus. Adhesions around the hiatus were slightly present but could be easily dissected without significant bleeding or injury. The right gastroepiploic vessels were preserved and the anal side of the gastric tube was removed after cutting at the duodenum. The oral side of the gastric tube was pulled from the thoracic cavity by cervical manipulation, and the rest of the esophagus was removed with the tumor. Roux-en-Y reconstruction was performed through the subcutaneous route with revascularization of the internal thoracic vessels and jejunal vessels. The operative time was 685 min, and total blood loss was 220 mL. Left recurrent laryngeal nerve palsy was observed as a postoperative complication and the patient was discharged on postoperative day 16. Histopathological examination of the resected specimen showed poorly differentiated SCC of the esophagus with invasion to the adventitia (pT3) but no lymph node metastasis (Figure 2A,2B). No recurrence had been seen as of five years after the second surgery. However, one month after the last surveillance (6 years after the second surgery), the patient was found unconscious at home and was later pronounced dead suddenly of unknown causes at a hospital where he was transferred.

Figure 2 Gross and histopathological findings of the resected esophageal squamous cell carcinoma. (A) Resected specimen showing a Borrmann type 2 advanced cancer (arrow) located just oral to the esophagogastric anastomosis. Resection was performed with an approximately 1 cm oral margin from the tumor edge. (B) Hematoxylin and eosin-stained section of the resected esophageal tumor (×20), showing poorly differentiated squamous cell carcinoma infiltrating the adventitia. The tumor was confined to the esophagus, and no invasion into the gastric tube or the anastomotic site was observed. The central defect represents the site where the circular stapler line was removed.

Case 2

An 81-year-old man had undergone thoracoscopic subtotal esophagectomy with gastric tube reconstruction via a posterior mediastinal route for thoracic esophageal cancer eight years earlier. The procedure was complete resection with negative margin, including a three-field lymphadenectomy, encompassing cervical, mediastinal, and upper abdominal lymph node dissection. The histopathological diagnosis was poorly differentiated SCC invading the submucosal layer without lymph node metastasis (pT1bN0M0, stage I). Follow-up upper gastrointestinal endoscopy revealed a GTC and he was referred to our department. The tumor was type 0–IIa+IIc and histopathological examination revealed poorly differentiated adenocarcinoma (Figure 3). CT showed no lymph node metastasis, so the patient was diagnosed with GTC, clinical stage cT1bN0M0. We planned thoracoscopic partial resection of the gastric tube.

Figure 3 Endoscopic image showing a 20-mm erythematous, depressed lesion (arrow) located approximately 1 cm anal to the esophagogastric anastomosis. The lesion was classified as 0–IIa+IIc and was clinically suspected to involve the submucosal layer massively. Five biopsy specimens were taken from the surrounding mucosa, all of which were negative for malignancy.

The patient was placed in the thyroid position under general anesthesia, to start cervical manipulation first. After first making a collar incision in the neck, we detected the vagus nerve and attached an intraoperative continuous nerve monitoring system. Because the adhesion between the left recurrent laryngeal nerve and gastric tube was slight, we were able to separate the gastric tube until esophagogastric anastomosis without injury to adjacent tissues. The patient was placed in a semi-prone position and thoracoscopic manipulation was initiated. Adhesions between the lung and chest wall were mild. The gastric tube was able to be detached circumferentially, although this took a long time due to strong adhesion between the gastric tube and surrounding tissue. Several injuries to the lung pleura required repair. The stomach was cut with a linear stapler at three cm to the anal side of the tumor and the gastric tube was withdrawn into the abdominal cavity and fixed to the abdominal wall. After creating an enterostomy for enteral feeding, the abdomen was closed. In the neck, an esophagostomy was made after the esophagus was resected. The operative time was 809 min, and total blood loss was 290 mL. The postoperative course was uneventful and the patient was discharged on postoperative day 10. Histopathological examination of the resected specimen revealed poorly differentiated adenocarcinoma with subserosal invasion (pT3) without lymph node metastasis (Figure 4A,4B). The distal margin was positive, so TGTR with perigastric lymph node dissection around the right gastroepiploic artery and reconstruction was performed in the same manner as in Case 1, one month after the surgery. A total of 8 lymph nodes were retrieved and pathologically examined. The operative time was 535 min, and total blood loss was 860 mL. Although anastomotic leakage occurred at the esophagojejunostomy site, drainage treatment was successful and the patient was discharged on postoperative day 26. No tumor was grossly visible in the resected specimen. Histopathological examination showed poorly differentiated adenocarcinoma with serosal invasion (pT4a) without lymph node metastasis. No tumor cells were observed at the resected margin. As of the time of writing, four years after the surgery, the patient has shown no recurrence.

Figure 4 Gross and histological findings of gastric tube cancer after partial resection. (A) Macroscopic appearance of the partially resected gastric tube, showing a 20-mm superficially depressed and slightly elevated lesion, consistent with early gastric tube cancer. (B) Hematoxylin and eosin-stained microscopic image (×40) showing poorly differentiated adenocarcinoma with subserosal invasion. The tumor showed a spreading pattern beneath the intact mucosa, and the resection margin was positive.

Discussion

TGTR for patients after subtotal esophagectomy with gastric tube reconstruction has been reported to show high morbidity and mortality rates (3,9,10). Sugiura et al. (3) reported that two of seven patients who underwent TGTR died of postoperative multiple-organ failure due to anastomotic leakage. Akita et al. (9) likewise reported that one of five patients who underwent TGTR for posterior mediastinum gastric tube died of postoperative pyothorax and renal failure. On the other hand, the usefulness of minimally invasive surgery for esophageal cancer compared with open esophagectomy in reducing the overall postoperative complications, especially pulmonary complications, has been demonstrated in randomized controlled studies and a meta-analysis (5,11). Although minimally invasive surgery for esophageal cancer has been widely accepted, few reports have described thoracoscopic TGTR for a gastric tube using the retrosternal route (7,8). Further, no reports have described thoracoscopic TGTR for a gastric tube on the posterior mediastinal route. We offer the first descriptions of successful thoracoscopic TGTR in the present cases.

Adhesions are the most significant factor that makes surgery for the gastric tube in the posterior mediastinum difficult. The gastric tube is surrounded by important tissues such as the recurrent laryngeal nerve, membranous portion of the trachea, inferior pulmonary vein, and aorta, necessitating careful dissection. The magnifying effect of the thoracoscope is considered to enable more precise and meticulous manipulation in dissection, facilitating clear recognition of boundaries with surrounding tissues. Further, if the initial surgery is performed thoracoscopically, adhesions between the lung and chest wall are likely to be much milder than with thoracotomy. As a result, thoracoscopic surgery could be more useful in such reoperations. In our cases, because the adhesions between the lung and chest wall were minimal, conversion to thoracotomy was not necessary for dissection of the adhesions. In addition, inserting the first port one rib space away from the wound from the previous port insertion was helpful to avoid lung injury. On the other hand, the adhesion between the membranous portion of the trachea and the stapler side of the gastric tube and anastomosis was markedly strong, as we had suspected preoperatively. To reduce the risk of injury to the trachea, we first started with a neck procedure in the present cases. Determining the goal of the thoracic procedure around the esophagogastric anastomosis site helped us to avoid injuries to the trachea and recurrent laryngeal nerve. Using an organ retractor to frequently adjust the direction of traction of the gastric tube also proved effective. Tensioning and development of a rough surgical field with traction on the gastric tube by the organ retractor facilitated recognition of the appropriate dissection line. Further, in Case 2, the use of an intraoperative nerve monitoring system allowed the preservation of recurrent laryngeal nerve function.

In addition to technical considerations, appropriate postoperative surveillance plays a critical role in the long-term management of patients after esophagectomy. Toh et al. reported that annual or biannual upper gastrointestinal endoscopy was the most common surveillance method after curative esophagectomy or chemoradiotherapy (12). Nakanoko et al. (13) later observed that many institutions now adopt prolonged surveillance beyond 5 years, particularly given that the median time to GTC diagnosis is approximately 5.6 years after initial surgery. In Case 1, the patient underwent postoperative surveillance with both endoscopy and CT every four months. Although this follow-up schedule was more frequent than what is generally recommended in the literature, a type 2 tumor was nevertheless detected during surveillance and required surgical resection. This suggests the possibility of rapid tumor progression and highlights the limitations of even close-interval monitoring. The optimal frequency and duration of postoperative surveillance after esophagectomy remain unresolved and warrant further investigation.

The balance between invasiveness, safety and curability should be considered when planning the surgical management of patients with residual esophageal cancer and GTC after gastric tube reconstruction via the posterior mediastinal route. The optimal extent of lymph node dissection for GTC remains controversial and is a factor that makes surgery more complicated. Tanigawa et al. (14) reported that lymphatic drainage pathways are often altered after gastrectomy, making it difficult to standardize the extent of lymphadenectomy in remnant gastric cancer. This principle can be applied to GTC as well. Therefore, careful consideration and individualized planning of lymph node dissection are essential in such cases. In Case 1, because the patient experienced recurrence of the residual esophageal cancer, lymph node dissection around the right gastroepiploic artery was considered unnecessary in principle. We therefore resected the gastric tube leaving the greater omentum with right gastroepiploic artery intact, to reduce the operative time and risk of injury to the inferior pulmonary vein and aorta. The resection was pathologically confirmed to have negative margins. Regarding postoperative management, adjuvant chemotherapy was not administered. At present, there is no clear evidence supporting the routine use of adjuvant chemotherapy after salvage surgery following definitive chemoradiotherapy for esophageal SCC. In Case 2, because the patient was diagnosed with early gastric cancer, we had planned to perform partial resection and reconstruction using the caudal gastric tube with a preserved right gastroepiploic artery. However, histopathological examination revealed positive resected margins and Borrmann type 4 advanced gastric cancer, so we performed additional lymph node dissection at the time of total gastrectomy. This discrepancy highlights the inherent difficulty in preoperative diagnosis of Borrmann type 4 gastric cancer, particularly in reconstructed gastric tubes. Previous studies have shown that clinical staging frequently underestimates the true depth of invasion in these tumors, even with current diagnostic modalities (15). Surgeons should maintain a high index of suspicion and be prepared to escalate treatment when findings suggest deeper invasion. Fortunately, no recurrence was observed in either of these two cases.

Despite favorable outcomes, this report includes only two cases, limiting generalizability. Additionally, while thoracoscopic TGTR was feasible in both cases, the procedure requires careful patient selection based on anatomical factors, surgical history, and cardiopulmonary function, and may not be applicable in all patients. Further studies with larger case series are necessary to refine patient selection criteria and establish standardized surgical strategies.

Conclusions

We reported herein two cases in which thoracoscopic TGTR was successfully performed for the posterior mediastinal gastric tube after subtotal esophagectomy. This approach is considered beneficial in terms of reducing invasiveness and facilitating precise dissection through the magnifying effect of the thoracoscope, particularly for patients whose initial surgery was performed thoracoscopically.

Acknowledgments

None.

Footnote

Reporting Checklist: The authors have completed the CARE reporting checklist. Available at https://ales.amegroups.com/article/view/10.21037/ales-25-9/rc

Peer Review File: Available at https://ales.amegroups.com/article/view/10.21037/ales-25-9/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://ales.amegroups.com/article/view/10.21037/ales-25-9/coif). The authors have no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All procedures performed in this study were in accordance with the ethical standards of the institutional and/or national research committee(s), and with the Helsinki Declaration and its subsequent amendments. Written informed consent was obtained from the patients for publication of this case report, accompanying images and the video. A copy of the written consent is available for review by the editorial office of this journal.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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