Thoracic Duct Preserving Thoracoscopic Esophagectomy in Prone Position for Esophageal Cancer

Ryuichiro Ohashi, MD, Masaru Jida, MD, Takafumi Kubo, MD, Norimitsu Tanaka, MD, Tomo Oka, MD, Yuji Onoda, MD, Ichio Suzuka, MD

Department of General and Gastrointestinal Surgery, Kagawa Prefectural Central Hospital

It remains controversial whether the thoracic duct should be preserved during radical esophagectomy for esophageal cancer. The thoracic duct is the largest lymphatic vessel in the body. It is suspected to play important roles in the transport of digestive fat, the regulation of body fluid, the immune system, and so on. Resection of the thoracic duct might contribute to radical lymph node dissection for esophageal cancer. However, injury of it can lead to chylothorax that is occasionally mortal. Thoracoscopic esophagectomy in prone position is a novel procedure and gradually spreading in Japan. Prone position provides stable and clean surgical field of the posterior mediastinum because the lung and bloody effusions remain in the anteror side of the thoracic cavity due to their gravity. High-definition endoscope gives detailed anatomical information by magnified view. Those enable precise dissection around the thoracic duct. We present procedures of thoracic duct preserving thoracoscopic esophagectomy in prone position and a series of patients who underwent the operations.

We retrospectively identified 10 patients who were planned to perform thoracic duct preserving thoracoscopic esophagectomy in prone position for esophageal cancer between 06/2011 and 08/2012. Patients were placed in a prone position. Procedures were performed right thoracoscopically with pneumothorax maintained with 4-6 mmHg of CO2 gas, while one-lung ventilation of the left lung. Four trocars were placed in the 9th, the 7th, the 5th, and the 3rd intercostal space, respectively. We carried out modified radical neck dissection and isolated both sides of the recurrent nerves prior to thoracoscopic esophagectomy. The thoracic duct was found on the right side of the descending aorta in the lower and the middle thorax. It passed near the origin of the right bronchial artery, and ascended posterior side of the left subclavian artery in the upper thorax. Lymph node dissection was made on the surface of the membrane surrounding the thoracic dust and the aorta.

Thoracoscopic esophagectomy in prone position was successful in all 10 patients. The thoracic duct was preserved in seven patients, but clipped due to injury during operation in three patients. The median operation time for thoracoscopic procedures was 240 minutes (range: 200-300). There was no operation related death. The postoperative complications were anastomotic leakage in two cases (20%), anastomotic stenosis in one case (10%), and hoarseness in three cases (30%). Neither chylothorax nor severe pulomonary complications occurred. Anatomical variations of the thoracic duct were found in three cases. The thoracic duct ascended to the right venous angle in one case and a small branch existed in two cases.

Thoracic duct preserving thoracoscopic esophagectomy in prone position is a feasible operation, although preservation is successful in seven of ten cases. It provides excellent view to detect the thoracic duct precisely, which will contribute to radical lymph node dissection safely under the condition of the preservation of the thoracic duct.

Session: Poster Presentation

Program Number: P262

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