Thoracoscopic Intrathoracic Esophagogastric Anastomosis Following Minimally Invasive Esophagectomy for the Patient After Total Laryngectomy. Report of a Case

Hiromitsu Kinoshita, Hiroyuki Kobayashi, Masato Kondo, Satoshi Kaihara. Kobe City Medical Center General Hospital

Background: As for reconstruction following minimal invasive esophagectomy (MIE) against esophageal cancer, it is common to perform cervical esophagogastric anastomosis. However, it is difficult in case that patient underwent tracheostomy for the treatment of larynx cancer. As far as we know in the literature, surgeons could not but choose Ivor Lewis esophagectomy and intrathoracic anastomosis under thoracotomy so far. Here, we experienced a case of esophageal cancer patient who had undergone laryngectomy before. We utilized a thoracoscopic intrathoracic esophagogastric anastomosis following MIE successively.

Case report: A 76-year-old man visited our hospital under the diagnosis of lower thoracic esophageal cancer. He had experienced total laryngectomy for laryngeal cancer 8 years ago and had tracheostomy in the neck. We diagnosed him as cT1bN0M0; stage IA esophageal cancer and recommended surgical therapy. Procedures: The gastric tube construction was done in the laparoscopic part of the operation in supine position. The esophagus was transected at the cranial level of the aortic arch after the completion of the upper mediastinal lymph node dissection in the prone position. Overlap side-to-side esophagogastric anastomosis was performed using endoscopic linear stapler. The entry hole of the linear stapler was closed with hand suturing. Permanent tracheostomy could be preserved. From the pathologic investigation, final staging of esophageal cancer was pT1bN1M0; stage IIB. Postoperatively, there was no complication.

Considerations: The surgery for esophageal cancer after laryngectomy has difficulties. Tracheostomy and former radical neck dissection (RND) against laryngeal cancer make cervical anastomosis harder. On the other hand, RND makes further cervical lymph node dissection needless. Therefore, Ivor Lewis MIE and thoracoscopic anastomosis is feasible solution for these cases. Although the procedures we introduced here is time-consuming and technically challenging, it is easier and safer than expected. Whereas, intrathoracic anastomosis has several advantages. It is more physiologically natural than other reconstruction routes. Gastric conduit would have better blood supply and the anastomosis site can be wrapped by the omentum, which result in the reduced rate of anastomotic leakage.

Conclusion: MIE with an intrathoracic linear-stapled anastomosis might be safe and suitable for Lower esophageal cancer after laryngectomy.

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