Yusuke Taniyama, Tadashi Sakurai, Makoto Hikage, Chiaki Sato, Hiroshi Okamoto, Kai Takaya, Takeshi Naitoh, Michiaki Unno, Takashi Kamei. Tohoku University, Department of Surgery
Background: Salvage thoracoscopic esophagectomy after chemoradiation therapy is extremely difficult because of fibrotic and edematous change in mediastinal tissue. Especially when the tumor is adjacent to trachea or main bronchus, dissection would be much harder. Furthermore, tracheobronchial necrosis might happen in salvage esophagectomy if the surgeon did not pay much attention to preserve tracheobronchial blood supply. Thus, we present the twists and methods of dissecting around trachea and bronchus in salvage thoracoscopic esophagectomy, especially focused on the preservation of blood flow of trachea and bronchus.
Surgical Procedure: Prone position with single-lumen intubation tube are employed for thoracoscopic esophagectomy in our institution. Preservation of bronchial artery is important to prevent tracheobronchial necrosis which can be fatal complication. To preserve this artery, restructuring of bronchial artery by 3D-CT help to understand the location of this artery. We also avoid injuring the longitudinal anastomosis of inferior thyroid artery and bronchial artery which locate along both side of the tracheal wall. Dissection of carinal lymph node is not recommended, except the case which have metastasis in those lymph nodes. Magnified view by thoracoscopy is necessary during the dissection of trachea and bronchus in salvage esophagectomy. Intraoperative bronchoscopy would help to dissect the strong fibrotic adhesion between tumor and tracheobronchial membrane. Transmitted light at the tracheobronchial membrane from thoracoscopic view, or traction of the membrane from bronchoscopic view is the signal of thinning tracheobronchial membrane. Single-lumen intubation make this procedure possible.
Result: 108 cases of salvage esophagectomy was performed in our institution from 2001 to 2017. Among them, tracheobronchial necrosis had happened in 4 cases. All those cases were operated before 2008 when we started to preserve tracheobronchial blood supply. Although 12 cases had direct invasion to tracheobronchial and resulted in R2 resection, none of cases showed tracheobronchial injury during operation.
Conclusion: It is important to preserve the tracheobronchial blood supply in salvage esophagectomy. Magnified view by thoracoscopy and observation by bronchoscopy helps dissecting the fibrous tissue between tracheobronchial membrane and tumor.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 93381
Program Number: P632
Presentation Session: Poster Session (Non CME)
Presentation Type: Poster
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