In April 2008, a 51-year-old man underwent endoscopic mucosal resection for superficial ESCC (pT1b, lymphovascular invasion +) and subsequent chemoradiotherapy (50Gy and 2 cycles of cisplatin + 5-fluorouracil regimen). In April 2009, he was treated with TPL, free jejunal graft reconstruction and tracheostomy for hypopharyngeal cancer. He then received multiple curative ESDs for superficial ESCC (2016, 2018 and 2020).
In February 2022 (at the age of 64), he was diagnosed with thoracic superficial esophageal cancer. A type 0-IIc lesion located on the left side of the wall in the middle thoracic esophagus (33–35 cm from the incisors) newly appeared (Fig. 1). Computed tomography detected neither LN involvement nor distant metastases. The tumor was classified as clinical stage I (cT1aN0M0), and endoscopic submucosal dissection (ESD) was performed for removal of this lesion. Curative resection had been clinically achieved; however, pathological diagnosis of tumor depth and the resection margin was very difficult since tight scar tissue had formed around the tumor. Close observation was selected considering that the risks associated with esophagectomy were high due to the patient’s complicated treatment history.
A follow-up endoscopic examination 2 months later (May 2022) detected stenosis attributable to intramural tumor recurrence in the previously treated area (Fig. 1). Endoscopic ultrasound-guided fine needle aspiration confirmed the presence of ESCC (Fig. 1). The patient was diagnosed with middle intrathoracic ESCC, classified as clinical stage II (cT3N0M0) based on computed tomography and 18F-fluorodeoxyglucose positron emission tomography evaluations (Fig. 1). The artery and vein of the free-jejunal graft were anastomosed with the transverse cervical artery and the internal jugular vein, respectively. Neoadjuvant chemotherapy was not given because the significance of re-administering drugs used in the first-line therapy and combination therapy for these patients has not been established [4].
With the patient in a prone position, the operative thoracic approach was performed by video-assisted thoracoscopic surgery with five access ports, as presented in Fig. 2. For salvage esophagectomy, we performed limited LN dissection, i.e., harvesting only LNs that were swollen or suspected of harboring a recurrence [5]. Although the esophagus was adherent to the thoracic duct layer with fibrosis, it was possible to preserve the thoracic duct. Although the ventral side of the tumor, paraesophageal nodes (#108) and subcarinal nodes (#107 and #109) also tightly adhered to the left and right main bronchi with severe fibrosis (Fig. 2), these structures were sufficiently mobilized. Prophylactic upper mediastinal lymphadenectomy around the remnant esophagus was minimized to avoid impairing the blood supply to the trachea. Both bronchial arteries, pulmonary branches of the bilateral vagus nerves and the azygos arch, were all carefully preserved (Fig. 2).
Next, in the supine position, a cervical incision was made along the upper side of the tracheostomy and the free jejunal graft and remnant esophagus were then carefully mobilized (Fig. 3). The adhesion around the free-jejunal graft, and adhesiolysis between the jejunoesophageal anastomosis and the membranous portion of the trachea were relatively loose. A gastric conduit was created via laparotomy and raised via the posterior mediastinal route. The esophagus was entirely removed, and end-to-side anastomosis between the jejunal graft and gastric conduit was performed. The operating time was 455 min, and the estimated blood loss was 332 g.
Four days after the operation, minor chyle leakage was recognized and was managed conservatively. Furthermore, minor pneumothorax was noted 7 days postoperatively, and was treated by drainage with a thoracic catheter. The patient was discharged on postoperative day 44. Pathological examination revealed the tumor to be pT3N2M0 Stage IIIB (Fig. 3).