Postpneumonectomy transthoracic Esophagectomy – a case report: using anatomic change to create Extrathoracic Esophagogastric anastomosis

Postpneumonectomy transthoracic Esophagectomy – a case report: using anatomic change to create... Background: Resection of primary esophageal cancer following previous pneumonectomy is a challenging procedure and was scarcely reported. Case presentation: Here we report a case in which reduced thoracic space was used in left transthoracic esophagectomy to counter the difficulties caused by previous left pneumonectomy. Conclusion: Retrograde dissection and infra-diaphragmatic esophagogastric anastomosis are examples of using postpneumonectomy changes to facilitate subsequent transthoracic esophagectomy for cancers of the lower esophagus. Keywords: Pneumonectomy, Transthoracic esophagectomy, Esophageal cancer, Dissection, Esophagogastric anastomosis Background carboplatin doublet chemotherapy. At postoperative The occurrence of primary esophageal cancer after pre- follow-ups, he had been shown to be recurrence free. ceding pneumonectomy for primary lung cancer is rare. Barium swallow and esophagogastroduodenoscopy For patients with previous pneumonectomy, transtho- were ordered and a distal esophageal mass was identified racic esophagectomy is always technically challenging which was 36 cm from the incisors with extension to the given the postpneumonectomy anatomic deviations and cardia. Biopsy confirmed poorly differentiated adenocar- a solitary lung as the remaining pulmonary reserve cinoma. Computed tomography (CT) of the chest and [1, 2]. We herein report a case of an adult patient who had abdomen demonstrated marked anatomic changes as a a history of left pneumonectomy for lung cancer 12 years result of previous pneumonectomy, i.e. hyperexpansion ago, and further received left transthoracic esophagec- of the right lung, mediastinal shift to the left hemi- tomy for a newly diagnosed esophageal cancer. thorax, elevation of the left hemidiaphragm and reduced left intrathoracic space with heterogeneous opacification (Fig. 1). No metastasis or lymphadenopathy was found Case presentation after thorough examination including brain magnetic A 72-year-old man came to our department with progres- resonance imaging (MRI) and bone scan. Pulmonary sive dysphagia for nearly 2 months. At presentation, he function test showed a forced expiratory volume in could only take down fluid. The patient used tobacco and one second (FEV1) of 0.98 L (46.6% of predicted) and a alcohol before he underwent left pneumonectomy for a forced vital capacity (FVC) of 1.12 L (40.8% of predicted). pT2N0M0 primary squamous cell lung cancer 12 years No neoadjuvant treatment was given to the patient. ago, which was followed by 4 cycles of gemcitabine/ Based on the patient’s will and examination results, a left transthoracic esophagectomy with the ad hoc design of retrograde esophageal dissection and superior diaphragmatic * Correspondence: dxjs1961@sina.com reconstruction was pursuit for curative intent. This proced- Department of Thoracic Surgery, Ningbo First Hospital, Ningbo 315010, ure was initiated with a regular posterolateral thoracotomy. China Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Li et al. Journal of Cardiothoracic Surgery (2018) 13:57 Page 2 of 4 Fig. 1 Preoperative computed tomography imaging of the patient showed typical postpneumonectomy changes, characterized by a hyperexpansion of the residual lung, mediastinal shift to the opacified postpneumonectomy space (asterisk) as well as b elevation of the hemidiaphragm superior to the level of the esophageal mass Thoracic probing identified the imaging-proven anomalies that highly obscured normal anatomy. As such, retrograde dissection starting from the abdomen was justified. This was achieved by the standard abdominal compo- nent of a typical left transthoracic esophagectomy (Fig. 2), which included exploration of the upper abdo- men, gastric mobilization with vascular pedicles and lymph node dissection. Retrograde dissection of the esophagus was facilitated by the elevated diaphragm, which stretched and widened the esophageal hiatus. It was carried cephalad until 5 cm proximal to the esophageal mass, at which point the esophagus was transected. After the frozen section con- firmed negative margin, the gastric conduit was pre- pared, and an end-to-end esophagogastric anastomosis was performed with an intraluminal circular stapler (Frankeman International Ltd., Suzhou, China), rein- forced by several 4–0 absorbable sutures. An abdominal drainage tube was placed, and the diaphragmatic was reanastomosed superior to the esophagogastric anasto- mosis for an intentional precaution of postoperative anastomotic complications (Fig. 3). In the end, one chest tube was inserted, and decompression and nasojejunal feeding were initiated right after surgery. In the postoperative course, ambulation was initiated on postoperative day (POD) 4. Oral feeding was restored on POD 7. Thoracic and abdominal drainage were ter- minated on POD 11 and POD 12 respectively after con- firmation of anastomotic integrity. The patient was discharged on POD 14 with a normal chest CT. Postop- Fig. 2 The retrograde dissection was initiated at the hiatus and carried cephalad after the abdominal operation was completed. The erative pathology revealed a stage IIA primary adenos- dashed lines denote the incision line of the diaphragm and the quamous esophageal carcinoma adventitia involvement mediastinal pleura (pT3N0M0). Li et al. Journal of Cardiothoracic Surgery (2018) 13:57 Page 3 of 4 pulmonary reserve; third, to establish infra-diaphragmatic anastomosis to allow for improved management improved management for potential anastomotic leak. These are important as they circumvent the technical hurdles arising from the previous pneumonectomy while maintaining safety at a reasonable level. Also, this procedure distin- guished itself by taking advantage of the existing anatomic abnormalities without additional use of dedicated devices, thus making it more affordable and less technology demanding. As an alternative, transhiatal esophagectomy could be an approach that avoid thoracic entry. However, this approach was also compromised by postpneumonect- omy changes, and risk was further added by previous mediastinal lymph node dissection. Albeit our treatment proved to be useful in this patient, the surgical approach should be optimized on an individual basis, and the pro- cedure presented here is only applicable for tumor of the lower esophagus. The lesson we took from this case is that a mindset of out-of-the-box thinking should always be ready for various real-life clinical scenarios. In summary, transthoracic esophagectomy post ipsilateral pneumonectomy is feasible, and safe dissection and extra- thoracic esophagogastric anastomosis can be achieved by even harnessing postpneumonectomy changes. An example is retrograde dissection plus infra-diaphragmatic esophago- gastric anastomosis, which facilitates transthoracic esopha- Fig. 3 Reconstruction of the gastrointestinal tract with the diaphragm being anastomosed superior to its original position so gectomy for cancers of the lower esophagus. that the esophagogastric anastomosis was left in the abdomen Abbreviations CT: Computed tomography; MRI: Magnetic resonance imaging; FEV1: Forced The patient was followed up for 12 m, and was re- expiratory volume in one second; FVC: Forced vital capacity; admitted once for incision wound infection on POD 30, POD: Postoperative day; ECMO: Extracorporeal membrane oxygenation which required open drainage but no antibiotic use. No relapse was found. Authors’ contributions QL Conception, manuscript writing, JG Conception, data collection, manuscript writing, CL Data collection, resource, XL Conception, data collection, resource, Discussion and conclusions manuscript writing. All authors read and approved the final manuscript. Esophagectomy in the setting of prior pneumonectomy is challenging and only few cases have been reported to date Ethics approval and consent to participate [1–5]. A dilemma remains regarding the approaching side, Ethics approval was obtained from the institutional review board. Consent to as pneumonectomy has left substantial deformity in the participate is not applicable in this case. ipsilateral thoracic space, whereas operating on the healthy side puts the residual lung at stake. Several techniques in- Consent for publication Written informed consent was obtained from the patient for the publication cluding endobronchial blockers [4] and extracorporeal of this report and any accompanying images. membrane oxygenation (ECMO) [5] have been introduced to enable surgery on the side contralateral to pneumonec- Competing interests tomy. However, in the current case, we opted to enter the The authors declare that they have no competing interests. pneumonectized hemithorax and performed transthoracic esophagectomy with adaptations of retrograde esophageal Publisher’sNote dissection and infra-diaphragmatic anastomosis. Springer Nature remains neutral with regard to jurisdictional claims in published The objectives of this method were three-fold: first, to maps and institutional affiliations. aid the dissection in the unfamiliar postpneumonectomy Author details area under the guidance of improved vision from the ab- Department of Thoracic Surgery, Ningbo First Hospital, Ningbo 315010, dominal side; second, to keep the contralateral hemi- 2 China. Department of Thoracic Surgery, Shanghai Pulmonary Hospital Tongji thorax intact so as to minimize impact on the residual University, Shanghai, China. Li et al. Journal of Cardiothoracic Surgery (2018) 13:57 Page 4 of 4 Received: 12 December 2017 Accepted: 30 May 2018 References 1. Petri R, Brizzolari M, Sorrentino M, Bassi F, Muzzi R, Zuccolo M. Minimally invasive esophagectomy in a previously pneumonectomized patient. J Laparoendosc Adv Surg Tech A. 2012;22(7):695–700. 2. Reardon MJ, Estrera AL, Conklin LD, Reardon PR, Brunicardi FC, Beall AC. Esophagectomy after pneumonectomy: a surgical challenge. Ann Thorac Surg. 2000;69(1):286–8. 3. Velotta JB, Vasquez CR, Sugarbaker DJ. Transhiatal esophagectomy after previous right pneumonectomy. J Thorac Cardiovasc Surg. 2014;148(2):e150–2. 4. Wang H, Liu J, Jiang C, Liu M, Jiang G. Transthoracic esophagectomy using endobronchial blocker after previous pneumonectomy. Ann Thorac Surg. 2014;97(2):723–5. 5. Xu HC, Ye P, Bao FC, Pan H, Yang YH, Wang LM, Wang ZT, Li ZB, He ZH, Han WL, et al. ECMO-assisted esophagectomy after left pneumonectomy. Int J Artif Organs. 2013;36(4):259–62. http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png Journal of Cardiothoracic Surgery Springer Journals

Postpneumonectomy transthoracic Esophagectomy – a case report: using anatomic change to create Extrathoracic Esophagogastric anastomosis

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Copyright © 2018 by The Author(s).
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Medicine & Public Health; Cardiac Surgery; Thoracic Surgery
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Abstract

Background: Resection of primary esophageal cancer following previous pneumonectomy is a challenging procedure and was scarcely reported. Case presentation: Here we report a case in which reduced thoracic space was used in left transthoracic esophagectomy to counter the difficulties caused by previous left pneumonectomy. Conclusion: Retrograde dissection and infra-diaphragmatic esophagogastric anastomosis are examples of using postpneumonectomy changes to facilitate subsequent transthoracic esophagectomy for cancers of the lower esophagus. Keywords: Pneumonectomy, Transthoracic esophagectomy, Esophageal cancer, Dissection, Esophagogastric anastomosis Background carboplatin doublet chemotherapy. At postoperative The occurrence of primary esophageal cancer after pre- follow-ups, he had been shown to be recurrence free. ceding pneumonectomy for primary lung cancer is rare. Barium swallow and esophagogastroduodenoscopy For patients with previous pneumonectomy, transtho- were ordered and a distal esophageal mass was identified racic esophagectomy is always technically challenging which was 36 cm from the incisors with extension to the given the postpneumonectomy anatomic deviations and cardia. Biopsy confirmed poorly differentiated adenocar- a solitary lung as the remaining pulmonary reserve cinoma. Computed tomography (CT) of the chest and [1, 2]. We herein report a case of an adult patient who had abdomen demonstrated marked anatomic changes as a a history of left pneumonectomy for lung cancer 12 years result of previous pneumonectomy, i.e. hyperexpansion ago, and further received left transthoracic esophagec- of the right lung, mediastinal shift to the left hemi- tomy for a newly diagnosed esophageal cancer. thorax, elevation of the left hemidiaphragm and reduced left intrathoracic space with heterogeneous opacification (Fig. 1). No metastasis or lymphadenopathy was found Case presentation after thorough examination including brain magnetic A 72-year-old man came to our department with progres- resonance imaging (MRI) and bone scan. Pulmonary sive dysphagia for nearly 2 months. At presentation, he function test showed a forced expiratory volume in could only take down fluid. The patient used tobacco and one second (FEV1) of 0.98 L (46.6% of predicted) and a alcohol before he underwent left pneumonectomy for a forced vital capacity (FVC) of 1.12 L (40.8% of predicted). pT2N0M0 primary squamous cell lung cancer 12 years No neoadjuvant treatment was given to the patient. ago, which was followed by 4 cycles of gemcitabine/ Based on the patient’s will and examination results, a left transthoracic esophagectomy with the ad hoc design of retrograde esophageal dissection and superior diaphragmatic * Correspondence: dxjs1961@sina.com reconstruction was pursuit for curative intent. This proced- Department of Thoracic Surgery, Ningbo First Hospital, Ningbo 315010, ure was initiated with a regular posterolateral thoracotomy. China Full list of author information is available at the end of the article © The Author(s). 2018 Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated. Li et al. Journal of Cardiothoracic Surgery (2018) 13:57 Page 2 of 4 Fig. 1 Preoperative computed tomography imaging of the patient showed typical postpneumonectomy changes, characterized by a hyperexpansion of the residual lung, mediastinal shift to the opacified postpneumonectomy space (asterisk) as well as b elevation of the hemidiaphragm superior to the level of the esophageal mass Thoracic probing identified the imaging-proven anomalies that highly obscured normal anatomy. As such, retrograde dissection starting from the abdomen was justified. This was achieved by the standard abdominal compo- nent of a typical left transthoracic esophagectomy (Fig. 2), which included exploration of the upper abdo- men, gastric mobilization with vascular pedicles and lymph node dissection. Retrograde dissection of the esophagus was facilitated by the elevated diaphragm, which stretched and widened the esophageal hiatus. It was carried cephalad until 5 cm proximal to the esophageal mass, at which point the esophagus was transected. After the frozen section con- firmed negative margin, the gastric conduit was pre- pared, and an end-to-end esophagogastric anastomosis was performed with an intraluminal circular stapler (Frankeman International Ltd., Suzhou, China), rein- forced by several 4–0 absorbable sutures. An abdominal drainage tube was placed, and the diaphragmatic was reanastomosed superior to the esophagogastric anasto- mosis for an intentional precaution of postoperative anastomotic complications (Fig. 3). In the end, one chest tube was inserted, and decompression and nasojejunal feeding were initiated right after surgery. In the postoperative course, ambulation was initiated on postoperative day (POD) 4. Oral feeding was restored on POD 7. Thoracic and abdominal drainage were ter- minated on POD 11 and POD 12 respectively after con- firmation of anastomotic integrity. The patient was discharged on POD 14 with a normal chest CT. Postop- Fig. 2 The retrograde dissection was initiated at the hiatus and carried cephalad after the abdominal operation was completed. The erative pathology revealed a stage IIA primary adenos- dashed lines denote the incision line of the diaphragm and the quamous esophageal carcinoma adventitia involvement mediastinal pleura (pT3N0M0). Li et al. Journal of Cardiothoracic Surgery (2018) 13:57 Page 3 of 4 pulmonary reserve; third, to establish infra-diaphragmatic anastomosis to allow for improved management improved management for potential anastomotic leak. These are important as they circumvent the technical hurdles arising from the previous pneumonectomy while maintaining safety at a reasonable level. Also, this procedure distin- guished itself by taking advantage of the existing anatomic abnormalities without additional use of dedicated devices, thus making it more affordable and less technology demanding. As an alternative, transhiatal esophagectomy could be an approach that avoid thoracic entry. However, this approach was also compromised by postpneumonect- omy changes, and risk was further added by previous mediastinal lymph node dissection. Albeit our treatment proved to be useful in this patient, the surgical approach should be optimized on an individual basis, and the pro- cedure presented here is only applicable for tumor of the lower esophagus. The lesson we took from this case is that a mindset of out-of-the-box thinking should always be ready for various real-life clinical scenarios. In summary, transthoracic esophagectomy post ipsilateral pneumonectomy is feasible, and safe dissection and extra- thoracic esophagogastric anastomosis can be achieved by even harnessing postpneumonectomy changes. An example is retrograde dissection plus infra-diaphragmatic esophago- gastric anastomosis, which facilitates transthoracic esopha- Fig. 3 Reconstruction of the gastrointestinal tract with the diaphragm being anastomosed superior to its original position so gectomy for cancers of the lower esophagus. that the esophagogastric anastomosis was left in the abdomen Abbreviations CT: Computed tomography; MRI: Magnetic resonance imaging; FEV1: Forced The patient was followed up for 12 m, and was re- expiratory volume in one second; FVC: Forced vital capacity; admitted once for incision wound infection on POD 30, POD: Postoperative day; ECMO: Extracorporeal membrane oxygenation which required open drainage but no antibiotic use. No relapse was found. Authors’ contributions QL Conception, manuscript writing, JG Conception, data collection, manuscript writing, CL Data collection, resource, XL Conception, data collection, resource, Discussion and conclusions manuscript writing. All authors read and approved the final manuscript. Esophagectomy in the setting of prior pneumonectomy is challenging and only few cases have been reported to date Ethics approval and consent to participate [1–5]. A dilemma remains regarding the approaching side, Ethics approval was obtained from the institutional review board. Consent to as pneumonectomy has left substantial deformity in the participate is not applicable in this case. ipsilateral thoracic space, whereas operating on the healthy side puts the residual lung at stake. Several techniques in- Consent for publication Written informed consent was obtained from the patient for the publication cluding endobronchial blockers [4] and extracorporeal of this report and any accompanying images. membrane oxygenation (ECMO) [5] have been introduced to enable surgery on the side contralateral to pneumonec- Competing interests tomy. However, in the current case, we opted to enter the The authors declare that they have no competing interests. pneumonectized hemithorax and performed transthoracic esophagectomy with adaptations of retrograde esophageal Publisher’sNote dissection and infra-diaphragmatic anastomosis. Springer Nature remains neutral with regard to jurisdictional claims in published The objectives of this method were three-fold: first, to maps and institutional affiliations. aid the dissection in the unfamiliar postpneumonectomy Author details area under the guidance of improved vision from the ab- Department of Thoracic Surgery, Ningbo First Hospital, Ningbo 315010, dominal side; second, to keep the contralateral hemi- 2 China. Department of Thoracic Surgery, Shanghai Pulmonary Hospital Tongji thorax intact so as to minimize impact on the residual University, Shanghai, China. Li et al. Journal of Cardiothoracic Surgery (2018) 13:57 Page 4 of 4 Received: 12 December 2017 Accepted: 30 May 2018 References 1. Petri R, Brizzolari M, Sorrentino M, Bassi F, Muzzi R, Zuccolo M. Minimally invasive esophagectomy in a previously pneumonectomized patient. J Laparoendosc Adv Surg Tech A. 2012;22(7):695–700. 2. Reardon MJ, Estrera AL, Conklin LD, Reardon PR, Brunicardi FC, Beall AC. Esophagectomy after pneumonectomy: a surgical challenge. Ann Thorac Surg. 2000;69(1):286–8. 3. Velotta JB, Vasquez CR, Sugarbaker DJ. Transhiatal esophagectomy after previous right pneumonectomy. J Thorac Cardiovasc Surg. 2014;148(2):e150–2. 4. Wang H, Liu J, Jiang C, Liu M, Jiang G. Transthoracic esophagectomy using endobronchial blocker after previous pneumonectomy. Ann Thorac Surg. 2014;97(2):723–5. 5. Xu HC, Ye P, Bao FC, Pan H, Yang YH, Wang LM, Wang ZT, Li ZB, He ZH, Han WL, et al. ECMO-assisted esophagectomy after left pneumonectomy. Int J Artif Organs. 2013;36(4):259–62.

Journal

Journal of Cardiothoracic SurgerySpringer Journals

Published: Jun 5, 2018

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