Subcarinal lymphadenectomy during minimally invasive esophagectomy with 2 anomalous pulmonary veins.

Central MessageSubcarinal lymphadenectomy during minimally invasive esophagectomy with 2 anomalous pulmonary veins with the help of preoperative 3D imaging technology plus MIE. Subcarinal lymphadenectomy during minimally invasive esophagectomy with 2 anomalous pulmonary veins with the help of preoperative 3D imaging technology plus MIE. Subcarinal lymphadenectomy is an essential procedure in curative esophagectomy for esophageal cancer.1Ando N. Ozawa S. Kitagawa Y. Shinozawa Y. Kitajima M. Improvement in the results of surgical treatment of advanced squamous esophageal carcinoma during 15 consecutive years.Ann Surg. 2000; 232: 225-232Crossref PubMed Scopus (499) Google Scholar The right superior pulmonary vein (RSPV) and its branches are usually located anterior to the right main or intermediate bronchus.2Matsubara T. Hirahara N. Zotani H. Tabara N. Tabara H. Tajima Y. Three-dimensional computed tomography image-oriented successful thoracoscopic subtotal esophagectomy for an esophageal cancer patient with an anomalous right superior pulmonary vein: a case report.Int J Surg Case Rep. 2020; 76: 178-182Crossref PubMed Scopus (2) Google Scholar Anomalous vessels are sometimes found during surgery.3Sumitomo R. Fukui T. Otake Y. Huang C.L. Video-assisted thoracoscopic lobectomy with an anomalous pulmonary vein.J Thorac Cardiovasc Surg. 2016; 152: 1398-1399Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar However, 2 anomalous coexisting branches, 1 passing posterior to the right main bronchus the other passing through the middle of the right main bronchus and pulmonary artery, jointly draining into the right atrium, is extremely rare. A 66-year-old woman presented with swallowing difficulty for the past 1 month and therefore was referred to our hospital. Past medical history included hypertension and cervical spine surgery. The patient's height and weight were 158 cm and 62 kg, respectively, with a body mass index of 24.8. Esophagogastroduodenoscopy showed a neoplasm of T2 stage in the middle thoracic esophagus, and pathological analysis of the tumor biopsy demonstrated squamous cell carcinoma. Contrast-enhanced computed tomography (CT) scans showed a space-occupying lesion measuring 3 × 2 cm in the lower thoracic esophagus. Whole-body 18F fluorodeoxyglucose-positron emission tomography CT scan revealed no metastatic lymph nodes. Moreover, 3-dimensional CT images clearly showed 2 anomalous coexisting branches, 1 passing posterior to the right main bronchus the other passing through the middle of the right main bronchus and pulmonary artery, jointly draining into the right atrium (Figure 1). The patient was finally diagnosed with lower thoracic esophageal cancer (cT2 N0 M0) according to the Japanese Classification of Esophageal Cancer. The patient underwent McKeown minimally invasive esophagectomy (MIE) with 2-field lymph node dissection. Initially, the patient was placed in the left lateral decubitus position. Four ports were placed in the chest (2 ports in the fourth and seventh intercostal space on posterior axillary line and 2 ports in the sixth and ninth intercostal space on the subscapular angle line) and the thoracic esophagus was mobilized, after which the subcarinal lymph nodes were harvested. During the operation, the subcarinal lymph nodes were removed along with the esophagus. Firstly, through the left side of the esophagus, the subcarinal lymph nodes were sufficiently separated from the left main bronchus. The mediastinal pleura was then opened at the border of the right main bronchus and the right lower lobe, and the subcarinal lymph nodes were subsequently separated from the right main bronchus. The patient's first anomalous pulmonary vein could be observed posterior to the right main bronchus into the pericardium. During the process of dissociating the tissue, a second anomalous pulmonary vein was seen to flow into the pericardium through the anterior of the right main bronchus. Throughout the procedure, the subcarinal lymph nodes were carefully removed to protect the 2 variant pulmonary veins from injury (Figure 2 and Video 1). Following the thoracic procedure, the patient was transferred to the supine position. The stomach was then mobilized, with careful preservation of the right gastroepiploic pedicle. Linear cutting staplers (EC60; Ethicon) were then used to make a 4-cm-wide gastric tube. Finally, a hand-sewn, 3-layer embedded cervical anastomosis was constructed between the proximal esophagus and the gastric tube. The patient started oral feeding at postoperative day 1 and was discharged on postoperative day 7. The venous drainage system from the right upper lobe of the lung usually comprises 3 main segmental veins that ordinarily run inside the right lung and merge with the RSPV.4Yamada S. Suga A. Inoue Y. Iwazaki M. Importance of preoperative assessment of pulmonary venous anomaly for safe video-assisted lobectomy.Interact Cardiovasc Thorac Surg. 2010; 10: 851-854Crossref PubMed Scopus (22) Google Scholar Some anomalies of the right pulmonary vein have been reported as highly frequent among surgical cases of lung cancer surgery, relative to the left side.5Tsuboi M. Asamura H. Naruke T. Nakayama H. Kondo H. Tsuchiya R. A VATS lobectomy for lung cancer in a patient with an anomalous pulmonary vein: report of a case.Surg Today. 1997; 27: 1074-1076Crossref PubMed Scopus (13) Google Scholar In such cases with aberrant veins there could be pitfalls, including massive bleeding during subcarinal lymphadenectomy because an anomalous RSPV is likely to involve the subcarinal nodal packet. In this case, the 2 anomalous pulmonary veins pass anterior and posterior to the right main bronchus, eventually jointly draining into the pericardium. It would have been difficult to identify the course of the mutated blood vessels relying on routine CT examination. The three-dimensional (3D) imaging showed the 2 anomalous veins passing anterior and posterior to the right main bronchus. Without this preoperative information, the subcarinal lymph node dissection would have been difficult to perform safely. As mentioned above, the aberrant veins were identified using contrast-enhanced CT imaging; exact preoperative 3D anatomical recognition of anomalous RSPVs is important to reduce the risk of fatal complications during subcarinal lymphadenectomy. MIE has been accepted as a common operation for esophageal cancer. It is less invasive and is useful for visualizing structural details. MIE plus preoperative 3D imaging technology can provide a guarantee for the safety of surgery. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiIzN2JiMjVlNWUwMTliMDkzZGQyYzNkN2ZlMGNjNGE3MSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjk0ODY4MDE4fQ.a6XdHucDhhQHztxxDlaDTHkK3vxxrN-Pzk1YBeWCJx5_wEGzEctpG5tKxChNH2c4CK5lYCDN2BwKAKdD31ekJ9U56fF-5wPWhkMoClIxjPj46E8M185eE8JXmNA6q51L0HWSmRoTWULy52k9y4TcxUEVEg-LUvdmhY9Tkt6kcZ3Zv95D0Z2rSVpcuxDMS55ceEaqxhh713EwKZqTOyWo6cQFP5ZOmEL0dd49o157WAleMlg_YBg4aQ2TrMxXzIhLIVxAJv20IwkBkAOOQoG2NcSk9mfh4frwqNVx1nK3QWyi8rdksenEmbWK2h152T89MxozmxpEoHOO4m-J3EEhcw Download .mp4 (66.88 MB) Help with .mp4 files Video 1The procedure that the subcarinal lymph nodes were carefully removed to protect 2 variant pulmonary veins from injury. Video available at: https://www.jtcvs.org/article/S2666-2507(23)00062-7/fulltext. Download .jpg (.38 MB) Help with files Video 1The procedure that the subcarinal lymph nodes were carefully removed to protect 2 variant pulmonary veins from injury. Video available at: https://www.jtcvs.org/article/S2666-2507(23)00062-7/fulltext.