Successful Left Thoracoscopic Esophagectomy for Congenital Esophageal Stenosis with a Useful Adjunct of Preoperative Endoscopic Marking

Abstract

Introduction:

Minimally invasive surgery is an alternative to open surgery in esophageal resection. Several studies have described thoracoscopic esophagectomy for esophageal stenosis in children. ^{1 –3} It is standard to conduct esophagectomy from the right thoracic cavity, so the aorta does not obstruct the procedure. So far, there have been no reports on left thoracoscopic esophagectomy in children. In a case of congenital esophageal stenosis, where the lesioned part was close to the esophagogastric junction, we show a successful left thoracoscopic esophagectomy with a useful adjunct of preoperative endoscopic marking.

Materials and Methods:

A 3-year-old female with Down's syndrome presented with the chief complaint of vomiting after eating solid food. The esophagogram and the esophageal endoscope revealed a pinhole stenosis in the lower esophagus, diagnosed as congenital esophageal stenosis. Balloon dilation was performed twice; however, esophageal perforation occurred on the second dilation. The symptoms did not improve after this, and so we performed thoracoscopic esophagectomy. Just before the thoracoscopic surgery, esophageal stricture was marked by injecting crystal violet using an esophageal endoscope. After this, in a right lateral decubitus position, four 5-mm ports and 3-mm forceps were inserted into the left thoracic cavity in the seventh intercostal space, anterior-axillary line; seventh intercostal space, midaxillary line; fifth intercostal space, midaxillary line; and sixth intercostal space, posterior axillary line. A 5-mm, 30-degree telescope was used. After the incision of the mediastinal pleura, the constricted part could be easily found by the dye mark. Dissection from the central esophagus to before the esophageal hiatus was thoroughly performed. A semicircle incision was made on the anal side of the stained part and extended to the oral side longitudinally. The constricted part was slightly thick and stiff. The position of the stump on the oral side was decided as above the constricted part, where the luminal diameter was sufficient. Anastomosis was performed with six stitches of 4-0 PDS knotted suture.

Results and Conclusions:

In the incised pathology specimen, the ciliated epithelium and bronchial glands were observed, but no cartilaginous tissues, and the patient was diagnosed with esophageal stenosis due to tracheobronchial remnants. A minor leakage was seen in the esophagogram 7 days after the operation; however, it healed with conservative treatment. Three months after the operation, the patient is eating baby food, and vomiting does not occur. In conclusion, left thoracoscopic views were excellent, and manipulations of the lower esophagus were easily handled. Injecting crystal violet into the mucous membrane of the constricted part with an esophageal endoscope before the operation made it easy to verify the constricted part with a thoracoscope.

No competing financial interests exist.

Runtime of video: 4 mins 56 secs