Minimally Invasive Esophagectomy After Permanent Dual Esophageal Stent Placement

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Clinical Presentation and Preoperative Course 

 A 72-year-old male presented with significant weight loss and dysphagia for one month. His medical history included coronary artery disease (s/p LAD stent), NSTEMI (on Plavix), atrial fibrillation (on Pradaxa), heart failure with reduced ejection fraction (EF 40 percent), diabetes, and hypertension. An esophagogastroduodenoscopy (EGD) showed a circumferential lobulated mass at the gastroesophageal (GE) junction, and a CT revealed a 3.0×3.5×3.9 cm mass with partial esophageal obstruction. 
 
Endoscopic ultrasound (EUS) confirmed a T3N1M0 GE junction adenocarcinoma (Siewert Type 1). Two overlapping permanent esophageal stents were placed with endoscopic stitches. A PET scan showed an increased standardized uptake value (SUV) at the GE junction without distant disease. The patient underwent neoadjuvant carboplatin, paclitaxel, and radiation therapy (CROSS trial regimen), with PET restaging showing a good response. 

Minimally Invasive Esophagectomy (MIE) 

The procedure began with laparoscopic mobilization of the stomach. The gastrohepatic ligament and lesser curvature were dissected, and a Penrose drain was secured around the GE junction for gastric conduit retrieval during the thoracic phase. The greater curvature was mobilized while preserving the gastroepiploic artery, with division of the short gastric arteries and transection of the left gastric artery. Dense adhesions from stent placement and radiation were encountered. The distal stent was removed, while the proximal stent was left in place to assist with gastric conduit retrieval. 
 
The stomach was tubularized along the lesser curvature using a thick-tissue stapler. Sutures were placed around the proximal stent and lesser curvature to secure the specimen for retrieval during the thoracoscopic phase. 
 
In the thoracoscopic phase, the patient was placed in the left lateral decubitus position. The mediastinal envelope was dissected superiorly to the azygos vein, which was divided with a vascular stapler. Dissection continued inferiorly toward the hiatus, with circumferential mobilization of the esophagus. An additional Penrose drain was used to assist with retraction. 
 
The diaphragm was partially dissected to visualize the stent. The esophagus was incised, and a 28 mm EEA stapler anvil was secured with purse-string sutures. The esophagus was fully transected, and the gastric conduit with the stent was pulled into the thoracic cavity. The proximal stent was removed through the posterior utility port. A gastrotomy near the staple line allowed for the placement of the stapler, creating the esophagogastric anastomosis. The anastomotic donuts were intact, and the stomach was further tubularized. The specimen was removed through the utility port, and the mediastinal envelope was closed with interrupted sutures. 
 
Intercostal nerve blockade with Exparel was performed, and chest drains were placed. The patient tolerated the procedure well. 
 
Postoperative Course 

The patient began a liquid diet on postoperative day one and was discharged on day three, per Enhanced Recovery After Surgery (ERAS) protocol. 
 
Key Takeaways 

This case demonstrates that an Ivor Lewis MIE is feasible despite challenges from stents and radiation-induced fibrosis. Dense adhesions required extensive proximal esophageal resection, complicating the anastomosis. Preoperative stenting should be avoided in operable esophageal cancer patients. However, MIE with mediastinal envelope closure can be safely performed using the ERAS protocol.

References

1. Van Hagen P, Hulshof MCCM, Van Lanschot JJB, et al. Preoperative Chemoradiotherapy for Esophageal or Junctional Cancer. N Engl J Med. 2012;366(22):2074-2084. doi:10.1056/NEJMoa1112088
2. Helminen O, Sihvo E, Helmiö M, et al. Preoperative Esophageal Stenting and 5-Year Survival in Patients Undergoing Esophagectomy for Esophageal Cancer: a Population-Based Nationwide Study from Finland. J Gastrointest Surg. 2023;27(6):1078-1088. doi:10.1007/s11605-023-05643-7
3. Nagaraja V, Cox MR, Eslick GD. Safety and efficacy of esophageal stents preceding or during neoadjuvant chemotherapy for esophageal cancer: a systematic review and meta-analysis. J Gastrointest Oncol. 2014;5(2):119-126. doi:10.3978/j.issn.2078-6891.2014.007
4. Banks KC, Alcasid NJ, Susai C, Velotta JB. Standardized Operative Approach for Total Minimally Invasive Ivor Lewis Esophagectomy in Hostile Abdomen. March 2023. doi:10.25373/ctsnet.22220854.v1
5. Banks KC, Barnes KE, Wile RK, Hung YY, Santos J, Hsu DS, Choe G, Elmadhun NY, Ashiku SK, Patel AR, Velotta JB. Outcomes of Anastomotic Evaluation Using Indocyanine Green Fluorescence During Minimally Invasive Esophagectomy. Am Surg. 2022 Nov 3:31348221138084. doi: 10.1177/00031348221138084.

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