J Med Assoc Thai Vol. 93 No. 9 2010 1103

Correspondence to:Tharavej C, Department of Surgery, Faculty of Medicine,Chulalongkorn Hospital, Sirinthorn Building, 1873 Rama 4 Rd,Bangkok 10330, Thailand.Phone: 0-2256-4117E-mail: Chadin@gmail.com

Thoracoscopic Approach for Esophageal Resection inChronic Severe Corrosive Esophageal Stricture:

Report of 2 CasesChadin Tharavej MD*, Patpong Navicharern MD*,

Suthep Udomsawaengsup MD*, Suppa-art Pungpapong MD*

* Department of Surgery, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand

Objective: The authors reported the feasibility and safety of thoracoscopic approach for resection of the esophagus in twopatients with diffuse corrosive esophageal stricture.Background: The unrelenting corrosive strictures of esophagus merit esophageal substitution. Because of the risk ofcomplications in the retained esophagus, such as malignancy, mucocele, gastroesophageal reflux, and bleeding, esophagealresection is deemed necessary. Transthoracic approach for esophageal resection is considered safe but requiring thoracotomy.Transhiatal resection of a scared esophagus could be associated with serious complications. Less was known regarding thesafety and feasibility of thoracoscopic resection of the esophagus in corrosive stricture of the esophagus.Material and Method: Thoracoscopic approach was used for mobilization of the scarred esophagus in two female patients.Laparotomy with colonic mobilization was performed in the second phase of the operation. Pharyngocolonic and esophagocolonicanastomosis were done via left neck incision in each patient. Intra-operative and post-operative complications were observed.Swallowing ability was assessed in the early postoperative period.Results: Thoracoscopic esophageal mobilization was successfully performed without complications. Any adhesions aroundthe esophagus could be clearly seen and divided using harmonic scalpel under direct vision. Operative duration of thethoracoscopic part was 104 and 120 minutes and total blood loss was 320 and 350 ml respectively. Postoperative period wasuneventful. The patient could have regular diet on day 8 and 9 after surgery.Conclusion: Thoracoscopic approach for esophageal resection could be safely performed for the extirpation of diffuseesophageal stricture. Postoperative complication is being assessed in the authors’ prospective trial.

Keywords: Thoracoscopic, Esophagectomy, Corrosive esophageal stricture

Esophageal substitution is one of thetreatments of choice in chronic unrelenting corrosiveesophageal stricture. The standard operative treatmentfor corrosive esophageal stricture has been eithercolonic bypass or esophagectomy. Because of the riskof complications in the retained esophagus, such asmalignancy, mucocele, gastroesophageal reflux, andbleeding, esophageal resection is deemed necessary.Transthoracic approach for esophageal resection isconsidered safe but requiring thoracotomy. Transhiatalresection of a scared esophagus could be associated

with serious complications including bleeding andtracheobronchial injury.

Minimally invasive surgery for esophagectomyhas been reported since 1992(1). These approaches toesophagectomy are based on the premise of reducingthe morbidity of the access incision by substitutingthe thoracotomy with thoracoscopy. The commondenominator in minimally invasive surgery is toperform the same operation as in the open approachbut through a smaller access incision. By reducingthe size of the access incision, the operative traumaassociated with the procedure is reduced withoutcompromising the principles of the surgical operation.Less was known regarding the safety and feasibility ofthoracoscopic esophageal resection in corrosivestricture of the esophagus. The present study aimedto report the feasibility of thoracoscopic approach for

J Med Assoc Thai 2010; 93 (9): 1103-6Full text. e-Journal: http://www.mat.or.th/journal

Case Report

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esophageal resection in two patients with severecorrosive stricture of the esophagus.

Case ReportCase 1

A thirty-one-year old female was referred toChulalongkorn Hospital with a history of dysphagiafor 10 months. She had a history of corrosive agentingestion with suicidal attempt one year ago. At thattime, she presented with upper airway obstruction andtracheostomy was done at the primary hospital. Shedeveloped severe dysphagia two months later andfeeding jejunostomy was performed. She could haveneither liquid food nor water. She has lost 18 kilogramssince the injury. On physical examination, shewas malnourished. She had jejunostomy tube andtracheostomy. Upper GI endoscopy showed completeobliteration of pyriform sinuses. Similar finding wasalso demonstrated by barium swallow. She wasscheduled for thoracoscopic esophagectomy withcolonic interposition after 1 month of intensivenutritional support. A thoracoscopic mobilization ofthe entire esophagus was carried out with a 4-porttechnique (Fig. 1-4). After esophageal mobilizationwas completed, the patient was turned to the supine

Fig. 2 Azygos vein was disconnected using endovascularstapler

Fig. 3 Middle third of the esophagus was lifted off fromnormal position

Fig. 4 The entire thoracic esophagus was completelymobilized

Fig. 1 Patient and port position for thoracoscopicesophageal mobilization: camera port 12 mm (C),2 working ports 5 mm (W), lung retractor port12 mm (R)

J Med Assoc Thai Vol. 93 No. 9 2010 1105

position. Upper abdominal midline incision wasperformed. Her stomach became a small (6 by 7 by 8 cm)fibrotic mass and total gastrectomy was unavoidable.Substernal left colonic interposition was used as anesophageal substitution. Cervical pharyngocolonicanastomosis and abdominal colojejunostomy weredone. Operative time and total blood loss forthoracoscopic part were 104 min and 320ml respectively.No intraoperative or postoperative complication wasobserved. She could have regular diet on day 8 afterthe operation.

Case 2A twenty-seven-year old female presented

with dysphagia for the last six months. She hadfeeding jejunostomy done from the outside hospital.She told that she had ingested a corrosive agentinadvertently seven months ago. Upper GI endoscopyrevealed severe stricture at 27 cm from incisor and wasunable to pass the scope. Barium swallow showed longstricture from upper thoracic esophagus all the way tothe esophagogastric junction. Her stomach wasdeformed with severe stricture at pylorus. She was puton nutritional support for three weeks. She underwentthoracoscopic esophageal mobilization with left sidecolonic interposition in the similar fashion to that ofthe first patient. Operative time and total blood loss forthoracoscopic part were 120 min and 350ml respectively.No intraoperative or postoperative complication wasevident. She could have solid food and was dischargedon day 10 after the operation.

DiscussionEsophageal resection has been condemned

as one of a high morbidity procedure. Up to40%morbidity rate after esophagectomy has beenreported. In an attempt to reduce morbidity fromesophageal resection, minimally invasive surgery hasbeen applied. To date, most reports of minimallyinvasive esophagectomy have focused mainly onesophageal cancer. Less was known regarding outcomeof minimally invasive surgery for corrosive esophagealstricture. In the present study, the authors successfullyapplied the thorocoscopic approach instead of openthoracotomy for esophageal mobilization in twopatients with severe corrosive esophageal stricture.

Over the past years, the standard esophagealresection operation for corrosive esophageal stricturehas been either the transthoracic or the transhiatalapproach. The downside of transthoracic esophagealresection is open thoracotomy, which is believed to

associate with a high-risk of pulmonary complications.The major concern for transhiatal approach is thelack of vision during mediastinal dissection of theesophagus. Because of the close proximity of the majorairways, aorta, and azygos vein, injury to these vitalstructures may occur during this blind dissection. Inaddition, severe adhesion around the esophagus andnearby structures associated with corrosive agentingestion increases further risk. The authors thereforeconsidered the application of minimally invasivetechniques to the thoracic dissection, allowingdissection under direct vision and without the need ofopen thoracotomy.

Techniques for thoracoscopic esophagealmobilization as part of a three-stage esophagectomyhave been previously described by manyinvestigators(2-8). However, the majority of thesepatients have esophageal cancer without focusingon severe corrosive esophageal stricture. Theseeight reports showed that 341 patients haveundergone attempted thoracoscopic mobilization oftheir esophagus, with a conversion rate of 6%, ananastomotic leak rate of 5%, and operative mortalityof 4%.

One significant finding that the authorsexperienced was a massive mediastinal adhesionaround the esophagus. This could make transhiatalesophageal resection complicated. No major structurewas injured during thoracoscopic dissection in thepresent study. In addition, no pulmonary complicationwas observed in these two patients after operation.They could resume their normal diet on day 8 aftersurgery.

In conclusion, the present report confirmsthat thoracoscopic approach for esophageal resectionin severe corrosive esophageal stricture is feasibleand safe. Whether morbidity rate is less than thatof standard operation needs to be clarified in aprospective trial.

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thoracoscopically assisted oesophagectomy forcancer. Br J Surg 1994; 81: 236-8.

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การผาตดหลอดอาหารโดยวธการผาตดผานกลองสอง ผานชองทรวงอกในผปวย หลอดอาหารตบจากการกนสารกดกรอนชนดไมสามารถรกษาดวยวธการถางขยายได: รายงานผปวย 2 ราย

ชฎล ธาระเวช, พฒนพงศ นาวเจรญ, สเทพ อดมแสวงทรพย, ศภอฐ พงพาพงศ

ภาวะหลอดอาหารตบจากการกนสารกดกรอนชนดทไมสามารถถางขยายได จำเปนตองไดรบการรกษาดวยการผาตดเปล ยนหลอดอาหารดวยอวยวะทดแทน ท งน เน องจากการท งหลอดอาหารท ต บโดยไมตดหลอดอาหารออกมภาวะเสยงทจะเกดโรคมะเรงหลอดอาหาร, มวโคซว, ภาวะกรดไหลยอน และภาวะเลอดออกจากหลอดอาหารตามมาได ดงนนหากตองการหลกเลยงความเสยงเหลานการตดหลอดอาหารออกเปนสงจำเปนเนองจากการตดหลอดอาหารวธมาตรฐานพบมปญหาแทรกซอนสง ศลยแพทยสวนใหญจงมกหลกเลยงการตดหลอดอาหารออก ในปจจบนการผาตดหลอดอาหารสามารถใชวธการผาตดผานกลองสองได รายงานสวนใหญการผาตดชนดนใชในการรกษามะเรงหลอดอาหาร สวนรายงานการผาตดทใชในการรกษาผปวยหลอดอาหารตบจากการกนสารกดกรอนยงมนอยมากวตถประสงค: คณะผ นพนธตองการรายงานความปลอดภยของการผาตดหลอดอาหาร ดวยวธการผาตดผานกลองสองทางชองทรวงอกในผปวยหลอดอาหารตบจากการกนสารกดกรอน 2 รายวสดและวธการ: การผาตดหลอดอาหารประกอบไปดวย 3 สวน สวนทหนงจะเปนการตดเลาะหลอดอาหารโดยผานการผาตดผานกลองสองทางชองทรวงอกดานขวา สวนทสองจะเปนการผาตดเปดแบบปกตผานชองทองเพอเตรยมลำไสใหญเพอใชเปนอวยวะทดแทนหลอดอาหาร และสดทายสวนทสามเปนการผาตดเปดผานแผลทคอดานซายเพ อนำลำไสใหญข นมาตอกบหลอดอาหารหรอหลอดคอ หลงการผาตดคณะผนพนธจะสงเกตและบนทกภาวะแทรกซอนตาง ๆ และความสามารถในการกลนผลการศกษา: การผาตดหลอดอาหารดวยวธการผาตดผานกลองสองสำเรจไดดวยด ในผปวยหลอดอาหารตบจากสารกดกรอนทงสองราย พงผดจากการอกเสบรอบหลอดอาหารสามารถมองเหนไดอยางชดเจนขณะผาตดและสามารถตดเลาะไดอยางปลอดภย หลกเลยงการบาดเจบทอาจเกดขนไดถาใชการผาตดหลอดอาหารดวยวธผาตดผานชองระหวางกะบงลมจากดานลาง (transhiatal) ระยะเวลาการผาตดในชวงการผาตดผานกลอง เพอตดเลาะหลอดอาหารเทากบ 104 และ 120 นาท ตามลำดบ โดยมการเสยเลอดไมมากเพยง 320 และ 350 มลลลตร ตามลำดบหลงการผาตดไมพบภาวะแทรกซอนใดๆในผปวยทงสองราย ผปวยสามารถกนอาหารปกตไดในวนท 8 และ 9หลงการผาตดสรป: การผาตดหลอดอาหารดวยวธการผาตดผานกลองทางชองทรวงอกสามารถทำไดอยางปลอดภย ในผปวยทมหลอดอาหารตบจากการกนสารกดกรอนชนดทไมสามารถรกษาดวยวธการถางขยายได

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