Subcarinal lymphadenectomy is an essential procedure in curative esophagectomy for esophageal cancer. The right superior pulmonary vein (RSPV) and its branches are usually located in front of the right main or intermediate bronchus. However, an anomalous posterior branch (aberrant V2) of RSPV passes behind the right intermediate bronchus, where the aberrant V2 may be embedded in the subcarinal nodal packet. This can lead to unanticipated bleeding when dissecting the subcarinal lymph node. We present a case study on the use of preoperative three-dimensional contrast-enhanced computed tomography (3D-CT) for performing a safe video-assisted thoracoscopic surgery-esophagectomy in lower thoracic esophageal cancer.
A 77-year-old man had esophageal cancer associated with an aberrant V2 passing behind the right intermediate bronchus. Esophagogastroduodenoscopy revealed a type 1 tumor in the lower thoracic esophagus. Contrast-enhanced and 3D-CT scans showed a space-occupying lesion with contrast enhancement and an aberrant V2 passing behind the right intermediate bronchus, respectively. The patient was then diagnosed with lower thoracic esophageal cancer (cT2cN1cM0 cStage II). As per the patient’s request, he underwent a surgery-first approach followed by adjuvant chemotherapy. The patient underwent video-assisted thoracoscopic surgery-esophagectomy (VATS-E) with three-field lymphadenectomy, and a large aberrant V2 involving the subcarinal nodal packet was recognized behind the right intermediate bronchus. After the thoracoscopic subtotal esophagectomy with three-field lymph node dissection, laparoscopy-assisted reconstruction of the esophagus was performed with elevation of the gastric conduit to the neck. Recurrent laryngeal nerve palsy was not observed. He started to receive rehabilitation for swallowing on day 3 and resumed oral intake on day 10 after surgery. The final pathological diagnosis was squamous cell carcinoma of the esophagus (pT3N1M0 pStageIII).
Preoperative contrast-enhanced 3D-CT clearly depicted the aberrant V2, which enabled us to perform a safe VATS-E with three-field lymphadenectomy. Thorough understanding of the anatomical configuration of the pulmonary vessels and bronchus is important for avoiding unexpected bleeding during subcarinal lymphadenectomy. 3D-CT imaging study is useful for recognizing the anomalous RSPV before surgery.
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