704
4. 5. 6. 7. 8.
CASE REPORT JUNGRAITHMAYR ET AL INTRAPULMONAL LN MIMICKING METASTASES
extracorporeal membrane oxygenation stabilization. J Pediatr Surg 1991;26:333–8. Deb SJ. Massive right-sided Bochdalek hernia with two unusual findings: a case report. J Med Case Rep 2011;5:519. Cullen ML, Klein MD, Philippart AI. Congenital diaphragmatic hernia. Surg Clin North Am 1985;65:1115–38. Akhtar K, Qurashi K, Rizvi A, Isla R. Emergency laparoscopic repair of an obstructed Bochdalek hernia in an adult. Br J Hosp Med (Lond) 2009;70:718–9. Shah R, Reddy MM, Mascarenhas AF. Bochdalek hernia in an adult presenting as an emergency. Indian J Chest Dis Allied Sci 1986;28:237–40. Mullins ME, Stein J, Saini SS, Mueller PR. Prevalence of incidental Bochdalek’s hernia in a large adult population. AJR Am J Roentgenol 2001;177:363–6.
Anthracotic Intrapulmonal Lymph Nodes Mimicking Lung Metastases Wolfgang Jungraithmayr, MD, Barbara Delaloye-Frischknecht, MD, and Walter Weder, MD Division of Thoracic Surgery and Department of Diagnostic Radiology, University Hospital Zurich, Zurich, Switzerland
FEATURE ARTICLES
Intrapulmonal round lesions show characteristic radiologic features that distinguish them from other lung pathologies. Typically, they display a sharp margin with a homogenous inner pattern. Differential diagnosis includes metastases, particularly if the patient has a history of malignancy. However, benign lesions, although less common, should also be considered. We here present the case of a 58-year-old man with a history of bladder and prostate carcinoma, showing multiple typical round lesions on chest computed tomography, mimicking metastatic disease to the lung. Subsequently, wedge-resected specimens revealed anthracotic lymph nodes, so that intrapulmonal lymph nodes should be anticipated even in patients with preceding malignant disease. (Ann Thorac Surg 2014;98:704–6) Ó 2014 by The Society of Thoracic Surgeons
T
ypical round lesions within the lung display characteristic morphologic features with well-recognized criteria, including a round shape with a sharp margin and a homogenous inner pattern. The differential diagnosis of typical round lesions includes a wide variety of tumors, reaching from rare malignancies such as angiosarcomas to benign lesions as, for instance, hamartomas [1]. A suspected diagnosis of lung metastases should be particularly raised if the patient has a history of primary malignancy. Another type of lesion that is not
Accepted for publication Sept 30, 2013. Address correspondence to Dr Jungraithmayr, Division of Thoracic Surgery, University Hospital Zurich Raemistr 100, Zurich 8091, Switzerland; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2014;98:704–6
considered a classical lesion but rather a preexisting nodule within the lung, are intrapulmonal lymph nodes (LN). They become visible upon enlargement either due to metastatic disease or due to uptake of foreign material, or in rare instances, in case of lymph duct obstruction. However, intrapulmonal LN rarely reach the size of typical round lesions nor do they resemble lung metastases, thus metastatic disease. This is a case of a patient with a history of bladder and prostate carcinoma presenting with multiple round lesions within the lung highly suggestive for pulmonary metastases, but histologically proved to be intrapulmonal anthracotic LN. A 58-year-old man was referred to our division by the urology department. In December 2012, he was simultaneously diagnosed with prostate carcinoma (pT2pN0) and bladder carcinoma (pT1pN0). These malignancies were treated by radiochemotherapy including four cycles of cisplatin and gemzar, to which the carcinomas responded well, and this treatment was followed by resection of the bladder and the prostate. At that time, chest computed tomography revealed numerous round lesions within the lung (Figs 1, 2). During the course of radiochemotherapy treatment, the pulmonary round lesions increased in size and numbers. No thoracic interventions were performed before. The patient’s general status of health was unremarkable, without respiratory distress. He had chronic obstructive pulmonary disease in stage GOLD II due to an active smoking history of 40 pack-years. He recently had pulmonary embolism on the right side, and has stable mild high blood pressure treated with metoprolol. He worked for 32 years in the finishing industry for metals (copper and other metals) during which time the patient worked with, but was never directly exposed to, metal dust or residues. After completion of the urologic interventions, we performed thoracoscopy and found wide adhesions, which made the finding of the described round lesions most difficult. After release of adhesions from the lower lobe, we succeeded in finding and wedge-resecting three of those described lesions, as depicted in Figures 1 and 2. Fresh frozen section did not reveal any malignancy. The definite histologic diagnosis confirmed the preliminary diagnosis, which corresponded to anthracotic LN.
Comment Intrapulmonally located LN are numerous and widely spread within the pulmonary tissue. However, under normal conditions, the size of intrapulmonary LN seldom exceeds a critical size, even if infiltrated by malignant cells or enlargement due to increased uptake of foreign material. Hilar LN, by contrast, normally reach a size that is comparable to LN from other locations such as axilla or groin. It is, therefore, surprising that intrapulmonal LN here were found to be almost 10 mm in size. Furthermore, as another unusual feature, these LN 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.09.109
Ann Thorac Surg 2014;98:704–6
CASE REPORT JUNGRAITHMAYR ET AL INTRAPULMONAL LN MIMICKING METASTASES
705
presented as round-shaped lesions with a sharp margin and a homogenous inner pattern, rendering all of them highly suggestive for pulmonary metastases. Additionally, these lesions were distributed throughout both lungs. Our preoperative diagnosis was, therefore, in favor of lung metastases. Indeed, most intrapulmonal LN seem to appear as single enlarged nodules rather than as multiple nodules [2]. Those found to be single nodules can in fact reach a size of 10 mm. As such, single nodules were evaluated by Ohtsuka and colleagues [3] for their dignity in a cohort of 82 patients, analyzing them in chest computed tomography scans, and of these, they found not fewer than 10 enlarged LN, but all of them were single lesions. Nagahiro and associates [2] reported three single nodules that increased in size after lobar resection for bronchial adenocarcinoma; these lesions turned out also to be intrapulmonary LN. One reason
for the growth of LN could be an obstruction of lymph draining ducts, either due to previous resection or to lung tissue remodeling. Wide adhesions—such as seen in this patient—which developed certainly not only because of emphysema, indicated previous inflammation, and that might have contributed to the enlargement of LN. Furthermore, this patient had an occupational history in metal coating, which might have also contributed to adhesions, inflammation, and LN enlargement. To the best of our knowledge, no association has been described between metal exposure and intrapulmonal LN enlargement. Also, no traces of metal dust were found within the resected LN. Intrapulmonal LN are reported to be oval, rather than strictly round [2, 4], which applies to the majority of the LN found here. Of note, the LN here all appeared in the basal segments of the lung. Another aspect of a typical feature of intrapulmonary LN is that they are often
Fig 2. Computed tomography of the chest shows another example of a typical round lesion (arrows) in (A) the sixth segment of the left lower lobe in the sagittal plane, as well as in (B) the axial plane.
FEATURE ARTICLES
Fig 1. Computed tomography of the chest revealed a representative round lesion (arrows) in the lateral segment of the left lower lobe in the axial plane in (A) the lung visualization and in (B) the soft tissue visualization in which the lesion was also detectable.
706
CASE REPORT PEEL AND DARLING MINIMALLY INVASIVE ESOPHAGECTOMY IN SITUS INVERSUS
located subpleurally [1]. That could have drawn our attention toward the preoperative diagnosis of intrapulmonary LN. However, with the combination of a double history of cancer and the suggestive shape of multiple and round lesions, numerously distributed in both lungs, a suspicion of lung metastases is certainly justified and should be definitely worked up by thoracoscopy or even thoracotomy.
References 1. Yokomise H, Mizuno H, Ike O, Wada H, Hitomi S, Itoh H. Importance of intrapulmonary lymph nodes in the differential diagnosis of small pulmonary nodular shadows. Chest 1998;113:703–6. 2. Nagahiro I, Andou A, Aoe M, Date H, Shimizu N. Intrapulmonary lymph nodes enlarged after lobectomy for lung cancer. Ann Thorac Surg 2001;72:2115–7. 3. Ohtsuka T, Nomori H, Horio H, Naruke T, Suemasu K. Radiological examination for peripheral lung cancers and benign nodules less than 10 mm. Lung Cancer 2003;42: 291–6. 4. Ehrenstein FI. Pulmonary lymph node presenting as an enlarging coin lesion. Am Rev Respir Dis 1970;101: 595–9.
FEATURE ARTICLES
Left Video-Assisted Thoracoscopic Surgery Esophagectomy in a Patient With Situs Inversus Totalis and Kartagener Syndrome John Peel, BHSc,* and Gail Darling, MD, FRCSC* Department of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
A 67-year-old man with situs inversus totalis and Kartagener syndrome was diagnosed with esophageal adenocarcinoma after presenting with chronic gastroesophageal reflux. Resection of the tumor was done by minimally invasive Ivor-Lewis esophagectomy using a left videoassisted thoracoscopic surgery approach, rather than the typical right video-assisted thoracoscopic surgery. Patients with situs inversus totalis may be considered for fully minimally invasive esophagectomy with laparoscopic gastric mobilization and video-assisted thoracoscopic surgery esophagectomy with an intrathoracic anastomosis using a similarly opposite-sided approach. Patients with Kartagener syndrome are also at increased risk for respiratory tract infections. This should be considered in the perioperative period, as well as when considering induction chemoradiation therapy. (Ann Thorac Surg 2014;98:706–8) Ó 2014 by The Society of Thoracic Surgeons
Accepted for publication Oct 11, 2013. *Both authors contributed equally to this paper. Dr Darling performed the operation. Address correspondence to Dr Darling, Toronto General Hospital, 9N955, 200 Elizabeth St, Toronto, Ontario, M5G 2C4 Canada; e-mail: gail. [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2014;98:706–8
S
itus inversus totalis (SIT) is a rare congential condition in which the internal organs of the thoracic and abdominal cavities experience a right-to-left reflection across the sagittal plane. This defect is typically asymptomatic, and often undiagnosed; it is usually only recognized after diagnostic imaging for unrelated conditions [1]. However, SIT may complicate laparoscopic surgical procedures owing to the changed location of anatomic landmarks. Namely, the mirror image anatomy complicates common procedures and mandates alternative approaches during surgery [1, 2]. Recent evidence supports treatment of esophageal adenocarcinoma with induction chemoradiation followed by surgery for locally advanced tumors [3]. However, in a patient with Kartagener syndrome, the risk of pulmonary infection during the induction phase must be considered. Here we describe a case of locally advanced adenocarcinoma of the esophagus treated with a totally minimally invasive esophagectomy using a laparoscopic and left video-assisted thoracoscopic surgery (VATS) approach. The patient is a 67-year-old man with a known history of SIT who was investigated by endoscopy for a history of chronic gastroesophageal reflux. He was diagnosed with an adenocarcinoma of the distal esophagus. The tumor was 2 cm in length, extending to the gastroesophageal junction and occupying one third of the circumference of the esophagus. Endoscopic ultrasound staged the tumor as T3 N1. Positron emission tomography and computed tomography revealed uptake of 18-flourodeoxyglucose only in the distal esophagus and adjacent lymph node, with a maximum standardized uptake value of 8.1 in the primary tumor and 2.6 in the adjacent lymph node. Situs inversus totalis was clearly demonstrated in the right-to-left translocation of thoracic and abdominal organs (Fig 1). Computed tomography revealed bronchiectasis and inflammatory pulmonary changes that were consistent with Kartagener syndrome. Bronchoscopy was performed to determine airway colonization and pneumonia risk. Pulmonary anatomy was reversed in that the bilobar lung was on the right and the trilobar lung was on the left. After multidisciplinary consultation and consultation with the patient, a decision to proceed with primary surgery was made because of the increased risk of pulmonary infection and sepsis during induction chemoradiation. As a result of the patient’s SIT, a left VATS approach was performed for the esophageal resection and mediastinal lymph node dissection with an intrathoracic anastomosis above the level of the azygous vein after preparation of the gastric conduit and modified D1þ intraabdominal lymph node dissection by laparoscopy. In our standard approach, we perform laparoscopy in the supine position rather than with the legs in lithotomy and the surgeon standing between the legs. The operating surgeon was positioned on the left side of the patient rather than on the right. We used the same port placement for this patient, with the camera port in the midline above the umbilicus, two 5-mm ports in the 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.10.058
4. 5. 6. 7. 8.
CASE REPORT JUNGRAITHMAYR ET AL INTRAPULMONAL LN MIMICKING METASTASES
extracorporeal membrane oxygenation stabilization. J Pediatr Surg 1991;26:333–8. Deb SJ. Massive right-sided Bochdalek hernia with two unusual findings: a case report. J Med Case Rep 2011;5:519. Cullen ML, Klein MD, Philippart AI. Congenital diaphragmatic hernia. Surg Clin North Am 1985;65:1115–38. Akhtar K, Qurashi K, Rizvi A, Isla R. Emergency laparoscopic repair of an obstructed Bochdalek hernia in an adult. Br J Hosp Med (Lond) 2009;70:718–9. Shah R, Reddy MM, Mascarenhas AF. Bochdalek hernia in an adult presenting as an emergency. Indian J Chest Dis Allied Sci 1986;28:237–40. Mullins ME, Stein J, Saini SS, Mueller PR. Prevalence of incidental Bochdalek’s hernia in a large adult population. AJR Am J Roentgenol 2001;177:363–6.
Anthracotic Intrapulmonal Lymph Nodes Mimicking Lung Metastases Wolfgang Jungraithmayr, MD, Barbara Delaloye-Frischknecht, MD, and Walter Weder, MD Division of Thoracic Surgery and Department of Diagnostic Radiology, University Hospital Zurich, Zurich, Switzerland
FEATURE ARTICLES
Intrapulmonal round lesions show characteristic radiologic features that distinguish them from other lung pathologies. Typically, they display a sharp margin with a homogenous inner pattern. Differential diagnosis includes metastases, particularly if the patient has a history of malignancy. However, benign lesions, although less common, should also be considered. We here present the case of a 58-year-old man with a history of bladder and prostate carcinoma, showing multiple typical round lesions on chest computed tomography, mimicking metastatic disease to the lung. Subsequently, wedge-resected specimens revealed anthracotic lymph nodes, so that intrapulmonal lymph nodes should be anticipated even in patients with preceding malignant disease. (Ann Thorac Surg 2014;98:704–6) Ó 2014 by The Society of Thoracic Surgeons
T
ypical round lesions within the lung display characteristic morphologic features with well-recognized criteria, including a round shape with a sharp margin and a homogenous inner pattern. The differential diagnosis of typical round lesions includes a wide variety of tumors, reaching from rare malignancies such as angiosarcomas to benign lesions as, for instance, hamartomas [1]. A suspected diagnosis of lung metastases should be particularly raised if the patient has a history of primary malignancy. Another type of lesion that is not
Accepted for publication Sept 30, 2013. Address correspondence to Dr Jungraithmayr, Division of Thoracic Surgery, University Hospital Zurich Raemistr 100, Zurich 8091, Switzerland; e-mail: [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2014;98:704–6
considered a classical lesion but rather a preexisting nodule within the lung, are intrapulmonal lymph nodes (LN). They become visible upon enlargement either due to metastatic disease or due to uptake of foreign material, or in rare instances, in case of lymph duct obstruction. However, intrapulmonal LN rarely reach the size of typical round lesions nor do they resemble lung metastases, thus metastatic disease. This is a case of a patient with a history of bladder and prostate carcinoma presenting with multiple round lesions within the lung highly suggestive for pulmonary metastases, but histologically proved to be intrapulmonal anthracotic LN. A 58-year-old man was referred to our division by the urology department. In December 2012, he was simultaneously diagnosed with prostate carcinoma (pT2pN0) and bladder carcinoma (pT1pN0). These malignancies were treated by radiochemotherapy including four cycles of cisplatin and gemzar, to which the carcinomas responded well, and this treatment was followed by resection of the bladder and the prostate. At that time, chest computed tomography revealed numerous round lesions within the lung (Figs 1, 2). During the course of radiochemotherapy treatment, the pulmonary round lesions increased in size and numbers. No thoracic interventions were performed before. The patient’s general status of health was unremarkable, without respiratory distress. He had chronic obstructive pulmonary disease in stage GOLD II due to an active smoking history of 40 pack-years. He recently had pulmonary embolism on the right side, and has stable mild high blood pressure treated with metoprolol. He worked for 32 years in the finishing industry for metals (copper and other metals) during which time the patient worked with, but was never directly exposed to, metal dust or residues. After completion of the urologic interventions, we performed thoracoscopy and found wide adhesions, which made the finding of the described round lesions most difficult. After release of adhesions from the lower lobe, we succeeded in finding and wedge-resecting three of those described lesions, as depicted in Figures 1 and 2. Fresh frozen section did not reveal any malignancy. The definite histologic diagnosis confirmed the preliminary diagnosis, which corresponded to anthracotic LN.
Comment Intrapulmonally located LN are numerous and widely spread within the pulmonary tissue. However, under normal conditions, the size of intrapulmonary LN seldom exceeds a critical size, even if infiltrated by malignant cells or enlargement due to increased uptake of foreign material. Hilar LN, by contrast, normally reach a size that is comparable to LN from other locations such as axilla or groin. It is, therefore, surprising that intrapulmonal LN here were found to be almost 10 mm in size. Furthermore, as another unusual feature, these LN 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.09.109
Ann Thorac Surg 2014;98:704–6
CASE REPORT JUNGRAITHMAYR ET AL INTRAPULMONAL LN MIMICKING METASTASES
705
presented as round-shaped lesions with a sharp margin and a homogenous inner pattern, rendering all of them highly suggestive for pulmonary metastases. Additionally, these lesions were distributed throughout both lungs. Our preoperative diagnosis was, therefore, in favor of lung metastases. Indeed, most intrapulmonal LN seem to appear as single enlarged nodules rather than as multiple nodules [2]. Those found to be single nodules can in fact reach a size of 10 mm. As such, single nodules were evaluated by Ohtsuka and colleagues [3] for their dignity in a cohort of 82 patients, analyzing them in chest computed tomography scans, and of these, they found not fewer than 10 enlarged LN, but all of them were single lesions. Nagahiro and associates [2] reported three single nodules that increased in size after lobar resection for bronchial adenocarcinoma; these lesions turned out also to be intrapulmonary LN. One reason
for the growth of LN could be an obstruction of lymph draining ducts, either due to previous resection or to lung tissue remodeling. Wide adhesions—such as seen in this patient—which developed certainly not only because of emphysema, indicated previous inflammation, and that might have contributed to the enlargement of LN. Furthermore, this patient had an occupational history in metal coating, which might have also contributed to adhesions, inflammation, and LN enlargement. To the best of our knowledge, no association has been described between metal exposure and intrapulmonal LN enlargement. Also, no traces of metal dust were found within the resected LN. Intrapulmonal LN are reported to be oval, rather than strictly round [2, 4], which applies to the majority of the LN found here. Of note, the LN here all appeared in the basal segments of the lung. Another aspect of a typical feature of intrapulmonary LN is that they are often
Fig 2. Computed tomography of the chest shows another example of a typical round lesion (arrows) in (A) the sixth segment of the left lower lobe in the sagittal plane, as well as in (B) the axial plane.
FEATURE ARTICLES
Fig 1. Computed tomography of the chest revealed a representative round lesion (arrows) in the lateral segment of the left lower lobe in the axial plane in (A) the lung visualization and in (B) the soft tissue visualization in which the lesion was also detectable.
706
CASE REPORT PEEL AND DARLING MINIMALLY INVASIVE ESOPHAGECTOMY IN SITUS INVERSUS
located subpleurally [1]. That could have drawn our attention toward the preoperative diagnosis of intrapulmonary LN. However, with the combination of a double history of cancer and the suggestive shape of multiple and round lesions, numerously distributed in both lungs, a suspicion of lung metastases is certainly justified and should be definitely worked up by thoracoscopy or even thoracotomy.
References 1. Yokomise H, Mizuno H, Ike O, Wada H, Hitomi S, Itoh H. Importance of intrapulmonary lymph nodes in the differential diagnosis of small pulmonary nodular shadows. Chest 1998;113:703–6. 2. Nagahiro I, Andou A, Aoe M, Date H, Shimizu N. Intrapulmonary lymph nodes enlarged after lobectomy for lung cancer. Ann Thorac Surg 2001;72:2115–7. 3. Ohtsuka T, Nomori H, Horio H, Naruke T, Suemasu K. Radiological examination for peripheral lung cancers and benign nodules less than 10 mm. Lung Cancer 2003;42: 291–6. 4. Ehrenstein FI. Pulmonary lymph node presenting as an enlarging coin lesion. Am Rev Respir Dis 1970;101: 595–9.
FEATURE ARTICLES
Left Video-Assisted Thoracoscopic Surgery Esophagectomy in a Patient With Situs Inversus Totalis and Kartagener Syndrome John Peel, BHSc,* and Gail Darling, MD, FRCSC* Department of Thoracic Surgery, University of Toronto, Toronto, Ontario, Canada
A 67-year-old man with situs inversus totalis and Kartagener syndrome was diagnosed with esophageal adenocarcinoma after presenting with chronic gastroesophageal reflux. Resection of the tumor was done by minimally invasive Ivor-Lewis esophagectomy using a left videoassisted thoracoscopic surgery approach, rather than the typical right video-assisted thoracoscopic surgery. Patients with situs inversus totalis may be considered for fully minimally invasive esophagectomy with laparoscopic gastric mobilization and video-assisted thoracoscopic surgery esophagectomy with an intrathoracic anastomosis using a similarly opposite-sided approach. Patients with Kartagener syndrome are also at increased risk for respiratory tract infections. This should be considered in the perioperative period, as well as when considering induction chemoradiation therapy. (Ann Thorac Surg 2014;98:706–8) Ó 2014 by The Society of Thoracic Surgeons
Accepted for publication Oct 11, 2013. *Both authors contributed equally to this paper. Dr Darling performed the operation. Address correspondence to Dr Darling, Toronto General Hospital, 9N955, 200 Elizabeth St, Toronto, Ontario, M5G 2C4 Canada; e-mail: gail. [email protected].
Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc
Ann Thorac Surg 2014;98:706–8
S
itus inversus totalis (SIT) is a rare congential condition in which the internal organs of the thoracic and abdominal cavities experience a right-to-left reflection across the sagittal plane. This defect is typically asymptomatic, and often undiagnosed; it is usually only recognized after diagnostic imaging for unrelated conditions [1]. However, SIT may complicate laparoscopic surgical procedures owing to the changed location of anatomic landmarks. Namely, the mirror image anatomy complicates common procedures and mandates alternative approaches during surgery [1, 2]. Recent evidence supports treatment of esophageal adenocarcinoma with induction chemoradiation followed by surgery for locally advanced tumors [3]. However, in a patient with Kartagener syndrome, the risk of pulmonary infection during the induction phase must be considered. Here we describe a case of locally advanced adenocarcinoma of the esophagus treated with a totally minimally invasive esophagectomy using a laparoscopic and left video-assisted thoracoscopic surgery (VATS) approach. The patient is a 67-year-old man with a known history of SIT who was investigated by endoscopy for a history of chronic gastroesophageal reflux. He was diagnosed with an adenocarcinoma of the distal esophagus. The tumor was 2 cm in length, extending to the gastroesophageal junction and occupying one third of the circumference of the esophagus. Endoscopic ultrasound staged the tumor as T3 N1. Positron emission tomography and computed tomography revealed uptake of 18-flourodeoxyglucose only in the distal esophagus and adjacent lymph node, with a maximum standardized uptake value of 8.1 in the primary tumor and 2.6 in the adjacent lymph node. Situs inversus totalis was clearly demonstrated in the right-to-left translocation of thoracic and abdominal organs (Fig 1). Computed tomography revealed bronchiectasis and inflammatory pulmonary changes that were consistent with Kartagener syndrome. Bronchoscopy was performed to determine airway colonization and pneumonia risk. Pulmonary anatomy was reversed in that the bilobar lung was on the right and the trilobar lung was on the left. After multidisciplinary consultation and consultation with the patient, a decision to proceed with primary surgery was made because of the increased risk of pulmonary infection and sepsis during induction chemoradiation. As a result of the patient’s SIT, a left VATS approach was performed for the esophageal resection and mediastinal lymph node dissection with an intrathoracic anastomosis above the level of the azygous vein after preparation of the gastric conduit and modified D1þ intraabdominal lymph node dissection by laparoscopy. In our standard approach, we perform laparoscopy in the supine position rather than with the legs in lithotomy and the surgeon standing between the legs. The operating surgeon was positioned on the left side of the patient rather than on the right. We used the same port placement for this patient, with the camera port in the midline above the umbilicus, two 5-mm ports in the 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.10.058
