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.


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


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

Ann Thorac Surg 2014;98:706–8



The final pathologic examination revealed a moderately to poorly differentiated adenocarcinoma of the gastroesophageal junction pT3 N1 M0 with only 1 lymph node with metastases of the 43 lymph nodes resected. All margins were uninvolved by invasive carcinoma, with the closest margin being the circumferential margin, 1.0 mm from the tumor.

Fig 1. Computed tomography imaging of a thoracic and abdominal coronal section. Note the right-to-left reflection of gross structures, which created a significant surgical challenge.

right and left subcostal region just anterior to the anterior axillary line, and two operating ports to the right and left of the camera port. The liver retractor was inserted through the left subcostal port, and the retracting instruments were inserted through the right subcostal port. This is our standard port placement: port placement was unaffected by SIT. We used the energy device through the left operating port rather than the right. The gastrocolic ligament was divided in the usual fashion, and the left gastric pedicle was approached initially from the right (ie, along the splenic artery) and then the gastrohepatic ligament was divided. The left gastric pedicle dissection was completed from the left. The ligament of Treitz was approached from the right when identifying the portion of jejunum to be used for the feeding jejunostomy. In the left chest, the anatomy was as one would expect if we were operating in the right chest so no special accommodations were required other than to approach through the left hemithorax. A 3-cm access incision was made in the fourth interspace through which the resected specimen was extracted in a sterile specimen bag. An intrathoracic end-to-end stapled anastomosis was performed.

Minimally invasive surgical techniques may improve patient outcomes. Reduced pulmonary complications—particularly pneumonia—have been reported with minimally invasive esophagectomy [4]. For this reason minimally invasive esophagectomy is preferred to open surgery for patients at increased risk of pulmonary complications. Laparoscopic plus VATS esophagectomy with lymphadenopathy is an accepted technique for treatment of esophageal cancer [5]. However, few cases have been reported for VATS esophagectomy in patients with SIT, but these previous reports have confirmed that situs inversus is not a contraindication for laparoscopic surgery. Yoshida and colleagues [6] first described a successful VATS esophagectomy with hand-assisted laparoscopic gastric mobilization in a patient with situs inversus, and laparoscopic techniques for other procedures have also since been described. These surgeries were performed in complete mirror image to the standard position. Similarly, in our case a left VATS esophagectomy needed to be performed instead of a right VATS. It has been estimated that situs inversus occurs with an incidence of 1/5,000 to 1/20,000 live births, and approximately 20% to 25% of cases are associated with underlying primary ciliary dyskinesia, presenting as Kartagener syndrome [7]. Situs inversus totalis and Kartagener syndrome can pose unique challenges during surgery, which may affect outcome success [1, 2, 4, 8]. This patient represents a particularly unique case because he presented also with bronchiectasis as a result of Kartagener syndrome. Patients with Kartagener syndrome are at high risk for respiratory tract infections, owing to poor mucociliary clearance [7]. Because it has been demonstrated that induction chemoradiation therapy may increase the risk for sepsis and respiratory infection, we suspect that patients with Kartagener syndrome are at increased risk for pneumonia after preoperative chemoradiation therapy and surgery [8]. For this reason our patient was treated with primary surgery rather than induction chemoradiation as would be our standard approach for clinical T3 N1 M0 adenocarcinoma. A surgical approach such as minimally invasive esophagectomy that is associated with reduced postoperative pulmonary complications seemed most appropriate for this patient.

References 1. Blegen HM. Surgery in situs inversus. Ann Surg 1949;129: 244–59.





2. Catheline JM, Rosales C, Cohen R, et al. Laparoscopic sleeve gastrectomy for a super-super-obese patient with situs inversus totalis. Obes Surg 2006;16:1092–5. 3. Stahl M, Budach W, Meyer HJ, Cervantes A. ESMO Guidelines Working Group. Esophageal cancer: Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2010;21(Suppl 5):v46–9. 4. Biere SS, van Berge Henegouwen MI, Maas KW, et al. Minimally invasive versus open oesophagectomy for patients with oesophageal cancer: a multicentre, open-label, randomised controlled trial. Lancet 2012;379:1887–92. 5. Osugi H, Takemura M, Lee S, et al. Thoracoscopic esophagectomy for intrathoracic esophageal cancer. Ann Thorac Cardiovasc Surg 2005;11:221–7. 6. Yoshida T, Usui S, Inoue H, Kudo SE. The management of esophageal cancer with situs inversus totalis by simultaneous hand-assisted laparoscopic gastric mobilization and thoracoscopic esophagectomy. J Laparoendosc Adv Surg Tech A 2004;14:384–9. 7. Afzelius B, Mossberg B. Immotile-cilia syndrome (primary ciliary dyskinesia), including Kartagener syndrome. In: Scriver CR, Beaudet AL, Sly WS, Valle D, eds. The metabolic and molecular bases of inherited disease, 7th ed. vol. 3. New York, NY: McGraw-Hill; 1995:3943–54. 8. Reynolds JV, Ravi N, Hollywood D, et al. Neoadjuvant chemoradiation may increase the risk of respiratory complications and sepsis after transthoracic esophagectomy. J Thorac Cardiovasc Surg 2006;132:549–55.


Metal Allergy to Titanium Bars After the Nuss Procedure for Pectus Excavatum Kazuhiro Sakamoto, MD, PhD, Kohei Ando, MD, and Daisuke Noma, MD Department of Respiratory Surgery, National Hospital Organization Yokohama Medical Center, Yokohama, Japan

The Nuss procedure requires the placement of metal bars in the chest cage to repair pectus excavatum. Metal allergies are one of the complications associated with this procedure. Given that titanium is a biocompatible metal, it induces few allergic symptoms. Therefore, titanium bars are recommended for patients with metal sensitivity. We report the case of a 17-year-old boy with pectus excavatum who had a metal allergy to titanium bars, which occurred after the Nuss procedure. The administration of oral steroids is useful for treating metal allergies. Metal allergies to titanium bars are very rare; however, they can still occur. (Ann Thorac Surg 2014;98:708–10) Ó 2014 by The Society of Thoracic Surgeons

Ann Thorac Surg 2014;98:708–10

metal allergies to stainless steel bars are one of the complications associated with this procedure [2, 4]. Given that titanium is a biocompatible metal, it provokes few allergic reactions. Therefore, titanium bars are recommended for patients with a metal sensitivity [5]. However, titanium bars are actually made of titanium alloy, which contains a small amount of other metals. We report a rare case of a metal allergy to titanium bars that developed after the Nuss procedure. A 23-year-old man with moderate pectus excavatum and a Haller computed tomographic index [6] of 5.38 visited our hospital. He had a history of metal allergies. Therefore, we confirmed the negative results for skin patch tests by using stainless steel and titanium alloy plates preoperatively. Owing to the negative results of the skin patch tests, the Nuss procedure was performed with the use of two stainless steel bars (Pectus bar, Biomet Corp, Jacksonville, FL) fixed with bioabsorbable sutures and no stabilizer. Postoperatively, the patient experienced a high fever, chest pain, and bilateral pleural effusion (Fig 1). A small amount of Staphylococcus epidermidis was cultured from the pleural effusion. Various antibiotics were administered, and the next two bacterial cultures of the pleural effusion were negative. However, his symptoms continued. A blood count revealed a white blood count of 10,700/mm2 and an elevated eosinophil level of 9.4%. The pleural fluid studies also revealed an elevated eosinophil level of 10% and an elevated immunoglobulin E level of 165 IU/mL. Because a metal allergy to the stainless steel bars was suspected, oral steroid therapy (prednisone 30 mg/day) was initiated on postoperative day (POD) 14. The steroid therapy resolved his symptoms immediately. We replaced the stainless steel bars with titanium bars on POD 19 because of the initial severity of his allergic reaction. The pleural effusion disappeared after the redo operation, and the patient was discharged on POD 29. The oral steroids were tapered to 3 mg/day during the next three months, and continued until the bars were removed two years later. The allergic reaction did not recur, and no side effects of the steroid were


he Nuss procedure, introduced by Donald Nuss and associates in 1998, is widely accepted as a standard operation for repairing pectus excavatum [1–3]. However,

Accepted for publication Oct 11, 2013. Address correspondence to Dr Sakamoto, Department of Respiratory Surgery, National Hospital Organization Yokohama Medical Center, 3-60-2 Harajuku, Totsuka-ku, Yokohama, 245-8575 Japan; e-mail: [email protected].

Ó 2014 by The Society of Thoracic Surgeons Published by Elsevier Inc

Fig 1. Chest computed tomography scan of the older brother on postoperative day 9, showing bilateral pleural effusion. 0003-4975/$36.00 http://dx.doi.org/10.1016/j.athoracsur.2013.10.089

Left video-assisted thoracoscopic surgery esophagectomy in a patient with situs inversus totalis and Kartagener syndrome.

A 67-year-old man with situs inversus totalis and Kartagener syndrome was diagnosed with esophageal adenocarcinoma after presenting with chronic gastr...
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