CASE REPORT – THORACIC
Interactive CardioVascular and Thoracic Surgery 22 (2016) 235–237 doi:10.1093/icvts/ivv299 Advance Access publication 3 November 2015
Cite this article as: Singh G, Costa J, Bessler M, Sonett J. Minimally invasive Ivor Lewis oesophagogastrectomy in a patient with situs inversus totalis. Interact CardioVasc Thorac Surg 2016;22:235–7.
Minimally invasive Ivor Lewis oesophagogastrectomy in a patient with situs inversus totalis† Gopal Singha, Joseph Costaa, Marc Besslerb and Joshua Sonetta,* a b
Section of Thoracic Surgery, Columbia University Medical Center, New York, NY, USA Division of Bariatric Surgery, Columbia University Medical Center, New York, NY, USA
* Corresponding author. Section of Thoracic Surgery, Columbia University Medical Center, 3rd Floor, Herbert Irving Pavilion, New York, NY 10032, USA. Tel: +1-212-3053408; fax: +1-212-3053474; e-mail: [email protected] ( J.R. Sonett). Received 23 June 2015; received in revised form 19 August 2015; accepted 24 August 2015
Abstract Situs 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. We describe a case of locally advanced adenocarcinoma of the oesophagus treated with minimally invasive oesophagectomy using a laparoscopic and left video-assisted thoracoscopic surgery approach in a patient with situs inversus totalis.
INTRODUCTION Situs inversus totalis (SIT) is a rare congenital condition characterized by a symmetrical ‘mirror-image’ orientation of all organs in relation to the midline. SIT occurs with an incidence of 0.1% of patients in the general population, and is asymptomatic, undiagnosed and is only recognized after diagnostic imaging for unrelated conditions [1]. Situs inversus itself has no pathophysiological significance and does not increase the prevalence of any pathology or malignancy. Minimally invasive procedures in patients with SIT may be technically challenging due to the anatomical orientation of organs. We would like to describe our experience in performing an oesophagogastrectomy in a patient with SIT.
CASE REPORT A 65-year old man with a history of dysphagia for 8 months was discovered to have SIT after diagnostic imaging was performed to investigate the cause of his symptoms. Preoperative oesophageal endoscopy was performed and it showed a 2.8 × 2.0 cm oesophageal mass at the gastroesophageal junction. A positron emission tomography-computed tomography scan confirmed the 2.8 × 2.0 cm oesophageal lesion with a standardized uptake value of 33.3. There was a single, mildly enlarged right paraoesophageal lymph node measuring 1.4 × 0.6 cm. There was no apparent hilar or mediastinal adenopathy. † Presented at the 23rd European Conference on General Thoracic Surgery, Lisbon, Portugal, 31 May–3 June 2015.
Chest X-ray showed dextrocardia (Fig. 1A) CT showed SIT (Fig. 1B). The patient elected to undergo chemotherapy/radiotherapy followed by surgery. Resection of the tumour was performed by minimally invasive Ivor Lewis oesophagectomy using a left video-assisted thoracoscopic surgery (VATS) approach, rather than the typical right VATS. The patient was positioned in a supine position with the operating surgeon on the left and the assistant on the right side. For pulmonary exclusion, they used a standard leftsided tube that was placed down the anatomic left main stem bronchus. They used the standard port placement, with the camera port in the midline above the umbilicus, two 5-mm ports in the 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. Dissection of lesser sac was followed by mobilization of the greater curvature. Kocherization of duodenum was followed by a pyloromyotomy, inspection of the pancreas and resection of the celiac axis lymph nodes. Gastric resection was completed to form the gastric tube. The thoracic part of the operation was performed by a left VATS with one access and three ports. The oesophagus was mobilized and a radical lymph node dissection was performed by taking down the subcarinal lymph nodes, level 9 and paraoesophageal lymph nodes followed by a subtotal oesophagectomy. The resected specimen was extracted in a sterile specimen bag. A side-to-side linear anastomosis was performed and checked for leak with endoscopy and visual confirmation using a thoracoscope and found to be widely patent (Fig. 2A–C). The final pathological examination revealed a moderately differentiated adenocarcinoma of the gastroesophageal junction T2 N1
© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
CASE REPORT
Keywords: Oesophagogastrectomy • Situs inversus totalis • Adenocarcinoma oesophagus
236
G. Singh et al. / Interactive CardioVascular and Thoracic Surgery
Figure 1: (A) Chest X-ray showing dextrocardia with a right aortic arch; (B) coronal CT scan showing situs inversus totalis. CT: computed tomography.
Figure 2: (A) Postoperative endoscopy showing patent anastomosis; (B) thorascopic image of side-to-side anastomosis while stapling; (C) thoracoscopic image of completed side-to-side anastomosis.
M0 with only one lymph node with metastases of the 20 lymph nodes resected.
DISCUSSION SIT is an anatomical variation in which there is transposition of abdominal and thoracic organs due to embryonic events that occur at the time of development. A laparoscopic VAT oesophagectomy is an accepted technique for the treatment of oesophageal cancer [2]. A minimally invasive oesophagectomy in a patient with SIT was first described by Yoshida et al. in 2004 [3]. Although the operation was performed safely, SIT may present unique challenges to laparoscopic surgical procedures owing to the changed location
of anatomic landmarks. This unusual orientation of abdominal and thoracic organs could complicate common procedures and require alternative approaches during surgery. There are reports in the literature describing the use of minimally invasive techniques in patients with SIT that had surgical procedures for gastric cancer and colon cancer [4, 5]. A review of the literature revealed that only 6 cases with SIT had laparascopic surgery for oesophageal cancer. In this patient, extensive preoperative imaging and planning facilitated identification of the anatomy and enabled a safe gastric dissection and creation of the gastric conduit in the abdomen, as well as the oesophagectomy and side-to-side anastomosis in the left chest. The surgical technique and sequence of operative steps was not altered, and the overall approach did not deviate from a patient without SIT. Experienced thoracic/laparoscopic surgeons
G. Singh et al. / Interactive CardioVascular and Thoracic Surgery
Funding NIH Institutional T32 (grant number 5 T32 HL 7854-18 to Gopal Singh). Conflict of interest: none declared.
REFERENCES [1] Schmutzer PV. Situs inversus totalis associated with complex cardiovascular anomalies. Am Heart J 1958;56:761. [2] Osugi H, Takemura M, Lee S, Nishikawa T, Fukuhara K, Iwasaki H et al. Thoracoscopic esophagectomy for intrathoracic esophageal cancer. Ann Thorac Cardiovasc Surg 2005;11:221–7. [3] 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. [4] Futawatari N, Kikuchi S, Moriya H, Katada N, Sakuramoto S, Watanabe M. Laparoscopy-assisted distal gastrectomy for early gastric cancer with complete situs inversus: report of a case. Surg Today 2010;40:64. [5] Fujiwara Y, Fukunaga Y, Higashino M, Tanimura S, Takemura M, Tanaka Y et al. Laparoscopic hemicolectomy in a patient with situs inversus totalis. World J Gastroenterol 2007;13:5035.
CASE REPORT
may be confronted with a case of SIT once in their entire career; therefore, extensive preoperative planning and cross-sectional imaging in a patient with SIT is crucial to avoid surgical errors. In this manuscript, we have described a patient with SIT in whom a minimally invasive oesophagogastrectomy has been performed without complications, without any increase in operative time and in mirror image to the standard position.
237
Interactive CardioVascular and Thoracic Surgery 22 (2016) 235–237 doi:10.1093/icvts/ivv299 Advance Access publication 3 November 2015
Cite this article as: Singh G, Costa J, Bessler M, Sonett J. Minimally invasive Ivor Lewis oesophagogastrectomy in a patient with situs inversus totalis. Interact CardioVasc Thorac Surg 2016;22:235–7.
Minimally invasive Ivor Lewis oesophagogastrectomy in a patient with situs inversus totalis† Gopal Singha, Joseph Costaa, Marc Besslerb and Joshua Sonetta,* a b
Section of Thoracic Surgery, Columbia University Medical Center, New York, NY, USA Division of Bariatric Surgery, Columbia University Medical Center, New York, NY, USA
* Corresponding author. Section of Thoracic Surgery, Columbia University Medical Center, 3rd Floor, Herbert Irving Pavilion, New York, NY 10032, USA. Tel: +1-212-3053408; fax: +1-212-3053474; e-mail: [email protected] ( J.R. Sonett). Received 23 June 2015; received in revised form 19 August 2015; accepted 24 August 2015
Abstract Situs 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. We describe a case of locally advanced adenocarcinoma of the oesophagus treated with minimally invasive oesophagectomy using a laparoscopic and left video-assisted thoracoscopic surgery approach in a patient with situs inversus totalis.
INTRODUCTION Situs inversus totalis (SIT) is a rare congenital condition characterized by a symmetrical ‘mirror-image’ orientation of all organs in relation to the midline. SIT occurs with an incidence of 0.1% of patients in the general population, and is asymptomatic, undiagnosed and is only recognized after diagnostic imaging for unrelated conditions [1]. Situs inversus itself has no pathophysiological significance and does not increase the prevalence of any pathology or malignancy. Minimally invasive procedures in patients with SIT may be technically challenging due to the anatomical orientation of organs. We would like to describe our experience in performing an oesophagogastrectomy in a patient with SIT.
CASE REPORT A 65-year old man with a history of dysphagia for 8 months was discovered to have SIT after diagnostic imaging was performed to investigate the cause of his symptoms. Preoperative oesophageal endoscopy was performed and it showed a 2.8 × 2.0 cm oesophageal mass at the gastroesophageal junction. A positron emission tomography-computed tomography scan confirmed the 2.8 × 2.0 cm oesophageal lesion with a standardized uptake value of 33.3. There was a single, mildly enlarged right paraoesophageal lymph node measuring 1.4 × 0.6 cm. There was no apparent hilar or mediastinal adenopathy. † Presented at the 23rd European Conference on General Thoracic Surgery, Lisbon, Portugal, 31 May–3 June 2015.
Chest X-ray showed dextrocardia (Fig. 1A) CT showed SIT (Fig. 1B). The patient elected to undergo chemotherapy/radiotherapy followed by surgery. Resection of the tumour was performed by minimally invasive Ivor Lewis oesophagectomy using a left video-assisted thoracoscopic surgery (VATS) approach, rather than the typical right VATS. The patient was positioned in a supine position with the operating surgeon on the left and the assistant on the right side. For pulmonary exclusion, they used a standard leftsided tube that was placed down the anatomic left main stem bronchus. They used the standard port placement, with the camera port in the midline above the umbilicus, two 5-mm ports in the 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. Dissection of lesser sac was followed by mobilization of the greater curvature. Kocherization of duodenum was followed by a pyloromyotomy, inspection of the pancreas and resection of the celiac axis lymph nodes. Gastric resection was completed to form the gastric tube. The thoracic part of the operation was performed by a left VATS with one access and three ports. The oesophagus was mobilized and a radical lymph node dissection was performed by taking down the subcarinal lymph nodes, level 9 and paraoesophageal lymph nodes followed by a subtotal oesophagectomy. The resected specimen was extracted in a sterile specimen bag. A side-to-side linear anastomosis was performed and checked for leak with endoscopy and visual confirmation using a thoracoscope and found to be widely patent (Fig. 2A–C). The final pathological examination revealed a moderately differentiated adenocarcinoma of the gastroesophageal junction T2 N1
© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.
CASE REPORT
Keywords: Oesophagogastrectomy • Situs inversus totalis • Adenocarcinoma oesophagus
236
G. Singh et al. / Interactive CardioVascular and Thoracic Surgery
Figure 1: (A) Chest X-ray showing dextrocardia with a right aortic arch; (B) coronal CT scan showing situs inversus totalis. CT: computed tomography.
Figure 2: (A) Postoperative endoscopy showing patent anastomosis; (B) thorascopic image of side-to-side anastomosis while stapling; (C) thoracoscopic image of completed side-to-side anastomosis.
M0 with only one lymph node with metastases of the 20 lymph nodes resected.
DISCUSSION SIT is an anatomical variation in which there is transposition of abdominal and thoracic organs due to embryonic events that occur at the time of development. A laparoscopic VAT oesophagectomy is an accepted technique for the treatment of oesophageal cancer [2]. A minimally invasive oesophagectomy in a patient with SIT was first described by Yoshida et al. in 2004 [3]. Although the operation was performed safely, SIT may present unique challenges to laparoscopic surgical procedures owing to the changed location
of anatomic landmarks. This unusual orientation of abdominal and thoracic organs could complicate common procedures and require alternative approaches during surgery. There are reports in the literature describing the use of minimally invasive techniques in patients with SIT that had surgical procedures for gastric cancer and colon cancer [4, 5]. A review of the literature revealed that only 6 cases with SIT had laparascopic surgery for oesophageal cancer. In this patient, extensive preoperative imaging and planning facilitated identification of the anatomy and enabled a safe gastric dissection and creation of the gastric conduit in the abdomen, as well as the oesophagectomy and side-to-side anastomosis in the left chest. The surgical technique and sequence of operative steps was not altered, and the overall approach did not deviate from a patient without SIT. Experienced thoracic/laparoscopic surgeons
G. Singh et al. / Interactive CardioVascular and Thoracic Surgery
Funding NIH Institutional T32 (grant number 5 T32 HL 7854-18 to Gopal Singh). Conflict of interest: none declared.
REFERENCES [1] Schmutzer PV. Situs inversus totalis associated with complex cardiovascular anomalies. Am Heart J 1958;56:761. [2] Osugi H, Takemura M, Lee S, Nishikawa T, Fukuhara K, Iwasaki H et al. Thoracoscopic esophagectomy for intrathoracic esophageal cancer. Ann Thorac Cardiovasc Surg 2005;11:221–7. [3] 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. [4] Futawatari N, Kikuchi S, Moriya H, Katada N, Sakuramoto S, Watanabe M. Laparoscopy-assisted distal gastrectomy for early gastric cancer with complete situs inversus: report of a case. Surg Today 2010;40:64. [5] Fujiwara Y, Fukunaga Y, Higashino M, Tanimura S, Takemura M, Tanaka Y et al. Laparoscopic hemicolectomy in a patient with situs inversus totalis. World J Gastroenterol 2007;13:5035.
CASE REPORT
may be confronted with a case of SIT once in their entire career; therefore, extensive preoperative planning and cross-sectional imaging in a patient with SIT is crucial to avoid surgical errors. In this manuscript, we have described a patient with SIT in whom a minimally invasive oesophagogastrectomy has been performed without complications, without any increase in operative time and in mirror image to the standard position.
237
