case_images: PMC10516131_01
case_images: Preoperative endoscopic findings. (A) shows a tumor found 25-31 cm from the incisors under upper gastrointestinal endoscopy. (B) shows distinct unstained areas in the tumor area under iodine staining (Lugol's solution, 5% elemental iodine and 10% potassium iodide). (C) demonstrates the intraepithelial papillary capillary loop (IPCL) typical of esophageal tumors under magnifying endoscopy (100x). (D) shows the tumor invading the submucosa on ultrasound gastroscopy. IPCL, intraepithelial papillary capillary loop.
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case_images: PMC10516131_01_fonc-13-1215717-g001.jpg
case_images: f1
case_images: Ultrasound gastroscopy indicated that the tumor may invade the submucosa ( Figure 1 ).
case_images: Preoperative 3D-CT reconstruction. (A) shows the opening of the left common carotid artery; (B) shows the opening of the right common carotid artery; (C) shows the opening of the right subclavian artery; (D) shows the opening of the left subclavian artery. (E, F) show the right aortic arch with branches and KD. LCA, left common carotid artery; RCA, right common carotid artery; RSA, right subclavian artery; LSA, left subclavian artery; RAA, right aortic arch; KD, kommerell diverticulum.
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case_images: PMC10516131_01_fonc-13-1215717-g002.jpg
case_images: f2
case_images: RAA and KD. RAA and KD were also detected ( Figure 2 ). 3D-CT reconstruction was performed to clarify this abnormal anatomy.
case_images: Sites of the four trocars (red circles). The patient assumed a right lateral semi-prone position for the procedure. The main operating port located in the left 4th intercostal mid-axillary line, the observation port in the left 7th intercostal mid-axillary line and the auxiliary operating ports in the 6th intercostal interval in the subscapular angle line and the 9th intercostal interval in the subscapular angle line. ML, midaxillary line; PAL, Posterior Axillary Line; SAL, Subscapular Angle Line.
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case_images: PMC10516131_01_fonc-13-1215717-g003.jpg
case_images: f3
case_images: The thoracoscopic procedure is performed using a 4-port approach with the main operating port located in the left 4th intercostal mid-axillary line, the observation port in the left 7th intercostal mid-axillary line and the auxiliary operating ports in the 6th intercostal interval in the subscapular angle line and the 9th intercostal interval in the subscapular angle line ( Figure 3 ).
case_images: Intraoperative findings. (A) shows the ductus arteriosus ligament between the KD and the left pulmonary artery trunk. (B) shows the esophagus was surrounded by a ring made up of the ductus arteriosus ligament, the aortic arch, the LSA, and the trachea. (C) demonstrates the LRLN emerging from the vagus nerve, bypassing the ductus arteriosus ligament, and traveling up the tracheoesophageal groove. (D) shows the upper esophagus being pulled above the ductus arteriosus ligament after the esophagus has been dissected. LSA, left subclavian artery; KD, kommerell diverticulum; DAL, ductus arteriosus ligament; LRLN, left recurrent laryngeal nerve.
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case_images: PMC10516131_01_fonc-13-1215717-g004.jpg
case_images: f4
case_images: Meanwhile, thick, strip-like tissue was observed between the KD and the left pulmonary artery trunk ( Figure 4A ). The esophagus was surrounded by a ring made up of the ductus arteriosus ligament, the aortic arch, the LSA, and the trachea ( Figure 4B ). We found that it traveled upwards along the groove between the trachea and the esophagus ( Figure 4C ). Therefore, we cut off the esophagus at the beginning of the descending aorta and pulled the upper esophagus out above the ductus arteriosus ligament ( Figure 4D ).
case_images: Postoperative upper gastrointestinal imaging. (A-C) show the results of the patient's upper gastrointestinal imaging one week after the operation, with no anastomotic fistula present.
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case_images: PMC10516131_01_fonc-13-1215717-g005.jpg
case_images: f5
case_images: Upper gastrointestinal contrast examination was performed one week after surgery, and no anastomotic fistula was found on the radiographic image ( Figure 5 ).