Laparoscopic transhiatal approach for resection of an adenocarcinoma in long-segment Barrett’s esophagus

Figure 1 Endoscopy findings (A, B) and computed tomography findings (C-F). A: An ulcerative lesion was found in a hiatal hernia 30 cm from an incisor; B: 0-IIc type esophageal cancer was detected 25 cm from an incisor; There was severe deformity of the trunk caused by kyphosis and muscular contractures (C-F); C: The arrow points to the permanent tracheal stoma; D: The arrow points to the metal clip near the 0-IIc type esophageal cancer; E: The arrow points to the metal clip near the ulcerative lesion in hiatal hernia; F: The arrow points to the sliding hiatal hernia.

Figure 2 Surgical technique. A: The esophageal hiatus was divided, and carbon dioxide was introduced into the mediastinum; B: Dissection of the anterior plane of the thoracic aorta was extended to the cranial side, and the root of the proper esophageal artery was confirmed under a magnified videoscopic view; C: While lifting the posterior mediastinal lymph nodes like a membrane, they were cut along the border of the left mediastinal pleura; D: This incision was extended to the left pulmonary hilum and aortic arch. Ao: Thoracic aorta; E: Esophagus; Lt: Left; PMLNs: Posterior mediastinal lymph nodes.

Figure 3 Thoracic esophagus was completely detached from the surrounding tissue. A: A hernial sac was identified on the cranial side of the right crus of the diaphragm; B: Dissection of the posterior and right sides of the esophagus was performed to the level of the arch of the azygos vein; C: While lifting the right mediastinal pleura like a membrane, an incision was made and extended to the right pulmonary hilum, and the lymph nodes were resected from the right main bronchus and carina; D: Intraoperative view after dissection of the subcarinal lymph nodes. Ao: Thoracic aorta; E: Esophagus; Lt: Left; Rt: Right; Br: Bronchus; SCLNs: Subcarinal lymph nodes.

Figure 4 Resected specimen. A: A resected specimen revealed a 0-IIc type tumor (72 mm × 56 mm in size) in the middle and lower thoracic esophagus in long-segment Barrett's esophagus. A metal clip was identified near the tumor; B: Mapping according to the histopathological examination. Although an Ul-IVs type ulcer (17 mm × 17 mm in size) was identified on the distal side of the tumor, cancer was not found in this lesion.

Figure 5 Histopathological examination. A: A histopathological examination revealed superficial adenocarcinoma (pT1a-SMM). The cancer lesion was surrounded by mucosa, including a columnar epithelium that continued to the stomach; B: Part of the small frame in (A) was magnified and shown; C: Duplication of the muscularis mucosae was identified in long-segment Barrett's esophagus. Hematoxylin-eosin staining; magnification, × 100 (A), × 150 (B) or × 50 (C).