Surgical case reports
Thoracoscopic Esophagectomy for Metachronous Esophageal Cancer after Heller-Dor Surgery for Achalasia with Marked Esophageal Dilatation: A Case Report
By An B, Abe T, Oe Y and 11 others.
Abstract
Introduction
Achalasia is associated with an increased risk of esophageal squamous cell carcinoma even after definitive surgical treatment. Heller-Dor surgery is an established surgical treatment for achalasia; however, marked esophageal dilatation may persist despite successful symptom control and pose technical challenges during subsequent esophagectomy.
Case presentation
A 73-year-old man with a history of Heller-Dor surgery for achalasia and prior endoscopic submucosal dissection (ESD) for esophageal squamous cell carcinoma developed a metachronous lesion at a different esophageal site. Histopathological examination after ESD demonstrated deep submucosal and vascular invasion, warranting additional curative treatment. Preoperative imaging showed predominant upper thoracic esophageal dilatation with a maximum diameter of 56 mm, whereas gastric deformity was minimal. The patient underwent prone-position video-assisted thoracoscopic subtotal esophagectomy with 3-field lymphadenectomy and retrosternal gastric conduit reconstruction. Intraoperatively, venous engorgement required meticulous dissection, while marked upper thoracic esophageal dilatation restricted the operative workspace around the left recurrent laryngeal nerve. An internal organ retractor provided stable esophageal traction with flexible repositioning of the traction point, facilitating adequate exposure. Despite intra-abdominal adhesions from the previous surgery, gastric conduit reconstruction was successfully completed as anticipated from the preoperative assessment of gastric anatomy. Final histopathological examination revealed no residual carcinoma or lymph node metastasis. The postoperative course was uneventful, and the patient remained recurrence-free at 2 years.