Ann Thorac Surg 2005;79:e34-e35
© 2005 The Society of Thoracic Surgeons
Case report
Novel Use of Weerda Laryngoscope to Remove Early Cervical Esophageal Cancer
Shunji Mizobuchi, MD, PhDa,*,
Hiroaki Nakatani, MD, PhDb,
Toyokazu Akimori, MDc,
Kenshi Kuge, MD, PhDa,
Yasunaga Okazaki, MD, PhDa,
Shiro Sasaguri, MD, PhDa
a Department of Surgery II, Faculty of Medicine, Kochi University, Kochi, Japan
b Department of Otolaryngology and Head and Neck Surgery, Faculty of Medicine, Kochi University, Kochi, Japan
c Department of Surgery I, Faculty of Medicine, Kochi University, Kochi, Japan
Accepted for publication January 20, 2005.
* Address reprint requests to Dr Mizobuchi, Department of Surgery II, Faculty of Medicine, Kochi University, Kohasu, Oko-cho, Nankoku, Kochi 783-8505, Japan (E-mail: mizoshun{at}kochi-ms.ac.jp).
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Abstract
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A 65-year-old man was followed up after endoscopic mucosal resection for esophageal cancer in February 2000. Thereafter, he received endoscopic mucosal resection, radiation therapy, and argon plasma coagulation for recurrent and multiple primary esophageal cancers. On follow-up examination, two additional esophageal cancers were detected by endoscopy in September 2003. One lesion was located 16 cm from the incisor close to the entrance to the esophagus. To preserve the larynx, this lesion was removed by mucosal resection using a Weerda distending operating laryngoscope. This report describes this novel use of a Weerda distending operating laryngoscope to remove superficial cervical esophageal cancer.
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Introduction
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Endoscopic treatment of esophageal cancer has improved the quality of life for patients because it is less invasive than open surgery. Thus, endoscopic mucosal resection (EMR) is becoming an important treatment option for patients with early esophageal cancer [1, 2]. In some cases, however, it is technically impossible to remove the tumor by EMR, especially when it is located in the cervical esophagus close to the entrance of the esophagus.
This report illustrates the use of a Weerda distending operating laryngoscope, EN-8588B (Karl Storz, Tuttlingen, Germany) to remove a superficial cervical esophageal carcinoma just below the entrance of the esophagus.
A 65-year-old man was followed up after EMR for esophageal cancer in February 2000. Thereafter, he underwent further EMR, radiation therapy, and argon plasma coagulation for recurrent and multiple primary esophageal cancers. On September 17, 2003, he underwent endoscopy, which demonstrated two lesions in esophagus. One was a protruded lesion, 1 cm in size, with a surface covered by normal epithelium 16 cm from the incisor. This lesion was located just below the esophageal entrance. The second lesion was located 32 cm from the incisor and measured 1.5 cm. Both of the lesions were evaluated as showing submucosal invasion on endoscopy. To determine whether the lesion below the esophageal entrance could be removed while preserving the larynx, a Weerda distending operating laryngoscope was used for examination under general anesthesia. As laryngoscopy showed that the lesion was located 1 cm to the anal side of the esophageal entrance, it seemed impossible to preserve the larynx during surgery for cervical esophageal cancer. As the patient rejected any esophageal cancer surgery that would include resection of the larynx, we recommended treatment that would involve mucosal resection for cervical esophageal cancer under the laryngoscope and open surgery for the thoracic esophageal cancer. We preferred open surgery instead of EMR for the second lesion in this case for the following reasons: (1) the lesion was diagnosed as having massive submucosal invasion on endoscopy; (2) the patient had received radiation therapy to the middle and lower mediastinum in June 2000; and (3) in May 2002, his condition was complicated by perforation of the esophagus after EMR for lower thoracic cancer.
On November 4, 2003, resection of cervical esophageal cancer was performed under the Weerda distending operating laryngoscope. After general endotracheal anesthesia, the laryngoscope was introduced into the cervical esophagus and positioned just proximal to the tumor (Fig 1). The instrument was opened slowly to dilate the esophagus. The scope was suspended for stabilization in the same manner as for suspension laryngoscopy. Under microscopy (OPMI 6S; Carl Zeiss GmbH, Jena, Germany) with a 3CCD color video camera (DXC-755; Sony, Tokyo, Japan), surgery was performed. Markings for the incision line were made by laser 5 mm to 10 mm outside the protrusion of the tumor. To achieve prolonged mucosal elevation, Glyceol (Chugai Pharmaceutical, Tokyo, Japan) was injected into the submucosal under and around the lesion. After sufficient mucosal elevation had been achieved around the lesion, a mucosal incision was made around the lesion with a scissors, grasping the mucosa with forceps. A submucosal incision was also made with the scissors, and the tumor was completely resected en bloc (Fig 2). The mucosal defect after mucosal resection was about one fourth of the esophageal circumference. The tumor in the resected specimen was a protruded lesion with its surface covered by normal epithelium (Fig 3). Microscopic findings and immunohistochemical stainings showed basaloid cell carcinoma penetrating to the submucosal layer (Fig 4). The postoperative course was uneventful, and the patient underwent the next surgery for thoracic esophageal cancer on November 12, 2003. The postoperative course of open surgery was also uneventful, and the patient was discharged 24 days after the open surgery. On endoscopic examination before discharge, the ulcer scar was completely healed without stricture. The patient remains well 1 year after surgery, and there is no sign of recurrence to date.
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Fig 1. Laryngoscopic appearance of superficial esophageal cancer at the cervical esophagus close to the entrance of esophagus.
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Fig 2. Laryngoscopic appearance after mucosal resection using the Weerda distending operating laryngoscope.
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Fig 3. The resected specimen (10 x 7 mm) is shown. The surface of the lesion was covered by normal epithelium.
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Fig 4. Photomicrograph of a cross-section of the resected lesion, showing basaloid cell carcinoma (hematoxylin & eosin; x 6.25). The tumor cells were located mainly under the epithelium.
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Comment
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Endoscopic esophageal mucosal resection is a minimally invasive local treatment of early-stage esophageal cancer [1, 2]. In some cases, however, it is technically impossible to remove the tumor by EMR. It is difficult to remove an esophageal cervical tumor close to the esophageal entrance by EMR because working space for endoscopic treatment is limited near the cricopharyngeus. However, the Weerda distending operating laryngoscope offers good visualization of the cervical esophagus because it dilates the esophagus as it is opened. Owing to its bivalved structure, the Weerda instrument provides a larger working channel allowing direct manipulation.
As the Weerda distending operating laryngoscope can be suspended to provide a stable working environment, the surgeon is able to use both hands without the need to steady the scope. Moreover, the assistant surgeon can facilitate surgery by watching the monitor as in open surgery. This novel method for accomplishing cervical esophageal mucosal resection using the Weerda distending operating laryngoscope is a safe and excellent procedure for the removal of superficial cervical esophageal cancers close to the esophageal entrance.
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References
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- Inoue H, Endo M, Takeshita K, et al. Endoscopic resection of early-stage esophageal cancer Surg Endosc 1991;5:59-62.[Medline]
- Makuuchi H. Esophageal endoscopic mucosal resection (EEMR) tube Surg Laparosc Endosc 1996;6:160-161.[Medline]
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Abstract
Introduction
