471. MINIMALLY INVASIVE ESOPHAGECTOMY WITH RESECTION OF THE DESCENDING AORTA DUE TO SUSPECTED TUMOR INFILTRATION

Background

Classically, esophageal neoplasms have had a poor survival, considering those T4b tumors that infiltrate the aorta, airways or vertebrae to be unresectable despite not having distant disease. With the advancement of surgical techniques, the improvement of neoadjuvant/adjuvant systemic treatments and the multidisciplinary approach to this pathology, these barriers of unresectability are gradually being broken.

Methods

This is a 68-year-old patient, a 1-pack-a-day smoker, who presented squamous cell carcinoma 30 cm from the dental arch treated with chemoradiotherapy according to the CROSS scheme. After surgery at another center, there is suspicion of infiltration of the descending aorta, for which he was referred to our center.

The case is discussed in a multidisciplinary committee and a decision is made to place TEVAR in the first stage and surgical resection of the lesion in a second stage.

Results

The patient underwent surgery performing a three-stage esophagectomy (McKeown) using prone thoracoscopy without selective intubation, through which a regulated esophagectomy was performed with total lymphadenectomy and en bloc resection along with the anterior wall of the descending aorta where there was suspicion of tumor infiltration, exposing the aortic prosthesis (Photo 2). The prosthesis is covered to isolate it from possible sources of infection with a patch of pericardium fixed with loose sutures to the aortic wall and biological glue. It was reconstructed using a mediastinal gastroplasty with cervical circular mechanical anastomosis. Postoperative period marked by cervical leakage that was resolved by conservative treatment.

Conclusion

Resection using a minimally invasive approach of an aortic patch in cases of suspected tumor infiltration in esophageal neoplasms without systemic disease may be a safe therapeutic option as long as it is performed in centers specialized in complex esophageal resections and with a multidisciplinary team that also involves cardiac surgeons. The oncological prognosis must be evaluated in the long term, but achieving R0 resections should not be worse than in locally advanced resectable tumors.