Aberrant subclavian artery causing difficulty in transhiatal esophageal dissection

Department of Surgical Oncology, Tata Memorial Hospital, Mumbai, India.
Diseases of the Esophagus (Impact Factor: 1.78). 02/2003; 16(2):173-6. DOI: 10.1046/j.1442-2050.2003.00322.x
Source: PubMed


The right subclavian artery normally arises from the brachiocephalic artery. Anomalies in development may lead to peculiar problems during surgery. We report a patient with esophageal carcinoma who had an aberrant right subclavian artery, posing specific difficulties during a transhiatal esophagectomy, requiring conversion of the procedure into a transthoracic approach. The embryologic basis of this anomaly and the clinical significance are discussed.

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    ABSTRACT: An aberrant right subclavian artery (ARSA) is an anatomical abnormality that occurs at a frequency of 0.4–2 %. It is important to be aware of this abnormality when performing radical esophagectomy for esophageal cancer because many patients with an ARSA have a right nonrecurrent inferior laryngeal nerve (NRILN) and right thoracic duct. We report three cases of esophageal cancer with ARSA treated by thoracoscopic esophagectomy. Case 1 was a 59-year-old woman with a relapse of a thoracic esophageal cancer after definitive chemoradiotherapy (CRT). Case 2 was a 76-year-old man with upper thoracic esophageal cancer who had received no treatment before the surgery. Case 3 was a 69-year-old man with upper thoracic esophageal cancer pretreated with neoadjuvant CRT. It was possible to predict an ARSA by computed tomography and the right thoracic ducts by magnetic resonance imaging before surgery in all three cases. Thoracoscopic esophagectomy with two-field lymph node dissection was performed, and the NRILN and the right thoracic duct were detected and preserved in all three cases. Because of ARSA, the operative field is limited around the left recurrent nerve, so a careful procedure is needed to avoid nerve palsy.
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    ABSTRACT: A nonrecurrent inferior laryngeal nerve (NRILN) is a rare anomaly. We report four cases of esophageal cancer with NRILN treated by transthoracic esophagectomy with three-field lymphadenectomy. All had been diagnosed as esophageal cancer. Under a diagnosis of concomitant NRILN based on preoperative computed tomography, we conducted transthoracic esophagectomy with three-field lymphadenectomy. The right subclavian artery on the right between the esophagus and vertebral column was recognizable perioperatively. The right recurrent nerve was not identified at the right subclavian artery during mediastinal dissection, but the NRILN was identified as going directly from the vagal nerve to the larynx during neck lymphadenectomy. The thoracic duct ran between the esophagus and the azygos vein, terminating at the right venous angle. Because the aberrant right subclavian artery is associated with the NRILN, right-sided terminating thoracic duct, etc., surgery must proceed under stringent controll with these abnormalities in mind. In patients with NRILN, cancer tends to metastasize to neck lymph nodes regardless of upper mediastinal lymph nodes, which is why esophagectomy with three-field lymphadenectomy is considered standard in treating thoracic esophageal cancer with NRILN.
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