Keywords
foregut duplication cyst - thoracoscopy - stapling device - VATS - pediatric
New Insights and the Importance for the Pediatric Surgeon
The use of a linear stapler to remove a foregut duplication cyst may benefit the patient
by minimizing the risk of iatrogenic esophageal rupture.
Introduction
Esophageal duplication cysts are a rare congenital anomaly predominantly found in
children with a male prevalence. Aside from possible compression on the trachea and
its expansion into the lung, there is a possibility of malignant alteration of the
mucous cells. Therefore, a surgical excision is highly recommended.
Video-assisted thoracoscopic surgery has been established for resection of mediastinal
masses in pediatric surgery.[1]
[2]
[3] However, there is little evidence in literature on optimal surgical approach for
resection of esophageal duplication cysts. This case report aims to present a new
approach using a linear stapler for complete resection of an esophageal duplication
cyst in pediatric patients.
Case Report
A 19-month-old male toddler with prenatal suspected cystic pulmonary mass was referred
to our department. At the age of 1 year a contrast magnetic resonance imaging showed
a 2 × 2 × 1.5 cm hyperintense fluid-filled cyst on the left paravertebral side with
contact to the esophagus in the posterior mediastinum, adherent to the bronchial hilum
cranially and to the descendent aorta. A thoracoscopic resection was anticipated.
The preoperative computerized tomography showed a progression of the mass to 3.0 × 3.3 × 4.0 cm
([Fig. 1]).
Fig. 1 (A) Computed tomography of the chest showing a foregut cyst in the posterior mediastinum
in the left hemithorax. (B) Exposed base of the foregut cyst with crossing vagus nerve at the base of the mass
and the descending aorta behind the base of the mass.
The patient was operated in a slight prone position with elevated left hemithorax
and single-lung ventilation. A 5-mm camera trocar was brought in below the inferior
angle of the scapula. Insufflation with 5 mm Hg was initiated. A second and a third
5-mm port were placed ventrocaudal and dorsal. The cyst could be easily identified,
then was dissected from the left lower pulmonary lobe with hook electrocautery. Careful
dissection of the surrounding pleura along the cystic mass was performed in the same
fashion. To the medial side the mass was adherent to the thoracic aorta and the pulmonary
hilum. The cyst was dissected in this part again using hook cautery and in addition
with a 3-mm vessel sealing device (JustRight, Bolder Surgical, Boulder, Colorado,
United States). A broad base connection to the esophagus was displayed ([Fig. 1]). Macroscopically the mass imposed as a foregut duplication cyst. A complete resection
at the base of the duplication cyst could be achieved with the use of a 5-mm stapling
device (JustRight, Bolder Surgical) ([Fig. 2]). There was no indication for an injury to the esophagus. The cyst was removed through
the ventrocaudal port site after increasing the port site to 2 cm. A chest drain was
not considered to be necessary. Postoperatively there was no sign of a pneumothorax.
A nasogastric tube was placed for 24 hours postoperatively. Enteral feeding was started
on day 1 postoperatively and the patient was discharged to home on day 4 postoperatively.
Fig. 2 (A) Placement of the stapling device. (B) Staple line on the esophagus (arrow) after resection.
Histopathology confirmed a foregut duplication cyst with a two-muscle layer cover
and mucinous cells.
Discussion
Resection through thoracotomy has been the standard of care for excision of foregut
duplication cysts. In recent years a thoracoscopic approach has been described for
this indication and proven to be safe.[1]
[4]
[5] The thoracoscopic approach offers advantages such as reduced postoperative pain,
shortening the length of hospital stay, and improved cosmesis.[6] In addition, the morbidity of a thoracotomy can be avoided.
In literature tissue dissecting devices using ultrasound or thermal energy for removal
through enucleation or partial resection have been described.[1]
[6]
[7]
[8]
[9] Kang et al9 described the successful resection of an esophageal duplication cyst using a stapling
device in a 53-year-old patient.
As foregut duplication cysts are arising from the esophageal wall they have to be
removed entirely without perforating the esophagus. The use of a 5-mm linear stapler
to remove a foregut duplication cyst may benefit the patient by minimizing the risk
of iatrogenic esophageal rupture and incomplete removal in a small operative field
due to its smaller size and therefor can be placed more accurate.
During dissection with meticulous hemostasis and exact placing of the stapling device
in the exact plane a clear visualization of the esophagus is of outmost importance
for safe and successful resection.[1]
Besides single-lung ventilation we preferred positioning the patient in a slightly
prone position allowing for a better visualization of the posterior mediastinum. A
chest tube should not be placed as standard procedure.
Conclusion
Thoracoscopic resection of foregut duplication cyst with a 5-mm stapling device proved
to be safe and successful in an 18 months old patient.
