PMC5244026_01
(a) Conventional endoscopy showed that the protruded mass was located at the left piriform sinus. (b) The tumor was very movable and was diagnosed as cervical esophageal cancer. (c) Transnasal endoscopy using the trumpet maneuver showed that the tumor had not widely invaded the hypopharynx. (d) The pedicle of the tumor was located at the left-anterior wall of the pharyngoesophageal junction.
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fig1
On the further examination, she was diagnosed with cervical esophageal cancer invading the hypopharynx (Figures 1(a) and 1(b)). The image of the pharynx using the trumpet maneuver with transnasal endoscopy in the present patient is shown in Figure 1(c). The pedicle of the tumor was located at the left-anterior wall of the pharyngoesophageal junction (Figure 1(d)).
(a) The curved laryngoscope enabled a view of the whole hypopharynx, including the apex of the piriform sinus and the orifice of the esophagus. The tumor was invisible from the hypopharynx. (b) The tumor was pulled up from the cervical esophagus to the hypopharynx. (c) The pedicle of the tumor was mainly located at the postcricoid area. (d) The flat, superficial part and the anal side of the tumor had spread to the cervical esophagus.
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Initially, the tumor was invisible from the hypopharynx (Figure 2(a)), as most of it was located in the cervical esophagus. Using the forceps, the tumor was pulled up from the cervical esophagus to the hypopharynx (Figure 2(b)). The pedicle of the tumor was mainly located at the postcricoid area (Figure 2(c)). The flat superficial part and anal side of the tumor had spread to the cervical esophagus (Figure 2(b)).
(a) ELPS is a video-assisted surgery performed by two physicians: a head and neck surgeon acting as the operator and an endoscopic specialist acting as the endoscopist. They observe the same TV monitor in the operation room. (b) The operator uses the curved forceps and the electric needle knife, while the endoscopist inserts the transnasal endoscope through the nose.
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Endoscopic laryngopharyngeal surgery is a video-assisted surgery performed by two physicians (Figure 3(a)): an operator and endoscopist who is an endoscopic specialist. The operator uses the curved forceps and the electric needle knife, while the endoscopist inserts the transnasal endoscope through the nose (Figure 3(b)).
(a) After saline was injected into the subepithelial layer, the head and neck surgeon dissected the lesion using the orally inserted curved grasping forceps with one hand and the orally inserted curved electric needle knife with the other. (b) The esophageal portion was resected by ESD. (c) The pharyngeal portion was resected by ELPS. (d) After tumor removal, the tumor was resected en bloc.
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Then a head and neck surgeon performed the circumferential mucosal incision using an electric needle knife (KD-600, Olympus Medical Systems, Tokyo, Japan) and forceps inserted transorally (Figure 4(a)). An endoscopist was therefore called in to help the operator dissect the anal margin using the electric knife inserted through a flexible endoscope (Figure 4(b), ESD procedure). After the circumferential incision, dissection was performed using the orally inserted curved grasping forceps with an electric knife in combination (Figure 4(c) with video https://www.youtube.com/watch?v=2FCFVLQtAN8). The tumor was resected en bloc (Figure 4(d)).
A histopathological examination revealed a diagnosis of invasive squamous cell carcinoma. A 25 x 18 x 10 mm superficial lesion was removed by en bloc resection.
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The histopathological findings were squamous cell carcinoma, 25 x 18 x 10 mm, subepithelial invasion, no microvascular permeation, and a negative vertical margin (Figure 5).
At the anal side of the specimen, the muscularis mucosa was examined, and the tumor was confirmed to have spread to the cervical esophagus.
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On the anal side of the specimen, the muscularis mucosa was examined (Figure 6), and the tumor was confirmed to have spread to the cervical esophagus.
(a) At 8 months after treatment, no local recurrence was observed. (b) No stricture was observed at the cervical esophagus.
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The patient is currently alive with no recurrence at 8 months after the surgery (Figure 7(a)), and there is no stricture at the cervical esophagus (Figure 7(b)).