Introduction
Aberrant right subclavian artery also known as arteria lusoria is the most common embryologic abnormality of the aortic arch [1]. It arises as the last branch of the aortic arch or from the proximal descending aorta. It follows an aberrant course behind the oesophagus. Most of the time, it remains asymptomatic but can cause symptoms, most frequent of which is dysphagia, more commonly recognised as dysphagia lusoria [1–3]. Concurrent presence of arteria lusoria and oesophageal cancer, although rare, can be dreadful if not noticed beforehand and taken due precautions during surgery [4, 5].
Herein, we report a case of a patient with oesophageal cancer and arteria lusoria, who underwent robotic-assisted minimally invasive esophagectomy (RAMIE) while avoiding the surgical pitfall of this association.
Case Summary
A 40-year-old gentleman, without any particular medical or surgical history, non-alcoholic and non-smoker, presented with dysphagia progressively evolving for 3 years, first to solids then to liquids. The patient also reported weight loss of around 6 kg over the year without alteration of his general condition.
On evaluation, an upper gastrointestinal endoscopy showed cricopharynx at 16 cm and gastro-oesophageal junction at 38 cm from upper incisor teeth. A non-obstructing ulcero-proliferative growth was seen approximately 27 to 36 cm. Biopsy confirmed the diagnosis of squamous cell carcinoma. A staging positron emission tomography scan with 18-fluorodeoxyglucose contrast (PETCECT) was performed, showing irregular, circumferential, stenosing parietal thickening of the lower third of the oesophagus. There was no thoracic lymphadenopathy or distant metastasis. Tumour was staged as cT3N0M0. It also identified an abnormal vessel arising from right side of descending aorta travelling posterior to oesophagus, confirming the diagnosis of arteria lusoria (Fig. 1).
Fig. 1.
A, B, C Axial view of contrast-enhanced CT scan showing aberrant take off of right subclavian artery from aorta and its retroesophageal course. D Intraop view of arteria lusoria in relation with other critical anatomical structures
After discussion in the Multidisciplinary Tumor Board, patient received neo-adjuvant chemo-radiation (NACTRT) by CROSS protocol, i.e. carboplatin-paclitaxel 5 cycles and 41.4 Gy/23 fraction radiation [6]. Six weeks after completion of NACTRT, re-evaluation was done by a PETCECT scan, which showed residual thickening at previous tumour site in the lower oesophagus. Patient was counselled regarding surgical options and possible risk, complications and cost involved. After due consideration, patient opted for RAMIE. Standard pre-operative work-up was done. RAMIE was performed using Da Vinci Si system with 3 robotic port technique and patient in semi-prone or modified swimmer’s position. Fourth port was utilised for assistant. After early ligation and division of azygous vein, oesophagus with meso-oesophagus was mobilised. Vagus nerve was cut slightly below the carina to safeguard the bronchial branch. Due precautions were taken to avoid iatrogenic injury to bronchus, thoracic duct, aorta and azygous vein while mobilising the lower oesophagus. Lower dissection was completed upto diaphragmatic crura exposing the gastro-oesophageal junction and fundus. Similarly, vagus nerve, phrenic nerve and trachea were safeguarded while mobilising supracarinal oesophagus. During intraoperative course, as we were aware of a retro-oesophageal course of arteria lusoria, posterior dissection was done very carefully after looping the oesophagus with umbilical tape at the level of azygous vein. During supra-azygous mobilisation, aberrant artery was kept constantly under vision to avoid any inadvertent injury. Minimal use of energy and adequate blunt dissection was done around the aberrant vessel (Fig. 1). After complete mobilisation of oesophagus until the apex, careful dissection was done in thoracic inlet to remove all the fibro-fatty tissue and non-recurrent laryngeal nerve was safeguarded on right side. After the complete mobilisation of oesophagus along with standard 2 field lymphadenectomy, intercostal tube drain was inserted and robot was undocked. Patient position was changed to supine and abdominal part of the surgery was performed to prepare the gastric conduit and D2 lymphadenectomy. Lastly, cervical handsewn oesophago-gastric anastomosis was done in left side of the neck. Intra-operative course was uneventful. Total blood loss was 100 ml and total operative time was around 240 min. Post-operatively patient had hoarseness of voice which recovered within a week. Further post-operative course was uneventful. Histopathology report showed complete response with no evidence of residual tumour and all 18 lymph nodes without evidence of metastasis. Postoperatively patient was kept on observation with regular follow-up. Patient is currently at 12 months of follow-up and doing well. Recent PETCT scan was suggestive of no evidence of disease recurrence anywhere.
Discussion
Knowing the surgical anatomy well is imperative and pre-requisite for all the complex surgical procedures. Oesophageal surgeries are particularly worth the mention because it is the only organ body which traverse 3 different anatomical zones, i.e. neck, thorax and abdomen. Oesophageal surgery is not only complex because of its close relations with other vital structures like aorta, pericardium and recurrent laryngeal nerves but also due to extent of surgical field in 3 different body parts. Use of minimally invasive techniques like video-assisted thoracic surgery (VATS) and robotic platforms have definitely reduced the morbidity associated with thoracotomy and laparotomy required for this operation. RAMIE offers all the advantages of VATS along with additional benefits of enhanced 3D vision, magnification and surgeon-controlled camera. RAMIE also gives a technical advantage especially during lymph nodal dissection in recurrent laryngeal nodes or A-P window nodes [7]. With this case, we wish to highlight certain points; first, aberrant right subclavian artery, although rare, is the most frequent anatomical variant of the aortic arch, representing 0.2 to 1.7% of aortic arch anomalies. The course of arteria lusoria is posterior to the oesophagus which causes compression leading to dysphagia. Second, the presence of an aberrant subclavian artery and oesophageal cancer is an extremely rare situation and increases the intensity of dysphagia. Moreover, if the diagnosis of arteria lusoria is already known, dysphagia may be attributed to it and ignored, potentially leading to a delayed diagnosis of oesophageal cancer [8, 9]. In our patient, dysphagia was present for 3 years, but it was likely that the oesophageal tumour that accentuated this dysphagia and led him to consult. Third, the real concern with this association is the surgical challenge during an esophagectomy with a high risk of haemorrhage [10, 11]. Fourth, this anomaly almost always has a variation on the course of right recurrent laryngeal nerve to enter directly into the larynx rather than the recurrent path leading to variation known as non-recurrent laryngeal nerve (Fig. 2). Lymph node dissection in the region of bilateral recurrent laryngeal nerves is one the most important station for 3-field dissection. Non-recurrent laryngeal nerve is higher in location in the neck; thus, mapping out the nodes is challenging. Thus, increasing the risk of damaging the nerve during cervical dissection in oesophagectomy can lead to vocal cord palsy due to altered course of nerve [12, 13]. This risk is reduced by preoperative imaging, which helps the surgeon to take the necessary precautions in avoiding the injury. Thoracic computed tomography remains the examination of choice to specify the anatomical relationships necessary for the surgeon to accurately anticipate the surgical procedure. This anticipation of the surgical procedure is essential to avoid intraoperative complications, which can be disastrous. Although rare, proper preoperative evaluation to know the anatomic variations is a must to avoid any mishaps. Lastly, higher resolution of robotics also helps in achieving meticulous dissection at relatively difficult to access locations and surgeon experience has helped in safe surgery avoiding complications.
Fig. 2.
Line diagram showing anatomical course of right recurrent (A) and nonrecurrent (B) laryngeal nerve
To our knowledge, ours is the first case report to describe arteria lusoria in patients undergoing RAMIE. Better quality and higher resolution provided by robotic platform confers distinct advantage in this situation.
Declarations
Conflict of Interest
The authors declare no competing interests.
Footnotes
Publisher's Note
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