Eur J Cardiothorac Surg 2008;34:216-218. doi:10.1016/j.ejcts.2008.04.019
Copyright © 2008, European Association for Cardio-thoracic Surgery. Published by Elsevier. All rights reserved.
Thoracoscopic stapled resection of multiple esophageal duplication cysts with different pathological findings
Chul Ung Kang,
Deog Gon Cho*,
Kyu Do Cho,
Min Seop Jo
Department of Thoracic and Cardiovascular Surgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, 93-6 Ji-dong, Paldal-gu, Suwon, Gyeonggi-do 442-723, South Korea
Received 13 February 2008;
received in revised form 6 April 2008;
accepted 14 April 2008.
* Corresponding author. Tel.: +82 31 249 7200; fax: +82 31 251 1755. (Email: superdrkang{at}hanmail.net; ebstein8{at}hitel.net; cscho{at}catholic.ac.kr; kyudias{at}cvnet.co.kr; minseop{at}catholic.ac.kr).
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Abstract
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Esophageal duplication cyst is a rare congenital esophageal anomaly of the foregut. This cyst usually occurs in isolation, and thus far, was treated by enucleation through thoracoscopic or thoracotomic surgery. Here we report a case of multiple esophageal duplication cysts that showed different pathological findings, i.e., the cysts were lined with pseudostratified ciliated columnar and stratified squamous epithelium. Esophageal cysts were incidentally detected in a 53-year-old man during the treatment of pneumonia. In chest-computed tomography, the cysts showed a thin wall and homogeneous inner density, while in endoscopy, no communication with esophageal mucosa was observed. We resected the esophageal cysts with endo-staplers under thoracoscopic surgery. No postoperative complications, including esophageal mucosal injury, occurred. A follow-up chest computed tomography revealed the complete resection of the cysts.
Key Words: Esophageal cyst • Thoracoscopy • Surgical staplers
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1. Introduction
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Esophageal duplication cysts are rare congenital anomalies of the foregut and account for only 3% of the mediastinal masses [1]. Since the first report by Robinson et al. in 1987 [2], there have been no reports on multiple esophageal duplication cysts (PubMed database).
This report describes a case of multiple esophageal duplication cysts with different pathological findings and safe complete resection of the cysts without esophageal perforation by using endo-staplers under the thoracoscopic surgery.
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2. Case report
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Masses were incidentally detected in a 53-year-old man during the treatment of pneumonia. The patient denied gastrointestinal symptoms such as dysphagia or anorexia. Chest computed tomography (CT) revealed two masses on the right side of the mid-to-distal esophagus. Both masses had a thin wall and homogeneous inner density and were compatible with cysts (Fig. 1A). An upper endoscopy showed no submucosal mass and communication with the esophagus.
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Fig. 1. (A) Preoperative chest CT showed multiple esophageal duplication cysts. (B) Thoracoscopic finding of two esophageal cysts. (C and D) Stapled resection of lower and upper esophageal duplication cysts after decompression. White and black arrows represent the upper and lower esophageal duplication cysts, respectively.
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A right thoracoscopic approach was used with three ports. A double-lumen endotracheal tube was used to deflate the right lung. The 3-cm sized cysts were located on both sides of an azygos vein and in the esophageal muscle layer (Fig. 1B). The cysts were decompressed, and the layers of the esophageal muscle were dissected. It was difficult to resect esophageal cysts with enucleation by electrocauterization because the cysts appeared to be fused to the esophageal mucosa at their basal edge. To prevent esophageal perforation, the fused parts were resected with endo-staplers (Fig. 1C and D). The resection margins achieved by endo-staplers were situated near the esophageal mucosa for complete resection. Intraoperative endoscopy showed no mucosal perforation and esophageal stricture. The esophageal muscle layer from where the cysts were resected was approximated and reinforced with the mediastinal pleura.
In pathological examination, the upper and lower cysts were lined with pseudostratified ciliated columnar epithelium and stratified squamous epithelium, respectively. Both cysts had a dual muscular layer, and no cartilage or bronchial glands were identified. These findings were compatible with esophageal duplication cysts (Fig. 2
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Fig. 2. (A and C) Upper and lower esophageal duplication cysts surrounded by multiple muscle layers, respectively (hematoxylin and eosin (H&E) stain, x40). (B) Pseudostratified ciliated columnar epithelium of upper esophageal duplication cyst (H&E, x200). (D) Stratified squamous epithelium of lower esophageal duplication cyst (H&E, x200).
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The patient was discharged without complication on the 6th postoperative day. Chest CT on the 20th postoperative day revealed complete resection of the esophageal duplication cysts.
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3. Discussion
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Esophageal duplication cysts are frequently located in the right posteroinferior mediastinum and were incidentally diagnosed in 37% of cases with mediastinal cysts [3].
Pathological diagnosis of an esophageal duplication requires the presence of a cyst in, or adjacent to, the esophagus, covered by two muscle layers and lined with a squamous, columnar, cuboid, pseudostratified, or ciliated epithelium. Both the embryonic esophagus and trachea are lined with ciliated epithelium; therefore, other studies have emphasized the use of cyst wall components (muscle layers, cartilages, or bronchial glands) rather than the cyst epithelium to differentiate between bronchogenic and esophageal duplication cysts [4].
The esophageal duplication cyst usually occurs in isolation. Mixed foregut cysts with components of both a bronchogenic cyst and an esophageal duplication cyst or multiple bronchogenic cysts with an esophageal duplication cyst have been reported [5,6]. Robinson et al. reported a case of multiple esophageal duplication cysts. By performing thoracotomy, they excised two esophageal duplication cysts, both of which were lined with a simple cuboid epithelium [2]. Our case is the first case of multiple esophageal duplication cysts that showed pathological findings different from those reported previously, i.e., the cysts were lined with pseudostratified ciliated columnar epithelium and stratified squamous epithelium.
Several imaging techniques such as CT, magnetic resonance imaging (MRI), and endoscopic ultrasound (EUS) have been used for the diagnosis of esophageal duplication cysts. EUS plays an important role in the evaluation of these lesions. In EUS, the duplication cysts commonly appear as thin-walled cystic structures [1].
Resection of the duplication cyst is a standard treatment. Although esophageal duplication cysts are often asymptomatic at the time of diagnosis and malignant degeneration is rare, surgical excision is advised because a definitive diagnosis is better performed on a surgical specimen and untreated esophageal duplication cysts can lead to dysphagia or bleeding. Posterolateral thoracotomy is the conventional surgical approach for removing cysts; however, recent advances in minimally invasive surgery have led to the development of a less traumatic approach for treating these lesions. Compared with the open approach, the thoracoscopic procedure offers the following main advantages: reduced postoperative pain, earlier recovery and discharge of the patient, and a superior cosmetic result [7].
The surgical technique must emphasize evaluation of the integrity of the esophageal mucosa, approximation of the muscle layers after resection of cysts to avoid pseudodiverticulum, and preservation of the vagus and phrenic nerves. Transillumination through an esophagoscope and aspiration of the cyst can sometimes be useful [1].
With regard to thoracoscopic resection, previous studies suggested enucleation of the cyst by electrocauterization or harmonic scalpel [1,8,9]. In our case, cystectomy was performed using endo-staplers. Cystectomy with staplers is superior to enucleation for reducing mucosal injury and for enabling the approximation of the muscle layer from where the cysts were removed. In the case of adhesive, voluminous or complicated cysts, thoracoscopic resection with staplers is expected to promote the indication of minimally invasive surgery.
This is the first report of a complete thoracoscopic resection of esophageal duplication cysts; the two esophageal cysts were detected in a single patient and showed pathological findings different from those reported previously.
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References
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Abstract
1. Introduction
