ISSN: 2578-482X
Authors: Yayun Sheng , Yao Yao , Shouqiang Yu , Chen Zhang , Cheng Cao , Huiping Chai and Feng Liu
Background: The surgical complexity of upper thoracic esophageal cancer (UTEC) is compounded by anatomical constraints and frequent comorbidities. This study introduces a novel multimodal approach combining Chai's Supra-Thoracic Apex (CSTA) technique with advanced minimally invasive procedures for UTEC management in hypersplenism patients. Technical Innovation: We present the first documented application of a three-dimensional suspension anastomosis system (TriSAS) integrated with: 1. The CSTA facilitated approximately 3.0 cm of proximal esophageal mobilization toward the subparietal pleural plane. Following laparoscopic splenic pedicle dissection and splenectomy completion, surgeons must conduct a thorough visual inspection of the pancreatic tail region to identify and address any residual hemorrhage originating from splenic vascular remnants. 2. A novel esophagogastric reconstruction method using an uncut gastric conduit that maintained the His angle at 30.0° at the newly established gastroesophageal junction. Case Presentation: A 63-year-old female with progressive dysphagia (Difficulty swallowing semi-liquids) was diagnosed with cT3N1M0 ESCC (8th AJCC) and portal hypertensive splenomegaly (platelet 52×10⁹/L). Preoperative Hospitalization: The patient was admitted 11 days prior to surgery for preoperative preparation, including instrument readiness and nutritional support. The 605-minute combined procedure achieved: • R0 resection (proximal margin 3.0cm) • 17-node lymphadenectomy (0% metastasis) • Laparoscopic splenectomy was completed. Outcomes: • Zero major complications (Clavien-Dindo≥III) • Hematological normalization (platelet 218×10⁹/L at POD7) • 10month dysphagia-free survival (EORTC QLQ-OES18) • Preserved BMI (24.1→15.2 kg/m²)d Gastric stasis on day 20 was managed with nasogastric decompression, metoclopramide, intravenous erythromycin, and proton pump inhibitors, resolving by day 38. Total Hospitalization: The total hospital stay was 59 days, primarily due to the management of postoperative gastric emptying disorder. Literature Synthesis: Our systematic review of 17 comparable studies demonstrates superior outcomes: This procedure achieved a marginal R0 resection with a 3.0 cm margin. No postoperative gastroesophageal reflux or anastomotic stenosis was observed during the 10 months following surgery, and the patient demonstrated tolerance to a semi-fluid diet without obstruction. On postoperative day 20, gastric stasis developed but was effectively managed with nasogastric decompression and gastric motility promotion therapy, resolving with full functional recovery by day 38. At the 10-month follow-up, the patient maintained adequate oral intake and self-care capacity. Subsequently, progressive dysphagia emerged, necessitating multiple hospitalizations for enteral nutritional support. An endoscopy performed on February 19, 2025, identified an impassable esophageal stenosis 16 cm from the incisor, while an ultrasound examination revealed right posterior thyroid lymphadenopathy. The patient declined radiotherapy and instead opted for the best supportive care. Conclusion: This blend of Chai’s apex technique, splenectomy, and suspension anastomosis proves viable for complex UTEC with splenomegaly, prioritizing clearance and function via meticulous reconstruction.
Keywords: Esophageal Squamous Cell Carcinoma; Hypersplenism; Thoracoscopy; Orvil; Chai's Supra-Thoracic Apex Technique; Laparoscopic Splenectomy; Uncut Gastric Conduit; Three-Dimensional Anastomotic Suspension; Minimally Invasive Esophagectomy
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